CEO SUMMARY: Many experts think that digital pathology will make it possible to create international pathology subspecialty referral networks. Now in its fifth year, a partnership between UPMC’s Pathology Department and KingMed Diagnostics of China uses telepathology to give Chinese patients access to the subspecialist pathologists at UPMC. KingMed’s case referrals to UPMC rose from 144 in 2012 to 810 last year and data show that patient outcomes are improving because of this telepathology service.
TWO FRONTIERS LOOM as opportunities for the anatomic pathology profession. One frontier is the regular use of digital pathology in support of clinical care. The other frontier is the opportunity to generate specimens and revenue from pathology cases referred to labs in the United States from other countries.
Both frontiers are being explored in a partnership between UPMC International and KingMed Diagnostics in China. Now in its fifth year, the partnership has demonstrated solid growth for UPMC’s Pathology Department.
In 2012, the first year of the program, UPMC pathologists reviewed 144 specimens. This year, specimen volume will total more than 800 cases, stated Liron Pantanowitz, MD, Professor of Pathology and Director of Pathology Informatics and Cytopathology at UPMC Shadyside.
Improving patient care is a primary goal of this partnership because patients in China have limited access to the subspecialist pathology expertise that exists here in the United States. According to a study published in the Journal of Pathology Informatics in November, Pantanowitz and colleagues explained how international telepathology consultations had significantly improved patient care.
Over the first three years of the partnership with KingMed, China’s largest diagnostics company, the two partners reviewed more than 1,500 pathology cases submitted electronically to UPMC. The journal authors determined that consultation with UPMC subspecialist pathologists resulted in significantly altered treatment plans for more than half of the cases in which clinicians in referring hospitals in China provided a patient’s primary diagnosis.
Telepathology for NGS
“Now we are expanding our anatomical pathology telepathology services to other clients in China,” stated Pantanowitz. “Also, our telepathology team is working on molecular telepathology for next-generation sequencing for our clients here in the United States.
“The experience with KingMed prompted us to streamline and improve our digital consultation portal. Now we are discussing comparable situations with India, Italy, and Kazakhstan,” said George Michalopoulus, MD, PhD, the Maud L. Menten Professor of Pathology and Chairman of the Department of Pathology.
“After reviewing 144 cases in 2012, our UPMC pathologists saw specimens referred from China rise to 614 in 2013, 803 in 2014, and 810 last year,” Pantanowitz added. “Most of these pathology cases were hematopathology specimens, followed by bone or soft tissue and then gynecologic or breast specimens. We expect to review more than 800 cases this year.”
To achieve these successes, the UPMC-KingMed partnership had to address three significant challenges involving training, workflow, administration, and information technology, Pantanowitz commented. “First, pathologists had to be trained and had to establish a suitable workflow to comfortably and confidently perform teleconsultation using whole slide images,” he said.
partnering With IT Staff
“Second, under administration, we had to appropriately triage consults, handle billing, and manage issues related to digital consults (such as timely troubleshooting),” he said. “Third were the IT challenges. These included partnering with UPMC IT staff from our information services division (ISD) with varied skill sets (such as web designers and programmers) to build, continually customize, and maintain our in-house telepathology system,” he explained.
By addressing the workflow issues successfully, the Pathology Department did not need to add pathologists to accommodate the increased workload each year. “Consults were routed only to subspecialists at our academic hospitals who already had these subspecialty skills and are well known experts in their respective fields,” Pantanowitz commented.
“And we did not need to add overnight shifts or extend hours for our pathologists, in part because our telepathology system allows our pathologists to consult from anywhere at any time,” he added.
One key to smoothing the workflow process was appointing Chengquan Zhao, MD, a native of China who speaks fluent Mandarin, to manage all correspondence between the two partners, Pantanowitz said. A UPMC Professor of Pathology, Zhao is a member of the Division of Gynecologic Pathology and Associate Director of Cytopathology and Director of Fine Needle Aspiration at UPMC’s Magee-Womens Hospital.
“All key correspondence was and still is handled by Professor Zhao,” Pantanowitz explained. “He takes care of all communications with KingMed. In addition, KingMed assigned a point pathologist on their side who is fluent in English.”
As it would be with any telepathology program, IT issues were a challenge for UPMC’s pathologists. “The main issue was slow Internet connectivity, which impacted viewing of whole slide images. To overcome this problem we now copy image files from China by transmitting them using high-speed image transfer software (called Aspera) to our own server in Pittsburgh,” he added.
“Also, the initial image viewer we built relied on Java. Since Java constantly pushes out updates (which means our users need to keep accepting them), we built a vendor-neutral HTML5 whole-slide imaging viewer that our pathologists can use as an alternative.
“Another challenge was communicating with clinicians halfway around the world when we identified a need for more clinical information, missing gross descriptions, or when KingMed sent insufficient tissue for evaluation. To solve this problem, we incorporated functionality into our telepathology system that allows UPMC consultants to communicate directly via synchronous back-and-forth chat and email with KingMed pathology,” he said.
“In addition, we keep the email trail within the system as part of working up a case, so that it is not lost,” he added.
“Despite these hurdles, the program was profitable,” he said. “But it took about two and a half years to recoup the hardware, software, and legal investment UPMC made.
“For other clinical labs embarking on this journey, I would say they need to understand that it is critical to have a dedicated pathologist liaison such as Dr. Zhao who is well respected, trusted, and under-tands both languages and cultures,” he added.
“As you might assume, a joint venture like this also requires strong commitment from leadership on both sides, to get it started and to sustain it. For that, we credit the visionary nature of our senior pathology faculty, including Michalopoulus and Samuel A. Yousem, MD, and the KingMed leadership as well,” Pantanowitz added. Yousem is the E. Leon Barnes Professor of Anatomic Pathology, Vice Chairman of Anatomic Pathology Services at UPMC, Director of the Division of Anatomic Pathology, and Co-Director of the Community Pathology Division.
“And, for any venture like this, you will need in-house IT expertise. We feel that our international telepathology program is a win-win endeavor. As indicated by the results in our paper published in the Journal of Pathology Informatics, international telepathology consultation improves patient care by facilitating access to pathology expertise. We also provide added value in our reports, by including prognostic information and treatment suggestions when appropriate. Finally, our good relationship with KingMed also has provided indirect benefits, such as education and academic collaboration,” he concluded.
Contact Liron Pantanowitz, MD, at 412- 623-3746 or firstname.lastname@example.org; and Chengquan Zhao 412-641-6678 or email@example.com.
Case Referrals from China to UPMC Pathologists Demonstrate the Benefits of Subspecialty Expertise
PATHOLOGISTS INVOLVED IN THE GROUNDBREAKING JOINT VENTURE between the University of Pittsburgh Medical Center Department of Pathology and KingMed Diagnostics of China recently published an analysis of the pathology cases handled by the two partners since the start of the relationship in 2012.
Table A shows that, in more than 50% of the cases, UPMC’s pathologists provided a diagnosis that significantly disagreed with that of the referring pathologists. Table B shows the sources of referred cases. Table C reports on the types of diagnoses for these cases. Table D provides a breakdown of the types of cases and the percentages of disagreement. This information was published in the Journal of Pathology Informatics. (J Pathol Inform 2015, 1:63.)
For China Project, UPMC Had a Key Resource: A Pathologist with Strong Connections to China
WHENEVER A LAB EMBARKS on an international venture, overcoming language and cultural barriers could be a significant problem. For its partnership with KingMed Diagnostics, the Pathology Department at the University of Pittsburgh Medical Center had a ready solution.
“The most important factor in our success was having a champion pathologist in Chengquan Zhao, MD, a Professor of Pathology here at UPMC. Dr. Zhao is very famous in China, and has been instrumental to the success of our program for many reasons,” said Liron Pantanowitz, MD.
Zhao is a guest professor at six universities or large hospitals in China and was the lead author of the article on the UPMC-KingMed partnership in the Journal of Pathology Informatics in November.
“I visited KingMed at least twice,” Zhao said. “Also, I do the slide teaching, lecturing, and lead the discussions about the consultation cases. We also provide the opportunity for KingMed pathologists to learn pathology in our department here in Pittsburgh, and for KingMed’s surgical pathologists in China we provide education based on the consultation cases.
“In addition, I am doing cooperative research with KingMed pathologists and mainly direct them for the clinical research. Since last year, six papers have been published in the main American pathology or cytopathology journals. Several other UPMC pathologists are also involved in these research activities,” he added. “We find that good academic relations can enhance the telepathology relationship.
“For several years, the UPMC Pathology Department has built an academic relationship with the pathologists at the 301 Military Hospital, one of the largest hospitals in China,” added Zhao. “In addition, we’ve had two national cooperative pathology conferences in Beijing, including lectures by several UPMC pathologists.”