Application of Medical Information System for Telepathology—Georgian Experience

Introduction

There is a very clear need for the expanded application of information technology (IT) in healthcare. Clinical workflow still depends largely on manual, paper-based medical record systems, which is economically inefficient and produces significant variances in medical outcomes. Medical information system (MIS) is at the heart of IT implementation policies in healthcare systems around the world. Most of these policies are based on beliefs about the positive value of MIS rather than on the available empirical evidence; as a result, policy documents comprise aspirational statements rather than detailed and realistic expectations. ¹

It is obvious and well known that the field of healthcare informatics is rapidly evolving. The new models and protocols of MIS are developed. They are based on implementation of profiles such as HL7 and digital imaging and communications in medicine (DICOM). Despite obvious advantages and benefits, practical application of MIS in everyday practice is slow. Research and development projects are ongoing in several countries around the world to develop MIS: examples include Canada, Australia, England, the United States, and Finland. ² MIS is used primarily for setting objectives and planning patient care, documenting the delivery of care, and assessing the outcomes of care. It includes information regarding patient needs during episodes of care provided by different healthcare professionals. ³ The amount and quality of information available to healthcare professionals in patient care has an impact on the outcomes of patient care and the continuity of care. The information included in MIS has several different functions in the decision-making process in patient care. It also supports decision making in management and in health policy.

Telepathology is a branch of telemedicine that involves the exchange of microscopy digital images through telecommunication for diagnosis, consultation, research, and/or education. The concept of telepathology to provide diagnostic services to remote locations was first described in the United States in 1968, ⁴ when monochrome images were transmitted in real time using a dedicated point-to-point microwave link. In little more than a decade, telepathology has developed from the prototype commercial system first described in 1986 ⁵ to today's multimedia computers, which can be purchased off the shelf at very low prices and can be used as the basis of telepathology systems. ⁴ There are technological concerns that may prevent the acceptance of telepathology by pathologists and thus hinder its application within the routine environment. Some pathologists believe that telepathology is too expensive and that it does not have a useful role in routine pathology. Others have doubted if computer monitors can be used for diagnosis. Results shown that there is no significant difference between a pathologist's performance using a microscope or a digital image. Many of the concerns expressed about the use of telepathology are not derived from knowledge. There is a need to involve as many pathologists as possible in the use of such systems. Many pathologists believe that fast access to expert opinion is the key to reduce the number of diagnostic errors. The last ones have been estimated about 5%. Although most of diagnostic errors are not critical to the patient, some could be. ⁴

It is well known that telepathology may be static (store and forward), dynamic (real time), or hybrid. Store-and-forward telepathology is a less-efficient method, but 95%–100% concordance between glass slide and static telepathology diagnosis has been reported. Static telepathology has limitations because of the disjointed nature of images. The diagnostic errors incurred with this method have been attributed to inappropriate field selection by the submitting pathologist. Dynamic telepathology using fully motorized robotic systems is cost prohibitive, but it has revolutionized the field. A concordance rate of 99%–100% has been reported between dynamic telepathology and light microscopy diagnosis. ⁶ Hybrid systems use virtual slides (the so called whole-slide images). Their diagnostic efficacy was shown in various studies. ⁷ The virtual slides are entirely digitalized glass slides at a very high resolution and can be viewed by multiple pathologists without any loss of resolution. ^8,9 The fully motorized robotic and hybrid systems are cost prohibitive for Georgia. However, these systems are routinely used in other locations, especially in countries with middle and high incomes.

The applications of telepathology can be classified into four major groups: primary opinion (first diagnosis on a case), second opinion (expert opinion about a case), third opinion (expert group opinion/discussion about a case), and distance learning. ¹⁰ Most frequently, telepathology is used for second opinion. ¹ In remote and rural areas telepathology is considered a boon. E-learning in pathology has also gained acceptance. Telepathology has been used for research applications, distance education, and remote consultations with astounding success.

Georgia is not lagging far behind in the field of telepathology. The first telepathology consultation was done in 2003. Since then, a number of distance consultations were implemented.

Objective

Healthcare IT models are constantly evolving as the industry expands. MIS is a comprehensive solution that automates the clinical, administrative, and supply-chain functions. It enables healthcare providers to improve their operational effectiveness, to reduce costs and medical errors, and to enhance quality of care. The aim of MIS was and is as simple as relevant: to contribute to and ensure a high-quality, efficient patient care. The relevance of “good” MIS for high-level quality of care is obvious. Without having appropriate access to relevant data, practically no decisions on diagnostic, therapeutic, or other procedures can be made. In such a situation, consequences will be fatal for patients.

MIS has been launched in Georgia. Its primary goal is patient management. However, the system is also targeted at creating a unified information space in the framework of the wider medical organization. The application of MIS in everyday practice of Georgian healthcare organization has been started in October 2008.

It is well known and obvious that telemedicine services are rapidly becoming an integral part in many hospitals and clinics around the world. ^11,12 In many programs, telepathology accounts for over 50% of all teleconsultations. Most studies of telepathology have focused on usage of robotic microscopes and online microscopy. ^13,14 Other studies have evaluated the use of digital images of slides. ¹⁵ The goal of this article is to present the application of MIS for telepathology under the conditions prevailing in Georgia. It shall be emphasized that in Georgia telepathology is used mainly for consultations in several centers in the form of static telepathology because of some limitations. This article presents the data of a pilot study. In its frames the concrete electronic medical records (EMRs) illustrated by the images have been used for telepathology consultation.

Materials and Methods

The MIS has been created with .Net technology and SQL database architecture. It involves a multiuser Web-based approach. This ensures local (intranet) and remote (Internet) access of the system and management of databases. .Net technology can be installed on computers running Microsoft Windows operating systems. It includes a large library of coded solutions to common programming problems. .Net technology is a Microsoft offering and is intended for usage by most new applications created for the Windows platform. Version 3.0 of the .Net technology included with Windows Server 2008 has been used for creation of MIS. The MIS is object-oriented software. It is realizing, client-server concept. Its architecture provides a secure, robust, and extensible system for managing multiple medical terminals within a centralized repository. The MIS has a flexible architecture that can run on numerous combinations. The recommended server operating requirement is Windows Server 2003. Hardware requirements are the following: memory, 1 GB; disk space, 1 GB. Internet Explorer 6.0+ and/or Mozilla Firefox 2.0+ can be used as client browsers. MIS was started to create in December 2007, and the draft version was released in April 2008. After some tests and corrections, the application of ready-for-use version of the MIS started in October 2008.

Two hundred electronic medical records (EMRs) with cytology diagnosis and illustrated by images were selected. After routine cytology investigation the slides were photographed using a 2.0 USB digital eyepiece microscope camera with resolution 3.0 MP. The images had a resolution of 2,048 × 1,536 pixels. The average number of images per case was five (183 cases, 91.5%). Each series of images per case began with a general view, followed by higher magnification of diagnostically interesting and actual areas. These areas were chosen by a cytologist. The images were taken by laboratory personnel trained in using the camera. The images were stored in a personal computer (Pentium IV). They were adjusted using Adobe Photoshop and uploaded to the corresponding EMR. The adjustment was mainly to improve contrast and brightness. This manipulation has been done by laboratory personnel. For security reasons the experts have been registered as users at MIS. E-mail notifications that cases are available for review have been sent to experts after uploading adjusted images to the corresponding EMR. The selected for telepathology cases were listed at home page of MIS.

Results

The MIS consists of three key modules:

Administration and configuration module

The administration and configuration module is dedicated for setting up users' basic rights. It allows users registration or blocking, defining, and configuring of their rights. All medical forms (consultation, clinical investigation, diagnosis, prescription, treatment, etc.) are generated by this module. It is a database of staff too. Each employee is provided a unique code, alongside with gathering biographical and professional data.

Using the working module, medical history can be generated, edited, and updated by medical personnel. At generation, a unique code is given to medical history. It consists of text and multimedia files—images, video, and voice. Planning of patient visits and schedule of staff are also implemented by this module.

Medical history and medical forms (consultation, examination report, etc.) can be fully or partially exported by the reporting module. The documents can be exported in various file formats, including pdf, rtf, and jpg. This module also implements statistical analysis of medical data (patient's age, sex, diagnosis, date of investigation, treatment parameters, etc.). It can be used for quality control of medical services. The functions of each module of the MIS are illustrated in Table 1.

From February 2009 to May 2009, 200 cases of cytology were cared by application of MIS. These were cases of gynecological cytology. All slides were conventional Papanicolau (PAP) tests. The slides were photographed with a 2.0 USB digital eyepiece microscope camera with a resolution of 3.0 MP. The images had a resolution of 2,048 × 1,536 pixels. The average number of images per case was five (183 cases, 91.5%). Each series of images per case began with a general view, followed by higher magnification of diagnostically interesting and actual areas. The cytologist selected these areas. The images were captured by laboratory personnel trained in using the camera, and they used Adobe Photoshop to adjust image contrast and brightness. Adjusted images were uploaded to corresponding EMR. All 200 EMRs were marked as cases for telepathology consultation. For security reasons, telepathology experts have been registered as users at MIS. Four Georgian certified cytologists were selected as experts for second-opinion consultations. Cases selected for telepathology were listed at MIS home page.

For quality control, each telepathology expert subjectively assessed the image quality. Image sharpness and quality were rated using a 4-level scale: 1, excellent; 2, good; 3, fair; 4, poor. The average number of consultants per case was three (172 cases, 86%). In 144 cases (72%) the first comment was made in <8 h. In 180 cases (90%) the primary diagnosis has been confirmed as a result of telepathology consultation. In 15 cases (7.5%) the diagnosis has been corrected. In five cases (2.5%) the images were of poor quality and insufficient for remote pathology consultation.

Overall, 97.5% of the cases were rated as having excellent or good image sharpness and contrast, with 2.5% being rated as fair or poor. With respect to image color, 95% of the images were rated as excellent or good, with only 5% being rated as fair or poor. There was a high positive correlation (r = 0.83) between color, sharpness, and contrast ratings. Images with excellent or good ratings generally received excellent or good color ratings. There were relatively low correlations between color (r = 0.27) and sharpness/contrast (r = 0.32) ratings and the decision confidence values.

Discussion

The practical application of MIS by medical clinic in Georgia started in October 2008. It is successfully used for

Clinical decision support—provides users with tools to acquire, manipulate, apply, and display appropriate information to aid in making accurate, timely, and evidence-based clinical decisions.

By the term “EMR” we describe a computerized legal medical record created in the clinic. Usually, however, the term “electronic health record” (also electronic patient record or computerized patient record) is used. EMRs are a part of an MIS that allows storage, retrieval, and manipulation of data. This is an evolving concept defined as a longitudinal collection of electronic health information about individual patients or populations. Such records may included a whole range of data in comprehensive or summary form, including demographical data, medical history, medication and allergies, immunization status, laboratory test results, radiology images, and billing information. In accordance with our model, EMRs are generated and maintained within clinic. This is a complete record that allows managing and follow-up workflow in healthcare settings and to increase patient safety through evidence-based decision support, quality management, and outcome reporting. EMRs can be continuously updated. A centralized data server solution is used for EMR's storage.

It has been revealed that the MIS has yielded significant benefits.

Easy access to patient data. The system provides convenient access to medical records at all points of clinic. Internet-based access improves the ability to remotely access such data.

Despite of such benefits, there are still barriers that prevent the MIS from being rolled out in every healthcare organization across Georgia.

Initial cost of acquisition. High price of the basic infrastructure is a stumbling block for many healthcare organizations.

Before practical application of MIS, education and training of staff is essential. The system is a very useful and easy-for-use tool. It ensures a situation where healthcare professionals spend more time for creating knowledge from medical information than managing of medical information. Further, MIS holds the potential to reduce medical errors.

Telepathology can be conducted using different technologies. The levels of image quality and cost vary. Perspectives and strategies of telepathology are currently evolving. The emerging operative requirements would allow self-sustainable large-scale exploitation, but recent technological developments are available to support integrated and cost-effective solutions to such requirements. However, after successful technological demonstration phases, only a few telepathology services have proceeded to large-scale exploitation. ^16,17 Telepathology is of decisive importance for ensuring of safe medical care. Use of telepathology consultation has many advantages over conventional light microscopy. The International Union Against Cancer has estimated that at least in 5%–10% of cancer cases a pathologist need consultation during routine work because of uncertainty (http://medstage.de/public/html/UICC/). Sending glass slides or paraffin blocks by mail or courier to experts in the field is time consuming especially in critical specimens for pathologists working alone in distant hospitals with no facilities for intradepartmental consultation. ¹⁸ Further, the probability of loss and damage is always present.

Today, telepathology seems to be the basic solution for this problem. Conventional pathology with glass slide has many limitations. For example, they may be easily broken, their stain is unstable and could fade with time, and the tissue mount can bubble and dry out. Finally, certain procedures such as fluorescent stains are not stable more than a few days. In such situation, the best replacement for conventional slide pathology is telepathology. The appearance never changes as long as the data integrity is maintained. However, despite mentioned advantages, telepathology in Georgia is not popular. In this study we evaluated the application of MIS for telepathology consultations in Georgia. It has been revealed that the mentioned system can be easily and effectively applied for remote consultations in pathology. We concluded that the MIS is a useful and applicable tool for distance consultations in difficult cases. It significantly increases knowledge exchange and thereby ensures a better medical service.