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CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
Brief report
Telehematology: critical determinants for successful implementation
Urs Luethi, Lorenz Risch, Wolfgang Korte, Margrit Bader, and Andreas R. Huber
Despite modern technologies, such as
immunophenotyping and molecular
probing, cytomorphologic examination
of stained peripheral blood smears by
microscopy remains the mainstay of
diagnosis in a large variety of diseases.
This holds true especially in underdeveloped or rural areas where profound
expertise and equipment are not easily
available. Although communication
technologies have been dramatically improved, telehematology has not become
routine. To date, little information is
available on which procedures are critical for successful implementation.
Therefore, a study evaluating possible
factors that prevented implementation
of telehematology was initiated. We
found that staining technique, smearing
procedure, training skills, number of
captured images, and prevalent disease
influenced the accuracy of diagnosis by
the reference laboratory. Using realtime teleconferencing allowed for over-
coming these deficits. Together, when
certain rules are observed, telehematology allows for rapid, accurate, standardized, and cheap expert advice. This technology should improve treatment of
patients in remote areas where expertise is not available. (Blood. 2004;103:
486-488)
© 2004 by The American Society of Hematology
Introduction
In clinical laboratory testing, evaluation of peripheral blood and
bone marrow smears is essential for diagnosis of diseases, especially those of the blood. Although technically simple, morphologic
analysis requires considerable skill. For accurate diagnosis of blood
diseases, well-trained and experienced medical laboratory technicians, as well as experienced hematologists, are required. Technicians in small peripheral medical laboratories may be inexperienced in evaluating rare pathologies. Because early diagnosis in
several hematologic diseases is important (eg, acute promyelocytic
leukemia associated frequently with disseminated intravascular
coagulation), rapidly available expert advice would represent a
major step in quality improvement of peripheral health care. In
remote areas, referral of the patient to tertiary care centers is only
justified after a solid diagnosis is obtained. Because many disorders
can be diagnosed by pathognomonic blood smears, dangerous
delays and unnecessary referrals could be avoided if appropriate
hematologic expertise is obtained in time. But unlike numerical
data such as complete blood count and biochemical markers, it has
been difficult to report cell morphology from remote sites. Digital
transmission in the field of the pathologic testing is used in
increasing frequency.1 In hematology, support of diagnosis and
clinical practices by using digitally transmitted images is not yet
routine. Recently, standardized systems for digital transmission of
visual information in hematology (telehematology) have become
available. It is now possible to handle images viewed through a
microscope on a computer by electronically capturing pictures of
peripheral blood and bone marrow smears by using charge-coupled
device (CCD) cameras in a standardized fashion. Although the
technical aspects of rapid transmission of high-quality images has
been solved, specific hematologic issues have not been addressed
to date, such as the role of staining procedure, level of experience
and training of staff obtaining images, and competence of staff
hematologist evaluating the images. To establish the hematologyspecific requirements for correct diagnosis of a blood smear
obtained at a remote site, patients with a variety of diseases were
analyzed in a blinded fashion. This test included 30 different cases
with distinct diseases. This technology could prove useful in
countries with large rural areas (China, Canada, Greece, etc) or in
emerging countries. Nevertheless, even in privileged countries with
high population density, second opinion gathering through standardized telehematology might prove useful as well.
From the Department of Laboratory Medicine, Kantonsspital, Aarau,
Switzerland; and the Institute for Clinical Chemistry and Hematology,
Kantonsspital, St. Gallen, Switzerland.
Reprints: Andreas R. Huber, Department of Laboratory Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland; e-mail: [email protected].
Submitted May 20, 2003; accepted August 14, 2003. Prepublished online as
Blood First Edition Paper, September 11, 2003; DOI 10.1182/blood-200305-1615.
486
Study design
In an experimental setting using a newly developed telehematology system
(LAFIA; Sysmex, Kobe, Japan), the situation between a small peripheral
routine laboratory and a hematology reference laboratory was simulated.
The transmitting workstation (peripheral laboratory) was located remotely
from the receiving workstation (reference laboratory). The reference
laboratory (featuring a technician with wide experience in hematology and
a hematologist) was requested to evaluate the chosen photographs of blood
smears received from the peripheral laboratory by e-mail (Figure 1). The
diagnoses were compared with direct microscopic evaluation of the smears
by an expert (gold standard) without the use of telehematology (Figure 2).
Several factors influencing the quality of expert advice were examined.
These factors included a staining or smear technique different from the
reference laboratory, different numbers of transmitted photographs (1 or 3
per case), and different levels of expertise of the person in the peripheral
laboratory selecting the photographs (hematologist, general practitioner,
and clinical chemistry technician). The effect of these factors on the
accuracy of expert diagnosis was assessed by transmitting (e-mail) different
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© 2004 by The American Society of Hematology
BLOOD, 15 JANUARY 2004 䡠 VOLUME 103, NUMBER 2
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BLOOD, 15 JANUARY 2004 䡠 VOLUME 103, NUMBER 2
IMPLEMENTING TELEHEMATOLOGY
487
Table 1. Selected cases
Case no.
Figure 1. Examples of blood smear photographs transmitted from the peripheral lab to the reference lab. Malaria (left) and acute leukemia (right) are selected.
Wright stain was used. Original magnification, ⫻ 500.
sets of photographs (JPG format) obtained from blood smears of 30
different cases covering a wide variety of common hematologic diseases
(Table 1). The effect of teleconferencing was evaluated by using real-time
transmission of the microscopic procedure. This dynamic system transmits
live images of smears from the microscope at the remote site to a monitor at
the reference laboratory. The expert gains the possibility to control the
microscopic procedure while viewing simultaneously, giving technical
instructions in selecting diagnostic fields, and adjusting focus magnification
and illumination. The 2 participants can communicate by phone and draw
each other’s attention to specific details. Therefore, with real-time hematology the smears can be analyzed as with locally available microscopy.
Statistics were based on the chi square test (applying Yates correction for
continuity), comparing the proportion of correctly reported expert diagnosis
to the gold standard. P values were calculated 2-tailed; the level of
significance was set at ⱕ .05.
Results and discussion
Images acquired by LAFIA provided a 640 by 480 pixel image
resolution and were stored in JPG format (approximately 250 kB).
These electronic images imported into a computer by a CCD
camera and sent by e-mail can reproduce microscopic findings very
accurately. As expected, using a hematologist in the peripheral
laboratory, the diagnostic accuracy in the reference laboratory
achieved 100% when transmitting 3 pictures per case. Interestingly,
when the hematologist was mailing only 1 photograph per case, the
diagnostic accuracy dropped to 57% (17 of 30; P ⬍ .001). The
difficulty was that a proper number of images of cells was not
Figure 2. Settings in the peripheral lab influencing the diagnostic accuracy in
the reference lab using telehematology.
Diagnosis
Case 01
Normal blood smear
Case 02
Malaria
Case 03
Sickle cell disease
Case 04
Thalassemia major
Case 05
Spherocytosis
Case 06
Hemolytic anemia
Case 07
HUS/TTP
Case 08
Megaloblastic anemia
Case 09
Microcytic anemia
Case 10
Ovalocytosis
Case 11
Howell-Jolly bodies*
Case 12
Pelger-Huet anomaly
Case 13
Osteomyelofibrosis
Case 14
CML-CP
Case 15
Myelodysplastic syndrome
Case 16
AML M2
Case 17
CML-BP
Case 18
May-Hegglin anomaly
Case 19
AML M4
Case 20
Hairy cell leukemia
Case 21
AML M7
Case 22
Parasitemia*
Case 23
Cytomegaly
Case 24
ALL
Case 25
AML M6*
Case 26
Infection/sepsis*
Case 27
Mononucleosis
Case 28
AML M5a
Case 29
Sézary syndrome*
Case 30
CLL
AML indicates acute myeloid leukemia; CML-BP, chronic myelocytic leukemia
blast crisis; HUS/TTP, hemolytic uremic syndrome/thrombotic thrombocytopenic
purpura; ALL, acute lymphoblastic leukemia; and CLL, chronic lymphocytic leukemia.
*Not represented in the test setting panel using a different smear technique.
reached with only 1 photograph per case. The expert diagnosis was
better when more cells were available for evaluating. Even when a
hematologist in the peripheral laboratory transmitted 3 pictures of
smears prepared with a different stain (Pappenheim) than that used
in the reference laboratory (Wright stain), the accuracy was lower
(27 of 30; NS, P ⫽ .24). Also the use of a different smear technique
(automation versus spun smears) decreased the accuracy to 72%
(18 of 25; P ⫽ .008). Disorders of red blood cells were judged
accurately in most cases in almost all settings. Problems in judging
the smears arose predominantly in disorders of white blood cells
(eg, lymphoproliferative disorders and acute leukemia), especially
when leukopenia was present additionally. Cell characteristics such
as nuclear reticular structure, presence or absence of nucleolus, and
granular or color tone of cytoplasm often enabled the diagnosis.
Further, a general practitioner transmitting 3 pictures allowed 63%
(19 of 30; P ⫽ .001), and the clinical chemistry technician
transmitting 3 pictures had only 37% diagnostic accuracy (11 of 30;
P ⬍ .001). Thus, a lower level of specialized knowledge of the
person in the peripheral laboratory choosing the photographs
resulted in a significantly lower accuracy of expert advice. The
lower skilled persons often selected photographs that were not
representative for the diagnosis, eg, healthy blood cells instead of
blast cells in the case of acute leukemia. This deficit was
compensated if real-time microscopy was available. This method
enabled a clinical chemistry technician to obtain images that
improved the accuracy significantly to 100% (P ⬍ .001). Interpretation of images sent by an inexperienced technician was more
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488
BLOOD, 15 JANUARY 2004 䡠 VOLUME 103, NUMBER 2
LUETHI et al
difficult as demonstrated. However, a basic knowledge in hematology at the periphery is sufficient for sending the right images to the
reference laboratory. No expert experience was necessary. Realtime hematology would overcome these difficulties, yet would be a
laborious and expensive alternative method. Standardization of
staining and smearing procedure, capturing of 3 images, and a
minimum of training of a technologist are sufficient for successful
telehematology together with a modest technical investment.
We conclude that transmitting blood smear photographs by way
of e-mail is feasible to offer rapid expert advice to peripheral
laboratories. However, there are factors negatively affecting the
accuracy of telehematology diagnosis. Real-time telehematology is
the method of choice to overcome these factors. As an other option
it facilitates a second opinion from a colleague, who has particular
expertise in a special field, or to confirm a clinician’s diagnosis by
asking the advice of an expert.
References
1.
Leong FJ. Practical applications of Internet resources for cost-effective telepathology practice. Pathology. 2001;33:498-503.
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
2004 103: 486-488
doi:10.1182/blood-2003-05-1615 originally published online
September 11, 2003
Telehematology: critical determinants for successful implementation
Urs Luethi, Lorenz Risch, Wolfgang Korte, Margrit Bader and Andreas R. Huber
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