The 31st Combat Support Hospital in Baghdad processes all manner of tissue
at unpredictable rates with only a single pathologist, far removed from
any kind of consultative ability or friendly academic center.
But remote military outposts like this have a real-time lifeline thanks
to the dynamic telepathology network constructed over the past few years
by the Armed Forces Institute of Pathology at Walter Reed Army Medical
Center, Washington, DC.
"They are processing tissue, and on occasion consultation is required,"
says Keith Kaplan, MD, MAJ, medical director of cytopathology and the
Army telepathology program, who championed the system and won funding
for it. "The question I asked is, ’Is this as good as looking through
the microscope? If this were a biopsy from a relative, would I be comfortable
with someone reviewing it by telepathology?’"
The 21-site system, which uses digital cameras linked to robotically
controlled microscopes so the distant pathologist can zoom in on or move
around a slide as needed, was used 282 times in the first 11 months of
2004, Dr. Kaplan says. The Internet-based system combines quicker turnaround
time than commercial overnight couriers and the manipulative capabilities
not possible with e-mailed photos, winning over skeptics and inspiring
pathologists to find uses for it that even Dr. Kaplan would not have predicted.
"The big thing is, it helps you with difficult diagnoses. You have an
expert in the field," says Dave Mendoza, MD, chief of anatomic pathology
at Blanchfield Army Community Hospital in Ft. Campbell, Ky., who first
used the system in 2003 at the 121st General Hospital in Korea. "I’m still
using it over here. It’s great to have an expert— somebody who does
nothing but look at skin, or nothing but look at breast all day."
Another user is Barbara Crothers, DO, chief of anatomic pathology at
Walter Reed and Dr. Kaplan’s boss, who was stationed in Korea in 2002
and 2003. "When you’re in a remote site, and you’ve got only one other
practicing pathologist with you, you just need someone else to bounce
the case off of," she says.
One nuisance for those stationed overseas is that courier deliveries
take longer— if they can get them at all, Dr. Kaplan says. "For
Korea and Germany it’s really been a benefit," he says. "They’ve told
me it’s actually decreased hospital stays because they’ve been able to
get the turnaround. People upload these cases, and they get a call within
a couple of hours."
Or at least the next morning. "I could put a case on as I was leaving
at the end of the day, and the next morning have a consultant’s report
faxed to me, waiting for me, kind of overnight, while I slept," Dr. Mendoza
says. A package from Korea might take two or three days to reach the AFIP,
and then "they have to accession it, they have to look at it. The typical
turnaround time was two weeks before we’d get a faxed report."
Dr. Crothers says the real-time nature of the system made a huge difference
in Korea. "We had a couple of cases whereby if I had had to actually send
the cases off to AFIP, it would have taken several weeks—as opposed
to a day or two." She recalls the overnight routine Dr. Mendoza described
but cites one drawback: "We could load only one slide at a time. They
couldn’t call us up and say, ’Could you load up another slide?’"
The system is not without other drawbacks: It’s not suited to multiple-slide
cases, those requiring special stains, and certain others, and it’s afflicted
with the same occasional technical difficulties as any Internet-based
Still, at this point, only technophobes are avoiding
it entirely, says Joseph P. Pulcini, MD, LTC, chief of anatomic pathology
at Brooke Army Medical Center at Ft. Sam Houston, Tex., who counts himself
among the early skeptics.
"I was very vocally saying this was a waste," Dr. Pulcini says of the
system, which, for the first five systems, was $48,000 per site. (The
price for additional sites was lower.) He knew it would cost "a couple
million dollars to get this up and running," and wondered, How often is
this going to make a difference in terms of patient care, to have an answer
in a few hours versus just sending a case out and having it in a few days?
And how efficient is it when you’re navigating a slide using a mouse and
a robot to focus? For the number of times it would make a real difference,
he thought, you could put someone on a plane with a first-class ticket
to the Mayo Clinic.
"And then I actually started using it," Dr. Pulcini says. "The learning
curve is not that steep." It’s mainly older pathologists and others uncomfortable
with technology who avoid it. "They’re not part of the video-game generation.
’What is that thing in the corner?’ They don’t want to know." But over
time, it has become an accepted part of the anatomic pathology service.
"I work in a large bureaucracy, obviously, which is where telepathology
is most useful—when you have a big, closed system like the Army.
We all work for the same people." Dr. Pulcini now uses it about twice
Eric Berg, MD, COL, chief of the Department of Pathology at Blanchfield,
says his department’s use of the system has jumped noticeably, to one
or two times per day, since Dr. Mendoza and another younger pathologist
came to work at the hospital. "They use it quite a bit," Dr. Berg says.
"It’s increased by virtue of the new people."
Dr. Kaplan thinks part of the resistance has come because earlier generations
of telepathology, which has been around in one form or another for nearly
three decades, did not deliver as promised. Skeptics say: "We’ve tried
this, and it didn’t work. We’ve heard about this before, and it doesn’t
work. I’m too busy to do what’s functional here. I don’t have time to
try what’s new and experimental, somebody’s science project."
"The idea of telepathology has been tried for years," Dr. Mendoza agrees.
"Until now, the resolutions on the screen just weren’t high enough. There
wasn’t enough throughput on the Internet to get good imagery. There’s
still room for improvement, but we’re light years from where we were even
five years ago."
Within the Army, usage has at least doubled over a year ago, when fewer
hospitals had systems installed and fewer pathologists used it where it
was in place, Dr. Kaplan says. "Initially, there was a bit of a lull,
a little bit of lag. Then people started using it," he says. "We’re working
on a system whereby I can track how many cases are being sent from where
Dr. Kaplan says he’s surprised by the amount of use the system has gotten
for specialties like hematopathology, hematology, and cytology. "The lack
of oil has not been a major hindrance," he says. "I use it for cytology
at 40X or 60X and have yet to defer a case because of the image quality."
He predicted a lot of reluctance, but the hematopathologists have turned
out to be the biggest proponents. "I thought for sure they’re not going
to want to look at [a sample] unless it’s dunked in oil, at 100X, on their
own microscope," he says.
Dr. Crothers says she sees it used most often for dermatopathology. "We
frequently will get a second or third opinion from someone in AFIP for
a case we’re pretty sure about but need a little hand-holding with," she
At Blanchfield in Kentucky, Dr. Berg says it’s used most often on breast,
prostate, and skin biopsies. "We use it half the time for patient satisfaction
as much as our own," he says. "You don’t want to leave them hanging all
weekend with a breast biopsy that’s in doubt."
Dr. Pulcini says he’s found it most useful for one-slide cases in unusual
fields like oral pathology, but he figures Brooke’s experience, because
of its large size, is different from most. "I’m still skeptical about,
OK, how often does this make a difference in terms of, do you have to
use telepath versus just sending the case out?’" he says, but adds, "We
have a lot of subspecialty-trained pathologists here. Our experience here
is unusual because we’re more set up to be consultants rather than need
consultation. A smaller place more often needs the help."
Remote telepathology is not useful for larger and complicated cases,
say Dr. Kaplan and others, though all have slightly different takes on
when not to use it.
"The images are 99 percent as good as what you see through your microscope.
But sometimes you need that one percent; you want to do your own steps
and stains and so forth," Dr. Kaplan says. "I suggest people not use them
for complicated pigmented lesions. It also has been an issue for very
minute biopsies, prostate needle-core biopsies, or very thin biopsies
where you’re looking for very small foci of disease."
Dr. Crothers would send out any multiple-slide breast case, "knowing
that our consultant is going to need to do more than review a couple of
images," and most cases that would require "further workup through molecular
markers, chemical stains, or any other kinds of special stains," she says.
"It’s somewhat more limited because you would have to do those special
tests first. That would be more time-consuming. In those cases, it’s easier
to just package up a case and send it out."
Dr. Berg has never used the system for more than a three-slide case.
"It’s pretty much limited to small biopsies, or single slides of interest
in larger cases," he says, adding, "It’s not useful for frozen sections—you
don’t get an answer quickly enough."
Dr. Pulcini would not recommend remote telepathology for cytology. "There’s
a lot of screening," he says. "You have to look for a lot of individual,
abnormal cells. There’s a lot of three-dimensionality involved." He shares
Dr. Berg’s skepticism about frozen sections but thinks the system can
work for that purpose "in a pinch."
"It’s very hard to call AFIP and say, ’I’ve got a frozen, drop what you’re
doing.’ The guy 2,000 miles away is not at your beck and call," he says.
Another limitation of the system is one that plagues
any Internet-based technology: interrupted connectivity, which can be
worse in the Army because of the elaborate system of firewalls set up
to meet security requirements.
"There may be hospital firewalls and base firewalls; there may be different
levels of security," Dr. Kaplan says. "There are some routers in Europe
and Asia that we don’t control. If those go down, that is beyond our control.
And if the hospital LAN is down somewhere, it doesn’t work. In Iraq, they
didn’t do cases [remotely] for a couple of months because they’ve had,
as you can imagine, some issues with power."
Dr. Mendoza remembers that the firewalls in Korea made the system harder
to set up there than stateside. "It was a little bit harder tunneling
through," he says.
"We have firewalls in place that the average private hospital would never
dream of," Dr. Pulcini says. "We have to be careful who gets let in."
Dr. Crothers cites another internal Army problem that surely affects
most large bureaucracies. "The information management people are constantly
upgrading, downloading, and changing things on the network," she says.
"They don’t always check to make sure what kind of impact their changes
are going to have on our system. Sometimes our system is not functional,
and that will put us up for a day or two."
Dr. Kaplan predicts that dynamic telepathology as it’s now known will
be eclipsed in perhaps five years by whole-slide telepathology systems,
which enable the pathologist to capture the entire slide at high resolution
and display it at multiple resolutions, with the goal of imaging all slides
in a multi-slide case. (Related article: "Digital
imaging, telepathology: what’s the holdup?" July 2004.)
Virtual slides will combine the ease of e-mailed stills with the manipulative
capabilities of the robotic microscopes. "Virtual slides are the Holy
Grail of all this," Dr. Kaplan says. "What we have now works well, but
you’re still dependent on routers and the Internet being up and the robotic
microscopes. For the military, [virtual slides] are going to be an awesome
Dr. Pulcini says the virtual slides will have "fewer moving parts" and
"might be more glitch-free" than the robotic microscope, but he sees some
of the same problems—as well as a new one. "Bandwidth becomes an
issue with a virtual slide. It’s a huge file," he says.
But whether it’s virtual slide or robotic microscope, the "ultimate hurdle,"
Dr. Pulcini says, "is that it takes longer to look at the specimen." If
it’s a large specimen with a lot of subtle features, you’re moving around
with a mouse rather than moving a real slide with your fingers.
"The advantage to [either] system is, it’s real time," he adds. "And
although this doesn’t usually happen, you can be on the phone with the
other pathologist. And you usually get a fax a couple of hours later."
Ed Finkel is a writer in Evanston, Ill. The opinions and assertions contained
in this story are not to be construed as official or reflecting the official
views of the U.S. Department of the Army or Department of Defense.
The Army telepathology network uses systems manufactured by Trestle
Corp., Irvine, Calif.