Section 2 -

Use of Virtual Slides at the AFIP – Reinventing Consultation and Education Bruce Williams Chair, AFIP Department of Telemedicine and Distance Learning

Click here to download additional handout in pdf format for the current section (101 KB) History of the AFIP Telemedicine Program Over the years, the AFIP Telemedicine Department has been an early adopter of telemedicine and digital imaging technology for use in consultation and education. Established in 1993, the AFIP's Telemedicine Department served primarily as a resource for military pathologists stationed in small 1- or 2-pathologist laboratories around the world. In 1995, the AFIP began accepting telemedicine cases from civilian contributors around the world. Today, the Institute's telemedicine caseload averages 500 cases/year and and continues to grow both in number and technological sophistication. The AFIP Telemedicine Department has also been integrally involved in the Institute's distance learning mission. Since 1995, the department has coordinated all Web activities for the AFIP, to include the AFIP and ARP home pages and online versions of the AFIP/ARP Tumor Fascicles. In 2003, coinciding with the launch of the AFIP's comprehensive distance learning initiative, the Department was officially renamed the AFIP Department of Telemedicine and Distance Learning. Today, the department employs a full-time online application developer and three online editors to support the AFIP's growing online initiative, AskAFIP™. Current Consultation Operations From November 1995 until December 2001, the Department's case workload was composed solely of static image-based cases. A retrospective publication on the utility of static imagery for diagnostic consultation conducted this period, revealed a 97.6% clinical concordance between telepathology and final diagnosis in these cases, with a 74% absolute concordance (Williams et al., Hum Pathol 2001 Dec;32(12):1309-17.) In 2001, the AFIP Department of Telemedicine, in partnership with Walter Reed Army Medical Center, was funded by the U.S. Army to deploy 12 real-time telemicroscopy systems at Department of Defense pathology laboratories within the United States and at several locations around the world. As of 2004, a total of 22 systems had been deployed at sites including the 44th Med Team (Pathology) in Baghdad, the 121st General Hospital in Seoul, and Landstuhl Regional Medical Center., FRG. The Army's successes with robotic telepathology in the area of frozen-section diagnosis are well-documented (Kaplan et al., Mod Pathol 2002 Nov;15(11):1197-204.) and the Army's four year experience with robotic telepathology was an overall successful one. In spite of a marked increase in the time required to read a case (often due to long latency periods between screen refreshes). Refresh rates ranged from 2 seconds between refreshes within the continental U.S. 10-15 seconds in Europe, and up to 67 seconds for atellite-based theatre communication with the 44th Med Team in Baghdad .) Average case turnaround time was maintained at 3.2 hours per case, as most cases consisted of a single slide (largely due to unattended operation at the distant location.) In Fall 2005, the Armed Forces Institute of Pathology assumed total control of the Army Telepathology program, and received additional funding to upgrade 12/22 systems to virtual slide scanners. The systems have been installed at laboratories of various sizes, ranging from small 1-man labs (Baghdad) to large laboratories with six or more pathologists (Walter Reed AMC and Madigan AMC). The systems that have been deployed are the Trestle DSM™ (Trestle Corporation, Irvine CA ). The utility of these systems, which includes the Trestle SL-50™ 50-slide autoloader and combined slide scanning and robotic operational capabilities has markedly increased the number of cases coming into the Department up to three times previous levels. The ability to view multiple slides per case, long-desired by AFIP consultants has not only further increased the specificity of accuracy of AFIP diagnoses, but has also opened up a new mission for AFIP telemedicine – telemedicine quality assurance. Until recently, Army pathology laboratories fulfilled CAP requirements for quality assurance by packaging slides and records for courier delivery to remote laboratories to be reviewed by another pathologist. In addition to offsetting personnel, laboratory, and shipping costs, telemedicine quality assurance results in significant decreases in turnaround time for these cases and allows for a volume of QA casework that far exceeds CAP requirements. Two laboratories, each employing a single pathologist, currently submit 100% of their caseload to AFIP for quality assurance purposes. Virtual slides also play an important role in repository services at the AFIP. Each year, a growing number of contributors request the return of submitted slides or blocks. The Institute now routinely archives digital scans of diagnostic slides in these cases in order to accede to the contributor's wishes. Virtual Slides in AFIP Education Our first experience with the use of virtual slides in education came in 1999; however, the throughput limitations of this evolving technology precluded its widespread use in AFIP programs until 2003. Since 2003, virtual slides have been the backbone of AFIP distance learning programs, beginning with the AFIP's Online Pathology Services and increasing in scope through this year's deployment of version 2.0 of AskAFIP™. Moreover, the AFIP scans and serves virtual slides for a range of other government agencies, including the National Cancer Institute, NASA, and the Uniformed Services University of Health Science, as well providing scanning services for the International Academy of Pathology, the American College of Veterinary Pathology, and the Charles Louis Davis Foundation. Digital slides for our many educational programs are created on an Aperio Scanscope T2™ slide scanner (Aperio Technologies, Vista, CA) Inc. Over 1000 virtual slides covering all facets of human and animal pathology are currently available to subscribers of AFIP's online courses and AskAFIP™. Digital slides are available as part of study sets, online courses, and various collections, based on permissions set by system administrators. Research collections are available only to certain subsets of users by a password-based account system. Virtual slides have also revolutionized the way that AFIP handles its traditional glass slide conferences. Analysis of the costs of mailing out glass slides and followup to participants around the world revealed that an 80% cost savings was realized by migrating these conferences to an online format. More importantly, the use of digital slides allowed for the participation by an unlimited number of individuals around the world, as opposed to the previous limitations imposed by a finite amount of glass slides which could be produced. Additionally new materials which had been cost-prohibitive in the traditional mail-out setting, such as the use of special stains and immunohistochemical preparations, could now be added with relative ease to the diagnostic material available on each case. Today the AFIP's Histopathology Quality Assurance Program (a mandatory requirement for all Veterans Administration pathologists), the Registry of Oral Pathology's Slide Conference, and the Department of Veterinary Pathology's Wednesday Slide Conference all utilize a digital format for reaching their participants around the world. Virtual slides also supplement many of the traditional glass study sets at the AFIP's CME courses. Three of the AFIP's most popular courses, the Anatomic Pathology Course, the Genitourinary Pathology Course, and the Descriptive Veterinary Pathology course utilize virtual slides as part of the curriculum, and provide attendees access to digitized versions of course study sets for the year following each course. Summary Virtual slides are an integral part of the AFIP's vision of the future, as well as the future of pathology - perhaps one day, microscopes will no longer be a fixture on the pathologists desktop. As the price and throughput of digital scanners continues to decrease, and more and more of the Institute's consultation and research partners explore the capabilities of these new systems, we believe that virtual slides will alleviate many of the constraints of traditional glass slides on diagnostic pathology practice, as well as revolutionize continuing medical education. In the Department of Telemedicine, we believe the expanding role of virtual slides in the day-to-day business of the AFIP is only a hint of things to come.