Needs and workflow assessment prior to implementation of a digital pathology infrastructure for the US Air Force Medical Service.

In the recent report by Ho et al., entitled “Needs and workflow assessment prior to implementation of a digital pathology infrastructure for the US Air Force Medical Service”, the investigators use contextual inquiry to answer questions related to anatomic pathology workflow needs and organizational infrastructure within their practice environment.[1] Contextual inquiry, the authors report, is designed to be a user-centered support tool for the design and development of software, devices, and systems in various industries and settings. Interestingly, this form of detailed evaluation to assess systems and processes with needs/wants/goals/deliverables within an organization has been infrequently reported in healthcare settings.[2]

I think the analysis is made more interesting in addition to being applied within a healthcare setting, but within a very diverse pathology practice setting in terms of size, scope, and practice need within the Air Force Medical Service. Rear Admiral Lamont Pugh, USN, Surgeon General of the Navy, in an address before the Association of Military Surgeons of the United States on November 17, 1952 said:

“Military medicine is a well-conceived, well advised, and well established device, system, or mechanism, the mission of which is to provide the Armed Services with a quality or brand of medical coverage that is not only essential to the proper and efficient function of the military but is moreover essential to the best interests of the individual and of the national welfare.”[3]

Few of us in healthcare, pathology, or laboratory medicine have worked in a practice setting so geographically diverse within a larger organization with its own challenges essential to its overall mission with both large regional and smaller peripheral practice locations as is seen within military medicine. The system of military healthcare strives to provide local care close to home to serve soldiers, sailors, airmen, marines, and their families’ local access to high quality care, treating when able, and referring when necessary to regional medical centers. It is a delicate balance between meeting staffing needs concordant with local base/installation requirements and efficiently delivering subspecialty care to the degree possible as far forward as possible, particularly in times of military conflict. In the paper, the investigators highlight the total number of healthcare facilities with pathology services, current staffing levels with both general and subspecialty pathologists, residents and years of experience among the pathologists, a relatively junior corps of 16 of 24 pathologists having less than 5 years of experience.

In 2002, investigators from Walter Reed Army Medical Center, Heidelberg Army Hospital, and the Armed Forces Institute of Pathology (AFIP) concluded in a retrospective review of frozen section cases from remote sites that: “The use of remote pathology may allow full surgical pathology support to remote centers by pathologists located at distant sites. The concept was that a validated remote pathology system, which met community standards of diagnostic accuracy, would help support the current number of pathologists while maintaining microscopic diagnostic support to community-sized hospitals and regional medical centers. Telepathology would enable full-time coverage and would reduce the travel time of the pathologist, which is expensive, nonproductive professional time.”[4] Given the wide geography and multitude of locations and populations served throughout the military healthcare system, meeting the needs and challenges of their healthcare beneficiaries provides some unique challenges in caring for those who protect our freedoms and providing subspecialty or expert care “as far forward as possible”.[56] This also creates an excellent environment to deploy telemedicine technologies that can have the greatest impact, both close to home and at a distance.[7] High turnover of technical and professional personnel requires frequent training and instruction of new staff and pathologists. Figures 1–7 show an early telepathology report from AFIP to hospital pathologist in Germany [Figure 1] and examples of systems in use at implementation of this program, pathologist reviews of external consults and in use for teaching/training with military residents [Figures 2–6]. Publications within the military healthcare and base newspapers identified the project as innovative and of importance to military healthcare beneficiaries [Figure 7].

Figure 1

Armed Forces Institute of Pathology Telepathology Report 2003

Figure 7

Cover story photo in Military Medical Technology Publication, 2002

Figure 2

Walter Reed Army Medical Center staff hematopathologist (left) reviewing cases with hematopathology fellow (seated at keyboard) with pathology residents, February 2003

Figure 6

Walter Reed Army Medical Center Telepathology System, July 2002 (KJK Office)

Walter Reed Army Medical Center staff pathologists reviewing case from Landstuhl Regional Medical Center, Germany, June 2004

Iraq Telepathology System (slide loader system), October 2006

Korea Telepathology System, January 2000

Information technology security issues within not only the Department of Defense but within networks on respective bases and furthermore, additional security measures within treatment facilities present some unique challenges to open yet safe and secure access to critical information that needs to be shared across facilities. Lastly, the size and scope of the nature of their integrated healthcare delivery system, across continents compared with across counties, or states presents additional costs and time expenditures to deploy, implement, train, and maintain specific applications, such as digital pathology within respective hospitals.

Subsequently, following thorough review of workflow needs with contextual inquiry, with improvements in technology, and our understanding of complicated workflows and sources of system process errors, the authors suggest in this paper that the Air Force Medical Service is positioned to benefit greatly from the adoption and implementation of digital pathology through global workload distribution, secondary consultations and quality assurance. There should be no doubt left that pathology organizations that serve distributed healthcare services, be it global or regional (i.e., integrated healthcare delivery systems, regional/national cancer centers) can be served well with system-wide pathology reviews efficiently, safely and with high quality diagnostic services with digital pathology.