Introduction

Telepathology is the practice of pathology at a distance. Images and data can be sent to various locations to allow primary diagnosis, quality assurance, research, and education. Telepathology has come a long way since its creation, giving rise to a variety of different technologies, but how has telepathology impacted pathologists to date, and where is this technology heading?

The Birth of Telepathology

The term “Telepathology” was initially coined by the American pathologist Ronald. S. Weinstein in 1986 who invented the first dynamic-robotic real-time system. This system was later patented [1] [2]. Following this, growth in telepathology occurred despite an initial lag due to the complex nature of the technology involved [3]. Since then, three main modes of telepathology systems have been developed: Virtual slide systems (whole slide imaging), real-time systems (robotics systems), and imaged-based (static) systems [4] [5].

Telepathology Systems Currently Available

Telepathology systems can be separated into 3 different categories: Virtual slide systems (also termed whole slide imaging), Robotic real-time (dynamic) systems, and Image-based (static) systems [4] [5]. A fourth category is also sometimes included: video streaming, where consultants can view the procedure live and make a diagnosis or provide a second opinion [6].

Image-based static systems are the simplest and most inexpensive option. Images of the most relevant part of the processed sample are taken, sent for analysis, and then emailed, or stored online on shared servers. As this is a simple technology, little maintenance is involved and the process requires only low amounts of bandwidth. However, only small sections of the sample are digitised, and not the whole specimen. This can make the diagnosis process more difficult, particularly if the images are not of high enough quality [4] [6].

Virtual slide systems or whole-slide imaging (WSI) mimics what is seen down the microscope by producing high-resolution images which can be viewed online at any time, allowing the user to zoom in and out on the image as needed. Unfortunately, this technology is expensive and scanning can be time-consuming, depending on the image quality required. Images may be large, and therefore servers will need plenty of storage which can add to costs. Also, as this technology is more complex, it requires extra maintenance.

Finally, real-time systems are the most expensive and technologically advanced method of telepathology. Everything from focus to slide position is controlled by the pathologist from afar in real-time. The advantages here are obvious, complete control over the system with the ability to see the image clearly and adjust the focus and position as needed. Pathologists can make a more accurate diagnosis. However, as this is the most technologically advanced method, it requires ongoing maintenance and support and it is a very costly addition to the digital pathology service [4] [6].

New and Future Advances in Telepathology

Technology is rapidly evolving and systems are frequently updated to provide better image quality, faster scanning times, and enhanced software. New systems are currently being developed that produce video files with high-power z-stacking enabled, allowing the user to collect images in multiple optical planes [7] [8]. There are now a variety of different platforms available which gives pathologists the choice of choosing the systems that work best for them. This allows pathologists to make more accurate readings and ultimately improve the quality of care for patients. New hybrid devices for whole-cell imaging with remote control of robotics are now available, providing the best of both worlds. Storage issues are not so problematic as data storage capacities have grown with the modernisation of cloud technology services. Furthermore, telepathology allows experts to review cases from different locations connecting pathologists from around the globe [9] [10].

In the future, pathologists may choose to use iPads, or similar devices, with specially developed Apps for diagnosis and communication. Larger, expensive systems for image viewing may become redundant. Social media can also be linked with telepathology, so pathologists and patients can connect for teleconsultations or second opinions. [5].

Future Challenges

Telepathology is not the only area of telemedicine that is evolving, healthcare services are providing more remote services such as televisits and telehomecare. If anything, the Coronavirus pandemic has sped up this process due to the necessity of social distancing. However, what are the impacts of this? Patient monitoring and consultations can be carried out at a distance, but will it ever replace face to face contact with a healthcare worker? Some healthcare providers are still sceptical about how effective telepathology can be, and others may not like using the technology, preferring to stick to the older tried and tested methods. Also, having contact with others is an important part of our nature. What are the ethical implications here? Are they being considered and factored into the transition process? Security, data confidentiality, and consent should also be respected. Conversely, some patients may be more likely to seek a consultation or second opinion if they can do it remotely.

Other issues that need to be addressed include legal and regulatory standards. Competency and training should also be managed to avoid malpractice. Costs need to be considered too. Firewalls can cause problems in some countries when attempting to share files which can be frustrating. Image sharing can also be problematic if the software of different users is incompatible [6]. Adopting a standardised format for image files would alleviate these issues.

Conclusion

Telepathology has come a long way since its creation, with more capable systems being introduced to the market as technology is continually improved. Telepathology adds many benefits to the field of pathology, providing services to distant locations, allowing rapid results for diagnosis, better patient diagnosis, and enabling challenging cases to be reviewed remotely. Technological advances are key, but ethical considerations and patient and pathologist preferences should also be key considerations. Perhaps in the future, we may have a pathology service that allows the patient the option of telepathology, traditional communication, or some mixture of both.

References

1. Weinstein, R. S., Holcomb, M. J., & Krupinski, E. A. (2019). Invention and Early History of Telepathology (1985-2000). Journal of pathology informatics, 10, 1. https://doi.org/10.4103/jpi.jpi_71_18
2. Weinstein, R. S. (1986). Prospects for Telepathology. Human pathology. 17 (5) 433-434. https://doi.org/10.1016/S0046-8177(86)80028-4.
3. Weinstein, A.K. et al. (1997) Telepathology: A ten-year progress report. Human Pathology. 28(1) 1-7. https://doi.org/10.1016/S0046-8177(97)90270-7.
4. Farahani, N., & Pantanowitz, L. (2015) Overview of Telepathology. Surgical Pathology Clinics. 8 (2) 223-231. https://doi.org/10.1016/j.path.2015.02.018.
5. Magdala de Araújo Novaes (2020) Chapter 10 – Telecare within different specialties, Editor(s): Shashi Gogia, Fundamentals of Telemedicine and Telehealth. Academic Press. Pages 185-254. https://doi.org/10.1016/B978-0-12-814309-4.00010-0 .
6. Pantanowitz, L. (2021). Telepathology – Still the #1 Application of Digital Pathology. Global Engage (presentation video by Liron Pantanowitz). https://r9cks5rg.pages.infusionsoft.net/
7. Mosquera-Zamudio, A., Hanna, M.G., Parra-Medina, R., Piedrahita, A.C., Rodriguez-Urrego, P.A., & Pantanowitz, L. (2019) Advantage of Z-stacking for teleconsultation between the USA and Colombia. Diagn Cytopathol. 47(1):35-40. http://doi.org/10.1002/dc.23992
8. Pradhan, D. et al., (2016). Evaluation of Panoramic Digital Images Using Panoptiq for Frozen Section Diagnosis. J Pathol. Inform. 7:26. https://doi.org/10.4103/2153-3539.181770 .
9. Pantanowitz, L., et al. (2014). American Telemedicine Association clinical guidelines for telepathology. J Pathol Inform. 5(1):39. https://doi.org/10.4103/2153-3539.143329
10. Healthcare-in-Europe.com. (2021) Telepathology: A prime application of digital pathology. European Hospital. https://healthcare-in-europe.com/en/news/telepathology-a-prime-application-of-digital-pathology.html