1. 1 EURO-TELEPATH “Telepathology Network in Europe” Proposer: Dr. Marcial García Rojo Pathology Department General Hospital of Ciudad Real Castilla La Mancha Health Service (SESCAM) SPAIN, marcial@cim.es COST Action IC0604

2. 2 Scope Adequate technological framework for the management of multimedia electronic healthcare records Informatics applied to Anatomic Pathology Research on standards to represent, interpret, browse, retrieve digital medical images World wide search engine Collaborate with Standardisation bodies with previous research conclusions

3. 3 Background Telepathology (since 1960s): r esearch, patient data monitoring and management, both patient and healthcare staff education by means of systems which allow a quick and full access to expert counselling and patient data, disregarding the actual location of patients and the demand of its information. Diagnosis and remote consultations Frozen sections (intraoperative studies) Surgical specimens manipulation Fine needle aspiration cytology evaluation Cytology screening Autopsies assistance Molecular pathology guidance

4. 4 Emerging digital pathology Gross study Digital photography Digital video Microscopy: Slides Digital photography Virtual microscopy: whole slide imaging Molecular Pathology Digital photography

5. 5 Whole Slide Imaging From static and dynamic telepathology to Whole Slide Imaging Conventional slides are fragile (crystal), They are not permanent, above all in immunofluorescence, joint crystals, … … In cytology it is not possible to deliver copies 6-11% of static images appear discordant with the original (conventional) diagnosis (incomplete information) VIRTUAL SLIDES ADVANTAGES Extraordinary quality in lower magnifications Dynamic map of the slide available High resolution images available transmitting only selected area (“image streaming”) Record and reproduce the path followed by the pathologist during slide examination Images storage is permanent and annotation can be performed over them, and these can also be saved Tissues are of only 25 x 20 mm

6. 6 Different technologies are integrated in the network Olympus SIS.slide Aperio ImageScopeUniv. Tampere. Webmicroscope UCLM. Sepia Project

7. 7 Previous European Research projects 1998: Eureka supported “PathSystem” project (ref. 1456). Prototype of Pathology management system incorporating state-of-the-art telematic principles and techniques 2000: “3D-PATHOLOGY”. A real time system for quantitative diagnostic PATHOLOGY and visualisation in 3D, was funded under 5th FP (Ref: IST-2000-29598). 2001: “E-SCOPE”. Fully Digital Microscopy for routine diagnostics and integration into hospital information workflow (IST-2001-33294 BP)

8. 8 Related COST actions 237: Multimedia Telecommunications Services 275 & 2101: Biometrics (Related to image analysis, and user identification) 276: Information and Knowledge Management for Integrated Media Communication 292: Semantic multimodal analysis of digital media (image analysis) B11: Quantification of magnetic resonance image texture (image research working groups) B19: Molecular cytogenetics of solid tumours

9. 9 History of the proposal: Standardization activities IHE Europe: Dr. Christel Le Bozec (INSERM & ADICAP. France): Editor of Pathology Technical Framework, and Project Manager DICOM in Europe: Dr. Marcial García Rojo, Spain, Secretary of WG26 (Pathology) in Europe activities. SNOMED CT: Reviewers of Spanish edition CEN TC251: Contacts with standardization bodies through the Spanish Society of Health Informatics (SEIS) (Board members are included in the Action)

10. 10 Recent references Boutonnat J, et al. A pilot study in two French medical schools for teaching histology using virtual microscopy. Morphologie 2006 Mar;90(288):21-5. “Teaching program in two French medical schools (Lyon and Grenoble) include virtual slides. Students works faster, on better resources” Kayser K, et al. [Rom J Morphol Embryol 2006;47(1):21-8 & Diagn Pathol 2006 Jun 10;1:10] Automated tissue-based virtual diagnosis. “The developed system is a fast and reliable procedure to fulfill all requirements for an automated "pre-screening" of virtual slides in tissue-based (eg. lung) diagnosis”. Gilbertson JR, et al. Primary histologic diagnosis using automated whole slide imaging: a validation study. BMC Clin Pathol 2006 Apr 27;6:4. “Image information contained in current whole slide images is sufficient for pathologists to make reliable diagnostic decisions. Further validation studies will be needed.”

11. 11 History of the proposal: Research activities Telepathology: Dr. Janina Slodkowska (Institute of Tuberculosis and Lung Diseases, Warsaw, Poland). Semantic interoperability and HL7: Dr. Bernd Blobel (University of Regensburg Medical Center, Germany). Pathology Information Systems: Dr. Christel Le Bozec, and Dr. Marcial García Rojo. Security infrastructure: Dr. Bernd Blobel Web based distance learning: Dr. Izet Masic (University of Sarajevo, Bosnia & Herzegovina). JPEG, JPEG2000: Ecole Polytechnique Fédérale de Lausanne Image analysis and diagnosis: Prof. Gloria Bueno (University of Castilla-La Mancha, Spain), and Dr. Janina Slodkowska. Industry research in equipment and software: Tribvn, France.

12. 12 Virtual Slide Congress in Internet (2 editions) http://www.conganat.org/vsc/

13. 13 History of the proposal: Practical experiences Telemedicine: Dr. Luis Gonçalves (Alentejo region telemedicine, Portugal), Dr. Ekaterine Kladiashvili (Georgian Telemedicine Union). Virtual microscopy and virtual slides atlases and seminars: Dr. Jorma Isola (Tampere University, Finland), and Dr Mikael Lundin (University of Helsinki, Finland). Virtual slides based telepathology: Dr. Marcial García Rojo. Digital Imaging network: Ykonos project (radiology) of SESCAM (Public Health Service in Castilla La Mancha, Spain). Terminology in pathology networks: ADICAP, Dr. Christel Le Bozec Software development and integration: SESCAM and Tribvn.

14. 14 DICOM WG26 meeting in Madrid

15. 15 EURO-TELEPATH “Telepathology Network in Europe” COST Action IC0604 Objectives and working programme

16. 16 Objectives (1) General: Evaluate and validate -in a networked environment- the common technological framework and communication standards required to access, transmit and manage digital medical records by pathologists and other medical specialties. 10 specific objectives: 1. Increase the use of automation procedures over 50% in Anatomic Pathology 2. Increase productivity. Reach up to 100 slides digitization per day 3. Norms and compression rules to obtain microscopic images with full diagnostic quality in minimum possible space (1-2 GB) 4. Best viewer design based on standardized (JPEG2000) format for microscopic pathology images

17. 17 Objectives (& 2) (cont’d): 5. Define a set of standardized DICOM file headings for pathology microscopic images. 6. Definition of new types of messages needed for pathological image information exchange (CEN, HL7, and other standards) 7. Increase the European scientific leadership in the emerging Pathology Technical Framework (IHE-Pathology) 8. Research in Pathology Information Systems and other hospital information systems to integrate a standardized workflow of pathology images 9. Agree on methodology to establish an open, web-based European teleconsultation service based on virtual slides 10. Design a central metasearch engine containing a +3500 virtual database of pathology images for joint research, teaching and observation purposes

18. 18 Expected benefits: Medical Allow users (healthcare professionals and specialists) to obtain better and faster diagnosis in all related fields of Medicine (oncology, dermatology, gynaecology, etc.), including Primary Care. Improve patient care through a better surveillance of treatment response effectiveness. Resolve drawbacks of irregular “in hand” data handling, allowing pathologists to select his/her collaborating team from previously arranged expert panels, with the capability of obtaining a response in a few hours or even minutes. Better adherence to up-to-date guidelines and protocols in the study of specimens which improves the continuous learning process of pathologists in each participating institution. Inter-institutional tools in the exchange of medical knowledge would facilitate new research projects of rare diseases, and to achieve a better classification and understanding of diseases.

19. 19 Expected benefits: Technical Coordination of the existing research efforts in telepathology Quality of electronic medical records to include greater detail in patient information (reports, images) accessible from different places. Improvement of quality, productivity and efficiency (turnaround time) in medical diagnosis. Improving specimens’ and patients’ identification procedures. Easier and safer access to key pathology data and images in multiple areas. Increased use of virtual slides instead of conventional fragile slides. Synergic workflow among specialists/doctors in a collaborative teamwork (consultation, education, research or quality assurance purposes). Promote research in 2D and 3D image production and processing, and multispectral image managing, specially in large images. Benefits for other research areas needing GB images: Computer vision, Astronomy, Geology, Planetary Sciences,

20. 20 Expected benefits: Socioeconomic Societal benefits Favour patient mobility Reinforce the overall quality and the ubiquity of health care services. Optimise scarce and expensive medical resources. European scale reform of medical data management legislation and consumer protection standards. Foster continuing medical learning programs, and basic and applied clinical research opportunities. Improve accessibility and working ergonomics for disabled pathologists-users. Economic benefits Common technological standard for "state-of-the-art" e-health solutions. Digitization centres serving other institutions without scanning facilities. Creation of ubiquitous teleconsultation and digitisation services. Cut down on costs for private and public health actors on licensing for image visualization software. Contribute to the cost effectiveness of the entire health care system Improve competitiveness of the European medical image industry.

21. 21 EURO-TELEPATH “Telepathology Network in Europe” COST Action IC0604 Working method, organization, and management (including working groups)

22. 22 Scientific program: Activities 1.Automation procedures in Pathology. Best technology available and under research. 2.Scanning solutions for Pathology microscopic slides. 3.Technological solutions for compression and storage problems with large image files. 4.Virtual slide standard viewer specifications which allow efficient reviewing of pathology images. 5.International standards (DICOM, HL7, SNOMED, CEN) and IHE initiative. 6.Model for pathology and other hospital information systems 7.An European-scope telepathology network 8.Collection of interesting and typical samples, and clinico-pathological sessions

23. 23 Use Case 1: referring center owns digitization system Pathologist Hospital A (sender) 1) Select slides2) Whole slide digitization (current use of scanners) 3) Images in web server 4) Filling form of consultation case

24. 24 Use case 2: Expert’s role Expert pathologist in Hospital B (consultant) 1) E-mail notification of new case 2) Review case in Portal Request additional data 7) Sender (Hospital A) and digitization center (B) are notified that report is available and case is closed 3) Diagnosis and report

25. 25 Use case 3: Intelligent scanners and integrated multifunctional workstations Next step in slide production scanners, consisting in elaborating intelligent scanners, operating jointly with: integrated analysis, annotation and search & retrieval multifunctional workstations secured storage and networking management resources. Objective: to perform advance research targeting the next generations of tools, terminals, networks and standards.

26. 26 Organizational structure of COST Action Chair / Management Committee / Secretariat 4 Working Groups Scientific Program (item #) 1. Users and working models Automation / Artificial Intelligence for classification studies (1) Scanning solutions / Clinical eval. (2) Proposal on PIS changes)(6) 2. Standards in Pathology DICOM, HL7, IHE, SNOMED, CEN (5) 3. Technological Compression & storage / search & retrieval (3) Image viewer / Image analysis (4) Compiling cases (8) 4. Implementation of Telepathology Networks Telepathology integration guidelines(7)

27. 27 Dissemination plan Researchers in the EURO-TELEPATH network: website and multimedia tools Pathologist community: Publications, conferences, expositions, virtual meetings. European Telepathology conference E-health, IT scientists and standard bodies: Technical documents, attendance to IHE, SNOMED, DICOM, HL7,… meetings, industry meetings, training schools, public web site Medical-scientific community in general: Journals, COST publication, non-technical reports, workshops and final conference, public web site.

28. 28 EURO-TELEPATH “Telepathology Network in Europe” COST Action IC0604 Distribution of tasks

29. 29 Current research groups Action kick-off 1. Finland: Tampere University & University of Helsinki 2. France: INSERM & Tribvn 3. Germany: University of Regensburg & Charité Universitätsmedizin Berlin 4. Italy: University of Udine 5. Lithuania: National Centre of Pathology & Kaunas University of Technology 6. Poland: Institute of Tuberculosis and Lung Diseases, Warsaw 7. Portugal: Hospital Espirito Santo 8. Serbia: University of Belgrade 9. Spain: University of Castilla-La Mancha, Hospital General de Ciudad Real & SESCAM 10. Switzerland: EPF Lausanne 11. United Kingdom: University of Nottingham Policy: A group of researchers (balance of female & young experts aged less than 35), shall be duly appointed to encourage and coordinate the network’s efforts.

30. 30 Partners’ background Action kick-off 1. Finland: Tampere University & University of Helsinki 2. France: INSERM & Tribvn 3. Germany: University of Regensburg & Charité Universitätsmedizin Berlin 4. Italy: University of Udine 5. Lithuania: National Centre of Pathology & Kaunas University of Technology 6. Poland: Institute of Tuberculosis and Lung Diseases, Warsaw 7. Portugal: Hospital Espirito Santo 8. Serbia: University of Belgrade 9. Spain: University of Castilla-La Mancha, Hospital General de Ciudad Real & SESCAM 10. Switzerland: EPF Lausanne 11. United Kingdom: University of Nottingham ClinicalPathologyICTIndustry

31. 31 Recruiting new research (university and industry) groups? Non-COST countries? Other groups: 12. England: Univ. Leeds, Aperio-Europe 13. Hungary: 3DHistech & Semmelweis University, Budapest 14. Ireland: SlidePath, Dublin 15. Georgia: G. Telemedicine Union 16. Norway: University Hospital of Tromsø 17. Spain: VICOMTech, San Sebastián 18. Sweden: University Hospital, Uppsala

32. 32 Working groups. Distribution of tasks 4 Working Groups: Partners Distribution. Select your choice(s) to participate in Working Group and/or specific tasks 1. Users and working models (6 tasks) 2. Standards in Pathology (5 tasks) 3. Technological (8 tasks) 4. Implementation of Telepathology Networks (5 tasks) (Telepathology integration guidelines)

33. 33 Distribution of tasks. Example WG1 Users (working models) 1.1. Review of existing bibliography and research projects of participating groups and other groups in all the aspects related to the Action. Performed by: Hospital General de Ciudad Real. Spain. Tampere University and University Hospital Institute of Medical Technology, Finland. 1.2. Consensus study of existing workflows in pathology departments. Performed by: Hospital General de Ciudad Real. Spain. Biomedical informatics group of the University of Helsinki, Finland. INSERM, France. 1.3. Full study analysis of 10 microscope brands. Performed by: Hospital General de Ciudad Real. Spain. Institute of Tuberculosis and Lung Diseases, Warsaw, Poland. 1.4. Study all visualization performance needs for pathologists. Performed by: Hospital do Espiritu Santo, Evora, Portugal. Tampere University and University Hospital Institute of Medical Technology, Finland. Biomedical informatics group of the University of Helsinki, Finland. 1.5. Image analysis tools study of existing solutions. ISA of the Superior Technical Industrial Engineering School of the University of Castilla La Mancha (UCLM), Spain. Biomedical informatics group of the University of Helsinki, Finland. 1.6. Design of image analysis tools implementation. ISA of the Superior Technical Industrial Engineering School of the University of Castilla La Mancha (UCLM), Spain. Tribvn ICS WF, France. Biomedical informatics group of the University of Helsinki, Finland.

34. 34 EURO-TELEPATH “Telepathology Network in Europe” COST Action IC0604 Time-table

35. 35 COST Action Time-table MC Meetings, WG1 Meetings, WG2 Meetings, WG3 Meetings, WG4 Meetings: 1 st and 3 rd quarter (2/year) Workshops: year 1 and year 3 Telepathology Congress: year 2 (Action dissemin.) Final Conference: year 4 (focused on results) STMS (visits): Proposals to COST (eg. year 1 and 4) Reports: yearly Publications: Review status: year 2 & year 4 Training School: year 3 Website

36. 36 Time-table overview

37. 37 EURO-TELEPATH “Telepathology Network in Europe” COST Action IC0604 Budget

38. 38 Economical dimension On the basis of the initial 8 countries representatives, the economic dimension of the research activities to be carried out under the Action has been estimated, at an estimate of 16 million euros. (Example: Serendipia Project in Spain  3.5 million Euros) “A COST Action is implemented through a concerted action, what means that the research is carried out in and financed by the participating countries themselves, while COST provides the means to organize the necessary co-ordination measures.” “It finances networking of nationally funded activities in supporting meetings, conferences, short term scientific exchanges and outreach activities. COST therefore does NOT fund research itself.” On average financial support of some € 90.000 p.a. as grant for up to 4 years can be expected.

39. 39 Financing COST Activities The COST IC0604 Action budget is able to finance the activities of MCs, WGs, which can include the following items: travel expenses and daily allowances for delegates to meetings; workshops/conferences; short term scientific missions (STSMs) - inter-laboratory exchanges; training schools Action Grants publications and dissemination; high level research conferences organised jointly with ESF; studies, reviews, assessments, strategic activities special provision for research from “near neighbours” countries.

40. 40 Financing meetings. Budget allocation (Management Committee) Meetings of: MC (2 MC member/country), WG1, WG2, WG3, WG4: 1 st and 2 nd quarter (2/year each) Workshops (< 80 participants): years 1 & 3 (balance from the various signatory countries). Telepathology Congress: year 2 Final Conference: year 4 MC should propose a budget allocation The contribution should not exceed € 10,000 for a meeting (if request is up to € 3,000, it will be granted as fixed grant). Printing of proceedings are financed separately from organization costs

41. 41 Meetings: eligible participants Management Committee (MC) Working Groups: a “small”(?) number of researchers (may be MC members or other researchers) selected by the MC. External experts and invited speakers from non-signatory countries: ≤ 5 per meeting non-COST (“Near Neighbours”) country: up to 4. For meeting participants, a distinction is made between participants, eligible participants and persons entitled for reimbursement. The participants are all of the people who attend a COST meeting. Among these participants, a certain number will be selected by the Management Committee from the eligible participants (see 2.1.3 - Eligible Participants) and approved by the MC Chair as entitled for reimbursement.

42. 42 Short Term Scientific Mission (STSM) and training school STMS (young scientists): year 1 and 4 (proposal): Exchange visits (1 wk-3 mo) to an institution or laboratory in another COST member state. The grant should normally cover only travel and subsistence (up to 2500 €) Training School (young researchers and re- training): year 3 (dissemination of results) < 5 days and ≤ 30 attendees Financing meeting (see rules) Travel and subsistence for lecturers (see rules) Fixed grants for attendees (<600 €/attendee. Otherwise the same as for STSMs)

43. 43 Reports and publications Reports: yearly The COST Office is printing general COST publications (annual report, domain flyers, booklets, brochures and posters). Publications: year 2 and year 4 MC will define the contents Options: External Publisher (choose 2 different publishers) OPOCE (The European Union’s publisher)

44. 44 Action Website COST Actions Management Committee (MC) may assign up to 2,000 € per annum from within an Action budget to the MC chair as grant holder for the general support of the Action management: Action Website (specific matters and MC operation), to be hosted on the server of one of the institutions represented on the MC.

45. 45 Action website http://www.conganat.org/eurotelepath/