Robert J. Corona DO, FCAP
Assistant Professor, Pathology
Director, Medical Informatics and Telemedicine
SUNY Health Science Center, Syracuse, NY

Bob Corona is Assistant Professor of Pathology and Director of Medical Informatics and Telemedicine. Contact him at: 315/464-7144; Email: coronar@vax.cs.hscsyr.edu

Two years ago, one of our affiliated teaching hospitals (Wilson Memorial, Binghamton, N.Y.) requested neuropathology services to support their team of neurosurgeons and neuroradiologists. We explored almost every commercial telepathology system available at the time. It was a confusing maze of new acronyms and new technologies. We settled on a room video teleconferencing (VTC) system provided through the kind loan of a VTEL system from Peirce-Phelps. Since then we have been using a loaned CLI room system. We attached a standard CCD NTSC composite video camera to the CODEC- based VTC system. Although it was an Aoff the shelf @ system, we found the resolution to be adequate for neuropathology applications including intraoperative frozen section consultations. Because of our interest in improving the quality of our system, we began to develop what we call the Prototype Pathology Information Infrastructure (PPII). More on this later.

In the meantime, the rest of SUNY HSC’s campus was moving in parallel with other telemedicine applications, and CareNet was established. CareNet is SUNY HSC’s new program in Medical Informatics and Telemedicine. We continue to provide neuropathology consultations and have recently added hematopathology, microbiology, and cytology services, as well as weekly interactive surgical pathology and neuropathology conferences.

To date, the SUNY/Syracuse telepathology system has been used for about a dozen diagnostic reads, and for another 15 or so second opinions. These are mostly in neuropathology and hematopathology. The difficult cases from Binghamton are now reviewed weekly with the residents and faculty at both sites.

Standards

The general issues of telemedicine such as interstate licensing (see Cross-State Licensure Issues, this issue), reimbursement, liability, security, standards and interoperability apply to telepathology as well. Other issues that are more specific to telepathology include image resolution, sequence selection, and annotation; compression variability; data/image archive and retrieval; and image analysis and image processing. General agreement exists that new telepathology systems need to be based on leading video teleconferencing technologies. The systems also need to adhere to the Digital Imaging and Communications in Medicine (DICOM) standards to be set by the CAP Image Exchange Committee. This committee is working closely with the American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA) to establish standards for pathology.

EQUIPMENT

In pathology, the light microscope provides an enormous amount of visual information. A pathology slide may have thousands of visual fields available for viewing. A series of the image fields used for diagnosis could result in files that exceed gigabits of information per glass slide. This amount of uncompressed information requires massive bandwidth to prevent unbearable delays during a real time consultation.

We have concentrated on two major communications technologies at SUNY HSC to transmit our pathology images: (1) Basic rate integrated services digital network (ISDN) operating with a total bandwidth of 128 kbps, and (2) asynchronous transfer mode (ATM) operating at 155Mbps. Without image compression, the obvious choice for telepathology applications is ATM. Unfortunately, it is too expensive for most users. ATM certainly has a future in our program but our objective is to do diagnostic quality telepathology over ISDN via a desktop computer. We presently use a Pentium-based system from Radiology Telenetwork Inc., which uses Intel’s ProShare VTC product. Our dynamic system consists of a SUN workstation and a Silicon Graphics workstation connected to the ATM backbone (NYNET) in upstate New York. High definition television (HDTV) displays are part of the systems to be connected via our ATM link. We are evaluating and developing both systems and looking closely at JPEG and wavelet compression to help us to do dynamic telepathology over basic rate ISDN. Our double blind study of compressed images using JPEG, wavelet, or a combination of both technologies suggests that wavelet compression is more suitable.

Future

Our future focuses on the merging of Laboratory Informatics systems with the communications technologies of telepathology. We continue to further refine our Prototype Pathology Information Infrastructure (PPII) with our other CareNet partners. The goal of PPII is to link leading-edge health care centers, high performance computing and communications centers, industry and government/military HPCC centers. This will build on the concept of multi-use National Information Infrastructure (NII) services. The PPII project will develop applications which are where possible, compatible with other NII areas such as education and information dissemination. This project also addresses a central health care problem with open scaleable technologies that reduce the costs of practicing pathology.

We also have proposed to build a Center for Informatics and Telemedicine Education (CITE). This center will allow us to educate tomorrow’s health care providers by providing them with the necessary tools to navigate through the maze of information available in practice of modern medicine. It will also be a center for research, providing an environment where medical students and faculty of all levels of technical literacy can work with emerging technologies in health care. SUNY HSC also is working with the New York State Board for Medicine, private industry, legal experts and the military to attempt to solve the problems of telemedicine including interstate licensing, reimbursement and liability issues.