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Telepathology for second opinion teleconsultation

Speaking at the 2020 Digital Pathology Congress Liron Pantanowiz reviewed why he thought telepathology is the number one application for digital imaging. In this blog, we report what he had to say about telepathology for second opinion teleconsultation.

There are many reasons to share an image. There is a recognised and persistent global shortage of pathologists, and many have not had the opportunity for subspecialty training. So there’s an increased demand for them to get expert diagnostic consultation.

Factors related to International Telemedicine Success
  • Low-cost & simple technologies work best. If they are hard to maintain and/or costly, they are difficult to sustain.
  • Bi-directional communication is essential between pathologist and pathologist. Email, chat function or some other mechanism, regardless of location can overcome this
  • Incentive-based programs work the best – pathologists would like to get paid for the work they do. (Charitable undertakings in developing countries have been successful, but they’re harder to sustain).
  • Strong team leadership buy-in from the top
  • User acceptance by the pathologists providing the consultation or sending it for a second opinion
  • Locally responsive services to solve IT problems and issues.

Now it is unlikely that routine cases will be sent for teleconsultation. The people that like looking at complex cases are those at academic medical centres – where you find many successful telepathology programs. Evidence from these programs, suggests that teleconsultants were able to provide or suggest a definitive diagnosis. Only in a few cases, they were uncertain about the diagnosis.

Uncertainty, however, was not due to the limitations of the technology. Either the sample quality was no good, or there was no ability to undertake ancillary testing. Professor Pantanowiz urged the audience “don’t sweat the small stuff”. He found the minor artefacts don’t matter. If tissue sections fall beyond the cover-slip and you cannot focus on them or there’s dirt on the slide, it doesn’t compromise the ability to render a diagnosis.

One of the problematics areas can be dealing with FNA and other cytology samples. There are technical challenges such as an inability to focus on cytology material. A solution developed to overcome this issue is adopting a cell-block only approach. Prof Pantanowiz reported that his team were able to provide a very meaningful second opinion interpretation for a wide variety of FNAs branding from the pancreas to body fluids. And that cell block also gave, an opportunity to do immunohistochemical staining, to refine the diagnosis.

In reviewing referral cases submitted to the University of Pittsburgh medical centre, the majority of cases came from a pathologist. But as the service developed and the diagnosis significantly changed management, clinicians started to seek a second opinion before embarking on some serious surgery or chemo, radiation.

Even though telepathology can be successful, there are also many challenges to be aware of and plan for.

  • Mechanism of slide scan: The image formats have to be compatible. Internet speed can certainly be a difficulty. Firewalls can be challenging. As can the absence of in-house IT support
  • Differences in culture: Invest time to build trust and develop a common language. Understand the way the healthcare system seeking a second opinion or consultation operates.
  • Lack of clinical information: Working without gross pathology or the ability to do ancillary testing could leave you with an HD image and not much more.
  • Communication channels: Poor bi-directional communication with the other pathologist will compromise the ability to deliver/receive a meaningful diagnosis.
  • Limited resources: Does the pathologist have the resources ability to answer the question being asked of him or her?

With today’s software, it is amazing how much can be accomplished.

This blog is a precis of a presentation given by Liron Pantanowitz, Professor of Pathology & Director of Anatomical Pathology, the University of Michigan at the 2020 Digital Pathology Congress.

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