CEO SUMMARY: Information is where both clinical laboratories and anatomic pathologists will continue to add value to healthcare in the future. At this year’s Executive War College in May, THE DARK REPORT asked several leading innovators in laboratory and pathology informatics to share their actual experience in funding and operating the earliest telemedicine and telepathology systems. Here is a revealing look at how Michael J. Becich, M.D. and his colleagues at the University of Pittsburgh Medical Center are evaluating and using laboratory informatics.
PART ONE OF A THREE-PART SERIES
TELEPATHOLOGY TODAY IS A FAILURE! That is the firm conviction of Michael J. Becich, M.D., Ph.D., Director of the Division of Pathology Informatics at the University of Pittsburgh School of Medicine.
“I call telepathology a failure for one reason,” said Dr. Becich. “In almost every case where some form of tele-‘X’ medicine has been tried, it has not succeeded. That is because the regulatory, legal, and reimbursement procedures needed to support telemedicine, and telepathology, remain undeveloped. That may continue to be true for sometime.”
Dr. Becich made these remarks at the Executive War College in New Orleans last May. Although disparaging about telemedicine as it exists today, Dr. Becich is firmly convinced that a seamless blending of clinical laboratory and anatomic pathology information is the success ticket for the future.
“I believe that informatics technology is building a new framework around the clinical disciplines we now call clinical laboratory and anatomic pathology,” he predicted. “At the University of Pittsburgh Medical Center (UPMC), we’ve developed a strategy we call ‘telehealth.’ We’re taking the infrastructure of today’s telepathology technology and turning it into added value services that attract clients and clinical consults to our enterprise.”
Unlike many academics, Dr. Becich has a keen sense for the healthcare marketplace and how pathologists must “sell” themselves to prosper within that marketplace. One of his goals is to develop UPMC’s pathology services into a national and international brand.
“We already see evidence that our high-tech informatics and telehealth capabilities give us a leg up on our competitors and bring new business into our pathology practice.”
Dr. Becich feels it is essential to under- stand two fundamentals about laboratory and pathology informatics. “The first fundamental is why telepathology and telemedicine has yet to succeed,” he noted.
“The second fundamental involves understanding why there is both a need and an opportunity for pathologists to incorporate teleservices and sophisticated informatics into their medical practice,” continued Dr. Becich.
Fundamental number one is actually an obstacle which needs to be overcome. For Dr. Becich, the collective failure of telemedicine through 1999 can be attributed to two main factors. “One is cost of the systems themselves,” he said. “The other is the lack of reimbursement.
“To date, there have probably been 60,000 telemedicine consultations. Yet virtually none of these consultations flow through the usual channels of reimbursement, such as government and private payers,” stated Dr. Becich. “I don’t know how any provider can support a telemedicine program without reimbursement.”
Steady Growth In Testing
“Of course, there are some notable exceptions,” he added. “The Veterans Administration is a sterling example of appropriate use of telepathology. They are leaders in its application.
“But overall, today’s brand of telemedicine does not deliver services in a way that compliments the mainstream practice of medicine,” said Dr. Becich. “That holds it back, but that situation is changing rapidly.
“Also, I would observe that the terms telemedicine and telepathology have negative connotations with many people,” Dr. Becich stated. “Telemedicine evokes images of an empty room some place full of data, without the human touch. There is also a fear that somehow telemedicine will displace local physicians who do the real work every day in every city and town around the country.
“I like to avoid the negative images that accompany terms like telemedicine and telepathology,” offered Dr. Becich. “We prefer to use the term telehealth within our organization, for reasons I will explain in a minute.
“Besides the lack of reimbursement, growth of telepathology has suffered because of the high cost of the technology,” he said. “The most successful of the telepathology systems in use today cost upwards of $250,000 per device to install.
“Few pathology practices can use such systems to generate the substantial revenues needed to get a return on an investment that big,” pointed out Dr. Becich. “Recent price drops allow an adequate system to be installed for as little as $150,000. But that is still a substantial investment to put a robotic, dynamic microscopy system into a remote site.”
Failure Of Telemedicine
Taken collectively, Dr. Becich’s comments indicate that telemedicine and telepathology has so far been a failure because of: 1) the high cost to install and operate systems using existing technology; 2) the lack of reimbursement by payers and government health programs for clinical services rendered through telemedicine systems; and, 3) the lack of legal and professional guidelines sup- porting effective medical services performed through telemedicine or telepathology capabilities.
THE DARK REPORT would add one more element to Dr. Becich’s evaluation of telemedicine and telepathology’s failure. That is the fear of local physicians that “out-of-state” doctors will use telemedicine to invade their turf and steal market share. That is one reason behind the jumble of state laws which govern licensure and how medical services can be offered within the state.
Dr. Becich’s second fundamental involving laboratory and pathology informatics deals with the medical community’s need for improved pathology services. “Telepathology has the potential to solve a lot of medical and operational problems.”
Within The UPMC System
“For example, take my needs as a working pathologist in the UPMC health system,” he noted. “Within a 1.5 mile radius of my hospital, I have three major hospitals, a cancer care center, an orthopedics center, as well as the UPMC acute care, trauma, and transplant services sites.
“If I need to look at a prostate biopsy, it may take me 20-25 minutes to get over there,” said Dr. Becich. “Or, someone must spend the same amount of time to get the slide to me. So, one function of our imaging system is for informal consults. Certainly these are not billable forms of revenue, but the time and courier savings are considerable.
“If the images are not up to the quality I need, the slide can certainly be packed and shipped to me,” he explained. “But currently about 85% to 90% of these cases are handled using our imaging system. Within our group practice, this has been a valuable solution.”
Imaging System
“UPMC’s relationship with Quest Diagnostics Incorporated generates cases in anatomic pathology, dermatopathology and related areas. We expect our imaging system to figure prominently in how we service this relationship,” noted Dr. Becich.
“It doesn’t stop there, however. The UPMC health system now numbers 18 purchased or merged hospitals and 138 affiliated medical practices. On June 1, UPMC’s hospital in Palermo, Italy become operational. Our imaging system is utilized in all of these environments,” said Dr. Becich.
“Thus, when dealing with clinicians from inside our extended healthcare enterprise, telepathology and the electronic movement of images and diagnoses makes good economic sense, even before considering outside reimbursement,” he observed.
Creating Telehealth Solutions From Telepathology
Dr. Michael Becich’s strategies for pathology-based telehealth services:
- Pathology is a visual discipline so implement digital imaging.
- Integrate imaging with laboratory information systems (LIS) and billing/ordering functions.
- Integrate imagining/LIS with the world wide web and develop an Internet strategy.
- Develop methods of publishing pathology reports on the Internet.
- Develop a strategy to receive and send images from outside centers and other specialists.
- Integrate multimedia pathology reports with electronic medical records (EMR) systems.
Coupled To LIS
“I should add that it is necessary to have this system coupled to your LIS,” he said. “We have the luxury of an integrated imaging system which sits atop our LIS. Because we are a teaching, research, and clinical center, there is an absolute hunger and thirst for pathology images from the multiple professional schools, nursing, pharmacy, dentistry, and the center for biomedical informatics.
“This was the justification for our original investment in telepathology capabilities,” said Dr. Becich. “It was a significant step for us. We now provide informatics and images that support an average of 60 clinical conferences per week!”
As Dr. Becich illustrates, one function of telepathology is to improve the organizational efficiency of pathologists within an integrated healthcare enterprise. But the real need for telepathology is in offering more sophisticated information and value to clinicians.
Here is where pathologists can fill a need and seize an opportunity at the same time. In so doing, pathologists elevate their contribution and importance to the healthcare community.
“In recent years, the growth in specialty laboratories has been phenomenal,” stated Dr. Becich. “The complexity of clinical pathology and anatomic pathology increases yearly.”
Patient Access To Records
“Yet, among clinicians, medicine is migrating to the primary care physician (PCP),” he observed. “Even more interesting, a greater number of patients are insisting on increased access to their clinical records so they can make more informed decisions about their course of treatment.
“Thus, even as pathology reporting becomes more complex, the recipient of the pathology report may not be as sophisticated as the medical specialist who traditionally referred cases to the pathologist,” Dr. Becich stated.
“Consequently, there’s a need for more sophisticated pathology information, but presented in a simple, easy to understand format,” he said. “Pathology informatics is the key to filling this need and seizing this opportunity.”
Telehealth Is Preferred Term
“That is why I prefer to use the word ‘telehealth’ over telepathology,” explained Dr. Becich. “Pathology reports must be tailored to the end user. These reports need to provide appropriate information which improves outcomes and benefits the patient.
“Right now, because of effective marketing of specialized pathology services, 30% of my caseload is referred by pathologists,” he said. “Is it right to send the same report to pathologists, and specialists, and primary care doctors? And what about patients who want to see their reports?
“It is my conviction that one of the biggest growth areas in healthcare will be in sharing information with patients,” predicted Dr. Becich. “This creates a new challenge, which is to design a pathology report that patients find useful.”
Enhance Clinical Value
Dr. Becich is describing the end process of healthcare integration. Interacting with the pathologist will be primary care physicians, certain specialists, and the patients themselves. To provide the necessary value, pathologists must develop ways of sharing information that enhance clinical practices.
“Take the primary care doc, for example,” stated Dr. Becich. “As lab testing becomes more complex, how does he deal with the diarrhea of paper coming out of our labs? If a patient has advanced liver disease, how does the doctor deal with 15 different paper reports and no graphical output?
“This is why pathologists have the opportunity to provide telehealth services,” he continued. “It is how we package and present the information we’ve developed that will make it easier for doctors to comprehend and apply that data for the benefit of their patients.”
Against the background of these two fundamentals, it becomes easier to understand why UPMC’s pathologists decided to acquire and adapt telepathology and informatics capability to today’s healthcare needs.
“Probably the first major insight we developed was agreement that pathology was a visual discipline,” noted Dr. Becich. “Whether it is gels, quantitative feedback from an instrument, anatomic or cytology slides, or even the autopsy itself, pathology services center around images.”
Convert To Digital Images
“So, the first step in our effort was to develop a way to convert this range of visual information into some type of digital images,” he said. “When we started our first imaging initiative at the University of Pittsburgh, I counted 54 different types of film in my department. Less than one-third of them could fit in the same size of jacket and be held together in any useful fashion.
“If you think about it, film is a nineteenth century solution,” stated Dr. Becich. “Once we went digital with all these images, it became easier to share the information within our system. It also allowed us to combine clinical data in new ways.”
It is this digital imaging capability which underpins the telehealth strategy of the UPMC pathologists. In upcoming installments of this story, THE DARK REPORT will explore how Dr. Becich and his colleagues are moving both anatomic and clinical pathology to a higher level of relevance and involvement in clinical activities.
It should be understood that the practice environment within the UPMC system is unique. This institution’s research and teaching missions allowed Dr. Becich to acquire technology which is generally out of reach for the typical community hospital-based pathologist.
At the same time, Dr. Becich and his colleagues were willing to push the boundaries of this technology. Their vision is that pathology becomes a necessary part of improving outcomes while lowering the cost of care.
It is these activities which bear watching by pathologists and lab executives throughout the country. Pathologists at UPMC will experience both successes and setbacks in their efforts to move the pathology profession into the 21st century. But this kind of pioneering work must be done if pathology is to increase its relevance in the integrated healthcare community of the future.
