Telepathology and The Future of Pathology (or Why did we change our Practice Model) Jagdish Butany,...
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Telepathology and The Future of Pathology (or Why did we change our Practice Model) Jagdish Butany, MBBS, MS, FRCPC Consultant Cardiovascular Pathologist/Director Autopsy Services Co-Editor-in-Chief, Cardiovascular Pathology Professor, University of Toronto &Dir.Divn.of Pathology ,Dept. of Laboratory Medicine and Pathobiology, Sectty/treasurer WASPaLM(2009--) University Health Network / Laboratory Medicine Program Toronto General Hospital , 200 Elizabeth Street, E11-444 Toronto, Ontario M5G 2C4,Canada. Tel: 416-340-3003 Fax: 416-586-9901 e-mail: [email protected] 2 Feb 2011, Birmingham, UK. HAVE NO CONFLICT OF INTEREST WITH ANY Equipment/Supplier!
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Transcript of Telepathology and The Future of Pathology (or Why did we change our Practice Model) Jagdish Butany,...
Telepathologyand
The Future of Pathology(or Why did we change our Practice Model)
Jagdish Butany, MBBS, MS, FRCPC
Consultant Cardiovascular Pathologist/Director Autopsy Services Co-Editor-in-Chief, Cardiovascular Pathology
Professor, University of Toronto &Dir.Divn.of Pathology ,Dept. of Laboratory Medicine and Pathobiology, Sectty/treasurer WASPaLM(2009--)
University Health Network / Laboratory Medicine Program Toronto General Hospital , 200 Elizabeth Street, E11-444
Toronto, Ontario M5G 2C4,Canada. Tel: 416-340-3003 Fax: 416-586-9901 e-mail: [email protected]
2 Feb 2011, Birmingham, UK.
I HAVE NO CONFLICT OF INTEREST WITH ANY Equipment/Supplier!
(a)Why did we implement telepathology (WSI) at UHN?
Imagine
1.Cover 3 sites2.No new staff available3.Increasing workload
• TGH, PMH, TWH
• No on-site TWH pathologist
• 2-10 frozen sections
per week (mostly
neurosurgery)
• Sept. 2004 – no NP
University Health Network
~ 1 mile
X
X
X
UHN
IMAGINE 2!
Research
S S
S
S= Service
UHN
IMAGINE3: 3 Departments of Pathology! # Q S Sites
Medical Laboratories
The Perfect Storm---!
Right Circumstances
Right Leadership Right Tools!! Available!
Problem!!
TWH Frozen Sections: The Problems to Be Solved
• Single pathologist traveling to TWH– Inefficient process - traveling time and waiting
– Disruptive to regular workflow – 99% of departmental activity occurs at TGH
• delays in regular sign-out affecting other UHN patients
– No possibility for consultation on difficult cases – possibly affecting TWH surgical patients.
• Compromised diagnostic accuracy• Unnecessary deferred diagnoses
The Robotic System: November 2004-October 2006
• 350 frozen sections
• accurate
• deferral rate < 10%
• slow (~ 10 minutes/slide)
Toronto GeneralTelepathology Work Station(not a pathologist’s office)
Toronto Western
The Robotic System
Whole-Slide Imaging: October 2006-Present
• > 1800 frozen sections/1500 patients
• 90% from neurosurgery
• 98.5-100% accuracy (month to month)
• 14-16 minute turnaround time
• 5% deferral rate
- 2 pathologists review all deferrals
Telepathology Was A Viable Solution
• > 90% of the cases are single block• Surgeons select the tissue of interest
– no need for gross assessment by pathologist– surgeon-defined margins – submit in toto for frozen section/smear
• Robotic microscopy (2004-2006)– most intense development and validation
• Transition to WSI (late 2006- present)
• Easy consultation with colleagues – better for patient care
• WSI had essentially no learning curve (compared to robotic microscope)
Whole-Slide Imaging: Architecture
This was TGH/UHN
Pathology 2000-2010Pathology 2000-2010
Future of Pathology
Frontiers in Laboratory Medicine
Feb 1-2, 2011, Birmingham UK.
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• Volume – aging population – higher sensitivity for early disease
• Demand– Sophisticated knowledgeable population– Culture of “instant gratification”
• New technologies– genomics– proteomics– informatics– robotics ‘tissue soup’ instead of tissue
Challenges for 2020Challenges for 2020
MONEY??
The Challenge for 2020 The Challenge for 2020
• Faster• Better
– Higher quality– Personalized
• Cheaper
• Innovative
The New Paradigm: The New Paradigm: FasterFaster
• Pathology must be faster
– “Same Day” diagnosis
– Automation
– 24/7 labs
FasterFaster
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The New Paradigm: FasterThe New Paradigm: Faster
• Speech-recognition integrated with LIS
means instant reporting without
the need for dictatyping
CHEAPER
Technologic Advances: “omics”Technologic Advances: “omics”
HT-SequencingDNA
MicroarrayExpressionProfiling
RNA
Mass SpectrometryProtein
Metabolomics
What is “Correct”?• Objective classification by
– mRNA expression– DNA sequencing– Response to therapy
The New Paradigm: BetterThe New Paradigm: Better
• Synoptic Reporting– Complete
• Standardized formats (CAP checklists)
– Adaptable and flexible• No more verbose reports that no one reads!
– Database technology• Statistics collection• Administrative tracking• QA monitoring• Academic data mining
The New Paradigm: BetterThe New Paradigm: Better
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The New Paradigm: BetterThe New Paradigm: Better(A Bit Controversial-(A Bit Controversial-still !!still !!))
Subspecialty Pathology– All cases reported by a pathologist with
expertise in the specific subspecialty required– Benefits:
• Better quality and faster patient care• Fiscal responsibility: 1 pathologist per case• Pathologist satisfaction – enhanced academic
excellence
– Challenges:• Requirement for appropriate staffing
in all areas and Built in redundancy
Requirements for Full Adoption Requirements for Full Adoption • Workflow integration
– From the lab to the pathologist
• LIS integration– Barcodes– Slide tracking and retrieval
CHEAPER
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Digital Pathology EnablesDigital Pathology Enables• Remote access
• Multiple viewers
• Immediate access to the right pathologist at the right time
BETTER
Computer-Assisted DiagnosticsComputer-Assisted Diagnostics• Automated analysis of:
– Measurement– Mitoses– Ki67 LI – Other IHC
• intensity• distribution
– Her2 FISH– Hematology
• Cellavision
– More?
• QA of technical quality– Section thickness– Stain quality
? Need for Westgard rules in AP?
Epigenetic Control: Epigenetic Control: Can it Override the Genotype?Can it Override the Genotype?
N Engl J Med. 2007 Feb 15;356(7):731-3
What Is Anatomical Pathology?What Is Anatomical Pathology?• Integrative
morphology based interpretation
• Consultant’s ReportGross Morphology
Chemistry on a glass slide
Immunoassay on a glass slide
The Virtual AutopsyThe Virtual Autopsy
After “The Anatomy Lecture of Dr. Nicolaes Tulp” – Rembrandt, 1632(Courtesy of Dr. Carlos Cordón, New York, USA)
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• Patient-Centred Care
• Individualized diagnostics
• Targeted therapies
All based on “omics”
Will “omics” replace pathology?
The New Paradigm: PersonalizedThe New Paradigm: Personalized
The Future of Pathology?The Future of Pathology?
$15.00 each $1000.00 each$15.00 each $1000.00 each
2020 Pathology2020 PathologyDigital radiology
Digital cardiology
Digital genetics
Biomarkers & CAD
ClinicalPathology
Gross Pathology
History, Physical,Family History
Digital EMR
QA
Labs/
Pathology:
the center
of
Personalized
Medicine !!Endoscopy
• Comprehensive & Integrated Pathology reports– Incorporation and integration of radiologic,
biochemical, morphologic , molecular, cytogenetic and epigenetic data
The 2020 ParadigmThe 2020 Paradigm
The Pathologist’s Cockpit
Gross Pathology
BiomarkersRadiology
Biochemistry
MolecularPathology
Histopathology
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• To provide the right diagnosis
• To provide the right material
• To provide the right leads
• To provide the right experiments
• To evaluate the consequences of genetic manipulation
• To PROVIDE An INTELLIGIBLE, COMPREHENSIVE REPORT!!
The Expanding Role of Lab MedicineThe Expanding Role of Lab Medicine
2020 2020
2020 2020 THE THE Pathologist !!Pathologist !!
The Pathologist and the Patient!!
2020 2020 PathologistPathologist
Pathologist and Patient!“The Diagnosis is----, and the prognosis is----.”
“AS IS YOUR PATHOLOGYSO IS YOUR MEDICINE.”
Sir William OslerMcGill Univ, Hopkins, London (UK)
IMAGINE!!
X
X
XX
KuwaitX
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The Future of PathologyThe Future of Pathology
The best way to predict the future is to invent it
Alan Kay
