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Quality-Collaborative Relationships in Surgical Pathololgy between Small and Large Hospitals

Posted Oct 25 2010 12:00am

We need to take some steps to ensure that our smaller hospitals continue to be viable both financially and in terms of the quality of care that they provide. This may be difficult for some of them in this new era of accountable care organizations (ACOs) with complex performance standards required by the government and insurance companies.

One of the challenges facing smaller hospitals, from the perspective of surgical pathology, is that the number of pathologists working in such a setting will be small -- perhaps one or two in many cases. It is impossible in such a small group to solicit multiple opinions about a challenging surgical pathology case. In a large academic pathology department, there are numerous colleagues close-at-hand to consult, all of whom will have sub-speciality expertise. These problems were evident recently in a story about an error that occurred in the diagnosis of ductal carcinoma in-situ of the breast (see: Seeking A Second Opinion as a Partial Solution to the DCIS Controversy ). When there is doubt about a case in a small pathology group, the slides are packed-up and shipped overnight to a favored surgical pathology consultant for an opinion. However, this takes time and effort and is generally not pursued for most cases.

I would like to see more "quality-collaborative" relationships developing between smaller hospitals and regional academic centers, particularly in the area of cancer care. The deployment of a digital pathology system and whole-slide-imaging (WSI) on both sides of such a relationship would make frictionless, routine review of many more surgical pathology cases the norm. Under such a system and with WSI, the pathologist at the smaller hospital would simply drag the file associated with a particular difficult case into the work-queue of the consulting pathologist working at the larger academic center. This latter individual would then interpret the case as part of his or her normal work day. The consultant's opinion would then immediately be transferred back to the AP-LIS at the smaller institution. We now have an early form of this process operating with Aperio's SecondSlide , a digital slide-sharing service. I am told, however, that this system is far from frictionless because it's relatively new.

One of the speakers at the recent Pathology Informatics 2010 conference in Boston stated in a lecture that it was difficult to justify the broad deployment of digital pathology in an academic department solely on a return-on-investment (ROI) basis. I would suggest that perhaps he was looking at the wrong spreadsheet to draw this conclusion, which is to say the calculation of the ROI solely for the division of anatomic pathology. Let's say that the quality-collaborative relationship described above was based on testing and consultation between a small and large hospital for both CP and AP work. In other words, the smaller hospital would send all of its outsourced CP specimens to the larger hospital in addition to its surgical pathology consultations. The ROI for digital pathology would look very different.

In fact, sending CP specimens to the neighboring academic center reinforces the notion of the quality-collaborative relationships being discussed here. With the rapid growth of molecular diagnostics and the integration of AP and CP (see: Integration of Anatomic and Clinical Pathology ), surgical pathology consultations will increasingly require the analysis of both serum and tissue biomarkers. Clarient has already established such a quality-collaborative relationship with pathologists in smaller hospitals. This was partly the basis for the recent purchase of the company by GE Medical (see: General Electric Goes Outside The Box In Healthcare ). Here are more details about this deal from a financial analyst:

Clarient is basically in the business of conducting cancer diagnostics tests on behalf of community pathologists, oncologists, and physicians. In simple terms, it is a model like that used by LabCorp and Quest Diagnostics - clinicians send samples to Clarient, and Clarient tests those samples and reports back on the presence/absence of cancer and other important details (like the type of cancer).

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