Telepathology 2/17/2011. and The Future of Pathology (or Why did we change our Practice Model) University Health Network IMAGINE3: 3 IMAGINE 2!

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1 Telepathology and The Future of Pathology (or Why did we change our Practice Model) Jagdish Butany, MBBS, MS, FRCPC (a)why did we implement telepathology (WSI) at UHN? 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, E Toronto, Ontario M5G 2C4,Canada. Tel: Fax: jagdish.butany@uhn.on.ca 2 Feb 2011, Birmingham, UK. I HAVE NO FONFLICT OF INTEREST WITH ANY Equipment/Supplier! University Health Network TGH, PMH, TWH No on-site TWH pathologist Imagine 2-10 frozen sections per week (mostly neurosurgery) Sept no NP 1.Cover 3 sites 2.No new staff available 3.Increasing workload UHN UHN S S IMAGINE 2! IMAGINE3: 3! # Q S Sites Departments of Pathology S Research S= Service 1

2 Medical Laboratories -----and sometimes u get lucky!! Problem!! Right Leadership The Perfect Storm---! Right Tools!! Available! Right Circumstances 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 The Robotic System 350 frozen sections accurate deferral rate < 10% slow (~ 10 minutes/slide) Toronto Western Toronto General Telepathology Work Station (not a pathologist s office) 2

3 Whole-Slide Imaging: October 2006-Present 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 > 1800 frozen sections/1500 patients 90% from neurosurgery % accuracy (month to month) minute turnaround time 5% deferral rate - 2 pathologists review all deferrals Robotic microscopy ( ) most intense development and validation Transition to WSI (late present) Whole-Slide Imaging: Architecture Pathology Easy consultation with colleagues better for patient care WSI had essentially no learning curve (compared to robotic microscope) This was TGH/UHN Future of Pathology Frontiers in Laboratory Medicine Feb 1-2, 2011, Birmingham UK. Challenges for 2020 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 MONEY?? 18 3

4 The Challenge for 2020 Faster Better Higher quality Personalized Cheaper The New Paradigm: Faster Pathology must be faster Same Day diagnosis Automation 24/7 labs Faster Innovative The New Paradigm: Faster Speech-recognition integrated with LIS means instant reporting without the need for dictatyping Technologic Advances: omics DNA HT-Sequencing RNA Metabolomics Protein Mass Spectrometry Microarray Expression Profiling 21 The New Paradigm: Better What is Correct? Objective classification by mrna expression DNA sequencing Response to therapy The 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 4

5 The New Paradigm: Better (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 25 in all areas and Built in redundancy Requirements for Full Adoption Workflow integration From the lab to the pathologist LIS integration Barcodes Slide tracking and retrieval Digital Pathology Enables Remote access Multiple viewers Immediate access to the right pathologist at the right time 27 Computer-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: Can it Override the Genotype? What Is Anatomical Pathology? Integrative morphology based interpretation Consultant s Report Gross Morphology Chemistry on a glass slide Immunoassay on a glass slide N Engl J Med Feb 15;356(7):

6 The Virtual Autopsy After The Anatomy Lecture of Dr. Nicolaes Tulp Rembrandt, 1632 (Courtesy of Dr. Carlos Cordón, New York, USA) The New Paradigm: Personalized The Future of Pathology? Patient-Centred Care Individualized diagnostics Targeted therapies All based on omics $15.00 $15.00each each Will omics replace pathology? $ $ each each 33 The 2020 Paradigm 2020 Pathology Digital radiology Digital genetics Comprehensive & Integrated Pathology reports History, Physical, Family History Digital EMR Labs/ Pathology: Incorporation and integration of radiologic, biochemical, morphologic, molecular, Biochemistry cytogenetic and epigenetic data the center Clinical Gross Pathology Pathology Biomarkers & CAD of Personalized QA Digital cardiology Endoscopy Medicine!! Radiology Gross Pathology Biomarkers Histopathology Molecular Pathology The Pathologist s Cockpit 6

7 The Expanding Role of Lab Medicine 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 Pathologist!! The Pathologist and the Patient!! 2020 Pathologist AS IS YOUR PATHOLOGY SO IS YOUR MEDICINE. Sir William Osler McGill Univ, Hopkins, London (UK) Pathologist and Patient! The Diagnosis is----, and the prognosis is----. The Future of Pathology IMAGINE!! The best way to predict the future is to invent it Alan Kay Kuwait 42 7