Webcasting Pathology Department Conferences in a Geographically Distributed Medical Center

Transcription

1 Webcasting Pathology Department Conferences in a Geographically Distributed Medical Center YUKAKO YAGI, MD, ISHTIAQUE AHMED, WILLIAM GROSS, BS, MICHAEL J. BECICH, MD, PHD, ANTHONY J. DEMETRIS, MD, ALAN WELLS, MD, DMS, CLAYTON A. WILEY, MD, PHD, GEORGE K. MICHALOPOULOS, MD, PHD, SAMUEL A. YOUSEM, MD, BARBARA BARNES, MD, AND JOHN R. GILBERTSON, MD As academic pathology departments have become increasingly based in large, regional medical systems spread across hundreds of square miles, new methods are needed to tie these increasingly distributed departments together as integrated units. An important part of that integration is the ability to share academic and teaching conferences across long distances. In this article we present an effective, low-cost webcasting system that has evolved at the University of Pittsburgh Medical Center Department of Pathology over the past several years based on inexpensive, widely available software. To date, the system has broadcast and archived more than 400 conferences and currently serves approximately 80 to 100 requests each week. Important factors in the success of the program include the creation of a faculty steering committee to control resources and Over the past 10 years, the University of Pittsburgh Medical Center (UPMC) has grown from a handful of continuous buildings in Pittsburgh s Oakland section to a major regional health system with 20 community, specialty, and tertiary care hospitals serving 29 western Pennsylvania counties. Figure 1 shows the distribution of UPMC hospitals in western Pennsylvania. The Department of Pathology has grown with the medical center, and this rapid growth has brought major challenges as the department seeks to retain and expand its tradition of education and academic discussion in a growing geographic footprint. For many pathologists, an important part of the Pathology Department s academic and educational mission is represented by a series of weekly conferences and grand rounds. In these formal activities, pathologists, residents, and researchers present didactic lectures on practice issues, diagnostic skills, or ongoing research. In the major teaching hospitals of UPMC, these meetings draw 30 to 100 attendees, are usually mandatory for residents, and often provide continuous medical education (CME) credit. As the medical center has expanded, however, the concept of a series of central, physical meetings became From the University of Pittsburgh Medical Center, Pittsburgh, PA. Accepted for publication March 31, Address correspondence and reprint requests to Yukako Yagi, Director of Telepathology, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 5230 Centre Avenue, Suite 338, Pittsburgh, PA /$ see front matter 2004 Elsevier Inc. All rights reserved. doi: /j.humpath manage growth, the availability of informatics faculty and support for technical staff, and the decision to operate the service as part of the core information technology infrastructure of the department. Webcasting will likely become an even more important academic and operational tool in the future as more of the department s conferences, seminars, and even working meetings are communicated through the webcasting infrastructure. HUM PATHOL 35: Elsevier Inc. All rights reserved. Key words: webcast conference, distance learning, continuous medical education. Abbreviations: CME, continuous medical education; PA, public address; UPMC, University of Pittsburgh Medical Center. less and less tenable. As care became distributed across the hospital network, the core academic and teaching audience of the conferences became dispersed across multiple physical locations. In some cases, a centers of excellence model developed in which the management of different disease types became centered at different institutions. For example, genitourinary pathology became centered in the Shadyside Campus; breast pathology, at Magee Woman s Hospital; and transplant pathology, at Presbyterian University Hospital. These campuses are approximately 1 mile apart, and traveling between them takes approximately 30 minutes. Attendance at a noon conference at another hospital could mean an hour of travel or nonproductive time in the middle of the working day. While the redistribution of service, academic, and teaching facilities within the City of Pittsburgh was making physical conferences problematic for their traditional audience of university-based pathologists, a new audience was seeking access. Many previously independent community hospitals had joined the UPMC network, and their pathologists wanted access to the academic and educational resources of the traditional teaching hospitals. However, a commute to downtown Pittsburgh, often from a different county, for an hourlong academic conference was never a serious option for these pathologists. There had to be another way. The UPMC had a history of pathology imaging, distance learning, and telepathology. The center supports a wide range of telepathology and tele-educational initiatives from educational web pages (ie, edu), imaging-capable LIS (CoPath), traditional cam- 790

2 WEBCASTING PATHOLOGY CONFERENCES (Yagi et al) FIGURE 1. Map of Pennsylvania with locations of major UPMC hospitals. (Source: UPMC website, era on microscope static systems, TV teleconferencing based dynamic systems, static robotic systems ( telepathology.upmc.edu), and whole slide imaging ( These systems had been used to support tele-education, teleconsultation, and telementoring across the UPMC health system, including active support for UPMC hospitals overseas. 1 This medley of campuses, systems, and requirements had created a complex environment in which different clinical groups would request different telemedicine services, which had to be implemented within the constraints of limited budgets and preexisting image and communication infrastructures. To manage and prioritize the wide range of sometimes-competing telemedicine and distance-learning initiatives, the UPMC Department of Pathology created the telepathology steering committee in This committee comprises the chairman, the anatomic pathology and clinical pathology directors, and the directors of the clinical divisions most actively involved in telepathology and tele-education. In late 2000, the steering committee directed the telepathology implementation group to investigate the use of teleconferencing for major academic and teaching conferences. The telepathology steering committee developed the following requirements for any system implemented to broadcast the department s academic or educational meetings: 1. The system must be inexpensive and cost-effective (thousands of dollars, not hundreds of thousands). The software must be widely available with little installation and maintenance expense, especially at the client (remote) sites. There should be limited licensing fees, and the purchase of additional client hardware should not be required. 2. The system should operate as a clinical system with high reliability. 3. The system should be easy to use with limited (or no) user training. Use should be intuitive or possible through limited on-line support. 4. The system should be portable and not be limited to a small number of conference rooms. 5. Access to the system should be limited to the UPMC internet or DNS domain ( upmc.edu). (This requirement evolved as discussed below.) 6. The system should support conferences in real time as well as in a searchable, archival mode. 7. There should be a mechanism to support CME. Teleconferencing, or webcasting, is not a new concept. Numerous companies sell teleconferencing equipment, and others market web-based meeting services. Some national meetings, including those of the APIII (Advancing Practice, Instruction and Innovation through Informatics) and ATA (American Telemedicine Association), have been webcasting selected proceedings for years. However, there is relatively little in the technical literature on the implementation of teleconferencing or webcasting services for academic conferences in pathology departments, especially beyond the support of medical school lectures. Most of the literature focuses on using teleconferencing as a diagnostic tool 2,3 or on highly capable (and expensive) systems, such as that developed by Japanese cancer centers. 4 In this article we report the implementation of a web-based conferencing system with the capabilities discussed above and a total equipment cost of under $10,000. After a 2-month trial period, the system began operation in March Since that time, it has served and archived more than 400 conferences. It currently broadcasts an average of 1 new conference per day to approximately 80 to 100 users per week. MATERIALS AND METHODS The web-based teleconferencing system is best described in 2 main areas: (1) hardware and software including the conference (video) server, conference (video) station, and the webcast client and (2) system operations and management. Figure 2 shows a diagram of the system. 791

3 HUMAN PATHOLOGY Volume 35, No. 7 (July 2004) FIGURE 2. Network diagram of the conference webcasting system. The video camera and multimedia laptop setup (video station) is portable to multiple conference rooms. Hardware and Software The system is relatively inexpensive; the total ocst of the hardware was less than $10,000 in In 2003 we installed a similar system for a non-upmc, government client for approximately $8,000 (with a much better camera and computers). A free limited version of the server software is available, and client software is free and easily accessible. Video Server We use a Dell Power Edge 4400 with 4 GB of RAM and a 220-GB hard drive running Windows NT4 and IIS. The Power Edge cost approximately $5000 in 2001 and is more than adequate for this application. Windows NT4 is the standard (approved) operating system for light-duty servers at UPMC. The Media Server software is RealSystem Server 8 from Real- Networks, Inc. (Seattle, WA). A free limited version is available from their website. This limited version allows a maximum of 25 concurrent users to access a live session, and unlimited users to access an archived session. Video Station The video station is the package of equipment placed in the conference room to webcast and record a conference. Because there are multiple potential conference rooms, the station is portable and configurable to different public address (PA) systems and furniture layouts. This package contains Multimedia Notebook PC (Dell Latitude C810, 512 MB memory, 18 GB hard drive, Windows 2000), a USB video capture card (Osprey-50; Osprey Video, Morrisville, NC), a digital video camcorder (MiniDV HandyCam; Sony America, New York, NY), and a tripod and a backup microphone. The cost of this package was about $3000 in To webcast a conference, the camcorder is fixed by the tripod at a convenient location for capturing video, as shown in Figure 3. The camcorder video is transferred to the notebook PC as an s-video signal by the USB video card. Audio is taken through the room s PA system or through the backup microphone on the digital video camcorder. The notebook PC is equipped with Real Producer Plus, version 8.51 to both capture (record) and broadcast the conference live through the network. This has been recently upgraded to Helix Producer Plus, version 9.01 (RealNetworks). Using Real Producer, the technician on site creates a RAM file (also called a metafile), with the file extension *.ram. The RAM file launches RealOne Player (RealNetworks), gives it the URL to a media clip, and can pass parameters to open an HTML page. The RAM file production method is easy to use and is well suited for simple presentations, such as a conference documented by single video clip that displays an HTML page as it plays. Note that if the conference room does not have network access, the conference can still be recorded for later display, as discussed below. Webcast Client To run the webcast, the client PC requires a sound card, speakers, a browser, and a media player. Most pathologist s PCs had been previously equipped with a sound card and 792

4 WEBCASTING PATHOLOGY CONFERENCES (Yagi et al) speakers with volume control. Real Media Player (RealOne Player) (RealNetworks) is part of the standard PC desktop at UPMC and thus was chosen as our webcast client. The standard UPMC desktop also included Microsoft Internet Explorer, which was used as the web browser required to access the system and use the utilities available at the webcast conference website. System Operations and Management General Operations It takes a trained technician approximately 20 hours per week to manage the system and broadcast 5 to 7 conferences. The great majority of this time is for setup and recording of conferences. However, more than one technician is needed, because conferences can occur simultaneously, early in the morning and late in the afternoon (more than 8 hours apart), or in different hospitals. Sick days and vacations must also be accounted for. Therefore, whereas only 1/2 full-time equivalent (FTE) is needed to run the system, multiple technicians must be trained and available to support a consistent level of service. An important aspect of maintaining service is providing ongoing training and ensuring the availability of on-line materials, as discussed below. Using the system entails going to the webcast web page (off the department s main home page, edu) and clicking on the conference of interest. Future conferences are announced on the webcast home page, including the time, location, conference type, lecture title, and speaker. When the conference begins, it is designated as a live conference and can be accessed in the UPMC domain by clicking on its hyperlinked title. (Access to some conferences is more closely held, as discussed below.) After the conference is over, the *.ram file is transferred from the portable video station to the video server, where it can be accessed in an archived form. In most cases, depending on the preferences of the faculty running the conference, archived conferences can be accessed outside of the UPMC domain or can ordered on DVD/CD. The conference archive can be searched by date (range), speaker, title, or conference type. Figures 4 and 5 show the operational workflows for users and technicians, respectively. User Support Most pathologists at UPMC have highly capable PCs (initially installed to support imaging) maintained by central information services. The machines have speakers and sound cards and are preinstalled with Real Player and Microsoft Internet Explorer. Hardware/software user support has therefore not been a major issue. That said, however, minimum system requirements, installation, and operations manuals are posted on the webcast home page ( teleconference.upmc.edu), and we have found these to be extremely important. If necessary, users may send a message from the webcast home page to the UPMC Help Desk, who will triage any problems to telepathology and webcast staff. Users can also make suggestions directly from the web page to the technical staff and to the telepathology steering committee. Communications Information on scheduled and archived webcasts posted on the website is kept current by department administrative staff, who notify the webmaster of any changes in the time, location, and nature of upcoming conferences. When a conference is being broadcast live, it is occasionally necessary to contact the technician in the conference room. The technician cannot use through the computer (and usually cannot use the conference room phone) during broadcasts. Therefore, text pagers with keyboards were requested for all technical staff. These pagers can be used at the conference locations to communicate between the technician and staff about emergency matters that may arise during a conference (eg, audio volume or frame alignment problems during the webcast) that may not be obvious to the technician locally. Only one pager was procured to be shared between staff, however. This helped mitigate most, but not all, communication difficulties. On-Line Help for Telepathology Staff Because of the numerous potential locations for teleconferences (and local differences, such as room size, lighting, PA systems, etc), an on-line manual was prepared to document this information. It contains details of each conference room, including locations of active ports, port numbers, PA configurations, contact information on administrative staff responsible for the room, and so on. The manual also includes standard protocols for creating video files and managing them in the system (eg, how to move files from live conference mode to the archived conference database). This resource is extremely important to keeping webcasting operations functioning smoothly when technicians go on vacation or when schedules become disrupted. Management and Administration Three groups define the course of the webcast conferencing initiative at UPMC. The first group is the technical development leaders and support staff, who are responsible for the development and operation of the system. The second is the telepathology steering committee, which is responsible for the overall direction of the system and its priorities. As discussed earlier, the telepathology steering committee consists of the department chairman, the anatomic pathology and clinical pathology directors, the division directors actively involved in telepathology and distance learning, and the system developers. It was organized in the late 1990s to manage implementation of teleconference-based telepathology systems in a growing number of UPMC hospitals and to manage telepathology, tele-education, and network pathology issues at UPMC. The steering committee is very important to the development group, because it provides legitimacy and support for telepathology and distance-learning initiatives. The committee meets every 3 months, with additional meetings as needed. Finally, and most important, there is the general user communitee of pathologists, researchers, and physicians the ultimate judges and definers of the system. User feedback is garnered through the web page, surveys, and direct interaction between users, developers, and the steering committee. RESULTS Overall Scope The webcast conference system became operational in March 2001 with an initial schedule of 3 weekly conferences. Favorable responses resulted in multiple requests to broadcast other conferences. The main limitation to additional conferences was the staffing required to produce a consistent, high-quality prod- 793

5 HUMAN PATHOLOGY Volume 35, No. 7 (July 2004) FIGURE 3. Portable video camera, tripod, and laptop PC (shown after a conference). uct. After consultation with the telepathology steering committee, it was decided to broadcast 5 regular, hourlong conferences per week, with 1 or 2 additional conferences per week on request. Figure 6 shows screenshots from a typical conference. The current regularly scheduled webcast pathology conferences are as follows: Current topics in laboratory medicine. A grand rounds environment in which faculty and residents present literature relevant to clinical pathology practices. Pathology departmental seminar. The main research seminar in the department, which often includes invited speakers from other institutions. Clinical pathology didactic lecture. A weekly teaching lecture in laboratory medicine. Anatomic diagnostic pathology conference. A grand rounds environment in which faculty present literature and case studies relevant to anatomic pathology. Anatomic pathology didactic lecture series. A weekly teaching lecture in anatomic pathology. To date, more than 400 pathology lectures have been webcast. All of these conferences have been archived and are available at the website. Usage Statistics In an average week, there are 80 to 100 completed requests for a live or archived conference, with a live to archived ratio of 40/60. Over the past year, requests have more than doubled, and the archived conferences have become increasing popular. Saturday and Sunday have the lowest number of visitors ( 10%), followed by Tuesday ( 13%), which is the one weekday that does not have a live conference. The most active day and time is Thursday from 11:30 to 1:30, the time of the anatomic pathology diagnostic conference. Importantly, physical attendance at these pathology conferences has not decreased. Webcasting thus has significantly increased the overall attendance (and, therefore, the importance and impact) of the academic conferences. Furthermore, other departments and institutions have seen the effectiveness of webcasting and begun to use the pathology webcasting service for their own conferences. DISCUSSION Managing Growth Webcasting of pathology conferences has been successful in the UPMC environment. With this success comes the challenge of managing increasing requests for new conferences and services within the confines of limited resources. It is becoming increasing easy to purchase and set up video servers, and there is always a temptation to capitalize more resources than can be maintained over time. The result can often be underutilization of resources and poor, unreliable service. At UPMC, the administrative body charged with directing and managing networked technologies, including webcasting, is the telepathology steering committee. As discussed earlier, the steering committee includes the chairman and division directors and has the ultimate authority on what systems will be implemented in the clinical department (the committee does not monitor the research labs) and what departmental resources will be expended. Although it requires time and effort of the part of senior faculty, the telepathology steering committee can be an effective mechanism for matching departmental telepathology and distance learning needs and resources. Another important administrative aspect central to the success of the system is that the system be treated operationally as a clinical system, with dedicated technician effort and user support provided directly through the UPMC help desk. From the very beginning, the system was treated not as a pilot or a project, but rather as an important, fully supported information technology resource for pathologists. 794

6 WEBCASTING PATHOLOGY CONFERENCES (Yagi et al) New services are continuously needed, requested, and approved if appropriate. Some of the most important ongoing developments include the upgrade of our RealNetworks server from the limited, free version to a more capable version that will allow up to 60 simultaneous users for real-time conferences. Three major trends have dictated this change. First, there has been a significantly increased number of pathologists using the real time system, especially for the anatomic pathology diagnostic conference. Second, other departments are considering this service for their own conferences. Finally, we are beginning to support regional and national medical conferences that attract far more activity. For example, in September 2003, the system was used to webcast the Second International Seminar on Head and Neck Cancer, hosted by the UPMC ENT Department, and there were more than 100 concurrent requests for real time access to the conference. Other services that have been implemented to extend the webcasting system include an improved database for archived conferences that will support more extensive searches (now in trials). This function is becoming increasingly important as the number of archived conferences increases into the hundreds. Other improvements include a comment submission feature on the web page and a service that will print (or burn ) the video of a conference onto a DVD or CD on request. Finally, CME credit is now available for all con- FIGURE 4. system. Workflow for a user of the conference webcasting Workflow for a technician webcasting a confer- FIGURE 5. ence. 795

7 HUMAN PATHOLOGY Volume 35, No. 7 (July 2004) FIGURE 6. Screen shots from a webcast conference. The technician webcasting the conference can decide whether to focus on the speaker or the slides. ferences that have been certified by the UPMC CME office (the 5 weekly conferences are all CME-certified). Registered users, after viewing a conference, can complete an on-line form that they can either fax or upload to the CME office. As part of the CME effort, an Oracle database documenting the activity of registered users on the web service has been developed. If and when it is implemented, this log will include the conferences accessed, the number of minutes viewed, previous CME activity, and the status of any CD/DVD orders. Projects in the planning stage include text messaging to allow remote audience interaction and voice recognition based scanning of conference videos to allow searching on the conference text. Security Initially, all conferences were available to all users within the UPMC network domain. However, during the system roll out, it was decided that although the scheduled conferences were academic in nature and do not use identified patient data, some of the conferences include discussions of topics that the steering committee felt should be limited only to pathologists and trainees. For example, there was concern that frank discussion of competing commercial assays might be compromised in a fully open environment. To support this requirement, the system was modified to support limited access to selected conferences to a list of UPMC pathologists and residents selected by a member of the steering committee. Access to conferences so designated now requires user registration at the web page with a user s UPMC network user ID and password. As the popularity of the on-line conferences began to spread, however, there was a growing desire among users to have access to archived conferences at home (outside the UPMC domain). Website administrators also received more than 70 s from around the world requesting that the conferences be opened to the public. Most of these requests came from physicians and patients who were searching a topic on the internet and found the web conference website. Today, most conferences are available (live and archived) in the UPMC domain and most of these are available, in archived form, though the public internet at teleconference.upmc.edu/pathconf/. A minority of conferences have restricted public access, as discussed earlier. Publication The debate on security and access reflects some of the ways in which webcasting changes the dynamics of the academic teaching conference. When the conferences are webcast and available in an archive, the speaker does not know the full extent (and nature) of the audience at the time of presentation. We therefore make it very clear to the speaker (and audience) that the conference is being webcast and that both the speaker and audience should proceed accordingly. Clearly, patient confidentiality must be meticulously maintained, but patient information is rarely, if ever, discussed in the type of educational conferences being webcast at UPMC. There are no patient identifiers, detailed case history presentations, or clinical photographs of patients. Any conference experiencing an 796

8 WEBCASTING PATHOLOGY CONFERENCES (Yagi et al) inadvertent breakdown in confidentiality would not be stored as an archive and thus would never become public, and the breakdown would be limited to the immediate live, UPMC audience. The use of copyrighted material presents similar issues. The use of copyrighted material is not common in the conferences being webcast. If it is known in advance that copyrighted material is to be incorporated in a conference, that conference would be limited to the pathology department through the mechanisms discussed above. Unexpected use of copyrighted material would cause the conference to not be archived, making it unavailable to the public. Finally, it is important to note that UPMC generates no income from the public availability of the academic conferences. There is no charge for the associated CME, and members of the steering committee (and, to our knowledge, our facility) have no meaningful relationships with the vendors that sell us hardware and software. Issues of security and access must be thought through carefully, yet is has been the conviction of the department that over time webcasting will drive academic conferences in positive directions. The decision of the UPMC Department of Pathology to make archives of certain conferences available outside the UPMC domain was driven in part by the desire to give other pathologists access to these educational resources. However, there is no good method for limiting access to pathologists (nor is there a desire to do so). Patients and family members searching for information about specific diseases can find archived lectures on the web, download them, and listen. Almost 10 years ago, the department began publishing educational pathology cases (with deidentified histories, diagnoses, discussions, and images) as teaching aids for pathology trainees. Today, there are more than 380 cases at path.upmc.edu/cases.html, and although these cases are actively used by trainees, the great majority of users (approximately 100,000 unique users/month) have from the very beginning been patients, families, and the general public. 5 We expect that some percentage of nonphysicians is interested in archived academic lectures as well. CONCLUSION As the physical bases of pathology departments evolve from stand-alone hospitals to large, regional medical systems spread across hundreds of square miles, new methods are needed to tie these increasingly distributed departments together as integrated units. A significant part of an academic department s identity and purpose resides in its academic and teaching conferences. As departments expand from buildings to counties, new technologies are needed to allow pathologists access to these conferences. Over the past several years, UPMC has developed an effective, low- cost, widely available webcasting system that has allowed increasing numbers of pathologists to experience the department s core teaching conferences regardless of their physical locations or personal schedules. Important factors in the success of the program have included the creation of a steering committee to control resources and manage growth, the availability of informatics faculty and support for technical staff, and the decision to operate the service as part of the core information technology infrastructure of the department. We expect that webcasting will become an even more important academic tool in the future as more conferences, seminars, and even operational meetings are communicated through the webcasting infrastructure. REFERENCES 1. Minervini MI, Yagi Y, Marino IR, et al: Development and experience with an integrated system for transplantation telepathology. HUM PATHOL 32: , Marchevsky AM, Lau SK, Khanafshar E, et al: Internet teleconferencing method for telepathology consultations from lung and heart transplant patients. HUM PATHOL 33: , Ricci MA, Callas PW, Montgomery WL: The Vermont Telemedicine Project: Initial implementation phases. Telemed J 3: , Mizushima H, Uchiyama E, Nagata H, et al: Telemedicine comes of age. Jpn J Clin Oncol 30:3-6, Dawson R, Gilbertson J, Kim S, et al: Pathology imaging on the web: Extending the role of the pathologist as educator to patients. Clin Lab Med 19: ,