E-health based innovations in pathology to promote early diagnosis of cancer – Exchange of experience and developing strategy plan and competence development programs to implement digital pathology in consultation practice and intraoperative pathology tele-diagnostics
Permanent shortage of specialists in pathology and an ever increasing need for more and more detailed pathology reports of tissue samples in possibly short turnaround times calls for new techniques such as digital pathology to best organize professional competence on a nationwide level. Digital pathology networking may help remote access to specialized knowledge by means of teleconsultation and also support the efficiency of quality initiatives in the pre-analtical, analitical and interpretational activities. The newly planned competence development for histotechnicians to participate in intraoperative pathology telediagnostics may open new dimensions in rapid on-site pathodiagnostics. Both pathology networking and intraoperative pathology telediagnostics are expected to significantly enhance effectiveness of cancer patient care.
The health status of the Hungarian population is extremely unfavourable in international comparison. Especially worrying is the percentage of oncological diseases and related mortality. In general, early detection and accurate diagnosis could significantly reduce costs of oncological treatment. Pathology plays a crucial role in the diagnostic process. Pathology service in Hungary is facing serious difficulties. The most important problem is the efficiency deficit that stems from the distortion of resources, which simultaneously worsens the quality of and access to health care services. In one third of the 76 hospital pathology departments around the country there is a shortage of professionals. The consequences are long turnaround times of the findings (2-4 weeks), lack of consultations which would be needed in instances of complicated cases and lack of rapid diagnostic aid during surgeries (intraoperative pathology diagnostics). Incompleteness of professional standards and generally accepted data sheets with key data elements for cancer protocols, hinder standardized pathology reporting and treatment of patients as well as result in ineffective data collection for cancer registries.A possible solution in this situation could be utilizing the potentials offered by digital pathology applications especially in building up a telepathology network for consultation practice and for intraoperative pathology telediagnostics. Recognizing the importance of digital pathology, after isolated attempts to implement digital microscopy in pathology services around Hungary, a Digital Pathology Working Group of the Hungarian Society of Pathology has been founded to facilitate communication between pathologists, health care providers, decision-makers, vendors and relevant international partners to enhance spreading and implementation of digital pathology nationwide.
Main references related to the project proposal
Fintha, Attila MD is co-founder and first and present Leader of the Digital Pathology Working Group of the Hungarian Society of Pathology (DP MCS). He acted as organizer in all of the Working Group’s conferences and with Dr. Glasz he was responsible organizer of the most important of these, held in Budapest, October 13th, 2016 entitled „Digital Pathology and the Reporting Pathologist”.
Fonyad, L MD PhD is co-founder of DP MCS. He first implemented digital slides in pathology training in Hungary, organized national and international validation studies regarding the application of digital slides in routine surgical pathology practice. He was a scholar of the Hungarian American Scholarship Fund at the Massachusetts General Hospital Pathology Imaging and Communication Technology (PICT) Center.
Glasz, T MD PhD is co-founder of DP MCS. He acted as organizer in all of the Working Group’s conferences and with Dr. Fintha he was responsible organizer of the most important of these, held in Budapest, October 13th, 2016 and titled „Digital Pathology and the Reporting Pathologist”.
Krenács, T PhD, DSc is senior research scientist who did pioneering work in the development of digital microscopy in Hungary. He is the founder and supervisor of the Pathology Program (for Immunohistochemistry and Histotechnology) of the Hungarian external quality assurance (EQA) system QualiCont Inc. since 1996. This Program is based on and supported by UKNEQAS ICC&ISH and has been in touch with NORDIQC.
Introduction of the content of the project, its relevance and goal, schedule of the activities
Content Within the project, exchange of experiences in the field of digital pathology is planned. By means of organizing study tours, a satellite symposium and a workshop in Norway and in Hungary, enhancing personal relationship between professionals is also expected.
Goals Design a national telepathology consultation network. Design a qualification program for histotechnicians expanding their competence to handle surgical samples intended for intraoperative pathology telediagnostics. Design a quality assurance system for utilizing telepathology including technological and interpretational systems.
Relevance Application of digital pathology solutions would improve capacity in human resources of pathological services with setting up a national pathological consultation network. Such a network could play a central role in enabling of sub-specialisation in the field of pathology by providing a platform for digital dissemination of pathology cases in the virtual space of each sub-speciality, leading towards more reliable diagnoses and efficient examinations available not only for the big multipurpose health care institutions but for rural hospitals as well, reducing of inequalities and improvement of accessibility of quality health services predominantly in the case of those groups of society most at risk. A teleconsultation network could also be a platform for assisting trained histotechnicians in intraoperative pathology diagnostics procedures from a distance giving rapid diagnostic aid by telepathology diagnosis during surgeries, especially when a possible positive result of the rapid pathology test could indicate further and irreversible intervention.
Schedule of activities Study tour of approx. 4 persons from Hungary to Norway – first half of Oct. 2017. Satellite Symposium at the 73rd Congress of the Hungarian Society of Pathology; Siófok, Hungary – 28-30 Sept. 2017 Workshop with the Section of Histotechnicians of the Hungarian Society of Pathology at the 73rd Congress of the Hungarian Society of Pathology; Siófok, Hungary – 28-30 Sept. 2017 Elaboration of guidelines and methodologies – Sept-Oct. 2017 Press appearances – Oct. 2017
Number of Study Tours – 1
Number of participants in Study Tours – min. 4 persons
Number of Satellite Symposium – 1
Number of participants in the Satellite Symposium – expected 60 persons
Number of Workshops – 1
Number of participants in the Workshop – expected 30 persons
Number of guidelines and methodologies created – 3
Number of public and professional press appearances – expected 4
Number of joint project idea synopsis – 1
Study tour
A study tour of professionals will be organized in the frame of the project. Our Partner institution, the Hungarian-Norwegian Chamber of Commerce is organizing a conference in e-health, IoT and in digital transformation related to healthcare and visiting Oslo’s healthcare institutions is also planned according to the program proposal. The main goal of this study tour is to exchange experiences in the field of innovative e-health based pathological tissue diagnostic and consultation methodology solutions already applied in Norway. Specific fields of interest and issues include and are not limited to the following:
- Technical requirements of a telepathology consultation network
- capacity planning of scanner/storage/slide server requirements
- bandwidth requirements and the issue of firewalls
- pathology workstation planning (monitor resolution, hardware requirements, etc.)
- type of consultation platform (question of vendor independence)
- Medicolegal aspects of a telepathology consultation network
- issues of patient privacy, security of patient data and informed consent
- licensure
- quality assurance
- malpractice and liability
- medical device regulation reimbursement
- Implementing telepathology at specific sites
- necessity of in-house training course for users
- necessity of in-house validation study
- technical support, troubleshooting, equipment maintenance
- key performance parameters to be documented.
Satellite symposium
A satellite symposium – Digital pathology in clinical practice – is planned in junction with the annual meeting of the Hungarian Society of Pathologists, which is to be held between 28 and 30 of September, 2017., in Siófok, Hungary. In the satellite symposium invited speakers from Norway and Hungary would share their experiences with functional diagnostic systems and future plans, a tutorial is also planned about decision support tools in digital microscopy and image analysis on digital slides and followed by an open discussion with stakeholders involved in designing, financing and extended implementation of digital pathology for teleconsultation practice.
Workshop
Also in junction with the society meeting, a workshop is planned with real-life simulation of intraoperative telepathology consultation (intraoperative frozen section/aspiration cytology examination). Input from the participants and intended-users are also expected from this event to successfully design a qualification program and proficiency testing (see below!) required before a user is permitted to use the system in real life practice.
Project plan
Constructing a professional project plan to aid implementation of a nationwide digital pathology network in Hungary and to assist funding agencies in decision making and budget planning is long-awaited. The project plan should deal with the following key aspects:
- Scope management
- Requirements management with special focus on technical requirements medicolegal aspects and current legislative regulations and legal environment
- Schedule management
- Financial management
- Quality management
- Resource management
- Stakeholder management
- Communications management
- Risk management
Competence development
A very special objective of the programme is to design a qualification program for histotechnicians and possibly operation nurses expanding their competence to handle surgical samples for intraoperative pathology telediagnostics. The methodology and learning material constructed for the competence development of histotechnologists and surgical assistants to apply routine pathology and digital pathology tools used in intraoperative pathology diagnostics procedures should include the following key chapters:
- General aspects of intraoperative pathology diagnostics – aims and scopes
- Specimen reception
- Specimen handling
- Communication of test results
- Troubleshooting
- Qualification test
Quality assurance
Due to complexity of sample processing (pre-analytics), the analytical and the post-analytical (interpretational) workflow including digital pathology activities, standardisation is a key element in the program. QualiCont Inc. supervised by the professional bodies of diagnostic disciplines including the Society of Hungarian Pathologists runs EQA programs for Immunohistochemistry and Histotechnology, and a recent interpretational scheme in Gynecological Cytology. The quality assurance system for utilizing telepathology should include
- declaration of quality control parameters with the possibility of new quality assurance parameter development
- methodology of regular training and evaluation of knowledge of laboratory personnel and digital pathology system users
- adaptation of standards, quality monitoring and guidelines published by international digital pathology working groups (Nordic countries, USA, Australia, Germany, etc)
Good governance Good governance of the project is supported by the expertise of the Promoters. All of them have experience in organizing meetings and projects in their fields of activity, two of them possess a PhD-degree, while Dr. Fintha is a key person in Hungarian renal pathology and the society thereof.
Gender equality The subject matter of this project contributes invaluably to gender equality in the pathology society, as digital pathology may well become a means of tele-working, a working modality especially suitable for female colleagues who would wish to fulfill their pathologist expertise e.g. during their maternity leave from home.
Sustainable development Digital pathology will further enhance sustainable development of health-care systems in many ways. Environmental friendly working is well characterised by paper-free operation: data are presented and transferred in silico, sparing tonnes of paper yearly. Sustainable development is given by the virtuality of new modality versions: a simple uploading of new softwares shall create a developed working environment.
Introduction of the publicity plan
We are going to reach the pathologist community through newsletters. The pathologist associations will be also informed when the exact date of the workshop is stated. The workshop will be free of any charges. IT, medical and Ph.D. will be invited through the informatics systems of the partnering Institutions. Communication to the wider public is also an important issue. The main printed and digital newspapers are going to be invited to the workshop to get an inside view at the field of cancer diagnostics. We hope these new approaches will interest them. The guidelines will be available at the open websites of the institutes, and the memoir of the workshop will be presented at the website of the partnering Institutions.
Strengths Pathology networking offers advantages on practically all conceivable levels. On the niveau of the reporting pathologist the direct access to remote data on each examined patient shall enhance insights into every patient’s history and therefore help a deeper understanding of their disease. Diagnostic difficulties shall be overcome by applying remote help through teleconsultation – even on an international level. Digital pathology techniques will assist intraoperative pathology telediagnostics. Long term expected impacts over the scope of this project are: 1. network mass data collection to help nationwide surveillance of population changes in health care data to assist decision making in health care politics; 2. anonymized national database to serve scientific purposes in larger series than ever for a more effective cancer research.
Weaknesses Digital pathology techniques require a new vision on pathology diagnostic capacities. Some pathologists, especially those having many years or decades of valuable experience, may find these techniques difficult to master, whereas members of the younger generations, who are more open to new technical modalities, may yet need several years before they become reliable experts. Therefore, complete evolving of the new technological era may take some years, yet a wishful cooperation between younger and older generations may accelerate this transition.
Opportunities New technological developments shall enhance our access to biological data, the analyses of which shall widen our understanding of pathology of disease. Given this widened understanding, a hope to more effective treatment of especially tumor patients will be the result. To put it short: a new era in diagnostics is likely to bare opportunities for a new era in therapy.
Threats System complexity and absence of sufficient funding is a threat. It may prove difficult to spread the knowledge about the fact that fundings invested into pathology diagnostics techniques shall have multiplied benefits in an indirect way on the therapy side.
Short summary of the project in English & Hungarian
Permanent shortage of specialists in pathology and an ever increasing need for more and more detailed pathology reports of tissue samples in possibly short turnaround times calls for new techniques such as digital pathology to best organize professional competence on a nationwide level. Digital pathology networking may help remote access to specialized knowledge by means of teleconsultation and also support the efficiency of quality initiatives in the pre-analtical, analitical and interpretational activities. The newly planned competence development for histotechnicians to participate in intraoperative pathology telediagnostics may open new dimensions in rapid on-site pathodiagnostics. Both pathology networking and intraoperative pathology telediagnostics are expected to significantly enhance effectiveness of cancer patient care.
A patológus szakorvosok számában mutatkozó állandósult hiány és a mind több részletet tartalmazó és minél rövidebb idő alatt elkészítendő patológiai leletek iránti, folyamatosan növekvő igény olyan új technikai megoldásokat tesz szükségessé, mint a digitális patológia, amely képes az egy országban rendelkezésre álló szaktudás leghatékonyabb összeszervezésére. A digitális patológiai hálózat felállítása térben távoli szaktudást is elérhetővé tesz a telekonzultáció segítségével, míg a szövettani szakasszisztensek továbbképzése az intraoperatív patológiai távdiagnosztikában való részvételre új távlatokat nyithat a helyszíni patológiai gyorsdiagnosztikában. Mind a patológiai hálózat felállítása, mind az intraoperatív patológiai távdiagnosztika komolyan növelni fogja a daganatos betegek ellátásának hatékonyságát.