Teleconferencing for Pathologists Adam Landman Heathcare Information Systems February 24, 1999
Outline <ul><li>Introduction to Pathology </li></ul><ul><li>Introduction to Telepathology </li></ul><ul><li>Major Software...
Introduction to Pathology
Surgical Pathology <ul><li>Diagnosis ~ 5 - 7 min, Turnaround < 15 min </li></ul><ul><li>Large universities and hospitals p...
What about smaller/outlying hospitals? <ul><li>“ Travelling Salesman” -- rely on periodic visits from pathologists </li></...
Introduction to Telepathology <ul><li>Telepathology  - practice of pathology from a distance </li></ul><ul><ul><li>viewing...
Telepathology System Types <ul><li>What kinds of images are displayed? </li></ul><ul><li>Who has control over selection of...
Static vs. Dynamic Systems Source: Weinstein, R.S., K.J. Bloom, and L.S. Rozek. 1990. “Static and Dynamic Imaging in Patho...
Telepathology Issue <ul><li>Static image analysis not normal </li></ul><ul><ul><li>Control of microscope </li></ul></ul><u...
Telepathology Issues (cont.) <ul><li>Static Imaging -- overall diagnostic accuracy fails to meet accuracy standards (Ito, ...
Telepathology Issues (cont.) <ul><li>Static imaging is unacceptable for diagnosis </li></ul><ul><li>Dynamic-robotic is bes...
Major Vendors White Pine Enhanced CU-SeeMe White Pine Software, Inc. 542 Amherst Street Nashua, New Hampshire 03063 800-24...
Requirements <ul><li>Developed requirements based on background and consultation with two experienced UPMC anatomic pathol...
Compatibility Requirement <ul><li>Compatibility with Existing Environment </li></ul><ul><ul><li>Teleconferencing software ...
Typical Technical Environment
Performance Requirements <ul><li>Image Quality </li></ul><ul><ul><li>Difficult to standardize </li></ul></ul><ul><ul><li>1...
Performance Requirements <ul><li>Compression </li></ul><ul><ul><li>Decrease file size, Increase network performance </li><...
Product Feature Requirements <ul><li>Multipoint data conferencing  - allows users to collaborate and share information wit...
Product Feature Requirements <ul><li>Whiteboard  – allows users to share pictures, draw diagrams, and graphically update i...
Standards Requirements <ul><li>Standards  - ensure users can call, connect, and communicate with people using compatible c...
Ease of Use Requirements <ul><li>“ Easy to Use” is imperative for Pathologists </li></ul><ul><li>Difficult to evaluate wit...
Administrative Requirements <ul><li>Miscellaneous software attributes: </li></ul><ul><ul><li>Cost </li></ul></ul><ul><ul><...
Evaluation <ul><li>Developed priority weights in collaboration with two experienced UPMC anatomic pathologists </li></ul>
Evaluation
Evaluation
Recommendation <ul><li>Microsoft NetMeeting 2.0 </li></ul><ul><ul><li>Cost-effective solution that delivers a complete, in...
Recommendation (Limitations) <ul><li>Not generalizable to larger user community </li></ul><ul><li>Needs more complete anal...
Acknowledgements/References <ul><li>Vaughn, G.L., “Tendencies of pathologists in observing frozen sections,” feasibility s...
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  1. 1. Teleconferencing for Pathologists Adam Landman Heathcare Information Systems February 24, 1999
  2. 2. Outline <ul><li>Introduction to Pathology </li></ul><ul><li>Introduction to Telepathology </li></ul><ul><li>Major Software Vendors </li></ul><ul><li>Requirements </li></ul><ul><li>Evaluation </li></ul><ul><li>Recommendation </li></ul>
  3. 3. Introduction to Pathology
  4. 4. Surgical Pathology <ul><li>Diagnosis ~ 5 - 7 min, Turnaround < 15 min </li></ul><ul><li>Large universities and hospitals provide this service on demand </li></ul><ul><li>Frozen Section - small sections of tissue removed from a patient during surgery requiring diagnosis </li></ul><ul><li>What about smaller or outlying hospitals? </li></ul>
  5. 5. What about smaller/outlying hospitals? <ul><li>“ Travelling Salesman” -- rely on periodic visits from pathologists </li></ul><ul><ul><li>Surgeries must be scheduled to coincide with visit </li></ul></ul><ul><ul><li>What if pathologist is not present? </li></ul></ul><ul><li>Glass slides express mailed to remote laboratory </li></ul><ul><ul><li>Patient may have to undergo second surgery after diagnosis is available </li></ul></ul><ul><li>Neither solution is very efficient! </li></ul>
  6. 6. Introduction to Telepathology <ul><li>Telepathology - practice of pathology from a distance </li></ul><ul><ul><li>viewing images on a video monitor rather than light microscope </li></ul></ul><ul><ul><li>Images acquired by video camera mounted on light microscope </li></ul></ul><ul><ul><li>Images transmitted over a telecommunications link to remote workstation for analysis by telepathologist </li></ul></ul>Referring Pathologist Telepathologist
  7. 7. Telepathology System Types <ul><li>What kinds of images are displayed? </li></ul><ul><li>Who has control over selection of images? </li></ul>FTP Video Conferencing Dynamic Robotic Slave Master Static Dynamic Images Microscope Control
  8. 8. Static vs. Dynamic Systems Source: Weinstein, R.S., K.J. Bloom, and L.S. Rozek. 1990. “Static and Dynamic Imaging in Pathology,” in: Mun, S.K., Greberman, M., Hendee, W.R., and Shannon, R. (eds.), Image Management and Communications in Patient Care: Implementation and Impact . Los Alamitos, CA: IEEE Computer Soc. Press, pp. 77-85.
  9. 9. Telepathology Issue <ul><li>Static image analysis not normal </li></ul><ul><ul><li>Control of microscope </li></ul></ul><ul><ul><li>Sequence of images can affect outcome </li></ul></ul><ul><ul><li>Omissions are unacceptable </li></ul></ul><ul><li>Can video images be used by pathologists to render primary diagnostic opinions or second opinions? </li></ul>
  10. 10. Telepathology Issues (cont.) <ul><li>Static Imaging -- overall diagnostic accuracy fails to meet accuracy standards (Ito, et al) </li></ul><ul><li>Video Microscopy -- validated for diagnostic pathology by Weinstein et al </li></ul><ul><ul><li>15” Sony Trinitron 950-line monitor </li></ul></ul><ul><ul><li>11” Sony 300-line monitor </li></ul></ul><ul><li>Dynamic-Robotic -- achieved overall diagnostic accuracy equal to that of light microscopy (Shimosato et al) </li></ul><ul><li>So what?? </li></ul>
  11. 11. Telepathology Issues (cont.) <ul><li>Static imaging is unacceptable for diagnosis </li></ul><ul><li>Dynamic-robotic is best, but expensive and difficult to setup and operate </li></ul> We will consider COTS Video Conferencing products (dynamic, slave)
  12. 12. Major Vendors White Pine Enhanced CU-SeeMe White Pine Software, Inc. 542 Amherst Street Nashua, New Hampshire 03063 800-241-PINE http://www.wpine.com/ Microsoft NetMeeting 2.0 Microsoft Corporation One Microsoft Way Redmond, WA 98052 800-426-9400 http://www. microsoft .com/ netmeeting /
  13. 13. Requirements <ul><li>Developed requirements based on background and consultation with two experienced UPMC anatomic pathologists </li></ul><ul><ul><li>Compatibility </li></ul></ul><ul><ul><li>Performance </li></ul></ul><ul><ul><li>Product Features </li></ul></ul><ul><ul><li>Standards </li></ul></ul><ul><ul><li>Ease of Use </li></ul></ul><ul><ul><li>Administrative </li></ul></ul>
  14. 14. Compatibility Requirement <ul><li>Compatibility with Existing Environment </li></ul><ul><ul><li>Teleconferencing software must be compatible with hardware and software environment </li></ul></ul><ul><li>Note: Compatibility is not pertinent to ultimate product comparison </li></ul>
  15. 15. Typical Technical Environment
  16. 16. Performance Requirements <ul><li>Image Quality </li></ul><ul><ul><li>Difficult to standardize </li></ul></ul><ul><ul><li>1,024x768 pixels, 16-bit resolution not currently possible with video conferencing </li></ul></ul><ul><ul><li>Current capability: </li></ul></ul><ul><ul><ul><li>128x96 pixels, Sub Quarter Common Intermediate Format (SQCIF) </li></ul></ul></ul><ul><ul><ul><li>176x140 pixels, Quarter Common Intermediate Format (QCIF) </li></ul></ul></ul><ul><ul><ul><li>352x288 pixels, Common Intermediate Format (CIF) </li></ul></ul></ul>Performance --> Image Quality , Compression , Frame Rate
  17. 17. Performance Requirements <ul><li>Compression </li></ul><ul><ul><li>Decrease file size, Increase network performance </li></ul></ul><ul><ul><li>Two standard video codecs: </li></ul></ul><ul><ul><ul><li>H.263 - low bandwidth (28.8 Kbps modem) </li></ul></ul></ul><ul><ul><ul><li>H.261 - high bandwidth (LAN and ISDN) </li></ul></ul></ul><ul><li>Frame Rate </li></ul><ul><ul><li>Video 24 fps, Film 30 fps </li></ul></ul><ul><ul><li>Internet frame rate much lower expectations (12-15fps) </li></ul></ul><ul><ul><li>Rate using two ranges: </li></ul></ul><ul><ul><ul><li>3-7 fps for low bandwidth </li></ul></ul></ul><ul><ul><ul><li>7-15 fps for high bandwidth </li></ul></ul></ul>
  18. 18. Product Feature Requirements <ul><li>Multipoint data conferencing - allows users to collaborate and share information with one or more meeting participants in real-time. </li></ul><ul><li>Audio conferencing - allows pathologist to talk in real-time with colleagues. </li></ul><ul><li>Video conferencing - allows pathologist to send and receive video images. </li></ul><ul><ul><li>consider how many concurrent video sessions are possible </li></ul></ul><ul><ul><ul><li>pathologist’s facial image </li></ul></ul></ul><ul><ul><ul><li>microscope field view </li></ul></ul></ul>
  19. 19. Product Feature Requirements <ul><li>Whiteboard – allows users to share pictures, draw diagrams, and graphically update information in real time. </li></ul><ul><li>Application Sharing – lets users share Windows application with other participants in a meeting. </li></ul><ul><ul><li>might be useful for application to control robotic microscope </li></ul></ul><ul><li>Chat – text-based chat application. </li></ul><ul><li>Binary File Transfer – enables files to be sent to participants during a meeting. </li></ul><ul><ul><li>natural integration of standard static telepathology </li></ul></ul>
  20. 20. Standards Requirements <ul><li>Standards - ensure users can call, connect, and communicate with people using compatible conferencing products </li></ul><ul><ul><li>International Telecommunications Union (ITU) Standards </li></ul></ul><ul><ul><ul><li>T.120 - standard for multipoint data conferencing </li></ul></ul></ul><ul><ul><ul><li>H.323 - standard for audio and video conferencing </li></ul></ul></ul><ul><ul><li>Broad industry support with > 120 vendors participating </li></ul></ul>
  21. 21. Ease of Use Requirements <ul><li>“ Easy to Use” is imperative for Pathologists </li></ul><ul><li>Difficult to evaluate without using software </li></ul><ul><li>Proxies </li></ul><ul><ul><li>Installation Wizard </li></ul></ul><ul><ul><li>Graphical User Interface </li></ul></ul><ul><ul><li>On-line Help </li></ul></ul>
  22. 22. Administrative Requirements <ul><li>Miscellaneous software attributes: </li></ul><ul><ul><li>Cost </li></ul></ul><ul><ul><ul><li>particularly important in hospitals and labs with budget constraints (everywhere!) </li></ul></ul></ul><ul><ul><li>Product support </li></ul></ul><ul><ul><li>Upgradeability </li></ul></ul><ul><ul><li>Cross-platform support </li></ul></ul>
  23. 23. Evaluation <ul><li>Developed priority weights in collaboration with two experienced UPMC anatomic pathologists </li></ul>
  24. 24. Evaluation
  25. 25. Evaluation
  26. 26. Recommendation <ul><li>Microsoft NetMeeting 2.0 </li></ul><ul><ul><li>Cost-effective solution that delivers a complete, integrated Internet conferencing solution suited to meet the needs of the practicing pathologist </li></ul></ul><ul><li>Sensitivity Analysis of weights </li></ul><ul><li>Formal methodology may have been overkill </li></ul><ul><li>CU-SeeMe major revision due March 1999 </li></ul>
  27. 27. Recommendation (Limitations) <ul><li>Not generalizable to larger user community </li></ul><ul><li>Needs more complete analysis </li></ul><ul><ul><li>hands-on usage of products </li></ul></ul><ul><li>General telepathology issues need consideration </li></ul><ul><ul><li>Medical-legal </li></ul></ul><ul><ul><li>Diagnostic accuracy </li></ul></ul><ul><ul><li>Patient confidentiality </li></ul></ul>
  28. 28. Acknowledgements/References <ul><li>Vaughn, G.L., “Tendencies of pathologists in observing frozen sections,” feasibility study, UAB Center for Telecommunications Education & Research, 1994. </li></ul><ul><li>Weinstein, R.S., K.J. Bloom, and L.S. Rozek. 1990. “Static and Dynamic Imaging in Pathology,” in: Mun, S.K., Greberman, M., Hendee, W.R., and Shannon, R. (eds.), Image Management and Communications in Patient Care: Implementation and Impact . Los Alamitos, CA: IEEE Computer Soc. Press, pp. 77-85. </li></ul><ul><li>Ito, H., H. Adachi, K. Taniyama, Y. Fukuda, and K. Dohi. 1994. “Telepathology Is Available for Transplantation-Pathology: Experience in Japan Using an Integrated, Low-Cost, and High-Quality System,” Modern Pathology , 17: 801-05. </li></ul><ul><li>Oberholzer, M., H-R Fischer, H. Christen, S. Gerber, M. Bruhlmann, M. Mihatsch, M. Famos, C. Winkler, P.Fehr, L. Bachthold, and K. Kayser. 1993. “Telepathology with an Integrated Services Digital Network – A New Tool for Image Transfer in Surgical Pathology, A Preliminary Report.” Human Pathology , 24: 1078-85. </li></ul><ul><li>Eide, T.J., and I. Nordrum. 1992. “Frozen Section Service via the Telenetwork in Northern Norway,” Zentralblatt Pathologie , 138: 409-12. </li></ul><ul><li>Bloom, K.J., L.S. Rozek, and R.S. Weinstein. 1987. “ROC Curve Analysis of Super High Resolution Video for Histopathology,” SPIE Proc Visual Image Process , 845: 408-12. </li></ul><ul><li>http://www. zdnet .com/ pccomp /features/fea0297/sub5.html/ </li></ul><ul><li>http://www. microsoft .com/ netmeeting </li></ul><ul><li>http://www. wpine .com/ </li></ul>Special thanks to Ms. Yukako Yagi, Dr. John Gilbertson, and Dr. Bob Dawson for their assistance and insightful comments.
  29. 29. Questions

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