A nationwide telepathology consultation and quality control program in China: implementation and result analysis

WHO estimated that China had 2.80 million newly diagnosed cancer patients in 2008 [1]. According to National Health and Family Planning Commission of China, cancer is the No.1 cause of death in China, accounting for 1.96 million deaths annually. As the most populous country in the world with a population exceeding 1.37 billion, China has the largest number of cancer patients worldwide. In addition, its population is rapidly aging. As the number of newly diagnosed cancer patient in China has been increasing rapidly, cancer diagnosis and treatment are becoming an important part of health care in China.

Accuracy of pathology diagnosis plays a key role in the effective management of cancer patients. China however, has limited pathology resources. The country has limited numbers of well-trained and experienced pathologists; most of them work in large teaching hospitals in big cities. A recent survey by Chinese Pathologists Association showed that a majority of pathologists in clinical practice in China had only one year of formal training. Pathology residency programs similar to those of Western countries are only available since 2010 and are limited in a couple of large medical schools. Most pathologists and even pathologists in large tertiary teaching hospitals or provincial referral hospitals are not sub-specialized. Pathologists in community hospitals often have difficulty in diagnosing rare or complex cancer pathology cases. Error in pathology diagnosis is not uncommon, which often results in medical legal problem. There is an urgent need for pathology consultation and pathology quality control in China.

Telepathology is the practice of pathology by interpreting digitalized images or whole slide images (WSI) by pathologists at a long distance. It could be applied in many areas of pathology practice, including remote consultation, quality control, teaching and continuing medical education [2, 3]. Telepathology offers the efficient utilization of subspecialty pathologists to solve problems of shortage of pathologists and subspecialists at remote sites or remote hospitals [4]. In order to improve the quality of pathology diagnosis by using limited pathology resources, the Pathology Quality Control Center of China, under the guidance of National Health and Family Planning Commission, developed and implemented a nationwide telepathology consultation and quality control program for cancer diagnosis in China in 2011. We here report the results of the implementation and two-years operation of the program.

In recent years, telepathology has been applied successfully in remote pathology consultation and in quality control [2, 7]. Since 2009, because of the availability of high speed Internet, 3G wireless networks and low cost "made in China" commercial virtual microscopes, telepathology has become the focus of attention among pathology community in China. A validation study of telepathology consultation in China showed that the mean accuracy of pathology diagnosis using virtual image is 94.2% as compared to H/E glass slide [5]. In 2010, Ministry of Health of China released an announcement to promote telepathology for cancer diagnosis in China and initiated a plan to build a nationwide telepathology consultation and quality control network. The goal is to provide telepathology consultation and to monitor the accuracy of pathology diagnosis of cancer in China. The program called for provinces to develop their own provincial telepathology consultation and quality control centers, each of them then connected to national center. By 2011, a website based consultation and quality control platform were implemented to connect a network of 60 hospitals from 20 provinces.

The results of the two-year experience and implementation showed that the number of consultation cases submitted to the platform increased quickly. Within one and half year, a total number of 16,247 cases have been reached. Most of the cases were diagnostic challenging cases. More cases were sent by hospitals from urban areas as compared with hospital from county/rural areas. The reason may be due to that hospitals in urban areas have more surgical pathology specimens and more pathology cases with diagnostic complexity as compared to county/rural areas. Another reason is that the pathologists and patients in urban hospitals were better informed about telepathology consultation platform than those in county/rural hospitals. Our results indicated that telepathology could play a role in cancer pathology diagnosis in both county/rural hospitals and city hospitals.

Analysis of the turn-around time of telepathology consultation showed that almost all of our consultation reports were released within 48 hours. Our turn around time is much shorter than the 7 average days of turn around time of conventional pathology consultation reported in US where glass slides were used [8]. A shorter turn-around time for cancer diagnosis reduces the anxiety of patients and increases the chance for immediate treatment. In view of turn-around time, consultation provided by telepathology has great advantage over conventional pathology consultation.

Pathology consultation or second opinion in pathology diagnosis plays a pivotal role in cancer diagnosis [9, 10]. Several reports from North America showed that the disagreement in pathology diagnosis between expert consultants and submitting pathologists were around 10% [11, 12]. The disagreement in diagnosis for lymphoma was as high as 16.4% [13]. Among Asian countries, the rate of disagreement in pathology diagnosis between expert pathologists and submitting pathologists is much higher, ranging from 16% to 64.3% [14, 15]. An analysis of 673 consultation cases sent to Twain Cancer Center showed that 16% of the cases had second opinion significantly differ from primary diagnosis [14]. Hsu et al reported that, among 2,686 consultation cases, 64.3% of cases had expert opinion different from preliminary diagnosis and 205 cases (12.3%) showed significant disagreement [15]. Our result of 16,247 teleconsultation cases showed that 24.2% (3,932 cases) of cases had experts' opinion significantly different from submitting pathologists. The significant difference means a change from malignant to benign or from benign to malignant. The rate increases to 28.8% (3,932 out of 13,647 cases) if cases without preliminary diagnosis were excluded from analysis. Our result is significantly high than those reported in North America and Twain but lower than those reported in other Asia countries or region. In addition, 16% of our cases were received without a preliminary diagnosis provided by community pathologists, which indicated that 40.2% of our cases benefit from telepathology consultation. Our results indicated that telepathology is very valuable in cancer diagnosis in China.

Due to the differences in cancer types and in biopsy rate, the distribution of consultation cases among different body organs and systems may be different between Western countries and China. Our results showed that in China, most of the consultation cases were from gastrointestinal tract/live and pancreas, gynecology, head and neck, bone and soft tissue, and respiratory system. Unlike Western countries, skin pathology, hematopathology and cytopathology accounted for low percentage of the consultation cases in China [10]. The difference in distribution of teleconsultation cases may provide guidance for training of subspecialty pathologists in China.

From May 2012, the program provided more than 40 Internet based pathology lectures by expert consultants. The lectures are free and open to all pathologists in the country. The result indicated that the platform could also play a role in providing continuing medical education for pathologists nationwide.

In future, telepathology or digital pathology will play a key role in pathology diagnosis and quality control, as its current development is accelerate by the advance of digital and internet technology, and is supported by the government. Telepathology is also cost effective and could play a role in health care reform. Telepathology consultation aids pathologists to diagnose difficult pathology cases, reduces errors in diagnosis and avoids unnecessary medical legal expenses; telepathology also benefits patients who no longer need to travel to large hospitals for a second opinion for cancer diagnosis, thus saving time and money for patients. We believe that in near future telepathology will become an important part of telemedicine and will play a role in health care reform in China.

We reported the implementation of a nationwide telepathology consultation platform in China and analyze the results of its two-year operation. An internet based telepathology open platform was established to connect 60 participating hospitals and 80 pathology experts. Our two-years results indicated that 16, 247 pathology cases were sent to the platform over one and half years. Telepathology provided a fast consultation service with a turn around time less than 48 hours and improved cancer pathology diagnosis in about 40% of cases submitted for consultation. Telepathology could play an important role in improving quality of cancer diagnosis and in solving a shortage of pathology resource in China.