TELEMEDICINE JOURNAL

Volume 2, Number 3, 1996

Mary Ann Liebert, Inc.

Telemedicine and Telepathology at the Armed Forces

Institute of Pathology: History and Current Mission
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FLORABEL G. MULLICK, M.D., PAUL FONTELO, M.D., M.P.H., and

CHARLES PEMBLE, D.M.D., M.S.D.

ABSTRACT

The Armed Forces Institute of Pathology uses telepathology and telemedicine programs to
support its mission of providing pathology consultation, education, and research. The
telepathology service is based on a static imaging or "store-and-forward" approach using both
proprietary equipment and open systems through the Internet. Initiated in 1993, the service
Telemedicine Journal 1996.2:187-193.

provides rapid expert consultation to pathologists globally. Diagnoses are provided by pathol¬
ogists in 22 specialized departments. Educational programs are delivered through the World
Wide Web. Category I continuing medical education credits can be obtained through Internet-
based courses. Research activities are focused on forensic applications and the creation of im¬
age databases.

EVOLUTION OF THE ARMED FORCES Today the AFIP has a total staff of 825 em¬
INSTITUTE OF PATHOLOGY ployees. Over 540 military and civilian per¬
sonnel work in 22 specialized pathology de¬
Armed Forces Institute of Pathology in consultation, education, and
The(AFIP) has a long history in U.S. military
partments
research with the remaining 285 employees
medicine, tracing its beginnings to the Army working ancillary or support services. Each
in
Medical Museum in 1862.1 Museum doctors year, the AFIP responds to over 48,000 surgi¬
were tasked to
originally disease and
study cal pathology and autopsy consultation re¬
trauma sustained in the Civil War. In the fol¬ quests from around the world, including the
lowing decades devoted their efforts to
they investigations of military and civilian aircraft
improving Army medicine. From these early accidents and other national disasters. The
days arose three national medical resources: AFIP's mission is not limited to the Depart¬
the National Library of Medicine, the Walter ment of Defense but extends to other federal
Reed Army Institute of Research, and the Army agencies and civilians as well.
Institute of Pathology. In 1949, the Army The AFIP is also home to the National
Institute of Pathology was renamed the AFIP, Museum of Health and Medicine, which pro¬
becoming a joint agency of the Army, Navy, duces exhibits, sponsors public health educa¬
and Air Force. tion programs, and displays America's largest

Armed Forces Institute of Pathology, Washington, D.C.

The veiws expressed in this article are those of the authors and do not reflect the offical policy of the Department
of Defense, the Department of the Army, the Department of the Air Force, or the U.S. Government.

187
 188 MULLICK ET AL.

collection of anatomic specimens and medical
artifacts. The AFIP offers more than 50 post¬
graduate courses and a wide range of other ed¬
ucational opportunities for pathologists and
other physicians as part of their continuing
medical education. The Institute also conducts
advanced research for investigating disease
processes, including electron microscopy, dig¬
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2. Policies and standard procedures for image
capture of valuable cases. Images may derive
from a variety of sources, including glass
slides, 2X2 photographic slides, gross spec¬
imens, clinical photographs, electron micro¬
graphs, and radiographs. A near-seamless in¬
corporation of digital image capture from
microslides can be integrated into the current

ital image processing, and DNA probes. system of photomicrography. With an addi¬
tional "exposure" by the photomicroscopy
specialist, digital image capture of selected
ELECTRONIC PATHOLOGY PROGRAM cases should become routine. A complemen¬

tary database of parametric data (e.g., clinical

The AFIP intends to take advantage of the na¬
tional information infrastructure and other
emerging telecommunication technologies in the
fields of telemedicine and telepathology. The
AFIP is a resolute proponent of incorporating a
strong program in electronic pathology into each
of its mission elements. Conventional pathology
Telemedicine Journal 1996.2:187-193.
history, therapy, and treatment outcome) will
be built to enhance the value of cases for
teaching or research.
3. An archive node for storage of large-image
and parametric databases. With proper se¬
curity considerations, access by authorized
AFIP personnel will allow for retrieval and

activities and other services including the transmission of these data. This will facili¬
Armed Forces Medical Examiner, the Depart¬ tate research and education efforts and al¬
ment of Environmental and Toxicologie Patho¬ low for innovative ways of sharing pathol¬
logy, the National Museum of Health and ogy information.
Medicine, the International Tissue Repository,
and the Department of Legal Medicine constitute
a vast resource for consultative and educational
services via telemedicine and telepathology. TELEPATHOLOGY PROGRAM
The Telepathology Program, formally initi¬
Consultation
ated in 1993, has been under development since
the beginning of a pilot project in early 1991. Today the AFIP has an active telepathology
Other, related projects include the electronic service, having processed 140 consultations in
Fascicle (an electronic textbook being pub¬ the first 6 months of 1996. Its primary objective
lished by the AFIP), the AFIP World Wide Web is to provide rapid diagnostic support to re¬
(WWW) site, and creation of CD-ROMs by sev¬ mote medical treatment facilities within the
eral individual departments. All of these efforts United States and abroad. It is both an
rely on the acquisition, storage, retrieval, and anatomic and a clinical pathology consultation
transmission of digital data—principally im¬ service. Cases are accepted if referred by a
ages and text. pathologist. The consultation service parallels
The Institute is seeking to consolidate and co¬ the standard consultation procedure at the
ordinate its diverse telemedicine efforts into a AFIP program. The accessioning process and
coherent plan that can efficiently accommodate review of cases are done by subspecialty
each department's needs. To do this effectively, branches; however, digitized images are re¬
a customizable telecommunication infrastruc¬ ceived instead of glass slides or paraffinized
ture common to all telemedicine projects is be¬ specimens.
ing established. This infrastructure includes the The AFIP's experience with telepathology
following: began with a pilot projected that extended from
1991 to 1993 (unpublished data). The trial had
1. World Wide Web access from every Local two objectives and was implemented in two
Area Network (LAN) connection in the phases. The pilot first sought to determine
Institute. what groups would be most likely to use such
 TELEMEDICINE AND TELEPATHOLOGY AT THE AFIP 189

a service. The second phase focused on med¬ AFIP telepathology service by telephone (202-
ical validation of the technique. During the trial 782-2882/2884), fax (202-782-9010), or electronic
period all telepathology consultations were ac¬ mail (e-mail) (telepath@email.afip.osd.mil) that
companied by transport of the physical glass images are being transmitted. Case consulta¬
slides. A total of 180 cases were processed in tions may be sent through one of three modali¬
the first 8 months of the project, and the con¬ ties: (1) by file transfer protocol on the Internet;
clusion was that solo pathologists rather than (2) by modem, using the Roche Image Manager
small groups or large departments use the ser¬ system (Roche Image Analysis Systems; Elon
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vice most frequently.
In the second phase of the pilot project, six
military hospitals, each staffed with one pathol¬
ogist, were equipped with a telepathology
system. The technology was based on an Ad¬
vanced Video Products (Westford, MA) system
with image capture resolution of 512 X 387 pix¬
els. Internal review of the pilot study estab¬
lished the validity of telepathology diagnosis,
with high concordance between video image
and glass slide diagnoses (i.e., no major change
in diagnoses was observed).
Telemedicine Journal 1996.2:187-193.
College, NC); or (3) through the Internet, using
Silicon Graphics "InPerson" (Silicon Graphics,
Inc.; Mountain View, CA) whiteboard system
(Fig. 1). To maintain confidentiality, images
transmitted on the Internet must be identified
by the local surgical accession number only. This
requirement does not apply to files transmitted
by modem, since this is a direct point-to-point
transmission. It is also essential that contributors
provide a secure fax number for the transmis¬
sion of the final consultation report. This applies
to both modem and Internet transmitted cases.

The telepathology consultation program was Each case must be accompanied by a faxed,
subsequently launched at the AFIP in 1993. In completed standard Contributor's Consultation
September 1994 the practice sending
of both Request form (AFIP Form 288-R). Relevant pa¬
digital images and glass slides was discontin¬ tient information and clinical history are re¬
ued. Glass slides were no longer requested, quired for the proper interpretation of images.
since developments in image acquisition tech¬ A $50 charge is applied for consultation from
nology provided higher-resolution images civilian pathologists. There is no charge for con¬
than were available during the pilot period. sultations from Veterans Administration and
Microscopic slides are now requested only if uniformed services medical treatment facilities.
deemed necessary by the AFIP consultant. Fees are also waived for research or educational
The AFIP telepathology service has been and cases of interest to the AFIP; for all veterinary
continues to be based on the "static image" or cases; for foreign contributors; for those enrolled
store-and-forward approach where static (still- in military, World Health Organization, and
frame) digital images are captured from the mi¬ other AFIP cooperative programs; and in cases
croscope. Within the AFIP, real-time tele¬ for which no source of funds is available.
pathology is currently only of academic interest The referring pathologist seeks the number
for several reasons. The AFIP receives case con¬ and types of images for transmission. As a
sultations from worldwide contributors; hence, pathologist, the contributor should be compe¬
time zone differences make it impractical to im¬ tent in choosing areas on the specimen that are
plement real-time consultations. The balance representative of the pathologic process for ad¬
between pathology personnel and regular case¬ equate diagnosis. The images provided should
load requirements does not allow adequate mimic the pathologist's routine examination of
support of real-time consultation. Regular sign- a microscopic slide. A typical case will have a
out of cases received through the standard con¬ low-power view to provide a general overview
sultation process (the dominant mode of con¬ of the specimen and progressively higher-
sultations received at the AFIP) would be power images of the areas of interest. The num¬
disrupted. Once these issues are resolved, real¬ ber of images varies from case to case. For ex¬
time telepathology may become a reality at the ample, adenocarcinomas of the prostate have
. been conclusively established from four images
The telepathology consultation process is ini¬ of needle biopsy specimens. Hématologie cases
tiated by the referring pathologist informing the may require more than 15 images including
 190
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Telemedicine Journal 1996.2:187-193.
FIG. 1. Telepathology equipment. Images from the microscope are captured and
digitized prior to transmission over the Internet.
bone marrow aspirates. On average, eight im¬
ages are transmitted. Occasionally, AFP pathol¬
ogists will communicate with the contributor if
more images are required or additional clinical
information is needed.
Once the images are accessioned, the perti¬
nent AFIP pathology branch is notified. One or
more pathologists review the images in the
telepathology service laboratories and provide
their opinions. Images are viewed using Adobe
Photoshop 3.0 (Mountain View, CA) on a 17-
inch NEC Multisync XE17 (Wood Dale, IL) or
Mediaconvert, a graphics tool in Irix 5.3, System
5 (Silicon Graphics; Mountain View, CA) on a
Silicon Graphics 20-inch monitor. Both monitors
have maximum resolution of 1024 x 1280 pix¬
els. No image enhancement is performed. A fi¬
nal diagnosis report is faxed to the contributor,
and a copy is sent by mail. In some cases an AFIP
pathologist will communicate with the contrib¬
utor to discuss the case. The AFIP endeavors to
provide rapid turnaround times. For cases re¬
ceived before 10:00 am, a final diagnosis is usu¬
ally reported to the contributor before the end
of the day. In most cases the final diagnosis is
faxed to the contributor within 2 to 4 hours (av¬
erage, 3 hours) after receiving the images.
MULLICK ET AL.
Telemedicine and telepathology standards of
practice (including licensure requirements) do
not yet exist. AFIP stipulates that the consulta¬
tion report on telepathology material include a
statement, "This report is not valid until coun¬
tersigned by the originating pathologist," em¬
phasizing the shared responsibility between
the two professionals. This statement will most
likely remain until national standards are de¬
fined and promulgated.
In general, AFIP consultants have been
pleased with the quality of the images received.
Good-quality images require high-resolution
cameras and image capture capability. Images
taken using cameras with at least 750 X 500 pix¬
els resolution have been the most adequate. The
cameras incorporated in most commercial
telepathology systems have resolving capabili¬
ties higher than what the AFIP considers to be
the minimum requirement (750 X 500 pixels).
The AFIP telepathology service can handle mul¬
tiple-image formats. Most cases have been sent
as Joint Photographic Expert Group (JPEG) com¬
pressed files. The format that pathologists use
often depends on bandwidth, especially for con¬
sultations transmitted over the Internet (smaller
file size, faster transmission). Although no for-
 TELEMEDICINE AND TELEPATHOLOGY AT THE AFIP
mal studies have been conducted, it appears that
image compressed 10-fold using JPEG are opti¬
mal for transmission without sacrificing diag¬
nostic information.
There is no homogeneity of attitude within
the AFIP regarding telepathology. Some
pathologists are still quite uncomfortable in
signing out cases based on images on a com¬
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puter monitor; others are not. It has been ob¬
served that younger pathologists are more cau¬
tious in signing out telepathology cases.
Feedback from younger pathologists shows
changing perspectives as they sign out more
telepathology cases and find a high degree of
concordance between their telepathology and
glass-slides diagnoses. Although this issue has
not been investigated systematically, if vali¬
dated by empirical studies, it may suggest a
need to add telepathology training to the
pathology residency programs. Anticipating
Telemedicine Journal 1996.2:187-193.
this requirement, the joint Walter Reed Army
Medical Center—Bethesda Naval Medical
Center pathology residency program will in¬
corporate a 2-week telepathology rotation at
the AFIP into their training program.
The greatest advantage of telepathology is
the rapidity in obtaining a second opinion on
difficult and perplexing cases. The 2- to 4-hour
turnaround time offers benefits to the standard
glass-slide consultation. The AFIP, with its
complement of more than 120 pathologists in
22 specialty departments, offers a unique re¬
source in telepathology.2 The capability to re¬
ceive image files through the Internet provides
an open system for case consultation. Early di¬
agnosis may translate into early intervention
and decreased length of hospital stay. Cost con¬
tainment constraints may provide an impetus
to increased use of telepathology. More re¬
search concerning the costs and benefits of
telepathology is required.
Education
The Telepathology Program also supports the
education mission of the AFIP through courses
on the WWW. There are currently nine contin¬
uing medical education (CME) courses on the
AFIP WWW site (http://www/afip.mil), two of
which are accredited to award Category 1 CME
credits. The educational courses are available to
191
anyone for browsing; however, physicians in¬
terested in obtaining CME credits must respond
to evaluation and content questions related to
the cases. There is no fee for military and other
U.S. government physicians, but civilian users
are charged $10 per credit hour.
An example of educational services has been
Internet-based conferences (using Silicon Gra¬
phics "in person") with the National Cancer
Center in Japan. These interactions have been
problem directed and provide a forum for the
exchange of information. Examples have in¬
cluded consultation on a rare case (Cronkhite-
Canada polyposis), in which the AFIP special¬
izes, and consultation on "flat" adenomas and
carcinomas of the gastrointestinal tract in which
the Japanese are particularly experienced. These
conferences have highlighted differences in di¬
agnostic criteria for early carcinomas. Emphasis
on other types of educational programming con¬
tinues to expand (Fig. 2).
The Department of Veterinary Pathology has
several ongoing initiatives in the area of edu¬
cation via the Internet. The Wednesday
Department Slide Conference, which previ¬
ously reached 135 institutions every week by
mail, now enjoys a worldwide audience on the
department's WWW site. Each week, confer¬
ence results and selected images from the
week's cases are posted to the web site, allow¬
ing veterinary pathologists around the world
to share in the educational experience. In ad¬
dition, syllabi from all of the department's
courses are archived at the web site, making up
an outstanding, publicly available collection of
reference material on all aspects of veterinary
pathology. The department is placing a large
collection of excellent-quality photographs of
gross specimens into the public domain via the
WWW to complement pathology teaching pro¬
grams worldwide.
OTHER AREAS OF TELEMEDICINE AT
THE ARMED FORCES INSTITUTE OF
PATHOLOGY
The Forensic Imaging Area of the Depart¬
ment of Cellular Pathology is involved pri¬
marily in the use of image processing and en¬
hancement for image analysis of forensic data.
 192 MULLICK ET AL.
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FIG. 2. A Telepathology Education Video Conference. Experts from the

Armed Forces Institute of Pathology (AFIP) and a group of over 40 faculty
and resident staff at the University of Puerto Rico Medical School (UPRMS)
participate in a real-time discussion on several consultation cases.
Telemedicine Journal 1996.2:187-193.

Current work, in cooperation with the tive role of the AFIP beyond traditional, fixed,
Department of Computer Science at the
University of North Carolina, is directed to¬
ward an interactive database for patterned in¬
jury analysis that will allow interactive consul¬
tation over the Internet. Patterned injury
analysis is used to study the mechanism of
trauma (e.g., identifying the type of weapon
used in a criminal act or the source of injury
sustained in an accident). This database will aid
investigators from distant areas in examining
patterned injury data with both a repository of
standard patterns and expert consultation.
Another forensic interest is interaction with
crime site investigators for data acquisition and
transmission from around the world using
standard telemedicine procedures. Addition of
a three-dimensional (3D) data acquisition de¬
vice (under development) for capture of the
physical layout of the scene would allow cen¬
tralized experts to recreate and evaluate a 3D
reconstruction of the site while performing
consultation.
A recent initiative has been the early inte¬
gration of the Institute's telepathology network
into the U.S. Navy's "Challenge Athena"
telemedicine project. Preliminary tests have be¬
gun to permit transmission of images to and
from ships at sea, thus extending the consulta¬
land-based medical centers. The objective is to
extend the AFIP's consultative and educational
resources to floating hospital ships, remote
field hospitals, and carrier-based medical facil¬
ities.
FUTURE EXPECTATIONS
Fundamental questions have been raised re¬
garding the future of telepathology. Will
everyone who now belongs to a pathology
group need to be physically present at the same
location? Can some consultation work be done
remotely? What is needed for telepathology to
replace the more conventional practice of
pathology?
Some researchers have suggested that high
bandwidth combined with real-time transmis¬
sion of images and remote control over the
sender's microscope system is the solution.
Other believe that electronics cannot replace
the present way of practicing pathology. Most
experts studying these issues believe that the
solution lies somewhere between these two ex¬
tremes. Further investigation is required to de¬
fine the appropriate role of telepathology in
clinical practice.
 TELEMEDICINE AND TELEPATHOLOGY AT THE AFIP 193

The future of telepathology at the AFIP is telepathology program at the AFIP provides
likely to have the following attributes: rapid turnaround times as well as access to ex¬
pert second opinions. Further potential benefits
•
Real-time telepathology with a remotely of telepathology are early management of the
driven mechanical stage and the ability to patient, shorter hospital stay, and cost savings.
capture high-resolution still images; Additional research is required to scientifically
•
Quality assurance and proficiency testing establish the costs and benefits of telepathology
on the WWW; services. The AFIP believes that telepathology
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•
AFLP-sponsored telepathology medical may be poised to assume a major role in total
meetings that will bring together a wide quality management of the patient.
variety of experts on-line; and
• Internet-based courses and seminars with
CME credits. REFERENCES
1. Henry RS: The Armed Forces Institute of Pathology: Its
First Century (1862-1962). Washington, DC: U.S.
CONCLUSIONS Government Printing Office; 1964.
2. Fontelo PA: Telepathology at the AFIP. Telemed Today
In the practice of pathology the need for rapid 1996;6:17-22.
turnaround time is emphasized. This includes
the academic setting but is particularly true of Address reprint requests to:
Telemedicine Journal 1996.2:187-193.

reference laboratories that are strictly service ori¬ Florabel G. Mullick, M.D.
ented without an educational or research mis¬ Armed Forces Institute of Pathology
sion. There is also a need to support solo pathol¬ 6825 Sixteenth Street, N.W.
ogists or those practicing in remote areas. The Washington, D.C. 20306-6000