The challenges of implementing a "patient-oriented" telepathology network; the Eastern Québec telepathology project experience

Transcription

1 The challenges of implementing a "patient-oriented" telepathology network; the Eastern Québec telepathology project experience Bernard Têtu MD Medical director Jean-Paul Fortin MD Marie-Pierre Gagnon PhD Université Laval Said Louahlia MD CHR Baie-Comeau Québec, Canada

2 Canada Population Surface 34 M 9,1 M km² Ontario 13 M 1,1 M km 2 Québec 8 M 1,7 M km 2 2

3 Integrated University Health Networks 1,729, ,600 Km 2 Reproduced with permission from the «Ministère de la Santé et des Services Sociaux, Gouvernement du Québec»

4 History of the Eastern Québec telepathology project 2004: Québec Ministry of Health mandates the Integrated University Health Networks to develop telehealth in the province. Laval University prioritizes telepathology 2007: Québec Ministry of Health and Canada Health Infoway fund the project 2010: Deployment 4

5 Density of population and Distribution of pathologists on the territory Reproduced with permission from the «Ministère de la Santé et des Services Sociaux, Gouvernement du Québec»

6 Telepathology clinical context Surgeon s perspective Part-time pathologist available or no pathology department : Schedule of operations depends on the presence of a pathologist Two-step surgeries (sentinel lymph node) Patients transferred if frozen section expected Difficulty recruiting surgeons 6

7 Telepathology clinical context Pathologist s perspective Insecurity, especially in early practice Impossibility to rapidly obtain a second opinion Immunohistochemistry performed in university hospitals: delays to get slides back Difficulty in being absent without disturbing the organization of the surgical unit Difficulties recruiting pathologists 7

8 Telepathology clinical context Reports of Commissions of Inquiry in Canada Creaghan Commission, New Brunswick: Recommendation #12: providing pathology services for regional hospital laboratories through pathology digital imaging Cameron Commission, Newfoundland: Recommendation #24: fund technical resources for pathologists who work alone, in the field of pathology digital imaging 8

9 Eastern Québec telepathology project Main objective Implement an innovative solution to provide uniform pathology coverage in the whole Laval University Health Network region Population-based and patient-oriented 9

10 Eastern Québec telepathology project Specific objectives Provide frozen sections anywhere, anytime Provide second opinion from a colleague or a panel of experts Allow fast return of immunohistochemistry performed in university hospitals 10

11 Eastern Québec telepathology project Deployment 21 sites (3 additional possible sites) 6 hospitals devoid of pathology laboratory 15 sites with pathology laboratory 3 with no pathologist 4 with 1 pathologist 8 with 2 or more pathologists 11

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13 Canadian Healthcare Technology October

14 Whole-slide scanner: nanozoomer (Hamamatsu) RS model (6 slides): 15 HT model (210 slides):

15 Grossing station (PathStand), videoconferencing device (Sony HD) and drawing tablet (Wacom) 15

16 Viewer and image sharing solution: mscope (Aurora) 16

17 Deployment January 2010 December 2011 Primary diagnosis of current cases: 829 Gross images for diagnosis: 500 Consultations from pathologist to pathologist: 95 Frozen sections: 72 Grossing assistance: 32 Immunohistochemistry:

18 Frozen sections Parathyroids (normal, tumor) Resection margins (breast) Sentinel lymph nodes Thyroid lesions Colon: margins, adenomas Breast: fibroadenomas, margins, carcinomas Pleural lesion Mesocolon: inflammatory lesion Soft tissues: spindle-cell lesion 18

19 Frozen sections Hospital A Hospital B Frozen sections: 16 cases 36 cases Time required: 26.7 min (17-38) 19.8 min (8*-36) Macroscopy: 5.6 min (3-14) 6.2 min (1-17) Cryostat section: 9.8 min (6-14) 5.5 min (1*-12) Scanning: 2.6 min (2-4) 2.7 min (1-6) Access to image: 2.8 min (1-8) 1.4 min (0-7) Interpretation: 2.1 min (0-9) 3.4 min (1-11) Diagnostic concordance: 100% * In cases of multiple specimens for a same case 19

20 Evans et al, Sem Diagn Pathol 2009; 26(4): Diagnostic concordance: 98% Turn-around time (without macroscopy): Robotic: min (11-45) Virtual slides: (9-35)

21 On site visits First visit (year 0): Understand the needs, provide information and identify location for equipments Second visit (year 1): gather information regarding the problems of implementation and provide support 21

22 Major challenges Seven challenges that required rapid solutions to keep the pace of implementation Change management Project is aimed at complementing and not replacing the use of glass slides 22

23 1. Surgeons must get used to ask for the service Although the surgeons of the hospitals with no pathology laboratory and no pathologists are motivated by the potential of the technology, they must get used to request coverage that has been unavailable for so many years 23

24 2. Network must adapt to a changing context Moving and retirement of pathologists during the course of deployment require change in the original project Find volunteers and provide rapid training Factors favoring changes: Surgeons of referring center afraid of not having frozen section coverage Technicians of referring laboratory fear to have to leave because of the reduced activity in the laboratory Technicians of consulting laboratory fear an increased workload with limited resources 24

25 3. Network must develop innovative solutions to transfer information 21 hospitals with or without pathology laboratory and different LIS Videoconferencing and grossing station allow rapid communication with the surgeons and/or the pathology assistant and/or technician for either grossing of oncology specimens or frozen sections Easy dictation and report format allows quick production of report and easy integration into any LIS 25

26 4. Pathologists must learn to work with images instead of glass slides Major challenge because pathologists have been using a microscope for over a century and are used to this environment No obligation to use telepathology Even if most pathologists recognize that the quality of the images is comparable, many remain reluctant to make primary diagnosis with this tool Strategies must be developed to allow pathologists to adapt to this new technology Better fees for telepathology helps 26

27 5. Regional and community hospitals must be involved Because of shortage of pathologists, University hospitals in Québec are unable to absorb the increased workload from telepathology Experts in university hospitals don t have enough dedicated time to both participate at the development of the technology and respond to an increased flow of new consultations Being actively involved, pathologists and surgeons in community hospitals participate with more enthousiasm 27

28 6. Surgeons and pathology staff must work differently With telepathology, tasks of pathology staff may change Surgeons must be increasingly involved in selection of cases to be frozen Closer coordination between surgeons and pathology staff of the referring hospital and the consulting laboratory must be developed There must be more collaboration between pathologists of the Eastern Québec territory 28

29 7. Mutual confidence between centers must be consolidated Technicians in hospitals without pathology laboratory have limited experience with histology This issue regards both the self-confidence of the technologist and the mutual confidence between the technician of the referring hospital and the consulting pathologist Common sectioning and staining procedures Technicians of referring centers trained in laboratories with which they will mostly collaborate Certain surgeons interested at participating at the training to develop closer relationships with the pathologists 29

30 Conclusion Telepathology improves quality of care: Prevents interruption of service with departure of pathologist Provides pathology coverage not available to remote communities Supports pathologists working alone Helps developing a more collaborative approach between pathologists and surgeons in a region 30

31 Conclusion Implementation of a «patient-oriented» telepathology network generates challenges that are mostly related to change management which require innovative solutions. The enthousiasm about telepathology is growing as pathologists and surgeons use the technology 31

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