J. Nine1, E. Schubert¹, C. Richert¹, B. Sholehvar¹, K. Horn¹, J. Gilbertson¹,
P. Dickman², F. He1, B.J. Moner³, C. Hatton¹, C. DiGiorgio¹, B. Gross1, F.
Wimberly⁴, P. Mango³ and M. Becich<sup>1

1</sup>Department of Pathology, University of Pittsburgh Medical Center
²Children's Hospital of Pittsburgh
³Reference Laboratory Alliance
⁴Pittsburgh Supercomputing, Pittsburgh, PA.

Address correspondence to: Michael J. Becich, M.D., Ph.D.

Department of Pathology - Room A610.2, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213. Telephone: (412) 647-6600 e-mail: becich+@pitt.edu FAX: (412) 647-6251

Our correspondent is Dr. Mike Becich, Assistant Professor of Medicine in the Department of Pathology, Division of Anatomic Pathology. Meet Mike at his home page, http://path.upmc.edu/people/faculty/becich.html

The U. of Pitt system is in a pilot phase, and had seen no official telepathology consults at the time of this report. The first phase of the project involves two remote sites, Brookville Memorial Hospital in Brookville, PA (dynamic and static imaging site) and Timken Memorial Hospital in Canton, OH (static imaging site). A pilot study will be done comparing telepathology to mailed slides.

Background

The first interactive telemedicine system was introduced in 1968 using transmission of black and white images via microwave telecommunication from Logan Airport in Boston to the Massachusetts General Hospital (1). Later, in 1986, Corabi International Telemetrics , Inc. introduced the first color robotic video/microscope system in conjunction with Rush Medical College in Chicago, Fort William Beaumont Army Medical Center in El Paso, Texas and the United States Surgeon General's Office in Washington, D.C. (2). Since then, centers throughout the United States and Europe have developed telepathology initiatives, with operative programs in place in some institutions. Telepathology is currently active in daily practice at sites such as the Mayo Clinics in Arizona, Minnesota and Florida (3), the Arizona-International Telemedicine Network (AITN) (4), Emory University in Atlanta (5), the Armed Forces Institute of Pathology (AFIP) (6) and in Europe at the University of Stuttgart (7) and in northern Norway (8), among others.

Perspective

As noted in Philip Seykora’s review in this issue, telepathology consultations can exist in two forms, static and dynamic. In static telepathology, digital images are electronically transmitted from a pathologist at an outlying hospital, usually via modem, or through an Internet connection, to the consultant. The consult pathologist reviews the images, renders his opinion, and transmits the results to the consultee. Static telepathology systems are in use in North Carolina at the University of Chapel Hill (9) and in Switzerland (10), among others. The second form of telepathology is a dynamic interaction between the referring pathologist and the consultant. This can be accomplished through videoconferencing, usually in concert with a remote control microscopic image station, with digital display monitors at both institutions. The referring institution places the slides on the stage, and the consultant controls the microscope remotely through an input device. Both pathologists can converse via videoconferencing or simple telephone connections. This method allows direct interaction and immediate feedback between referring pathologist and consultant, permits the consultant pathologist to query his colleagues on the case, and provides the opportunity for the referring physician to receive the opinions of multiple consultants from different sites at one time. In some instances, the referring institution houses a microscope that can be remotely controlled by the consultant without direct interaction with a referring pathologist. Dynamic telepathology was first deployed in 1968. Subsequently, a few telepathology networks have been formed at the Mayo Clinics (3), and in Arizona (2-4), Norway (8) and Germany (7) among others.

The University of Pittsburgh Program

At the University of Pittsburgh Medical Center (UPMC), we are piloting a community telepathology network in western Pennsylvania and eastern Ohio. This project started approximately four years ago with the implementation of a pathology digital image database (Figure 1) program at the UPMC. Currently, we have a large, active digital image archiving system, with three gross pathology image capture stations (Figure 2), ten microscopic capture stations (Figure 3), and twenty-four digital display stations (Figure 4) situated throughout the medical center. Most gross surgical specimens, when accessioned, are digitally captured and archived in bitmap format on a centralized image file server (a RAID 5 storage device), currently with 24 Gigabytes of storage space, that houses approximately 10,000 digital images. Microscopic images of selected complex or interesting cases are then digitized and stored on the same server. This digital image project strategically coincided with the development of the World Wide Web (WWW), and the introduction of the National Center for Supercomputing Applications' (NCSA) Mosaic program. Thus, we embarked upon the development of a Web site designed to distribute this wealth of information to the pathology sector. To accomplish this, we used a Pentium-based (Intel Corporation, Santa Clara, CA) computer running a Linux operating system (Linux System Labs, Chesterfield, MI). Currently, we have developed an active departmental Web site (Figure 5) with over 370,000 accessions from over 12,000 machines around the world. This site provides a large amount of educational material presented in the form of abstracts and poster exhibits, as well as pathology case studies (Figure 6) within a searchable image database. We are currently developing material for continuing medical education (CME) credit (Figure 7). In addition, the complete consultation brochure (Figure 8) for anatomic and clinical pathology, as well as intra-departmental conference schedules and newsletters, is included at this site.

In mid-1994, a regional reference laboratory known as the Reference Laboratory Alliance (RLA) (Figure 9) was formed. The participating community hospitals can receive rapid clinical laboratory results through modem and/or Internet connections with our centralized laboratory information system.

More significantly, through the use of our departmental Web page, referring pathologists will soon be able to retrieve image-based surgical pathology reports through our On-Line Reporting System (Figure 10). This provides the referring pathologists with an enhanced, hypertext markup language (HTML) scripted, image based report (Figure 11) that includes key diagnostic gross and microscopic images, as well as images from any ancillary studies (electron microscopy, flow cytometry, etc.) that may have been done. The reports include e-mail addresses of the consult pathologist at the RLA (Figure 12), so the community physician can provide instant feedback or submit questions regarding the case. These methods of receiving clinical laboratory data or image-based surgical reports through the Internet, using our WWW site, we refer to as telereporting.

Future plans at the UPMC include the advent of telereporting and the development of telepathology consultation systems for Hematopathology and Genitourinary pathology at two sites in the area. An additional four sites are scheduled for full telepathology access in the near future. These projects will include an initial evaluation process whereby one to two hundred consult cases will be reviewed simultaneously through both telepathology and traditional consult methods. Problems that need to be addressed include the issues of security and access/logon procedures, a continuing topic with all long distance computer transactions.

Conclusion

The advent of image based telereporting leads to a number of desirable results:

• It provides a clearer picture of the pathologist's findings, such as tumor size, grade, relationship to resection margins, etc., and so improves patient care.
• It enhances the ability to confer, educate and communicate with referring physicians, which in turn provides a better service and increases the consultation base.
• The installation of user friendly, Internet based telepathology capabilities fosters a sense of acceptance of high technology communication systems among community pathologists.
• The use of an HTML based telepathology system introduces the exploration of HTML as a viable new standard for medical record keeping, with the integration of images from other interpretive fields (radiology, gastroenterology, cardiology, etc.).

In summary, an important benefit of both telereporting and telepathology is education. The direct interaction between referring physician and consultant provides an educational aspect never before achievable, with the patient as the end beneficiary. Equally important is the decreased expense and time investment of the telepathology procedure. Traditionally, consultations could take a week or more for reports to be received, and the accompanying professional charges could be substantial. Couple this with the many instances when consult slides are lost, broken, or not returned, and the benefits of telepathology become apparent. The cost for the telepathology system can be justified by making the integrated workstation not only useful for static/dynamic telepathology but also for education (CME creditable case material) and Internet connectivity. This helps to overall decrease the costs incurred by the rural pathologist or hospital administrator, since the equipment is not dedicated to just one activity.

References

1. Weinstein RS (editorial). Telepathology comes of age in Norway. Human Pathology, 22:511-13, 1991.
2. Weinstein RS, Bloom KJ, Rozek S. Telepathology and the networking of pathology diagnostic services. Arch Pathol Lab Med 111:646-652, 1987.
3. Krupinski EA, Weinstein RS, Bloom KJ, Rozek SL. Progress in telepathology: system implementation and testing. Adv Pathol Lab Med 6:63-87, 1993.
4. Bhattacharyya AK, et. al. Case triage model for the practice of telepathology. Telemedicine Journal 1:9-17, 1995.
5. Erickson D. Do you see what I see? Pathologists lead the way for long-distance diagnosis. Scientific American July 1990:88-89.
6. http://www.afip.mil/telepath/howtosend.html
7. http://www.uni-stuttgart.de/UNIuser/ipe/histkome.html
8. Nordrum I, et. al. Remote frozen section service: a telepathology project in northern Norway. Human Pathology 22:514-17, 1991.
9. Cronenberger JH, Hsiao H, Falk RJ, Jennette JC. Nephropathology consultation via digitized images. Ann NY Acad Sci 670:281-292, 1992.
10. Kayser K, Oberholzer M, Weisse G, Weisse I, Everstein Hv. Long distance image transfer: first results of its use in histopathological diagnosis. Acta Pathol Microbiol Immunol Scand 99:808-814, 1991.