Using Digital Pathology in a Multi-Site, Geographically Distributed Integrated Delivery Network

Paul M Urie MD PhD

The Digital Pathology Experience at Intermountain

Healthcare

• Hospitals – 20 in Utah and 1 in Idaho• 13 Urban sites and 8 rural sites• 2,584 licensed beds

• Medical Group - employed physicians• 500 physicians in 150 clinics

• Affiliated Physicians – 2,800 physicians

• SelectHealth – 390,000 insured members

• Highly integrated Information systems and data network

Intermountain Healthcare Profile

Intermountain Healthcare Hospitalsin the State of Utah

Alta ViewAmerican ForkBear RiverDelta CommunityDixie RegionalFillmore CommunityGarfield MemorialHeber ValleyIntermountain Medical Center

LDS HospitalLogan RegionalMcKay-Dee HospitalOrem CommunityTOSHPrimary Children’sSanpete ValleySevier ValleyUtah Valley RegionalValley View

• Urban North – Cassia, Logan, McKay-Dee• 5 pathologists, 22,000 surgical cases

• Urban Central – LDS, IMC, Alta View, PCMC• 23 pathologists, 52,000 surgical cases,

molecular pathology and flow cytometry

• Central clinical laboratory

• Urban South – UVRMC, AFH, OCH, Rurals• 5 pathologists, 22,000 surgical cases

• Southwest – Dixie and Valley View• 5 pathologists, 16,000 surgical cases

Pathologist Distribution and Volumes

Pathology Service Problems

• Cases reviewed by the sub-specialty trained pathologists – consultations

• Peer reviews for quality assurance

• Frozen section interpretations at remote locations

• Tumor board and conference presentations

• Review of immunohistochemistry slides from the central lab

• Image analysis to quantify IHC slides

Digital Pathology Test Hypotheses

• Pathology presentations at Tumor boards and other conferences

• Frozen section consultations

• Remote interpretation of immunohistochemistry slides performed at the central lab

• Remote consultations by pathologists within Intermountain Healthcare

• Remote consultations by Stanford Surgical Pathology Consultants

• Impact on IT resources and network

Digital Pathology Pilot Project at Intermountain Healthcare

• Aperio ScanScopes and Spectrum software

• Duration of 90 days

• IMC Central lab – ScanScope XT and satellite server

• AFH – ScanScope CS and satellite server

• Dixie – ScanScope CS and satellite server

• Lake Park Data Center – Spectrum Server

• WAN with 100 MB links

• 4 pathologists – sponsor and study directors

• 11 participating pathologists

• Approximately 12 Intermountain support personnel

• Standard questionnaires – quantitative ratings and comments• Pathologists• Tumor conference participants• Support personnel

• Quantitative timings of functions

• IT monitors of network usage

Digital Pathology Pilot Project at Intermountain Healthcare Data

Collection

Digital Pathology Project Pilot Sites

Intermountain Medical Center

American Fork

Dixie Regional

Findings of the pilot: Overview

• Tumor conferences – overwhelmingly positive results in three sites

• Frozen sections – 6 pathologists, 127 cases and 2 sites demonstrated 97-100% concordance with glass slides

• Remote interpretation of IHC slides – excellent scans with at least 24 hr improvement in turnaround time

• Remote consultations – inadequate testing with mixed results though interest remains high

Digital pathology can solve or at least ameliorate some distance-related problems in a

geographically distributed health care system

Tumor Conference: More Efficient Preparation Process

• “This is 2 to 3 times as fast”

• “Time savings of at least 50%...”

• “This is so much easier…there was less stress, it took less time, got me out of the zoo of taking photos”

Pathologst Preparation Time Saved Per Week (# of minutes)

0

3060

90

120

1 2 3 4 5 6 7 8 9

Week of Pilot

Average time saved = 65 minutes/week(preparation for one tumor conference)

Tumor Conference: Better Preparation Process

• “The tech scans the slides freeing me up to do other tasks”

• “I can pre-select the areas of highest interest”

• “I liked that the label was scanned and I could double-check to make sure it’s the right patient”

Pathologist Satisfaction with DP for Preparation - Frequency Distribution of

Ratings (1 = worst, 5 = best)

0 01

2

6

1 2 3 4 5

Tumor Conference: A Better Presentation

• “The low power images are as good as the microscope”

• “I like being able to put up the H&E and the immuno right next to each other”

• “It conveyed more information to clinicians”

• “You can show relationships that are hard to show with only a single picture”

Pathologists' Rating of Image Quality

(1 = worst, 5 = best)

1

2

3

4

5

HighPower

LowPower

Camera

DigitalSlide

Tumor Conference: Overall Comments

• “This is a superior way of presenting a case”

• “It was like going down to pathology to look at slides with the pathologist”—Radiation Oncologist

• “This would enable system-wide conferences”

• “Dr. X, though initially slow to put his trust in the technology, now seems to prefer it”

• “It would be nice to have the same level of technology as the radiologists”

Frozen Sections: Overall

• 2 studies, 2 sites, 6 pathologists, 127 cases

• Overall conclusions by study directors:• “I would be comfortable making a frozen

section diagnosis on a digital slide”• “With the appropriate technical support

and experience, use of the Aperio digital slides can effectively be used for nearly all frozen sections…”

• 97-100% concordance rate, no major discrepancies

Frozen Sections: Learning Curve

• “The diagnosis and scanning times got better as we got more practice”

• “It took a little longer to view a digital image, but if you factor in the time to drive to American Fork, it saves time”

Incremental Time to Diagnosis Using Digital Slides (minutes)

-5

0

5

10

15

Frozen Sections: Comments

• “This could improve patient care because you can get consultants to look at a frozen”

• “Frozens are of great interest to me because I’m the only one here”

• “A slightly higher deferral rate can be expected”

• The possible issues include: • Added time involved

in scanning slides• Trust in non-

pathologist to select and prepare sections

• Technical scanning problems, even minor ones, in this time-sensitive setting

Remote Viewing of Immunos, Special Stains: Promising but Not Fully Tested

Image Quality

• Both low and high power image quality rated 4.7 on scale of 1-5

• “The digital slide was an accurate representation”

• “I could do any regular immuno…more limited for a few microorganisms”

• “The quality of the scans was excellent”

Turnaround Time• “This did speed up the

case”• “This would save at

least a day”• “A day early would be

great. It would be huge over the weekend”

• “This would take the wildcard of the courier out”

Remote Second Opinions: Inadequate Testing but Interest Remains High

• A few consultations requested from Stanford• Some consultants enthusiastic, others not• In one case “it worked the way it was supposed

to”…they called right back, suggested some immunos. We did those and scanned them and kept the billing inside”

• Remote consultations within Intermountain did not take off, though “despite these failures, they may be beneficial in certain circumstances”

• “I would use this quite a bit”

Network Architecture

• Slides scannedand stored locally

• Slides viewed fromanywhere on the network

UID

NIC2NIC1

ILO2

American Fork

IMC

Dixie

Image Pointersstored on

centraldatabase

(not images)

IT Concerns and Solutions

IT Concern Solution

“Moving images will impact the network”

Meta-data only is moved across the WAN. Images viewed remotely using pixel-on demand (40 Kb/sec).

No negative impact was seen

“Can you guarantee patient confidentiality outside IHC?”

Authentication for pre-approved users only. Pre-pilot agreement on approach to scrub patient data at conclusion

“How do we support a project we don’t understand?”

Pre-pilot discussions, regular communications while live

“Equipment arrives and never goes away”

Project scope clearly defined

General Issues / Considerations

One-time/Pilot Issue

Ongoing Issue

Pre-Installation / Installation Issues

•Time-consuming to agree upon project scope, define network architecture

Training Issues

•Difficult to engage participants for a time-limited event

•Time-consuming to learn new application, come up the learning curve

Usage Issues

•Access to outside consultants

•Hard to scan difficult slides (poorly-cut, frozens, etc.)

•Availability of skilled staff to choose tissue and cut slides for frozens

•Server access

•Scanner noise

Conclusions

• Tumor conferences – overwhelming positive results

• Frozen sections – 97-100% concordance with glass slides

• Remote interpretation of IHC slides – excellent scans with at least 24 hr improvement in turnaround time

• Remote consultations – inadequate testing with mixed results though interest remains high

Primary conclusion: digital pathology can solve or at least ameliorate some distance related problems in a geographically distributed health care system

• Generous and extraordinary support from Aperio

• Intermountain pathology staff and IT department staff

• Intermountain affiliated pathologists

AcknowledgementIntermountain Healthcare Digital Pathology

Experience