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PubMed1996

Telepathology diagnosis by means of digital still images: an international validation study.

Telepathology affords the means to provide pathological diagnosis and consultation to remote sites. However, before telepathology can become an acceptable medical tool, it will be vital to determine the diagnostic accuracy of this technology. We report the results of a single-blind study of the accuracy of diagnosis performed using computerized still images obtained from a telepathology workstation used in a French telepathology network. Four pathologists, each working alone, reviewed a total of 200 cases of routine surgical pathology (50 cases each), and performed diagnosis based on both computer CD-ROM still images (CD) and conventional glass slides (GS). Concordance between GS and CD diagnosis, as well as accuracy, were determined. Other factors related to performance were also measured, including diagnostic certainty, reasons for uncertainty, and causes of diagnostic error. Overall, there was good agreement between CS and CD diagnosis. There was 87.5% concordance between CS and CD diagnosis, and comparison to consensus (correct) diagnosis showed accuracy of 95.5% and 88.5% for GS and CD diagnosis, respectively. Marked variability in accuracy of CD diagnosis was observed among the four pathologists, and issues related to image selection and/or quality appeared responsible for 60% of the diagnostic errors. The lack of sufficient images and clinical information were frequently cited as reasons for diagnostic uncertainty, as well as feelings of insufficient expertise. It is likely that the opportunity for interaction with the referring pathologist and the use of subspecialty consultants would likely improve the performance of telepathology.

CD-ROM↗
PubMed2001

Clinical evaluation of an international static image-based telepathology service.

Telepathology is the use of telecommunications technology as a means to facilitate transfer of image-rich pathology data between remote locations for the purposes of diagnosis, education, and research. Although varying levels of technology exist to accomplish this task, static image--based systems are currently the most widely used around the world. Field selection and image quality have often been identified as major impediments to the successful use of static images for diagnostic telepathology. Between November 1994 and July 1999, the Armed Forces Institute of Pathology (AFIP) performed electronic consultation on over 1,250 static image--based cases, recording a clinically significant concordance rate of 97.3% between telepathology and final diagnosis (in cases in which follow-up material was available). For the same subset of cases, an absolute concordance rate of 73.7% was attained. A review of the case flow and construction of the AFIP telepathology system is presented, as well as factors that have an impact on the diagnostic accuracy of static image-based telepathology sytems in general.

Diagnostic Errors↗
PubMed2000

Clinical trial of telepathology as an alternative modality in breast histopathology quality assurance.

Telepathology is a potential alternative to conventional histopathology. A clinical trial using a robotic telepathology system was conducted to assess the clinical and technical utility and effectiveness of telepathology in the U.K. breast screening pathology quality assurance program. Eighty-seven cases of breast disease were chosen at random from a series of 192 cases from the U.K. Breast Screening Pathology National Quality Assurance Scheme (NEQAS) collection. There were 20 benign, 23 carcinoma in situ (CIS), and 44 invasive malignant cases. The diagnostic accuracy of telepathology (TP) compared with conventional light microscopic (LM) diagnosis was 98.8%; this included a single case deferred for LM examination. The figure was similar when compared with expert consensus diagnosis (CD). In invasive tumor typing, TP accuracy was 95.4% (42/44 cases), the difference being attributable to slide color fading and would have had no impact on patient management. The accuracy of TP versus LM and expert consensus in tumor grading was 91.3% for carcinoma in situ (21/23 cases), a discordance with no relevance to patient management. TP grading of invasive tumor compared with LM diagnosis, had an accuracy of 86.4% (38/44) with a clinically significant accuracy of 97.7% (43/44). The time taken for TP diagnosis averaged 3.9 minutes per case by the end of the study. This data demonstrates that telepathology diagnostic accuracy is comparable to conventional microscopy and may therefore be envisaged as an alternative to conventional light microscopy for more rapid proficiency testing in breast screening (and perhaps other) quality assurance schemes.

Biopsy↗
PubMed2000

Telepathology networking in VISN-12 of the Veterans Health Administration.

The Veterans Integrated Service Network (VISN)-12, headquartered in Chicago, has implemented a telepathology network between the eight VISN-12 hospital laboratories and Loyola University Medical School linked by an economical, high-speed wide-area network (WAN). Implementation of the WAN has reduced monthly telecommunications costs in VISN-12 by approximately 67%. In addition to telepathology, the WAN enables real-time teleradiology (general, computer tomography, and ultrasound), telefluoroscopy, telenuclear medicine imaging, telepsychiatry, and other forms of teleconsultation. Current applications of telepathology in VISN-12 include: primary diagnosis and consultation in surgical pathology, interpretation of serum protein electrophoresis and immunofixation gels, provision of support for consolidated microbiology laboratories, review of problematic peripheral blood smears, and distance learning. We have learned a variety of lessons from telepathology. The enthusiasm and technical skill of providers are essential for success. As well, frequent communication and rapid technical support are necessary. Finally, in a supportive environment, telepathology is a tool that can help bring together clinical laboratories with shared missions and goals.

Computer Communication Networks↗
PubMed1995

Case triage model for the practice of telepathology.

OBJECTIVE: To implement and evaluate a practice model for telepathology. METHODS: A case triage practice model was devised in which general pathologists review all cases and refer them to subspecialists only when necessary. In 1993, the Arizona-International Telemedicine Network (AITN), a high-resolution static imaging telepathology diagnostic network, linking six sites to the University of Arizona in Tucson, began testing the model. Work flow through the network was analyzed, and diagnostic concordance was assessed in 150 surgical cases by comparing the diagnoses of the referring (transmitting) pathologists with diagnoses of the consulting (receiving) telepathologists as well as by comparing the referring pathologists' diagnoses with the consensus diagnoses reached by an independent review panel. Data analysis was controlled for subspecialty case type. Telepathologists had access to the referring pathologists' preliminary diagnoses, and the review panel had access to the original glass slides and the surgical pathology reports prior to rendering their respective diagnoses. RESULTS: The triage pathologist completed the telepathology consultation without the assistance of a subspecialty pathologist in 66% of the cases. The review panel examined the original glass slides from 134 cases by light microscopy. Concordance rates of the telepathologists' or review panel's diagnoses with the referring pathologists' diagnoses were not statistically different (93.1% v 83.6%, respectively; P > 0.05). CONCLUSION: The case triage model is suitable for the practice of telepathology. It significantly reduces the need for subspecialty pathologists. Static imaging telepathology is useful and reasonably efficient for rendering diagnostic opinions in the majority of referred cases. Tissue sampling limitations imposed by static imaging occasionally resulted in diagnostic errors.

Adult↗
PubMed2000

Reliability of telepathology for frozen section service.

One of the most promising applications of telepathology (pathology at a distance by electronic transmission of images in pathology) is frozen section diagnosis, especially because by means of this tool operations requiring an intraoperative histopathological diagnosis are feasible at hospitals without a pathologist on-site. For the introduction of this diagnostic tool into pathologist's daily practice the evidence of its diagnostic accuracy comparable to that of the conventional frozen section diagnosis is crucial. For this purpose the literature on the diagnostic accuracy of telepathological frozen section diagnosis was reviewed. In a metaanalysis these studies and reports, in which a total of more than 1290 cases had been examined, showed a slightly lower overall diagnostic accuracy (of the telepathological frozen section diagnosis) of about 0.91 than the conventional frozen section diagnosis with an average accuracy of about 0.98 found in an analysis of several studies (on frozen section diagnosis of different organs). This difference is at least predominantly caused by a higher rate of deferred and false negative frozen section diagnoses in the telepathological method, while the specificity of both methods, each more than 0.99 was not significantly different. In conclusion, the introduction of a telepathological frozen section diagnosis for hospitals without an acceptable access to a pathologist is justifiable already at the current state of the technological development especially when considering the advantages (time saving, reduction in costs) compared to the alternative of surgical interventions without access to an intraoperative diagnosis.

Frozen Sections↗
PubMed2003

A cost comparison of telepathology and a visiting pathologist service.

We compared the costs of a dynamic, robotic telepathology service for intraoperative frozen sections with the cost of a once-weekly visiting pathologist service established between the small Reutte Hospital, located in north-western Tyrol, and the department of pathology of the University of Innsbruck. Telepathology required either 15 min or 30 min per case in order to make a diagnosis, depending on the type of tissue and the operator's experience in handling the telepathology system. Costs were calculated for a five-year period. The main costs of the telepathology service were for set-up, whereas the main costs of the visiting pathologist service concerned personnel. The threshold at which telepathology was cheaper than the visiting pathologist service was 46 cases per month (15 min for diagnosis) or 135 cases per month (30 min for diagnosis). The present case-load (eight cases per month) at the study hospital was below this threshold.

Austria↗
PubMed1998

A pilot study of low-cost dynamic telepathology using the public telephone network.

A pilot trial of a low-cost telepathology system was conducted. A video-codec operating to the CIF standard was used to transmit pictures over the public telephone network. Twenty-seven specimens from the routine pathology workload of a district hospital were examined. The average length of time spent examining each specimen was 14 min (range 2-40). The telepathology diagnoses were judged by conventional light microscopy of the specimens, performed by the same observer at a later date, and by a different observer. For the same observer, 23 diagnoses were correct (85%) by telepathology, three were acceptable (11%) and one was incorrect (4%). The results were slightly worse for a different observer: 21 diagnoses were correct (78%) by telepathology, five diagnoses were acceptable (19%) and one diagnosis was incorrect (4%). The technique was slower than conventional dynamic telepathology (such as that based on communication by ISDN or leased circuits) and picture quality was poor by comparison. However, these are not necessarily disadvantages in the context of the developing world, and since only a telephone connection is required, the technique could become an important method of improving the distribution of scarce resources, such as pathology expertise.

Female↗
PubMed2005

Clinical application of dynamic telepathology in Mohs surgery.

BACKGROUND: Telepathology is an expanding technology in multiple fields for remote pathology diagnosis and consultation. The use of telepathology in Mohs surgery has been very limited. OBJECTIVE: To describe the clinical experience of using a telepathology system for intraoperative consultations on difficult frozen sections during Mohs surgery. MATERIALS AND METHODS: Intraoperative consultation with a dermatopathologist was obtained using a dynamic telepathology system for all questions arising on frozen sections during Mohs surgery for nonmelanoma skin cancers during a 2-year period. RESULTS: The most common reason for consultation was to distinguish basal cell carcinoma from a benign histologic simulant on Mohs frozen sections. Other uses included determining tumor histology and distinguishing inflammation from residual tumor. CONCLUSION: Dynamic telepathology is a useful and convenient adjunct in the Mohs surgery practice for intraoperative consultations on difficult frozen sections.

Basal Cell Carcinoma↗
PubMed1999

Telepathology and pathology at distance: an overview.

Telepathology is probably the latest addition to the world of pathology. The costs of pathologic tests have increased, the requirements for shortened turnaround time are omnipresent and we are all aware of the current litigious environment. Telepathology is one of the answers to at least some of these requests. Here we review the current status of telepathology in the world of telemedicine; compare differences, similarities and applications of static and dynamic telepathology; and give a short introduction to the basic setup of a telepathology laboratory.

Humans↗
PubMed1999

Basic aspects of and recent developments in telepathology in Europe, with specific emphasis on quality assurance.

Telepathology is the diagnostic work of a pathologist from a distance and includes all specific fields of diagnostic pathology, such as frozen section services, expert consultation, cytometric and histometric measurement, and continuous education. For about 15 years experience has been collected at several universities in the United States and Europe based upon analog telephone lines (9.2 kbaud), digitized lines (ISDN, 64 kbaud), broad band connections (1.5 Mbaud) and the World Wide Web (28 kbaud). Potential use can be expected in the application of telepresentation, remote slide preparation, remote central diagnostics and telediscussion. The transfer of still images is well developed; that of live images is used in only a few institutions for frozen section services. The image quality and spatial resolution as well as the transfer speed are sufficient for expert consultations, morphometric measurements, quality assurance and education. All applications focus on discontinuous work flow. Although the European Community focuses on user needs and standardization aspects of telepathology by sponsoring a widespread telepathology project (Europath), implementation of telepathology into routine application in the continuous work flow has still to be developed. The technical equipment has still to be adjusted to the labor flow charts in routine pathologic diagnostic procedures. Telepathology seems to be the appropriate technique to offer both improvement in diagnostic quality and inclusion of the "control institution" into diagnostic responsibility.

Critical Pathways↗
PubMed2002

Optimal imaging in static telepathology.

Telepathology is the most recent addition to the diagnostic armory of the Pathologist. In spite of its relative limitations, as compared to Dynamic Telepathology, Static Telepathology has been widely accepted as a low-cost diagnostic and consultation tool, especially in those remote areas where expert opinions or second opinions on histopathology, cytopathology or haematopathology are not readily available to the reporting pathologist. For an accurate Telepathology performance, optimal quality of images is required. Knowledgeable use of available hardware and software have made it possible to produce high quality images, making Static Telepathology a reliable diagnostic tool.

Computers↗
PubMed2004

New developments in digital pathology: from telepathology to virtual pathology laboratory.

AIMS: To analyse the present status and future development of computerized diagnostic pathology in terms of work-flow integrative telepathology and virtual laboratory. PRESENT STATUS: Telepathology has left its childhood. The technical development of telepathology is mature, in contrast to that of virtual pathology. Two kinds of virtual pathology laboratories are emerging: a) those with distributed pathologists and distributed (>=1) laboratories associated to individual biopsy stations/surgical theatres, and b) distributed pathologists working in a centralized laboratory. Both are under technical development. Telepathology can be used for e-learning and e-training in pathology, as exemplarily demonstrated on Digital Lung Pathology Pathology (www.pathology-online.org). FEATURES OF VIRTUAL PATHOLOGY: A virtual pathology institution (mode a) accepts a complete case with the patient's history, clinical findings, and (pre-selected) images for first diagnosis. The diagnostic responsibility is that of a conventional institution. The internet serves as platform for information transfer, and an open server such as the iPATH (http://telepath.patho.unibas.ch) for coordination and performance of the diagnostic procedure. The size of images has to be limited, and usual different magnifications have to be used. A group of pathologists is "on duty", or selects one member for a predefined duty period. The diagnostic statement of the pathologist(s) on duty is retransmitted to the sender with full responsibility. First experiences of a virtual pathology institution group working with the iPATH server (Dr. L. Banach, Dr. G. Haroske, Dr. I. Hurwitz, Dr. K. Kayser, Dr. K.D. Kunze, Dr. M. Oberholzer,) working with a small hospital of the Salomon islands are promising. A centralized virtual pathology institution (mode b) depends upon the digitalisation of a complete slide, and the transfer of large sized images to different pathologists working in one institution. The technical performance of complete slide digitalisation is still under development and does not completely fulfil the requirements of a conventional pathology institution at present. VIRTUAL PATHOLOGY AND E-LEARNING: At present, e-learning systems are "stand-alone" solutions distributed on CD or via internet. A characteristic example is the Digital Lung Pathology CD (www.pathology-online.org), which includes about 60 different rare and common lung diseases and internet access to scientific library systems (PubMed), distant measurement servers (EuroQuant), or electronic journals (Elec J Pathol Histol). A new and complete data base based upon this CD will combine e-learning and e-teaching with the actual workflow in a virtual pathology institution (mode a). The technological problems are solved and do not depend upon technical constraints such as slide scanning systems. PERSPECTIVES: Telepathology serves as promotor for a new landscape in diagnostic pathology, the so-called virtual pathology institution. Industrial and scientific efforts will probably allow an implementation of this technique within the next two years.

Artificial Intelligence↗
PubMed1995

The validity of intraoperative frozen section diagnosis based on video-microscopy (telepathology).

The validity of intraoperative frozen section diagnosis (IFSD) via telepathology between Hokkaido University School of Medicine (HUSM) and a remote hospital was evaluated. Video-microscopic images of hematoxylin-eosin (HE)-stained frozen sections were transmitted by a cytoscreener via the Pathtran 1,000 system and a telephone line to a color monitor at HUSM (120 km from the submitting hospital) with a resolution of 512 x 480 pixel matrix. The pathologists at HUSM made diagnoses on the received images. Of the 59 cases, there was diagnostic concordance between telepathology and permanent paraffin sections in 19 malignant, 36 benign, and one borderline case. The latter was a case of atypical ductal hyperplasia of the breast. The telepathology diagnostic modality was inconclusive in three cases, two of which were benign and one malignant by paraffin section examination. These results provide evidence for the diagnostic adequacy of video-microscopic images, the interpretation of which compared favorably with that of conventional frozen sections. Although the need for IFSD is increasing, the proportion of hospital pathologists accepting this modality is not. For the appropriate use of telepathology, it is necessary that more pertinent personnel, especially cytoscreeners and pathologists receive a thorough training and become familiar with the system. Telepathology offers pathologists a diagnostic modality that responds to the needs of physicians and serves to enhance the pathologist's position in health care services.

Adult↗
PubMed1997

Telepathologic review: utility, diagnostic accuracy, and interobserver variability on a difficult case consultation service.

The diagnostic accuracy of telepathologic analysis has not been compared to that of conventional light microscopic review on a difficult case consultation service. The anatomic pathology consultation files of the University of Iowa were retrospectively examined, and 105 difficult cases from a variety of organs were chosen for real-time telepathologic and light microscopic review. The telepathologic and light microscopic crude agreement of five pathologists were compared, with use of the original consultation diagnosis as the "gold standard." Cases were scored as correct, partially correct, or incorrect. After making a video diagnosis, the pathologists reported whether they wanted to review the case with use of a light microscope. The pathologists performed significantly better with the light microscope, even after excluding cases in areas of inexpertise (P = .005). The mean percentage of cases that the pathologists wanted to review with the light microscope was 64%, and the major reason for review was diagnostic uncertainty. Cases incorrectly diagnosed with use of the video monitor were almost always requested for review. We conclude that, on a difficult case consultation service, pathologists perform significantly better with use of light microscopic than with telepathologic analysis; rarely make an incorrect diagnosis and do not request that case for light microscopic review; and exhibit high telepathologic diagnostic accuracy in areas of expertise.

Adolescent↗
PubMed1994

Current status of telepathology.

Telepathology is moving from the experimental stage to become a regular feature of pathology practice. This has been made possible by technical advances in telecommunications and image processing. Since 1990 the University Hospital of Tromsø has provided local hospitals in northern Norway with a remote frozen section service and with access to video conferences for the review of microscopic findings and for the discussion of major diagnostic issues. Several other hospitals in Norway are now participating in this development and practical relations among pathology laboratories for the purpose of consultation and education will be the next step in the procedure. Similar developments in telepathology have taken place in other countries. Standardization of network and telepathology workstations will be needed before extensive international collaboration can be achieved. Progress in high quality video devices, high capacity telecommunication lines and improved image compression techniques will increase the usage of telepathology services and make them cost-effective. Thus, telepathology will contribute to the development of pathology services in the next century.

False Negative Reactions↗
PubMed2002

[Frozen section telepathology in the clinical routine of a breast cancer center].

For an intraoperative frozen section service, the period from surgeon's sample excision to the time of transmitting the diagnosis by the pathologist, should not last longer than 20 min. In a period of 16 months we performed 389 frozen sections by telepathology (298 patients) in our breast cancer center, using the Leica telepathology system (TPS 1.5). In 173 out of the 389 sections, an invasive carcinoma was diagnosed (312 frozen sections with the aim to verify malignancy and 77 to verify a tumor-free retroareolar resection margin). The overall error rate amounted to 7 out of 389 sections (about 2%; false-negative in 5 cases, false-positive in 2 cases) and is equivalent to the error rate without telepathology. The mean time for diagnosis per case was 15 min. For the future, it is desirable that hospitals without their own pathologists also perform frozen sections within an adequate time by using telepathology systems.

Biopsy↗
PubMed2004

Diagnostic telepathology: long-term experience of a single institution.

OBJECTIVES: The paper reviews the development of the application of telepathology in a department of surgical pathology between 1991 and 2003. The goal of the efforts during this time was to give up the concept of programming a single application, available only between two fixed workstations with sophisticated devices and special software, and to find the virtual "largest common denominator" for implementing as many different applications as possible with the same basic system. METHODS: A new telepathology system was designed as a client-server system with a relational database at its centre. The clients interact together by transferring the questions (texts and images) to a record (case) in the database on the server and by transferring the answers to the same record on the database. RESULTS: The new "open" telepathology system iPath (http://telepath.patho.unibas.ch) has been very well accepted by many groups around the world. The main application fields are: consultations between pathologists and medical institutions without a pathologist (e.g. for frozen section diagnoses or for surgical diagnoses in hospitals in South Asia or Africa), tumour boards, field studies and distance education (http://teleteach.patho.unibas.ch). CONCLUSIONS: Having observed that with iPath we have succeeded in satisfying all our telepathology needs, we are inclined to put the emphasis on the nature of the tasks being performed, as opposed to the methods or technical means for performing a given task. The three organisation models proposed by Weinstein et al. (2001) can be reduced to only two models: the model of discussion groups and the model of expert groups (virtual institutes).

Global Health↗