In the past several weeks we have all seen or been directly impacted by a worldwide pandemic.
Nearly 1/3 of the world’s population is currently on “lockdown”, “shelter in place”, “stay at home” or other similar orders from local, state and national authorities in respective parts of the world. My parents told me about when the city swimming pools had to be closed over concern of poliomyelitis, but few of us have experienced anything like this before. Epidemiologists and sociologists will have plenty to study for the next decade and break down.
Will we be quick to shake hands or use that door handle or push our way into a line in a crowded subway terminal again?
In recent days there has been much discussion about “virtual visits”, “telehealth” and “remote wellness” using technologies that are common to all of us. While telemedicine, including telepathology, has been mired in endless regulations, laws, guidelines – and the big one – lack of reimbursement – this national health emergency has renewed the call for telehealth applications (with payment). Centers for Medicare and Medicaid Services (CMS), virtually overnight, loosened decades worth of burdensome rules regarding licensing, credentialing, personal health information over the Internet, patient’s rights, HIPAA and providers liability and responsibilities.
Doctors at my hospital are being issued tablets for virtual visits to keep the worried well sheltered in place, away from hospital and out of the system in terms of who needs to be seen and who does not. While screening mammograms, colonoscopies, prostate biopsies, pap smears and removal of those pesky moles have been put on hold during this pandemic, renewed attention has been focused on “remote reads” for pathologists. Remote reads, vis-à-vis looking at slides from a remote site (presumably from a home office setting) rather than exposing oneself in a hospital, i.e. telepathology, has been talked about for decades.
The U.S. Army had a worldwide telepathology program back in 2000. Regional telepathology services were around before and since but nothing of a huge scale in terms of patients served/slide volumes. The Army program saw perhaps 2,500 cases annually at the peak which largely ended when the Armed Forces Institute of Pathology (AFIP) closed its doors about a decade ago. Ron Weinstein, who coined the term “telepathology” did so in 1986 – at a lecture at AFIP.
This is not new, but renewed interest, with calls from the College of American Pathologists and Association of Pathology Informatics, among a couple of organizations, to call upon CMS, and specifically, request changes to the Clinical Laboratory Improvement Act (CLIA) which prohibits remote reads from non-CLIA settings. Thus, while the technology has existed, the ability to use it – and for completeness, from a CLIA inspected basement (or attic) home office to perform pathology services remotely, has not.
It is important to remember that CLIA itself, the legislation and subsequent requirements for proficiency testing on glass pap smear slides, was a direct result of “at home pap mills” where cytotechnologists may have been distracted by televisions, screaming kids, work at home spouses, delivery people at the door, etc… Kind of like what were to happen, if, say, many of us were ordered to stay at home, with children going to school on laptops, with delivery people bringing you food and leaving, perhaps, only to go to the hospital to escape it all!
Nonetheless, as we said in the military 20 years ago, this is a way to “get the subspecialty care as far forward as possible”.
As healthcare providers/workers, whatever the term in this week, including those of us who work in hospital-based laboratories, we have had to measure and balance covering our services with minimizing exposure in a setting where known cases are present.
And thus, working remotely, as many of our neighbors are doing in a variety of industries, presents us in pathology with another opportunity for telepathology and perhaps easing some restrictions to do so. While we remain cognizant that this requires an infrastructure in place to do so – a digital pathology environment in your laboratory as well as a professional office setting in your remote work area free from the kind of distractions mentioned previously.
Anyone in healthcare who has ever used a telephone, or now, Facetime or Skype or Zoom or more, to speak with a colleague, supervisor, technologist, patient or family member has engaged in the practice of telemedicine – the practice of medicine at a distance.
Appendicitis, the surgeons will tell you, is a nocturnal disease – few cases present between 9 and 5 when the banks are open. It presents at 2 or 3 in the morning. Every night calls go out to work up and treat these cases. Blood bank calls are similar – they start after the evening news. We take the call and make recommendations, call our clinical colleagues and do the best we can with what we have at 4 AM from our bedrooms, or basements if you are still playing cards.
Pathology and our industry partners can do this and the reality is we should have been able to do it for decades. I can think of a few hurricanes, tornadoes, floods, viruses, bacteria and even a sniper in DC where staying home meant staying safe and where telepathology could have maintained some resources.