The Eastern Québec Telepathology Network: a three-year experience of clinical diagnostic services

Intraoperative assessment of axillary sentinel lymph nodes by telepathology

PURPOSE

Although axillary dissection is no longer indicated for many breast cancer patients with 1-2 positive axillary sentinel lymph nodes (ASLN), intraoperative ASLN assessment is still performed in many institutions for patients undergoing mastectomy or neoadjuvant therapy. With recent advancements in digital pathology, pathologists increasingly evaluate ASLN via remote telepathology. We aimed to compare the performance characteristics of remote telepathology and conventional on-site intraoperative ASLN assessment.

METHODS

Data from ASLN evaluation for breast cancer patients performed at two sites between April 2021 and October 2022 was collated. Remote telepathology consultation was conducted via the Aperio eSlideManager system.

RESULTS

A total of 385 patients were identified during the study period (83 telepathology, 302 on-site evaluations). Although not statistically significant (P = 0.20), the overall discrepancy rate between intraoperative and final diagnoses was slightly higher at 9.6% (8/83) for telepathology compared with 5.3% (16/302) for on-site assessment. Further comparison of performance characteristics of ASLN assessment between telepathology and conventional on-site evaluation revealed no statistically significant differences between deferral rates, discrepancy rates, interpretive or sampling errors, major or minor disagreements, false negative or false positive results as well as clinical impact and turn-around time (P ≥ 0.12).

CONCLUSION

ASLN assessment via telepathology is not significantly different from conventional on-site evaluation, although it shows a slightly higher overall discrepancy rate between intraoperative and final diagnoses (9.6% vs. 5.3%). Further studies are warranted to ensure accuracy of ASLN assessment via telepathology.

Validation of whole slide imaging for frozen section diagnosis of lymph node metastasis: A retrospective study from a tertiary care hospital in Thailand

BACKGROUND

The use of whole slide imaging (WSI) for frozen section (FS) diagnosis is helpful, particularly in the context of pathologist shortages. However, there is minimal data on such usage in resource-limited settings. This study aims to validate the use of WSI for FS diagnosis of lymph node metastasis using a low-cost virtual microscope scanner with consumer-grade laptops at a tertiary care hospital in Thailand.

METHODS

FS slides were retrieved for which the clinical query was to evaluate lymph node metastasis. They were digitized by a virtual microscope scanner (MoticEasyScan, Hong Kong) using up to 40× optical magnification. Three observers with different pathology experience levels diagnosed each slide, reviewing glass slides (GS) followed by digital slides (DS) after two weeks of a wash out period. WSI and GS diagnoses were compared. The time used for scanning and diagnosis of each slide was recorded.

RESULTS

295 FS slides were retrieved and digitized. The first-time successful scanning rate was 93.6 %. The mean scanning time was 2 min per slide. Both intraobserver agreement and interobserver agreement of WSI and GS diagnoses were high (Cohen's K; kappa value >0.84). The time used for DS diagnosis decreased as the observer's experience with WSI increased.

CONCLUSIONS

Despite varying pathological experiences, observers using WSI provided accurate FS diagnoses of lymph node metastasis. The time required for DS diagnoses decreased with additional observer's experience with WSI. Therefore, a WSI system containing low-cost scanners and consumer-grade laptops could be used for FS services in hospital laboratories lacking pathologists.

Substantial improvement of histopathological diagnosis by whole-slide image-based remote consultation

Consultation by subspecialty experts is the most common mode of rendering diagnosis in challenging cases in pathological practice. Our study aimed to highlight the diagnostic benefits of whole-slide image (WSI)-based remote consultation. We obtained diagnostically challenging cases from two institutions from the years 2010 and 2013, with histological diagnoses that contained keywords “probable,” “suggestive,” “suspicious,” “inconclusive,” and “uncertain.” A total of 270 cases were selected for remote consultation using WSIs scanned at 40 × . The consultation process consisted of three rounds: the first and second rounds each with 12 subspecialty experts and the third round with six multi-expertise senior pathologists. The first consultation yielded 44% concordance, and a change in diagnosis occurred in 56% of cases. The most frequent change was from inconclusive to definite diagnosis (30%), followed by minor discordance (14%), and major discordance (12%). Out of the 70 cases which reached the second round, 31 cases showed discrepancy between the two consultants. For these 31 cases, a consensus diagnosis was provided by six multi-expertise senior pathologists. Combining all WSI-based consultation rounds, the original inconclusive diagnosis was changed in 140 (52%) out of 266 cases. Among these cases, 80 cases (30%) upgraded the inconclusive diagnosis to a definite diagnosis, and 60 cases (22%) changed the diagnosis with major or minor discordance, accounting for 28 cases (10%) and 32 cases (12%), respectively. We observed significant improvement in the pathological diagnosis of difficult cases by remote consultation using WSIs, which can further assist in patient healthcare. A post-study survey highlighted various benefits of WSI-based consults.

Frozen section telepathology service: Efficiency and benefits of an e-health policy in South Tyrol

Objective/Background

Telepathology has been widely adopted to allow intraoperative pathology examinations to be performed remotely and for obtaining second opinion teleconsultation. In the Italian northern region of South Tyrol, the widespread geographical distances and consequent cost for the health system of having a travelling pathologist cover intraoperative consultations in peripheral hospitals was a key driver for the implementation of a telepathology system.

Methods

In 2010, four Menarini D-Sight whole slide scanners to digitize entire pathology slides were placed in the peripheral hospitals of Merano, Bressanone, Brunico, and in the hub hospital of Bolzano. Digital workstations were also installed to allow pathologists to remotely perform intraoperative consultations with digital slides. This study reviews the outcome after 12 years of telepathology for this intended clinical use.

Results

After an initial validation phase with 100 cases which yielded a sensitivity of 65% (CI 43–84%) and specificity of 100% (CI 95–100%), there were 2058 intraoperative consultations handled by telepathology. The cases evaluated were mainly breast sentinel lymph nodes, followed by urological, gynecological and general surgical pathology frozen section specimens. There were no false-positive cases and 165 (8%) false-negative cases, yielding an overall sensitivity and specificity of 65% (CI 61–69%) and 100% (CI 99–100%), respectively.

Conclusion

Telepathology is reliable for remote intraoperative diagnosis and, despite technical issues and initial acquaintance issues, proved beneficial for patient care in satellite hospitals, improved standardization, promoted innovation, and resulted in cost savings for the health system.

Evaluating the success of the tele-pathology system in governmental hospitals in Kuwait: an explanatory sequential mixed methods design

BACKGROUND

Telepathology is the practice of reviewing and exchanging pathological images through telecommunication systems to obtain diagnoses remotely. Studying the factors that make such a system successful and favourable is important to ensure the merits of its implementation in clinical practice.

OBJECTIVE

This study aims to evaluate the success of a telepathology system from the users' perspectives, using specific evaluation criteria, namely: system quality, information quality, technical service quality, user satisfaction, and benefits.

METHODS

A sequential explanatory mixed methods design was adopted in this study, which consists of two phases. Initially, a questionnaire was distributed via WhatsApp to all of the pathologists (total: 45) working at governmental hospitals in Kuwait. Followed by, semi-structured interviews with ten senior pathologists.

RESULTS

Forty pathologists responded to the questionnaire, giving an 89% response rate. There were 42.5% of the respondents aged between 35-44 years old, and 52.5% were male. The quantitative results reveal that most of the respondents were satisfied with the quality of the telepathology system with a mean of 2.6025 (Standard Deviation (SD) = 0.47176), whereas they were dissatisfied with the quality of the information with a mean of 2.4100 (SD = 1.580) and the technical support services with a mean of 2.2750 (SD = 0.99535). In addition, there was disagreement on the benefits of telepathology in clinical practice among the pathologists with a mean of 2.4667 (SD = 0.77552). The qualitative results indicate that the lack of interest in and little experience with using the system were behind the general dissatisfaction of most of the respondents. All of the interviewees were satisfied with the performance of the telepathology system and considered it successful; however, the quality of the technical support services, including training workshops, was deemed deficient.

CONCLUSION

This study concluded that telepathology system in Kuwait is functioning well and has been successful in its implementation; however, pathologists are dissatisfied with it, mainly due to the deficient quality of the technical support services provided. In addition, the successful implementation of such advanced technologies requires careful steps to be taken on multiple levels: technical, organisational, and managerial. Recommendations were suggested.

Effectiveness of a Cloud-Based Telepathology System in China: Large-Sample Observational Study

BACKGROUND

Whole-slide imaging allows the entire slide to be viewed in a manner that simulates microscopy; therefore, it is widely used in telepathology. However, managing the large digital files needed for whole-slide imaging is difficult. To solve this problem, we set up the Chinese National Cloud-Based Telepathology System (CNCTPS). CNCTPS has been running for more than 4 years and has accumulated a large amount of data.

OBJECTIVE

The main purpose of this study was to comprehensively evaluate the effectiveness of the CNCTPS based on a large sample. The evaluation indicators included service volume, turnaround time, diagnosis accuracy, and economic benefits.

METHODS

Details of 23,167 cases submitted to the CNCTPS from January 2016 to December 2019 were collected to analyze the service volume, turnaround time, and economic benefits. A total of 564 patients who visited the First Affiliated Hospital of Zhengzhou University and obtained final diagnoses were followed up to analyze the diagnostic accuracy of the CNCTPS.

RESULTS

From 2016 to 2019, the service volume of the CNCTPS increased from 2335 to 9240, and the number of participating hospitals increased from 60 to 74. Consultation requests from county-level hospitals accounted for 86.57% (20,287/23,167). A total of 17,495 of 23,167 cases (75.52%) were confirmed, including 12,088 benign lesions, 5217 malignant lesions, and 190 borderline lesions. Of the cases, 3.85% (893/23,167) failed to be diagnosed for reasons such as poor slice quality and incomplete sampling. The median turnaround time was 16.93 hours and was shortened yearly (between 2018 and 2019: adjusted P=.01; other groups: adjusted P<.001); 82.88% cases were diagnosed in 48 hours. There was a discrepancy between the diagnosis and final diagnosis for 11 cases, including 4 false-positive cases and 7 false-negative cases. The sensitivity and specificity were 97.66% and 98.49%, respectively. The diagnostic accuracy of the system was 98.05%, with no statistical difference from the final diagnosis in the hospital (P=.55). By using this system, a total of US $300,000 was saved for patients every year.

CONCLUSIONS

The novel cloud-based telepathology system has the potential to relieve the shortage of pathologists in primary hospitals. It can also simultaneously reduce medical costs for patients in China. It should, therefore, be further promoted to enhance the efficiency, quantity, and quality of telepathology diagnoses.

Laboratory medicine: The exemplar for value-based healthcare

Value-Based Healthcare (VBHC) aims to improve the overall quality, safety, and sustainability of healthcare while reducing delivery costs of more effective care. Despite advantages associated with VBHC transformation, the road to its adoption has been lengthy. Laboratory Medicine (LM) is in a prime position to lead the transition to VBHC because of its key role in diagnosis and treatment of patients. Laboratory medicine results inform/influence 50% to 70% of all clinical decisions. This article summarizes some issues associated with adoption of VBHC and related healthcare innovations and suggests potential approaches using LM-specific examples to help accelerate adoption. Laboratory medicine is both a useful model for VBHC implementation and facilitator for related innovation adoption by helping to target patient populations that would benefit most from specific interventions. The critical value of rapidly adopted diagnostic technologies used during the COVID-19 pandemic and economic recovery provide important insights about the need to embrace and accelerate VBHC implementation.

Remote Reporting from Home for Primary Diagnosis in Surgical Pathology: A Tertiary Oncology Center Experience during the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic accelerated the widespread adoption of digital pathology (DP) for primary diagnosis in surgical pathology. This paradigm shift is likely to influence how we function routinely in the postpandemic era. We present learnings from early adoption of DP for a live digital sign-out from home in a risk-mitigated environment.

MATERIALS AND METHODS

We aimed to validate DP for remote reporting from home in a real-time environment and evaluate the parameters influencing the efficiency of a digital workflow. Eighteen pathologists prospectively validated DP for remote use on 567 biopsy cases including 616 individual parts from 7 subspecialties over a duration from March 21, 2020, to June 30, 2020. The slides were digitized using Roche Ventana DP200 whole-slide scanner and reported from respective homes in a risk-mitigated environment.

RESULTS

Following re-review of glass slides, there was no major discordance and 1.2% (n = 7/567) minor discordance. The deferral rate was 4.5%. All pathologists reported from their respective homes from laptops with an average network speed of 20 megabits per second.

CONCLUSION

We successfully validated and adopted a digital workflow for remote reporting with available resources and were able to provide our patients, an undisrupted access to subspecialty expertise during these unprecedented times.

Digital Pathology: Advantages, Limitations and Emerging Perspectives

Digital pathology is on the verge of becoming a mainstream option for routine diagnostics. Faster whole slide image scanning has paved the way for this development, but implementation on a large scale is challenging on technical, logistical, and financial levels. Comparative studies have published reassuring data on safety and feasibility, but implementation experiences highlight the need for training and the knowledge of pitfalls. Up to half of the pathologists are reluctant to sign out reports on only digital slides and are concerned about reporting without the tool that has represented their profession since its beginning. Guidelines by international pathology organizations aim to safeguard histology in the digital realm, from image acquisition over the setup of work-stations to long-term image archiving, but must be considered a starting point only. Cost-efficiency analyses and occupational health issues need to be addressed comprehensively. Image analysis is blended into the traditional work-flow, and the approval of artificial intelligence for routine diagnostics starts to challenge human evaluation as the gold standard. Here we discuss experiences from past digital pathology implementations, future possibilities through the addition of artificial intelligence, technical and occupational health challenges, and possible changes to the pathologist's profession.

Validation of a digital pathology system including remote review during the COVID-19 pandemic

Remote digital pathology allows healthcare systems to maintain pathology operations during public health emergencies. Existing Clinical Laboratory Improvement Amendments regulations require pathologists to electronically verify patient reports from a certified facility. During the 2019 pandemic of COVID-19 disease, caused by the SAR-CoV-2 virus, this requirement potentially exposes pathologists, their colleagues, and household members to the risk of becoming infected. Relaxation of government enforcement of this regulation allows pathologists to review and report pathology specimens from a remote, non-CLIA certified facility. The availability of digital pathology systems can facilitate remote microscopic diagnosis, although formal comprehensive (case-based) validation of remote digital diagnosis has not been reported. All glass slides representing routine clinical signout workload in surgical pathology subspecialties at Memorial Sloan Kettering Cancer Center were scanned on an Aperio GT450 at ×40 equivalent resolution (0.26 µm/pixel). Twelve pathologists from nine surgical pathology subspecialties remotely reviewed and reported complete pathology cases using a digital pathology system from a non-CLIA certified facility through a secure connection. Whole slide images were integrated to and launched within the laboratory information system to a custom vendor-agnostic, whole slide image viewer. Remote signouts utilized consumer-grade computers and monitors (monitor size, 13.3-42 in.; resolution, 1280 × 800-3840 × 2160 pixels) connecting to an institution clinical workstation via secure virtual private network. Pathologists subsequently reviewed all corresponding glass slides using a light microscope within the CLIA-certified department. Intraobserver concordance metrics included reporting elements of top-line diagnosis, margin status, lymphovascular and/or perineural invasion, pathology stage, and ancillary testing. The median whole slide image file size was 1.3 GB; scan time/slide averaged 90 s; and scanned tissue area averaged 612 mm². Signout sessions included a total of 108 cases, comprised of 254 individual parts and 1196 slides. Major diagnostic equivalency was 100% between digital and glass slide diagnoses; and overall concordance was 98.8% (251/254). This study reports validation of primary diagnostic review and reporting of complete pathology cases from a remote site during a public health emergency. Our experience shows high (100%) intraobserver digital to glass slide major diagnostic concordance when reporting from a remote site. This randomized, prospective study successfully validated remote use of a digital pathology system including operational feasibility supporting remote review and reporting of pathology specimens, and evaluation of remote access performance and usability for remote signout.

[Beyond benefit evaluation: Considering the unintended consequences of telehealth]

La télésanté est considérée comme un levier incontournable dans les choix des politiques en santé. Toutefois, il subsiste de nombreux enjeux face à son intégration réussie dans les pratiques cliniques. À ce jour, un grand nombre d’initiatives en télésanté peine à dépasser le stade de projet pilote. Cette situation s’explique en partie par une culture de l’innovation qui est principalement focalisée sur les bénéfices attendus de la technologie et moins sur les changements et les transformations qu’elle peut entraîner. La télésanté est utilisée dans des établissements de santé dont la dynamique sociale est pour le moins complexe. Son introduction entraîne des conséquences inattendues pouvant affecter aussi bien les patients, les communautés, les professionnels, les établissements que les systèmes de santé et la société dans son ensemble. L’objectif de cet article est de discuter de certaines des conséquences inattendues découlant de l’utilisation de la télésanté dans les établissements et systèmes de santé.

Systematic Review of the Use of Telepathology During Intraoperative Consultation

OBJECTIVE

To compare studies that used telepathology systems vs conventional microscopy for intraoperative consultation (frozen-section) diagnosis.

METHODS

A total of 56 telepathology studies with 13,996 cases in aggregate were identified through database searches.

RESULTS

The concordance of telepathology with the reference standard was generally excellent, with a weighted mean of 96.9%. In comparison, we identified seven studies using conventional intraoperative consultation that showed a weighted mean concordance of 98.3%. Evaluation of the risk of bias showed that most of these studies were low risk.

CONCLUSIONS

Despite limitations such as variation in reporting and publication bias, this systematic review provides strong support for the safety of using telepathology for intraoperative consultations.

The Role of Telecytology in the Primary Diagnosis of Thyroid Fine-Needle Aspiration Specimens

INTRODUCTION

The Acibadem Health Group (AHG) has been using telepathology/digital pathology stations since 2006. In 2013, the system was changed from videoconferencing to digital pathology (whole-slide imaging) utilizing 3DHISTECH scanners and software. In 2017, digital cytology started to be used for routine cytopathologic diagnosis for thyroid fine-needle aspiration (FNA) cases.

MATERIAL AND METHODS

Two hundred and twenty-seven thyroid cases were received for analysis using telecytology (TC) during the period from November 2017 to May 2018. Rapid on-site evaluation was performed at the Atakent Hospital of the AHG by a cytotechnologist and scanned on the same day. For every case, there were Diff-Quik- and Papanicolaou-stained FNA smears. Each glass slide was digitized with a 3DHISTECH whole-slide scanner in 1 focal Z-plane at ×40 magnification.

RESULTS

Two hundred and twenty-seven thyroid FNA specimens were retrieved, of which 25 had histologic follow-up. Samples were classified as nondiagnostic in 3%, benign in 74%, atypia of undetermined significance/follicular lesion of undetermined significance in 13%, suspicious for follicular neoplasia/follicular neoplasia in 3%, suspicious for malignancy in 4%, and malignant in 3%. When only the "suspicious for malignancy" and "malignancy" categories were considered positive tests, cytology sensitivity and specificity using TC for diagnosis was 100%.

CONCLUSIONS

Our data demonstrate that TC is suitable to provide a primary diagnosis in daily routine cytology practice. Despite the promising results, there were some challenges stemming from the novelty of using TC for the primary diagnosis. The study also addresses both advantages and disadvantages of TC in daily practice to increase the efficiency of the technique in primary diagnosis.

Rise of the Machines: Advances in Deep Learning for Cancer Diagnosis

Deep learning refers to a set of computer models that have recently been used to make unprecedented progress in the way computers extract information from images. These algorithms have been applied to tasks in numerous medical specialties, most extensively radiology and pathology, and in some cases have attained performance comparable to human experts. Furthermore, it is possible that deep learning could be used to extract data from medical images that would not be apparent by human analysis and could be used to inform on molecular status, prognosis, or treatment sensitivity. In this review, we outline the current developments and state-of-the-art in applying deep learning for cancer diagnosis, and discuss the challenges in adapting the technology for widespread clinical deployment.

Parathyroid Frozen Section Interpretation via Desktop Telepathology Systems: A Validation Study

Background

Telepathology can potentially be utilized as an alternative to having on-site pathology services for rural and regional hospitals. The goal of the study was to validate two small-footprint desktop telepathology systems for remote parathyroid frozen sections.

Subjects and Methods

Three pathologists retrospectively diagnosed 76 parathyroidectomy frozen sections of 52 patients from three pathology services in Australia using the "live-view mode" of MikroScan D2 and Aperio LV1 and in-house direct microscopy. The final paraffin section diagnosis served as the "gold standard" for accuracy evaluation. Concordance rates of the telepathology systems with direct microscopy, inter-pathologist and intra-pathologist agreement, and the time taken to report each slide were analyzed.

Results

Both telepathology systems showed high diagnostic accuracy (>99%) and high concordance (>99%) with direct microscopy. High inter-pathologist agreement for telepathology systems was demonstrated by overall kappa values of 0.92 for Aperio LV1 and 0.85 for MikroScan D2. High kappa values (from 0.85 to 1) for intra-pathologist agreement within the three systems were also observed. The time taken per slide by Aperio LV1 and MicroScan D2 within three pathologists was about 3.0 times (P < 0.001, 95% confidence interval [CI]: 2.8-3.2) and 7.7 times (P < 0.001, 95% CI: 7.1-8.3) as long as direct microscopy, respectively, while MikroScan D2 took about 2.6 times as long as Aperio LV1 (P < 0.001, 95% CI: 2.4-2.7). All pathologists evaluated Aperio LV1 as being more user-friendly.

Conclusions

Telepathology diagnosis of parathyroidectomy frozen sections through small-footprint desktop systems is accurate, reliable, and comparable with in-house direct microscopy. Telepathology systems take longer than direct microscopy; however, the time taken is within clinically acceptable limits. Aperio LV1 takes shorter time than MikroScan D2 and is more user-friendly.

Review of the use of telepathology for intraoperative consultation

INTRODUCTION

The use of telepathology in intraoperative consultations has been increasing due to limited time and availability of pathologists, and the demand for increased access to pathology subspecialists in difficult cases. The five main categories of telepathology are (1) static, (2) dynamic, (3) robotic, (4) whole slide imaging (WSI), and (5) hybrid methods. The majority of these methods have been found to offer diagnostic accuracy rates similar to conventional microscopy, at the cost of slightly prolonged time to evaluate slides.

AREAS COVERED

Herein we discuss the salient features of each telepathology method and provide examples of their performance reported in the literature.

EXPERT COMMENTARY

Telepathology systems from any of the aforementioned categories can be employed to achieve timely and accurate diagnoses as long as they meet clinical needs and are validated for the intended use case. The decision to purchase a particular system depends on the clinical application, specific needs and budget of the laboratory, as well as the personal preference of the telepathologists involved. The adoption of telepathology practice is likely to expand in order to meet the increasing demand for subspecialist consultation and as technology advances to improve diagnostic accuracy and workflow.

Clinical Videoconferencing as eHealth: A Critical-Realist Review and Qualitative Meta-Synthesis

Background

Earlier work has described videoconferencing technologies, peripheral equipment, organizational models, human relations, purposes, goals and roles as versatile, multifaceted, and those used differently in different clinical practices. Knowledge about benefits and challenges connected to specific characteristics of services are lacking. A 2005 systematic review of published definitions of electronic health (eHealth) identified 51 unique definitions. In addition, the “10 E’s of eHealth” was developed. In 2015, the question “What Is eHealth: Time for an Update?” was posed.

Objective

Considering videoconferencing as eHealth, the objective of the paper is twofold: to demonstrate and cluster (different) clinical videoconferencing practices and their situated implications and to suggest interpretive concepts that apply to all clusters and contribute to generative learning of eHealth by discussing the concepts as add-ons to existing descriptions of eHealth in the “10 E’s of eHealth.”

Methods

We performed a literature search via the National Center for Biotechnology Information, encompassing PubMed and PubMedCentral, for quality reviews and primary studies. We used the terms “videoconferencing” and “clinical practices.” The selection process was based upon clearly defined criteria. We used an electronic form to extract data. The analysis was inspired by critical and realist review types, grounded theory, and qualitative meta-synthesis.

Results

The search returned 354 reviews and primary studies. This paper considered the primary studies, and 16 were included. We identified the following 4 broad clusters: videoconferencing as a controlled technological intervention within existing health care organizations for expert advice, controlled mixed interventions with experimental organizational arrangements, videoconferencing as an emerging technosocial service involving dialogue and empowerment of patients, and videoconferencing as a controlled intervention to improve administrative efficiency. The analysis across the clusters resulted in a proposal to add the following 4 D’s to the existing 10 E’s: (inter)-dependent, differentiated across services and along temporal lines, dynamic in terms of including novel elements for meeting incremental needs, and demanding in terms of making new challenges and dual results visible and needing fresh resources to meet those challenges. For a normative discussion about what eHealth should be according to authors’ conclusions, results suggested ethical, in that users interests should be respected, and not harmful in terms of increasing symptom burden.

Conclusions

Services were enacted as dynamic, differentiated concerning content and considerations of quality and adaptive along temporal lines. They were made to work from an ongoing demand for fresh resources, making them interdependent. The 4 D’s—Dynamic, Differentiated, Demanding, and (inter) Dependent—serve as pragmatic add-ons to the “10 E’s of eHealth.” Questions concerning outcome of specified balances between standardization and customization in clinical settings should be addressed in future research along with the emerging dual character of outcome: services being considered both “good” and “bad.”

The Challenges of a Complex and Innovative Telehealth Project: A Qualitative Evaluation of the Eastern Quebec Telepathology Network

Background: The Eastern Quebec Telepathology Network (EQTN) has been implemented in the province of Quebec (Canada) to support pathology and surgery practices in hospitals that are lack of pathologists, especially in rural and remote areas. This network includes 22 hospitals and serves a population of 1.7 million inhabitants spread over a vast territory. An evaluation of this network was conducted in order to identify and analyze the factors and issues associated with its implementation and deployment, as well as those related to its sustainability and expansion.

Methods: Qualitative evaluative research based on a case study using: (1) historical analysis of the project documentation (newsletters, minutes of meetings, articles, ministerial documents, etc); (2) participation in meetings of the committee in charge of telehealth programs and the project; and (3) interviews, focus groups, and discussions with different stakeholders, including decision-makers, clinical and administrative project managers, clinicians (pathologists and surgeons), and technologists. Data from all these sources were cross-checked and synthesized through an integrative and interpretative process.

Results: The evaluation revealed numerous socio-political, regulatory, organizational, governance, clinical, professional, economic, legal and technological challenges related to the emergence and implementation of the project. In addition to technical considerations, the development of this network was associated with major changes and transformations of production procedures, delivery and organization of services, clinical practices, working methods, and clinicaladministrative processes and cultures (professional/organizational).

Conclusion: The EQTN reflects the complex, structuring, and innovative projects that organizations and health systems are required to implement today. Future works should be more sensitive to the complexity associated with the emergence of telehealth networks and no longer reduce them to technological considerations.

Future-proofing pathology: the case for clinical adoption of digital pathology

This document clarifies the strategic context of digital pathology adoption, defines the different use cases a healthcare provider may wish to consider as part of a digital adoption and summarises existing reasons for digital adoption and its potential benefits. The reader is provided with references to the relevant literature, and illustrative case studies. The authors hope this report will be of interest to healthcare providers, pathology managers, departmental heads, pathologists and biomedical scientists that are considering digital pathology, deployments or preparing business cases for digital pathology adoption in clinical settings. The information contained in this document can be shared and used in any documentation the reader wishes to present for their own institutional case for adoption report or business case.

The Empirical Foundations of Telepathology: Evidence of Feasibility and Intermediate Effects

INTRODUCTION

Telepathology evolved from video microscopy (i.e., "television microscopy") research in the early 1950s to video microscopy used in basic research in the biological sciences to a basic diagnostic tool in telemedicine clinical applications. Its genesis can be traced to pioneering feasibility studies regarding the importance of color and other image-based parameters for rendering diagnoses and a series of studies assessing concordance of virtual slide and light microscopy diagnoses. This article documents the empirical foundations of telepathology.

METHODS

A selective review of the research literature during the past decade (2005-2016) was conducted using robust research design and adequate sample size as criteria for inclusion.

CONCLUSIONS

The evidence regarding feasibility/acceptance of telepathology and related information technology applications has been well documented for several decades. The majority of evidentiary studies focused on intermediate outcomes, as indicated by comparability between telepathology and conventional light microscopy. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include use of telepathology and whole slide imaging for teaching, research, and outreach to resource-limited countries. Challenges still exist, however, in terms of use of telepathology as an effective diagnostic modality in clinical practice.