Introduction. Description of the Technology

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1 Telepathology Education: Reaching Out to Cytopathology Programs Throughout the Country Donna K. Mulford, M.S., CT(ASCP)CMIAC Editor, The ASC Bulletin University of Rochester Medical Center Introduction In the April 2004 issue of The ASC Bulletin, Dr. Eva Wojcik published an article entitled Virtual Microscopy Is it Time to Discard Our Microscopes? Telepathology technology has made that vision possible. Telepathology is defined as the use of telecommunications technology to facilitate the transfer of image-rich pathology data between remote locations for the purposes of diagnosis, education and research. 1 It is an important aspect of telemedicine and continues to gain in popularity. The current level of technology provides fast, convenient, and economic application of diagnoses via telepathology. Internet transmission of digital images makes it possible to consult healthcare professionals anywhere in the world. Description of the Technology Telepathology systems are divided into three main types: static image systems, real-time systems, and virtual slide systems. Static image systems have major benefits of being the most reasonably priced, and usable in the widest range of settings, but have the significant drawback of only being able to capture a selected subset of microscopic fields. 1 Real-time systems and virtual slides allow a consultant pathologist the opportunity to evaluate the entire slide. With real-time systems, the consultant actively operates a microscope located at a distant site, changing focus, illumination, magnification, and field of view. Virtual slide systems use automated scanning to capture an overview image of the entire slide, which can then be forwarded to another location for diagnosis. 2 While real-time and virtual slide systems appear ideal for telepathology, there are certain drawbacks to each. Real-time systems perform best on local area networks, but performance may suffer if employed during periods of high network traffic or Internet usage. Scanning of virtual slides, at this point, is a relatively time-intensive and costly operation, requiring anywhere from minutes to hours to accurately scan a single slide. 1 Although many have observed this evolution with skepticism and doubt, the field has emerged as a legitimate and contributory component of the practice of pathology. 3 It can provide urgent services at sites that do not have adequate coverage, provide back-up coverage, assist in generating a second opinion, and assist in education. In fact, students from across the country are using laptop computers or video projection from a computer to view images broadcast at educational sites miles away. We are witnessing this through distance learning. The Millenium students are familiar with virtual technology and have embraced it, as have the educators who are responsible for teaching these students. These technologies can enhance and expand the learning experiences of cytotechnology students, residents and fellows. 1

2 Valuable continuing education possibilities for healthcare professionals are possible through telepathology. Individuals learn what they need to know from textbooks, lectures, and hands-on experiences in traditional educational settings. As part of the learning process, they often spend hours reviewing reference material and the medical literature for information that can lead to a correct diagnosis. The Internet and CD-ROM technology can relieve this time-consuming task. Virtual E-Books and journal articles are available on the Internet; the information can be searched and viewed rapidly. Today s practitioners are looking to locate information quickly. Medical information changes so fast it is often difficult to stay ahead of the many new discoveries. One does not have to find a manual or a reference book just consult the computer sitting right beside the microscope. Under the direction of Barbara Guidos and the ASCPSTAR GYN Committee, the American Society for Clinical Pathology (ASCP) recently initiated a cytology resources outreach program for cytotechnology schools. This initiative began in 2004 with a glass slide gyn offering to cytotechnology training programs. The plan was to provide cytology students and eventually residents/fellows from around the country with the opportunity to view the same slides from the ASCPSTAR slide library. Programs receive performance reports on their students, and statistics on the cases, from a national database of slide performance statistics. In actuality, using glass slides to achieve this proved difficult. However, by adding a telepathology component combining both static and real-time imaging, the vision for providing cytology education programs with unique cases from a national database was accomplished. Working together with Olympus, Inc. this effort has expanded to the Rochester Cytopathology Consortium s American Society of Cytopathology (ASC) Center of Excellence. Olympus, Inc. and Soft Imaging System Corp. (SIS) have made this possible with NetCam, an exciting new feature included in the MicroSuite FIVE imaging software. 4, 5 Using the TCP/IP Internet protocol, NetCam allows the Olympus DP70 camera and SIS FireWire cameras to broadcast live images over the Internet via an assigned static IP address. Up to fifty remote client computers can simultaneously log on and view a live image using a standard web browser and the IP address of the microscope imaging system that is running NetCam. The primary user is able to manually or automatically adjust the focus, exposure time, lamp voltage, and other options on the microscope as well as capture static images with the camera. Remote viewers can view the live and captured images passively, but unlike the primary user their client computers have no microscope or camera control. The primary user can make adjustments at the microscope if the client is unable to view the image. The live transmitted image is limited to a pixel resolution of 800 x 600 pixels. The captured image can be observed on the client s computer either compressed or at full resolution. Captured images can be sent to others via , or be transmitted by other standard Internet means. The primary user must install the MicroSuite software on the server computer that will be used to broadcast the images. Each client computer must have a Java-enabled 2

3 web browser, with Java Runtime Environment or higher (Java is a free download). The client computer does not need to have MicroSuite. Once NetCam is enabled, a client can connect to the server via the Internet Explorer web browser by entering the IP address of the server (e.g., If the NetCam server is behind an institutional firewall, the network administrator will have to set up a Virtual Private Network (VPN), or open ports 80 and 5879 to allow remote access. The primary user can monitor the clients who are logged on, and may ban or disconnect clients who should not have access. If transmission is slow, the image may be compressed to improve transmission, resulting in a slightly lower quality. The DP70 Camera is a 12-bit high-resolution color camera designed for biomedical and material sciences applications. 5, 6 It has a compact design and can be connected to all types of light microscopes with a standard C-mount. The native resolution of the camera is 1360 x 1024 pixels, but it can capture four different resolutions, through binning or pixel-shifting technology. Building upon the functionality of earlier versions of the MicroSuite imaging software, the current version offers solutions for both monochrome and color image acquisition and processing. With fully integrated camera control, most CCD and video cameras are supported. The software features a user-friendly graphical user interface, and follows standard Windows conventions. In addition to an extensive selection of image processing filters and display tools, there are tools for interactive and automated measurements, with automatic generation of data and statistical results, all exportable to Microsoft Excel. Annotation capabilities include arrows, text, and highlighting. The software has report generation capabilities, using standard and user-designed templates, with the option of including images, histograms, text boxes, and database fields. Reports can be exported to Microsoft Word as Rich Text Format. Finally, the user has the option of archiving images and related spreadsheets, graphs, and diagrams to a fully searchable user-definable Structured Archive (STAR) database or to a web-based database. 4 Discussion Cytology students, residents and fellows can sharpen their skills through digital imaging technology. They are evaluated on their ability to recognize disease processes through the microscopic evaluation of patients specimens. The use of different viewing modalities will allow the students an opportunity to gain additional experience in identifying abnormalities. Most students do not have access to rare and unusual lesions or interesting cases. The library of slides in schools may be limited. With digital imaging technology, students have the opportunity to view slides of a wider variety of cases. The quality of digital images has improved significantly with technological advances, and those who participated in the panel luncheon entitled New Horizons in Digital Imaging at the 53 rd Annual Meeting of the American Society of Cytopathology can attest to the excellent digital quality the DP70 camera with NetCam provides. During this presentation, both live and static images were transmitted from the Rochester Cytopathology Consortium in Rochester, New York, to San Diego, California, through 3

4 NetCam. The workshop participants were able to view the slides in real-time, and appreciate the quality of the images and the value of the system with respect to telepathology. Using the Internet as a telecommunications network for static images is a low cost, widely available alternative for consultations. Several international telepathology services have been established, and institutions such as the University of Pittsburgh Medical Center and others provide routine consults over the Internet using static telepathology. 3 Several studies have shown diagnostic accuracy rates from % using various telepathology methodologies. 3 Telepathology systems have also been used in the examination of cytologic preparations, with inconsistent diagnostic rates. Although telecytology is a promising tool, there are limited references available. Raab et al. reviewed 50 cervical-vaginal smears in their study and showed a wide range of individual performance, concluding that accuracy of telecytology is high, but less than that of the light microscope. 7 Lee and colleagues reviewed 50 selected cervical smears ranging from benign to malignant, published kappa statistics, and showed moderate to excellent agreement between diagnoses from glass slides and digital images. These authors suggest the use of telecytology as an alternative method for the cytologic diagnosis of cervical smears, particularly in quality assurance programs. 8 In the Rochester Cytopathology Consortium and ASCP pilot project, several cytotechnology programs across the United States have access to the primary NetCam site through the Internet. These schools include the State University of New York - Upstate Medical University Program in Cytotechnology, the Albany College of Pharmacy Cytotechnology Program, Akron General Medical Center School of Cytotechnology, Thomas Jefferson University Cytotechnology Program, the University of Tennessee Health Science Center Cytotechnology Program, Memorial Sloan-Kettering Cancer Center School of Cytotechnology, University of North Carolina at Chapel Hill Cytotechnology Program, University of North Dakota Cytotechnology Program, and the Interservice Cytotechnology Program at Brooke Army Medical Center. Other programs that have been invited to participate in future NetCam sessions offered through the Rochester Cytopathology Consortium or jointly with ASCP, include the University of Connecticut Health Center Cytotechnology Program, the University of Puerto Rico School of Cytotechnology, Indiana University School of Medicine Cytotechnology Program, the University of Kansas Medical Center Cytotechnology Program and DMC University Laboratories Program in Cytotechnology. Schools will be invited to attend the sessions at a gradual rate and as the sessions continue, the number of schools participating will increase, until all the cytotechnology programs are logged on to the NetCam system. To date, involved students are comfortable looking at images transmitted from miles away. During the sessions, they have the opportunity to answer test questions that pertain to these images. Although most pathologists and cytotechnologists would prefer to look at the actual glass slide, images viewed on the computer screen are of excellent quality and are a nice addition to teaching. The educational benefits using this system are that students 4

5 across the country can view images that might be from rarely seen conditions, and participate in the same question and answer session as other participants across the country. The cytotechnology schools are on different schedules, and some of the programs have chosen not to participate if the topic being presented has not yet been covered in class. The schools have sent back evaluation forms for the pilot project and have welcomed the NetCam sessions that have been presented. To date, gynecologic sessions and one respiratory session have been presented. The sessions include conference call access for communication between the provider and the schools. Sessions scheduled for presentation in the upcoming months include body cavity fluids, breast fine needle aspirations and core needle biopsies, thyroid fine needle aspirations, and abdominal fine needle aspirations and immunocytochemistry applications. A review of gynecologic cytology will be presented later this summer, prior to the American Society for Clinical Pathology Board of Registry examination. Schools can participate in sessions as the topics are covered in their curriculum. Summary/The Future Computer-enhanced medical education is the future, and telepathology is allowing cytology schools from across the United States to join together for cytologic educational sessions provided by a Center of Excellence. Using the vast image and slide library from ASCP will expand the technology s capability of providing educational programs with additional benefits, including benchmarking data. However, acceptance of this new technology by many may be a challenge. Years ago, my Program Director, Dr. Denis Coble, at the School of Cytotechnology at the State University of New York Upstate Medical Center, handed me a poem at graduation entitled, A Parting Comment. A portion of his comment read, Know what you know, know what you don t know, and know where to find what you don t know. Computer technology has been able to provide much of what I don t know, and telepathology may be an option for schools to incorporate knowledge from the Centers of Excellence sites and enhance the education of the next generation of cytotechnologists and cytopathologists. ASCPSTAR will offer cytology educational programs in 2006 that include the use of telepathology and other electronic technologies to create multi-media programs. This will not only benefit educators and students, but all cytology professionals who wish to participate. As the profession becomes more familiar with telepathology and its applications, sessions in all areas of gynecologic and nongynecologic cytopathology can be incorporated into educational curricula. Telepathology systems can also provide participants with sessions in advanced areas that may not be available for detailed instruction at their own institutions, and for sessions with pathologists who are experts in the field of cytopathology. We must welcome this changing technology and embrace it so that we will be able to provide the best education to our cytotechnology students, residents, fellows, and ourselves. References 5

6 1. Definition of Telepathology, Medicine Net, Inc. Web site. Available at: Accessed 2/1/ Wojcik, EM. Virtual Microscopy Is it Time to Discard Our Microscopes? The ASC Bulletin. 2004; 41: Kaplan, K. Telemedicine Applications in Cytology. The ASC Bulletin. 2004; 41: Welcome to MicroSuite FIVE- Software for Imaging Applications. Olympus, Inc. Web site. Available at: Accessed 2/01/ Soft Imaging System Web site. Available at: Accessed 2/01/ DP70 Digital Camera. Olympus, Inc. Web site. Available at: Accessed 2/01/ Raab SS, Zaleski MS, Thomas PA, et al. Telecytology: Diagnostic Accuracy in Cervical-Vaginal Smears. Am J Clin Pathol. 1996; 105: Lee ES, Kim IS, Choi JS, et al. Accuracy and Reproducibility of Telecytology Diagnosis of Cervical Smears. A Tool for Quality Assurance Programs. Am J Clin Pathol. 2003; 119: For additional information about the Rochester Cytopathology Consortium s NetCam project, please contact Donna Mulford at Donna_Mulford@URMC.Rochester.edu. 6