Impacts of a Large Decentralized Telepathology Network in Canada

Introduction

Telepathology ^{1 –5} is defined by the American Telemedicine Association as “the electronic multimedia communication across a network of pathology-related information, between two or more locations for use-cases between pathologists and/or qualified laboratory personnel, and may include involvement by clinicians and/or patients.” ¹ This particular form of telemedicine has several applications: it can be used for distant primary diagnoses, expert referrals, quality assurance, and education. ² For distant diagnoses in the absence of a local pathologist or a telepathology system, slides must be physically sent to another facility, hence delaying diagnoses. With telepathology, the slides are examined remotely, and diagnoses can be swiftly provided. In some particular instances pathology examinations are performed while the patient is still undergoing surgery, and the surgeon needs a pathology diagnosis to properly resume his or her procedure. For these specific examinations, called intraoperative consultations (IOCs), delays are not an option. When there is no pathologist on-site and a surgical procedure requires an IOC, the patient is transferred to another hospital, a visiting pathologist is called on-site, or a procedure is performed in two steps (creating time for the slides to be sent and read elsewhere). In short, telepathology offers an alternative by enabling a preliminary diagnosis, provided by a distant pathologist and rendered from macroscopic and/or microscopic images of a frozen tissue section that has been processed rapidly during surgery. ³

Telepathology is a fast growing segment of the telemedicine field. Indeed, recent figures show that its market is expected to grow from $2.2 billion in 2013 to nearly $4.5 billion in 2018. ⁴ It has been implemented in many countries across the world. Canada is recognized as a world leader in this area, with several telepathology projects being deployed nationwide. The large geographic size of the country, combined with an unequally dispersed population and a shortage of pathologists in several remote regions, has contributed to the development of telepathology in Canada. ⁵

The province of Quebec, where the present study was conducted, is the second most populated province in Canada with its 8.2 million inhabitants. ⁶ In this article we report a benefits evaluation study of the Eastern Quebec telepathology network. This network covers a broad territory of 410,000 km², with a population of only 1.7 million inhabitants. In remote areas, population density ranges between 0.4 and 9.1 inhabitants/km². The project currently involves 18 operational sites, making it one of the largest telepathology networks in the world. A vast majority of the 48 pathologists involved in this project are concentrated in the teaching medical center located in Quebec City. Of the other sites, six have no pathology laboratory and no pathologist, seven have a laboratory but no pathologist, and four count one practicing pathologist. Each participating hospital was equipped with a macroscopy station (PathStand™ 40; Diagnostic Instruments, Sterling Height, MI) and two videoconferencing devices (PCS-XG80DS Codec; Sony, Tokyo, Japan) equipped with a drawing tablet (Bamboo CTE-450K; WACOM, Saitama, Japan). Each site was also equipped with either a Nanozoomer 2.0-RS or -HT digital whole-slide scanner (Hamamatsu Photonics, Hamamatsu City, Shizuoka Prefecture, Japan), and the images are saved on a local dedicated telepathology server. The whole-slide images are visualized at 1680×1050 pixel resolution with mScope version 3.6.1 (Aurora Interactive Ltd., Montreal, QC, Canada) software. More details about the telepathology modalities and software can be found elsewhere. ⁷ The equipment was deployed in the 18 sites in late 2010, whereas clinical activities began in January 2011.

Although the telepathology project covers the full range of applications mentioned above, its primary objective was to provide IOCs to community hospitals lacking on-site pathologists. A disruption in pathology services can have several negative impacts on surgeries, which may either be canceled or performed in two separate interventions because it takes time for the requested diagnostic material to arrive by mail. A service disruption can also cause some anxiety among patients and their relatives. Alternatively, a more invasive surgical intervention may be performed to avoid a second procedure, or the patient may be transferred to another hospital that has a pathologist on-site.

IOCs are performed on a regular basis; they are originating from 13 of the 18 operational sites, and there are 5 referral sites. Most IOCs are for breast cancers (sentinel lymph nodes, margin close to breast cancer), lung cancers (bronchial margins, mediastinal lymph nodes), ovarian, pleural, peritoneal, or omental lesions, or stomach, head, and neck cancers. ⁷ As of January 2015, in total, 1,733 IOCs have been performed via telepathology across the network.

The second goal of the project was to achieve substantial gains in terms of speed and quality of surgical services in remote areas, in particular by avoiding the need for two-step surgeries and the transfer of patients to urban centers. Lastly, the telepathology network also aimed at facilitating recruitment and retention of surgeons in remote regions.

Besides its size and scope, another important and distinctive characteristic of the telepathology network in Eastern Quebec is the decentralized organization of the IOC service. ⁸ Indeed, in contrast to other telepathology projects elsewhere in Canada ⁹ and abroad, ¹⁰ there is no single responding site to which community hospitals without pathologists turn for pathology services. Each requesting hospital is responsible for identifying one or more partner institutions with which it can sign service agreements. It was also initially decided that the teaching hospital located in Quebec City would be most helpful at providing expert opinions to pathologists working alone and to act as a safety net for regional hospitals with temporary interruption of IOC service.

The main objective of this study is to provide a deeper understanding of the perceived and actual impacts of this telepathology network on clinicians, patients, and the overall healthcare system in Eastern Quebec.

Materials and Methods

From a methodological standpoint, we adopted a mixed-methods approach. We first conducted a series of semistructured interviews with telepathology users (pathologists, surgeons, laboratory technicians) and hospital managers. Interview guides containing the specific issues to be discussed with each group of respondents were developed and used during the data collection phase. The data collection process continued until theoretical saturation ¹¹ was reached (i.e., when additional data no longer contributed anything new). All in all, 43 interviews (34 with clinicians and 11 with managers) were conducted during seven field visits.

The interviews were tape-recorded and then transcribed verbatim, producing 1,110 pages of transcripts. These were then coded and analyzed using a grid of success indicators for telepathology projects developed by a pan-Canadian committee of experts. ¹² Open coding was also performed so that any unforeseen themes that emerged from the data were also captured. ¹³ Coding was performed using the NVivo (QSR International, Doncaster, VIC, Australia) software package. Ethics approvals for this study were obtained from the lead author's academic institution.

Second, pre–post quantitative data on the impacts of the telepathology network (e.g., number of service disruptions, average time between initial diagnosis and surgery) were collected and analyzed, where available. These data were extracted from the admission, discharge, and transfer and laboratory information systems (e.g., OPERA, Omnitech, paper registers) of the hospitals involved.

Results

Prior to system deployment, the clinicians we interviewed had some concerns about system reliability. As one of the surgeons said, “I had no problem with the remote pathologist reading the slides, but I was a little concerned that the technology wouldn't work.” Following some initial technical problems during the start-up period, the system and technological infrastructure deployed in the various sites proved to be highly reliable. One of the most serious technical problems caused a 30-min delay during a planned IOC, which had no consequences for the patient. As for system friendliness, most users had only positive comments to share. Overall, they found the software to be both simple to learn and easy to use.

The quality of the digital slides generated by the system was also considered satisfactory by pathologists. Furthermore, a quality assurance investigation conducted by a small group of pathologists showed a 98% concordance rate between the 104 diagnoses made on the digital slides of the IOC cases and the corresponding final diagnoses rendered on paraffin material. ¹⁴ For the more complex or ambiguous cases often seen in hematopathology or pulmonary pathology, however, many pathologists mentioned that, in most cases, a precise diagnosis could not be rendered on digital slides with routine staining only because the paraffin blocks are often required to perform additional analyses. When faced with such cases, they would rather follow the “normal” procedure rather than use the telepathology system, as one pathologist reported:

I send all my consultations on complex cases by mail for the simple reason that the first thing that a pathologist working remotely will do is ask for special colorations or additional ones.

As mentioned earlier, the main objective of the telepathology network was to provide continuous coverage of IOCs in regional hospitals that do not have a pathologist on-site. Based on the data that we extracted from the admission, discharge, and transfer and laboratory information systems, it is clear that telepathology enabled continuous IOC coverage. In fact, no service disruptions were recorded in the requesting sites that used telepathology. As one surgeon noted:

When our pathologist left, we already had telepathology in place, so we had no cause for concern. And my patients didn't need to wait four weeks for a visiting pathologist to come to our hospital. As far as I know, not a single surgery was cancelled since telepathology was introduced.

The level of satisfaction with regard to IOCs enabled by telepathology was high among the surgeons we met. One explanation is that the wait time added by using telepathology is considered acceptable: “Telepathology adds about five or six minutes per report compared with when our pathologist was on-site,” one said. The data we extracted from the admission, discharge, and transfer and laboratory systems at one of the requesting sites showed that IOCs via telepathology took an average of 21 min compared with an average of 15 min for IOCs performed on-site. This result was also supported by the quality assurance investigation. ⁷

In order to assess whether telepathology delayed surgery scheduling compared with usual care, we measured the average wait time between the initial diagnosis (leading to the decision to operate) and the day of the resulting surgery. The data collected in one of the requesting sites were mainly for core needle biopsies and endoscopic biopsies. These analyses are performed on permanent sections prepared after processing in formalin and paraffin and not on frozen section material processed during a surgery. These must be interpreted within 24–48 h because they are used to determine whether cancer is present or not and to schedule surgery. In total, 16 cases were found in the preperiod (when the analysis were performed by an on-site pathologist), and 12 cases were found in the postperiod (when the analysis were performed remotely by a pathologist using telepathology). The average wait time for all these cases declined from 77 days (pre) to 62 days (post). Based on these results, it appears that performing diagnoses at a distance does not add to the wait time, as might have been expected by shipping biopsy material to a remote laboratory. Although this is an encouraging sign, more data need to be collected and analyzed to confirm this result.

The second objective of this project was to reduce the delays and increase the quality of client services in remote regions, by avoiding the need for two-step surgeries and the transfer of patients to larger urban hospitals. Although no reliable secondary data were available with regard to these particular indicators, all the surgeons we interviewed mentioned that the use of the technology helped avoid two-step surgeries and improved access to care services. As they see it, the added value associated with telepathology is mainly due to improved quality of care, as one of them explained:

Without telepathology, there may be two surgeries instead of one for the same patient; there may also be more invasive surgeries than we would have performed if we had received the opinion of a pathologist in a timely manner. This means a lot for our patients, and it can also make all the difference in the surgery itself.

According to the pathologists we met, telepathology helps prevent medical errors as one explained below:

When I send a request for a second opinion to a colleague, he quickly confirms the diagnosis. This way, you protect yourself [professionally], because these are mainly cancer cases.

The third objective of the project was to ease the recruitment and retention of surgeons in remote regions. During our site visits, we encountered at least one case of recruitment and one case of retention. Telepathology is perceived by our respondents as having positive impacts on an institution's ability to retain and recruit surgeons. Two surgeons working in remote hospitals noted:

Telepathology ensures that the pathology service is maintained, which is essential for surgeons and specialists. There are more specialties in hospitals that have pathologists than in those that don't. Telepathology should therefore help us keep specialists here, such as gynecologists. When you're thinking of putting down roots somewhere, you can be sure that whether or not the hospital has a pathologist is part of the equation.

It's our luck that we have access to telepathology. In my case, if we didn't have it, I definitely wouldn't have come to work here. I am an oncologist surgeon, so I simply wouldn't have.

For laboratory technicians, it appears that telepathology can also add value to their day-to-day jobs, as one reported:

We play a more important role, especially since we are responsible for manipulating large specimens used during intraoperative examinations. … These are new and major responsibilities that enrich our job.

For some technicians, however, telepathology is perceived as somewhat of a threat: “My fear is that one day our work will be transferred elsewhere, and then we'll be nothing more than specimen wrappers,” said one technician, echoing a pervasive fear that laboratories in remote regions might close following the departure of pathologists. In an environment characterized by limited resources, some technicians working at requesting sites also fear additions to their workload.

Discussion

The primary aim of this study was to better understand the perceived and actual impacts of one of the largest telepathology networks in the world. Our findings reveal that telepathology is highly useful in remote hospitals that do not have a pathologist on-site. Telepathology helps ensure coverage of IOCs, which improves quality of and access to care for populations living in remote areas. As mentioned earlier, however, certain limitations inherent in the available technology mean that telepathology cannot be substituted completely for diagnoses performed under a microscope.

The benefits highlighted in this study should not leave the impression that implementing telepathology is a trivial matter. On the contrary, many problems may be encountered as reported elsewhere. ⁸ On a technical level, for instance, it is vital that the technology and software components perform well and are reliable once the system is up and running. Early technical disruptions must be prevented so to ease user buy-in into the system. There needs to be a breaking-in phase and some testing before telepathology can be used for IOCs. As for the postdeployment phase, our interviewees often noted that quality technical support represents a critical success factor.

From a user perspective, one should not underestimate the effort required to learn how to use the technology and the effect that this has on clinical practices. We observed deeply rooted work habits that lead to some resistance, mainly among technicians. As stressed by Meyer and Paré, ⁸ the success of telepathology is also associated with the development of a relationship of trust between the various stakeholders. For example, the surgeon must trust the pathologist taking part in an IOC, and the pathologist, in turn, must trust the technician preparing the slides or handling challenging specimens. In this regard, the effort required for change management should not be underestimated. Failing to do so may create an unfavorable context. According to our respondents, the presence of a clinical champion in each site is another key condition for success.

Implementing telepathology also carries many challenges for hospital administrators such as identifying partners and signing contractual agreements between referring and consulting institutions, harmonizing clinical practices between partners (e.g., cutting of specimens), building a telepathology laboratory (if there is none), and reorganizing work, at both the requesting and the responding sites. Several committees played key roles in implementing the telepathology project in Eastern Quebec. For instance, a project management committee was formed of a medical director for the project, a project manager, and an information technology specialist. The committee's main responsibilities were to plan deployment of telepathology in the area served, to coordinate and oversee collaboration in accordance with the plan, to prepare a risk and change management plan, and to report periodically on project progress to the ministerial authorities. During the predeployment phase, committee members visited each of the teams responsible for implementing telepathology in each hospital. It is important that a steering committee, made up of 18 pathologists from all the concerned regions, was also formed. The committee had a mandate to propose organizational models, draft a clinical protocol for telepathology, advise the executive committee and the management committee, and monitor network deployment activities to ensure a coherent implementation. This committee also took part in the final selection of equipment and software, assisting in clinical and technical assessments.

With the increasing complexity of medicine in general, and pathology in particular, one pathologist explained that such specialization runs the risk of contributing even more to the current shortage of pathologists in remote regions, justifying the continuous investments in telepathology in the coming years:

Young pathologists are specializing more and more. I'm a product of the 90s, a time when we did everything. Nowadays, pathologists are often better in one specific branch within our field. In this context, sending a pathologist to a remote region is not very appealing.

To conclude, the deployment of the telepathology project in Eastern Quebec has helped to ensure continuous coverage of IOCs in remote hospitals that do not have a pathologist on-site and, consequently, prevent service disruptions. Surgeons who used telepathology during IOCs believe that this approach helps them improve the quality of care they provide to patients, in particular by reducing the number of two-step surgeries and patient transfers to larger urban centers. From an organizational perspective, telepathology has also contributed, at least to some extent, to the recruitment and retention of surgeons in remote regions. Notwithstanding such encouraging findings, more empirical research is needed to investigate the benefits and challenges associated with the implementation of large decentralized telepathology networks.