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Think Tank „Telemedicine – bridging the countries“

Aurich, 21.-22.4.2018

After a short introduction by Dr. Gerhard Stauch four working groups started discussing different topics:

Working Group 1 - Diagnostic Telepathology (Prof. Kunze, Prof Dalquen):

Statements of Quality Standards in Diagnostic Telepathology on static Images

1. Since clinical information is necessary to check the plausibility of the morphological diagnosis, the lack of it is a frequent and most important cause of inaccurate and doubtful histological diagnoses. Standardization by a more detailed inscription table for the clinical information is desirable, which contains the rubrics “Gender”, “Age”, “patients history”, “Laboratory data”, and “Macroscopy/Tumor size”.

2. The selected images have to be representative for the entire lesion. This includes a careful visualization of margins, an appropriate number of images and choice of appropriate magnifications (one or two low power images in addition to high power views: for histological specimens taken with the 40 x objective, for cytological smears with objectives 40x, 63x or 100x depending on the size of the cells of interest).

3. Referral cases with severe deficiencies of preparation, staining, and imaging are not appropriate for telepathology consultation. Such cases are frustrating and time consuming for the consultants and a risk for the referring pathologists as well as for the patients. Therefore standardized rating of the quality of cases by the consultants appears desirable.

4. The photographic quality of images depends on focusing, microscope illumination and correct white balance of the camera. Focusing has to be done on the monitor and the Koehler illumination of the microscope has to be controlled separately for each slide and each objective (s. the iPath-manual and the instructions for active users of the Histopathology Forum).

5. The diagnostic standards in telepathology should be in accordance with the best practice in conventional pathology. Every lowering of the standards is not justified and should be avoided.

6. The quality of morphological diagnostics is essentially determined by the application of modern methods. For teaching reasons the need of ancillary methods to come to definite diagnosis should be communicated, irrespectively of their availability to the sender.

Cooperation between referring pathologists and consultants

  1. Good communication between referring pathologists and the consultants is a precondition for accurate and reliable diagnostic assessments.

  2. The demands on the consultant include:

  • Professional competence

  • Reasonable response time: From clinical point of view the aim should be to give the comments principally within one and if that is not possible within maximally three days after the images were set on the iPath.

  • Giving objective and critical comments with advices for the diagnosis or differential diagnosis but without an unreasonable self-expression or patronizing know-it-all attitude.

  1. Requirement of the comments:

  • They must be well-founded on the morphology represented by the images.

  • Application of the up-to-date terminology.

  • If ambiguous features are presented, most probable differential diagnosis is indicated.

  • If necessary to come to definite diagnosis ancillary tests are recommended irrespective of their availability.

  • Recommendations regarding preparatory and photographic techniques should be included into the comment to stimulate the technical improvement.

  • Recommendation for additional clinical diagnostic procedures.

4. Cooperation between referral and consultant needs information regarding

  • Results of ancillary methods

  • Actual clinical findings of diagnostic relevance

  • Follow-up of the patients, which is most important for reasons of quality control of the consultant’s diagnoses and therewith for improving his professional competence.

5. The demands on referring pathologists include:

  • Skillful selection of cases

  • Submission of representative images from well prepared slides

  • Information about age, gender, symptoms and localization

  • Application of available ancillary methods and submission of additional images corresponding to the requests of consultants

  • Information about the results of ancillary methods and actual clinical findings of diagnostic relevance. Missing feedbacks are particularly frustrating and discouraging for the consultants and not beneficial for further cooperation.

  • Referring pathologists only are authorized to transfer a case with the related images from one iPath group into another.

  • Referring pathologists are responsible for the final diagnoses.

Working group 2: Teaching and internship (Dr. Hinsch)

Personal: not enough teaching personal, retired pathologist will be contacted. They should be encouraged to go to cambodia for a workshop. The workshop can be organized and travel expanses paid for by the SES, after a request from Dr. Vathana. It should be tried to encourage them afterwards to futher accompy the young colleagues in their training via skype.

Hospitation: List of institutes, which are willing to take in interns. Produce guidelines for the organisation of an internship. Contact DAAD for organisation and funding (including housing). MOU with the university hospital in Phnom Penh to get an official contract to get refunding for the hospitation.

Weekly teaching sessions: Continuitation of the weekly teaching session when the residents are back in cambodia in the end of 2018. Teaching session for the new generation of pathologist after they received some basic lessons.

Changing the concept for the teaching session: upload and discussion of cases by the residents. Handling of the cases with a more practical approach: how to handle a case, what stainings to do, what to write in the report.

Other discussed topics:

  1. Does it make sense to provide longer internships (1-1,5 Jahre)? Problem: Because reports in germany are only written in german the residents would have no possibility to write reports by themselves.

  2. Collect specimen and slides for teaching purposes and send them so interested students

  3. Upload videos of macroscopy into the teaching group for self-lerning

  4. Scientific work: finding new contacts for long term internships via scientific word, like Davy Lim in Rotterdam

  5. Include other countries? Not enough pathologists. Pathologists are invited to join the current sessions

Working group 3: Recruiting and collaboration with clinical colleagues, publications, dissertations (Dr. Lessel)

  1. Using iPath for e-learning: residents will be invited to take part in diagnosing the uploaded cases, but they have to register as residents.

  2. The uploaded cases could be used for publications, e.g. case reports, in scientific journals.

  3. Inclusion of experts for tropical diseases (Tropeninstitut Hamburg). Infectious diseases, which are rare in europe, should be diagnosed scillfully. Experienced experts can help, contact to the experts can be mediated by participants of the workshop.

  4. Inclusion of methological and technical problems and solutions in iPath: the quality of the uploaded pictures, histologies and radiologic images is often not optimal and limits the accuracy of the diagnosis. Medical consultants and medical technicians can help to improve the quality by giving feedback and advice based on own experience. Virtual internships can be established.

  5. Presentation of the iPath network at the yearly Interplast meeting 2019 (march 1st./2nd. 2019) in Bad Honeff. Contact via PD Lei Li.

  6. Initiating meetings for retired pathologists. It is meant to adress retired pathologists who want to keep up to date in their speciality. Perhaps more consultants for iPath can be recruited at those meetings.

  7. Other topics:

  8. Information about country-specific therapeutic options should be given to the consultants involved in the diagnostic process, perhaps this could be communicated in future meetings.

  9. Making sure of the competence and espertise of the consultants: consultans are legitimized by the board certification, experts, if needed, are available.

  10. A feedback by the local pathologist about decisions regarding therapy and about the outcome would be useful

Working group 4: Financial matters, organisation, future development (Ms. Hubler, Dr. Singh)

  1. Financing based on contributions from the users:

  2. User with a large amount of cases (more than 30/month) are asked for a financial contribution.

  3. Communities with more than 25 groups receive a bill (making a contract?).

  4. Financing based on using the data for scientific projects, after getting permission by the referring user, e.g. deep learning:

  5. Deep learning is the use of neuronal networks for the development of automatized processes, in case of pahology for the development of automatized diagnostic logarithms.

  6. Ipath provides a large amount of data. This could be used to test existing systems for their functionality, a starter set of about 1000 categorized cases would be necessary.

  7. Financing through fundraising: producing a short documentation about iPath, contacting organisations like lion`s club and rotary club.

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