Back to the Future: Video Telepathology
The following non-bolded text that appears are excerpts from an upcoming book chapter to be published shortly.
Preparation for the book chapter pre-dated now a couple of looks at Remote Meeting Technologies "Anytime, anywhere, anything!" technology that makes the claim "No specimen is too big or too small for iMedHD™ and our Be There Anywhere™ telemedicine solutions. Even gross specimens, autopsy, gram stains, and transbronchial needle aspirations can be safely and securely broadcasted to another location on site, across town, across the country, or across the world! The compact iMedHD™ is the ideal solution for cost effective, real-time High Definition sharing of images over the internet. iMedHD™ is compatible, flexible, and will enable collaboration on multiple applications throughout the pathology department and laboratories including Consultations, Gross, Intraoperative, Tumor Boards and FNA & TBNA".
Reviewing slides and gross images in high-definition got me to thinking about the first experiences with telepathology and video microsocopy:
Telepathology is the practice of pathology at a distance, obtaining macroscopic and/or microscopic images for transmission along telecommunication links with remote interpretations (telediagnosis), second opinions or consultations (teleconsultation), and/or for educational purposes. “Tele” is a Greek prefix that means “distant.” Various terms that have been used in conjunction with telepathology include digital microscopy, remote robotic microscopy, teleconferencing, teleconsultation, telemicroscopy, video microscopy, virtual microscopy, and whole slide imaging. In the practice of telepathology, the original material (tissue, glass histology slide, etc) is separated by distance from the remote consultant (telepathologist). Remotely viewed digital or analog images, or digital whole slides, get interpreted by the telepathologist on a computer monitor (or even a cell phone screen) rather than through conventional light microscope eyepieces. Today, virtually ubiquitous access to the Internet, or to other broadband telecommunications linkages, on many continents, facilitates nearly global image sharing. As a result, telepathology has been used to aid a growing number of laboratories in providing pathology services over great distances, and has even been used by others to increase the efficiency of services between hospitals less than a mile apart.
With increasing sub-specialization in pathology, the use of telepathology to access subspecialists (e.g. neuropathologists, dermatopathologists) is also on the upswing and is proving to be cost-effective in at least certain settings. The practice of telepathology is not only limited to rendering diagnoses, but can also play important roles in quality assurance (e.g. re-review of cases), teaching, and research. When telepathology is widely viewed as an acceptable ancillary technique, it will likely become a common tool integrated into mainstream diagnostic pathology.
Pathology and oncology, just as the rest of medicine is becoming increasingly subspecialized, particularly in community settings.
Dr. Ron Weinstein introduced the term “telepathology” into the English language in 1986. In the late 1960’s, he was a pathology resident at the Massachusetts General Hospital (MGH) when the first real-time “television microscopy” service was established between the Logan Airport Medical Station and the MGH in Boston, Massachusetts. He observed early demonstrations of the technology and became aware of the limitations of video microscopy when microscopic field selection was performed by a nurse or a medical technologist at the Logan Airport clinic. The vast majority of cases did not require an on-site pathologist, since most of the clinical cases involved remotely viewing blood smears and urines. This Logan Airport television microscopy system was not used for surgical pathology cases.
Nearly two decades later, Weinstein differentiated video microscope technologies, including “television microscopy” and “video microscopy,” from “telepathology” for good reason. He proposed that the “practice of telepathology” would require that a “telepathologist”, who would be rendering a telediagnosis, should be able to control remotely all relevant light microscope functions (e.g., using a motorized, robotically controlled light microscope) in order to use telepathology for surgical pathology cases. Ideally, selection of the diagnostic microscopic fields would be made by the remote telepathologist, using some type of dynamic telepathology system that would accentuate inclusive microscope field selection at a range of viewing magnifications.
Now, thanks to Remote Meeting Technologies, true high-definition, brilliant color, high-definition video is possible for pathology for both gross and microscopic imaging. True 1920 x 1080p resolution shared very quickly over standard networks.
No scanning, uploading or downloading required. Point-to-point connectivity with browser-based viewer for ease of use and easy to control.
Perfect technology for remote consultations, frozen sections, cytology evaluations, gross review at a distance, etc…
This is not to suggest you can avoid purchasing a whole slide scanner as well for the complete imaging platform but I think there is going to be a renewed trend towards live non-robotic imaging between pathologists, although the lack of stitching here to create an image is a nice point from the regulatory perspective, like, not subject to it…
True 1080p microscopy to share with colleagues, cinicians and patients with brilliant monitors to show every detail.
If you are looking for real-time imaging with high-def video, check out Remote Meeting Technologies. Combined with very low-cost high-speed networks you can share diagnostic quality images quickly and easily.
So now, more than 25 years after the first telepathology demonstration in this country, forget about low resolution of 300 lines over expensive satellite networks and the like, and see pathology in high-definition.
It is fun to look back and to the future. What will the next generation of this latest technology look like? Perhaps teleport to the bedside without the Delorean?
Telepathology became a newsworthy item in 1986 with the first public demonstration of a satellite-linked color-video dynamic telepathology system. Fort William Beaumont Army Medical Center in El Paso, Texas, and Washington DC were linked for the demonstration. The dynamic-robotic telepathology system used for the demonstration was designed and fabricated by Weinstein’s group at Rush Medical College, in Chicago in partnership with Corabi International Telemetrics, Inc., a Rush University spin-off company located in a nearby Illinois state-owned biotechnology incubator facility, in west Chicago. The Corabi patented technology combined the use of digital and analog video imaging for the first time. Digital imaging was used to produce a small tissue map, which was captured and displayed, in a low resolution digital image format, on a navigation system monitor. This auxiliary imaging system was used by the remote telepathologist to manage the robotic motorized microscope’s functions. The telepathologist always knew exactly where the motorized microscope’s objective was positioned in relation to the actual tissue section mounted on the glass slide. Use of the auxiliary navigation system also helped ensure that each entire slide was imaged by the telepathologist-system operator in the course of a telepathology diagnostic session. The magnitude and expense of the effort to create this external navigation system reflected Weinstein’s high level of concern that the Achilles heel of telepathology could turn out to be inadequate histopathology image sampling. His concern proved to be well founded as “limiting sampling” static image telepathology (i.e., sampling of one or only a few fields), was practiced in early commercial static image telepathology systems. Such systems are no longer marketed in the United States. Real-time analog imaging was used for viewing the images of the slide during the diagnostic session in the Texas-Washington, D.C. robotic telepathology demonstration.
The story appeared on page 7 of the Metro section in the Washington Post:
For the actual Texas-to-Washington, D.C. proof-of-concept demonstration of robotic-dynamic telepathology, a histopathology slide of a hematoxylin and eosin (H&E)-stained breast frozen section, was processed into a low resolution whole slide digital image, using a low resolution camera mounted on a light box. After the navigation system digital slide was produced, the same breast tissue frozen section slide was remounted on the stage of an Olympus remotely controllable motorized photo-microscope. A stream of analog video images, viewed on a larger monitor, was used for rendering the diagnosis. The analog video images were transmitted, via satellite, to the boardroom of COMSAT Corporation, in Washington, D.C. A telepathologist, Dr. Alexander Miller, seated at a Corabi prototype workstation, was able to control all of the functions of the motorized microscope in Texas, including stage movements, magnification, focus and illumination, while viewing the real-time images, at 525 lines of resolution, with a video monitor refresh rate of 30 frames per second. The navigation system, positioned near the large video monitor, displayed tissue mapping parameters. Superimposed over the low resolution digital image of the breast frozen section, displayed on the navigation system screen, was a small box-shaped icon indicating the location and size of the field-of-view (FOV) of the glass slide being actively displayed on the main video monitor. Velocity of the stage movements, displayed as lateral movements of the small FOV box, showed the exact relationship of the light microscope’s objective lens to the underlying tissue section. The location of FOV was automatically updated as Dr. Miller, in Washington, D.C., robotically repositioned the glass slide on the microscope’s motorized stage in Texas. Changes in magnification initiated by Dr. Miller, by the press of a button, appeared natural. Focus was easily controlled during scanning of the slide, and readily re-established with each change in magnification. Two-way audio communication was maintained between the laboratory in Texas and the Washington, D.C. COMSTAT boardroom throughout the dynamic telepathology diagnostic session. Technicians and doctors in Texas were in constant communication with Dr. Miller.
