Thomas P. Baker, MD
As many CAP members know, the Armed Forces Institute of Pathology will close in 2011 under the Base Realignment and Closure Law of 2005. BRAC law identified several pieces of the AFIP that will continue on after its closure, including the Office of the Armed Forces Medical Examiner, the National Museum of Health and Medicine, and the AFIP Tissue Repository. As stated in law, other functions will be integrated into existing capabilities within the Department of Defense.
The National Defense Authorization Act of 2008 included language to create a Joint Pathology Center (JPC) that will “serve as the pathology reference center for the federal government.” The law identified the mission of the JPC to include pathology consultation, research, and education (including graduate and continuing medical education), as well as maintenance, modernization, and use of the already existing AFIP Tissue Repository. After much work and deliberation at Department of Defense Health Affairs, including coordination with other federal agencies, the mission of the JPC was officially delegated to the Department of Defense in April 2009. The Joint Task Force National Capital Region Medical (JTF CapMed), responsible for all military health care in the National Capital Region, was officially assigned the responsibility of establishing the JPC in December 2009.
The vision of the JPC is to serve as the premier federal pathology reference center serving the Military Healthcare System and other federal agencies. In addition to the capabilities identified in the National Defense Authorization Act, the JPC will develop key strategic partnerships with other Department of Defense entities, the Veterans Administration, and other federal agencies. These partnerships will serve as a “force multiplier” that will greatly enhance the mission of the JPC and allow for significant interagency collaboration in research and education.
At the core of the Joint Pathology Center will be a group of more than 30 skilled subspecialist pathologists with extensive experience covering a broad range of organ systems and diseases. The JPC will offer organ/diseased-based subspecialty pathology consultation in such unique areas as environmental pathology and infectious disease pathology as well as the more commonly identified subspecialties. This array of skills and subspecialties will allow for a one-stop-shop approach to consultation on difficult and challenging cases.
Supporting the consultative service of the JPC will be a large, robust, state-of-the-art histology laboratory that will provide an array of special stains and immunohistochemical and immunofluorescent stains. To capitalize on efficiencies gained, the histology laboratory will be part of the new Walter Reed National Military Medical Center within JTF CapMed, and will be a 24/7 operation using the latest in technology and with a Lean Six Sigma approach that emphasizes quality and turnaround time. The laboratory will be staffed with more than 30 histotechnologists and ample support staff.
Robust molecular laboratory capabilities will also support the JPC consultative service and will initially include a panel of more than 20 probes for hematologic and other malignancies. The JPC strategic plan calls for expanding the probes available as adjunct studies for pathology consultation as well as implementing new technologies. The molecular laboratory will be staffed initially with 15 personnel—a molecular pathologist, a PhD scientist, molecular medical technologists, and other support personnel.
The JPC will also assume the unique service (provided now by the AFIP) of a laboratory devoted to biophysical toxicology. The laboratory currently provides several different tests in support of the federal government that includes depleted uranium testing on various biologic specimens. Additionally, the laboratory will continue to provide in-depth testing of imbedded fragments in support of DoD and VA health care initiatives. This laboratory will be staffed with a PhD chemist/toxicologist and three technologists.
The AFIP Veterinary Pathology Program will also become a part of the JPC. This program provides another unique service that includes a one-of-a-kind veterinary pathology consultation function to the DoD and several other federal agencies. Additionally, the AFIP will transition its veterinary pathology educational programs to the JPC, including the only veterinary pathology residency in the Department of Defense. This service will be staffed with seven veterinary pathologists, 10 veterinary pathology residents, and support staff.
The JPC will use telepathology for consultations to the DoD and the VA medical facilities. Its strategic plan calls for working with the Army, Navy, Air Force, and VA pathology consultants to develop an enterprise-wide approach to providing telepathology services to the DoD and VA as well as identifying and incorporating the needs of other federal agencies.
Other capabilities critical to supporting the federal government are muscle biopsy and nerve biopsy interpretation and transmission electron microscopy. With these capabilities, unique and hard-to-find pathology services will be provided to augment consultation and as primary services to the federal government.
The JPC’s education mission is twofold: continuing medical education and graduate education. It will develop a robust online CME curriculum. The focus of the online educational activities, at least initially, will be on maintenance of certification requirements and the needs of the solo pathologist in support of the DoD and VA. Educational activities will include online lectures, videoteleconferences, and a digital slide repository for CME credit. The JPC will partner with the Uniformed Services University of Health Sciences to provide CME credit for these activities. Graduate education will include subspecialty rotations for federal government residencies and fellowships and support of the dermatopathology fellowship at National Naval Medical Center and of the Navy Oral Pathology Fellowship. As the JPC matures, we will work closely with the Uniformed Services University of Health Sciences to identify and implement other educational opportunities.
The JPC will work closely with the new Walter Reed National Military Medical Center to provide research. The JTF CapMed is developing an institutional review board approval process to allow streamlining of protocol approval across multiple distinct organizations within the JTF CapMed. Although the JPC will have intrinsic laboratory capabilities for research, there will be ample opportunity to engage in original research through existing capabilities within the JTF as well as with strategic partners such as the Uniformed Services University of Health Sciences, the VA, and other federal agencies. There are already several similar models within the DoD involving partnership and collaborative involvement in research.
The AFIP currently houses the largest tissue repository in the world, one that the research community has deemed a national treasure. The repository includes more than 7.8 million cases consisting of 55 million glass slides, 31 million paraffin blocks, and more than 500,000 wet tissue samples largely from cases submitted to the AFIP for consultation during the past century. On a disease-by-disease basis, the repository contains some of the largest collections of specimens in the world. Additionally, the tissue repository contains case material from more than 28 closed or downsized military medical facilities that is representative of community hospital pathology material. There is tremendous potential for use of the repository in support of medical research within and outside of the DoD. However, we need to develop a plan for use of the repository in a sustainable and appropriate manner. With the full support of the DoD Health Affairs, we are in the final stages of initiating a comprehensive study of the repository that will use expertise in the field to help develop a roadmap for its use. Though we expect the various phases of this study to take up to two years to complete, the result will be a comprehensive plan consisting of the mission and vision of the tissue repository and details regarding who will have access to the material, how material will be accessed, and the resources required to use the repository.
How will the JPC differ from the AFIP? It will be a streamlined organization that will be closely affiliated with the world-class academic Walter Reed National Military Medical Center (being established now from the merger of Walter Reed Army Medical Center and National Naval Medical Center). The organization will focus on high-quality and expeditious consultation using state-of-the-art technologies in support of the federal government. It will continue the AFIP’s critical mission of supporting the Armed Forces Medical Examiner. As described, it will focus its educational opportunities on the needs of the pathology community within the federal government. It will use existing capabilities and extensive partnerships in conducting research and in support of clinical research. Additionally, completion and implementation of the plan for use of the tissue repository will greatly enhance the research capabilities of the JPC. Unlike the AFIP and in accordance with the requirements identified in BRAC law and the National Defense Authorization Act, the JPC will not provide pathology consultation for the civilian community but will provide consultative services for agencies of the federal government, primarily the DoD and the VA.
The JPC established its Office of Director this month and will begin accepting consultations in April 2011. The AFIP will cease all consultative services in April 2011. The JPC is working closely with the AFIP to ensure no disruption in clinical services as functions are transitioned to the JPC. Additionally, the JPC is working on a strategic communication plan to ensure that its stakeholders and customers have a good understanding of the organization, services provided to its customers, and the timeframe for establishment. Our goal is to make the transition of consultative services as seamless as possible for our customers.
The JPC will soon be a fully functional organization serving the pathology needs of the federal government. As the organization matures and as the study on the use of the tissue repository is completed and implemented, there is great opportunity to make this a one-of-a-kind organization that will truly be the premier pathology reference center for the federal government.
Dr. Baker is a Colonel in the U.S. Army and interim director of the Joint Pathology Center, Joint Task Force National Capital Region Medical, Bethesda, Md. He is chief of the Integrated Department of Pathology, Walter Reed Army Medical Center and National Naval Medical Center, and a member of the CAP Cancer Committee.