Telemedicine and diagnosis

Adriana Albini

September 27, 2022

The adoption of telemedicine and its range of applications grew exponentially in the early days of the Covid-19 pandemic, and the general consensus now is that it is here to stay, albeit perhaps with a more hybrid bias of in-person and remote visits. Telediagnosis, or TeleDx, i.e., the identification of a disease at a site remote from the patient, has expanded to include primary care, revolutionising the way in which patients and doctors communicate with each other and establish rapport. It is still early days to fully evaluate the effect of virtual vs in-person visit on diagnostic error, but there are guidelines for health professionals to conduct effective virtual examinations, and many best practice examples, both in terms of ways to gather information from the patient (from wording of questionnaires to digital records, home environment, and so on) and technological innovations.

In cancer care, pathology plays a central role in the final diagnosis upon which clinicians will develop treatment for their patient, and remote pathology can offer many advantages, such as easier access to pathology experts, consultation among specialists, timely and secure availability of images, and so on. Up until the 1990s, pathologists worked almost entirely within the constraints of the analogue world, with physical glass slides and microscopes. Some attempts were made at capturing virtual images of slides through a tiling method, which was time consuming and prone to error, as it required accurate placing and extensive stitching together of images. But at the end of that decade, engineer Dirk G. Soenksen (founder, and CEO of Aperio) devised a much more efficient system based on a linear scanner, the ScanScope, that allowed for tightly focussed and fast slide image capture, opening a new era for the practice of pathology. Whole slide imaging, or WSI, was first employed in education and research but in recent years, with the improvement of its technology, it has received regulatory approval by the FDA and around the world for diagnostic use as well. The potential for feeding AI algorithms to provide diagnostical support is massive, as virtual slides are accumulating fast and standardised databases are being built.

“Telemedicine in Cancer Care Continuum: implementation and integration”, was an online conference developed by the SPCC in collaboration with the American Society of Clinical Oncology (ASCO), which took place on 6-7 May 2022. In his presentation, Liron Pantanowitz, Professor of Pathology, and Director of Anatomical Pathology at the University of Michigan, talked about telepathology in both its non-acute and acute settings, focussing more extensively on the latter. The term ‘telepathology’ was coined by Ronald S. Weinstein in 1986, after he organised the first public event of satellite-enabled dynamic-robotic distant pathology, but the very first live telepathology ever performed dates as far back as to 1968. Massachusetts General Hospital set up a two-way television link with Boston’s Logan Airport that enabled doctors at the hospital to remotely study blood smears, urine samples and X-rays for patients at the airport, and even listen to their heartbeat with an electronic stethoscope. However, as in the case of telehealth in general, the adoption of digital pathology had to wait until the Covid-19 pandemic to be widely implemented. To facilitate continuity of healthcare while social distancing, certain restrictions were lifted, such as CLIA in the US, allowing pathologists to work from home and sign out cases.

The first use of telepathology Prof. Pantanowitz looked at was for frozen section consultation. There are several challenges when a pathologist is asked to provide an intraoperative consultation. The pathology specimen is fresh, not easy to cut. The frozen section itself is difficult to prepare and is often filled with artifacts. These artifacts not only make it hard to read the glass slides but can compound the problem when using digital images. The turnaround time needs to be rapid. Usually, pathologists strive for less than 20 minutes to provide the surgeon with an answer. And they are under serious diagnostic pressure because if they get it wrong, it is difficult to reverse the surgical decision that has been made based on their diagnosis. Over the past 54 years different modes of practising telepathology have been developed. A pathologist on site can take static images, which is easy but too time-consuming. There is also video microscopy, live streaming from one pathologist to another. If there is no pathologist present on site to read the slides, there are systems such as robotic microscopy, where the pathologist can remotely take control of the functions on a microscope, such as navigation and focus. And there is also Whole Slide Imaging, which is the entire digitization of a slide to be remotely reviewed. Thanks to advancements in technology, hybrid devices are now available from many vendors with robotics and Whole Slide Imaging functions in one scanner.

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