1. Robotic Telepathology: Practical Applications Bruce E. Dunn, M.D. Chief Pathologist, Veterans Integrated Service Network (VISN) 12 Professor and Vice-Chair, Dept of Pathology, Medical College of Wisconsin

2. Conflict-of-interest statement Bruce E. Dunn, MD has no financial interest in any commercially-available telepathology system

3. 21 Veterans Integrated Service Networks (VISNs)

4. Hospitals and CBOCs in VISN 12

5. Robotic Telepathology (TP) at Iron Mtn Iron Mountain is an active, rural DVA hospital with a general surgery program –1000 - 1500 surgical pathology cases per year –Occasional frozen sections requested 1996: part-time Iron Mountain pathologist retired Full implementation of commercial hybrid dynamic store/forward system operated by two senior pathologists in Milwaukee Feasibility study performed - published in 1997

6. Three Phases of Robotic TP at Iron Mtn Phase I: mid-1996 – early 1999 –Two senior surgical pathologists exclusively read cases with extensive documentation –2,200 cases available for TP –Summary published in 1999 Phase II: early 1999 – end of 2004 –One senior pathologist retired; three junior pathologists hired –Consolidation in VISN resulted in increased AP workload –5,841 cases available for TP Phase III: 2005 – present (through July 2006) –One original senior pathologist and two new pathologists –ASAP Imaging TM implemented –2,015 cases available for TP through July 2006

7. Objectives Compare rates of case deferral and major TP discordance with light microscopy (LM) among seven pathologists during three phases of robotic telepathology Compare rates of major discordance before and after implementing the ASAP Imaging TM system

8. Summary of Cases (1999) Organ/systemPercent of total Gastrointestinal42.9 Skin27.5 Prostate10.2 Hernia sac 3.8 Urinary bladder 2.6 Bone/synovium/tendon 2.1 Penis/testis/spermatic cord 1.9 Gallbladder 1.3 Extremity amputation 1.1 Appendix 0.5 Gynecologic 0.5 Breast 0.3 Miscellaneous 5.2

9. Technical Aspects of Workflow Tissue grossed in Iron Mtn by experienced PA (tele-gross imaging available) Slides processed by Iron Mtn histotechnician Telepathology systems “linked up” PA places slides onto stage in Iron Mtn Pathologist controls robotic microscope remotely from Milwaukee

10. Current and Future

14. Robotic Microscopy Commercial hybrid dynamic store/forward system Olympus microscope with motorized stage, objectives, lighting control CODEC used for gross & microscopic imaging and videoconferencing 4x,10x, 20x 40x 100 (oil free) objectives Dynamic imaging: 350 x 288 x 24-bit color Static imaging: 1520 x 1144 x 24-bit color Images transmitted at 768 kbps over WAN 2005: ASAP Imaging TM enables remote access with live streaming imaging

15. VISN 12 Telepathology Network Hines Madison Tomah North Chicago Westside Milw Iron Mtn VHA WAN Internet VHA WAN Internet DR GS RM DR GS NRM GS NRM KEY POP – point of presence VistA – VA computerized patient record system WAN POP Multi-site conferencing DR POP Dedicated Server Tomah Madison Hines Micro Iron Mtn Milwaukee N. Chicago Chicago Interface to HIS

16. Current and Future

17. Methods Each of 7 pathologists read cases by TP, completed reports where appropriate, then read same cases by LM Over 50% of cases read by second pathologist by LM Revised reports generated based on LM diagnosis, if necessary, and clinician notified Reasons for case deferral to LM documented Pathologist-specific rates of deferral and discordance determined Notes: –TURP and bone marrow cases deferred automatically –Gastric biopsies reviewed for H. pylori-like organisms by PA in Iron Mtn by LM

18. Current and Future Non-Robotic Telepathology System

19. Deferral to Light Microscopy Reasons for deferral: case difficulty, need for consultation, special or immuno stains, “short staffing” If case referred to Milwaukee due to computer unavailability (malfunction or upgrade), or the assigned pathologist was not yet competent to use telepathology, then case not counted as a deferral

20. Discordance Rates by Pathologist Deferred cases not included Major discordance –Benign versus malignant –Different patient outcome or therapy Report modified and clinician called

21. Phase I Individual Summaries Pathologist A BTotal Total opportunities 1121 10792200 No. deferred 34 22 56 Deferral rate (%) 3.0 2.0 2.5 TP cases 1087 10572144 Maj discord 5 2 7 Discordance (%) 0.46 0.19 0.33

22. Phase II Individual Summaries Pathologist B C D E Total Total opportunities223115821031 997 5841 No. deferred 319 290 270 326 1205 Defer rate (%) 14.3 18.3 26.232.7 20.6 TP cases19121292 761 671 4636 Maj discord 7 5 8 1 21 Discordance (%) 0.37 0.39 1.050.15 0.45

23. Phase III Individual Summaries (ASAP) (July 2006) Pathologist B D E F GTotal Total opportunities 795 17185683 3352015 No. deferred 40 0 12 78 65 195 Deferral rate (%) 5.0 06.5 11.419.4 9.7 TP cases 755 17 173 605 2701820 Maj discord 1 0 0 2 1 4 Discordance (%) 0.13 0 0 0.330.370.22

24. Comparison by Phase (July 2006) Phase I II III Total Total opportunities 2,200 5,841 2,015 10,056 No. deferred 56 1,205 195 1,456 Deferral rate (%) 2.5 20.69.7 14.5 TP cases 2,144 4,636 1,820 8,600 Maj discord 7 21 4 32 Discordance (%) 0.33 0.45 0.22 0.37

25. Pathologist B: Major concordance rate (N=3,724) (July 2006)

26. Pathologist-Specific Discordance Rates

27. Major Discordance Rate by Technology (July 2006) Pathologist TechnologyB E All Pre-ASAP 0.30 0.15 0.41* ASAP 0.130 0.22 *0.33 excluding pathologist D

28. Summary Pathologist-specific discordance rates ranged from 0.12% to 1.03%, with median of 0.37% and overall rate of 0.37% Despite extensive experience of one senior pathologist, occasional discordances continue to occur The rates of discordance using ASAP Imaging TM are lower that those observed previously All TP cases continue to be reviewed by LM

29. References Dunn, B.E., U.A. Almagro, H. Choi, N.K. Sheth, J.S. Arnold, D.L.Recla, E.A. Krupinski, A.R. Graham and R.S. Weinstein. 1997. Dynamic- robotic telepathology: Department of Veterans Affairs feasibility study. Human Pathol. 28:8-1. Dunn, B.E., H. Choi, U.A. Almagro, D.L. Recla, and R.S. Weinstein. 1999. Routine surgical telepathology in the Department of Veterans Affairs: Experience-related improvements in pathologist performance in 2200 cases. Telemed J. 5:323-337.