By Sarah Schmelling

 The Trestle MedMicro is a networked digital microscope, with an optional robotic system for slide loading, connected to a server that manages remote viewing and control.

Ola Kassim, MD, chief pathologist and director of laboratory medicine for the West Parry Sound Health Centre in Ontario, Canada, had a geography problem.

The center, a comprehensive, integrated health care system that provides acute and chronic care and nursing home functions in one main building, has to serve 70,000 residents of Parry Sound and its surrounding communities through a network of rural clinics. It is Kassim’s responsibility to oversee all the lab work that is done throughout the center’s reach. “We provide all the laboratory needs for patients who have been treated by the West Parry Sound Health Centre, as an inpatient or outpatient, or through home visits in the community,” he says. “We also do all the work for the patients who go to see their doctors in our clinics.”

 Ola Kassim, MD, can access the MedMicro system either locally or remotely from his Toronto office.

This may not seem overwhelming until you look at a map of Ontario and the area the center serves. “It is at least one and a half hours to the nearest major health care center,” Kassim says. “So in a sense, we’re by ourselves here.”

Until a few months ago, this meant that if Kassim needed to consult with colleagues on a set of slides to provide a diagnosis, he had to either send the slides by courier, drive with them to the other facility himself, or actually put the slides in a taxi and pay for them to be driven up to 3 hours away. “It could take 24 to 48 hours, when we really needed the answer immediately,” he says.

A Product for the Locationally Challenged
The solution to Kassim’s problem came when he simply typed the word “telepathology” into a Web search engine. While he knew that for many people this term meant taking digital photos of a slide, he had heard talk at industry conferences of a more advanced technology that allowed real-time digital shots to be shared via the Internet.

The product he found through his search was MedMicro, an Internet microscopic solution developed by Irvine, Calif-based Trestle Holdings Inc. Through the integrated combination of a robotic microscope and advanced software, MedMicro allows Kassim to view and navigate slides remotely via the Internet in real time, and consult with colleagues who are able to simultaneously see what he’s seeing.

“Say I’m away from the lab, in a meeting or at home, and my staff needs to show me something important, such as a probable case of malaria,” he says. “The technologists do a blood film and look at it, but they have to confirm whether it’s there or not.”

What used to happen, he explains, is that they had to call him wherever he was and he had to drive in, or they had to wait until he was physically in the lab—which could be the next day, or the next week. Now, with the robotic microscope, he can actually make a diagnosis remotely. “I can confirm whether malaria is there or not, which can be very critical, because if it’s there, the doctors will want to start treatment immediately,” he says. He explains that a delayed diagnosis, and therefore delayed treatment, could mean complications, or even death.

“So, in fact, the Trestle products allow an immediate diagnosis on a remote basis, at a remote location for anything that can be diagnosed under a microscope, without compromising quality or resolution,” he says.

In addition to simply viewing the specimen, a user can navigate around the slide and see it as they would while physically using a microscope—between one and six magnifications. Kassim explains that with earlier telepathology methods, a user would have to take separate photos at every different magnification and of every different part of the slide. “Remember that at any given time, I’m only looking at 1% of the surface of the slide,” he explains. “So imagine taking a picture of every part of a slide, which could be 100 at one magnification, and then multiply it by six. That means that person would have to look at 600 pictures.”

Instead, with the robotic microscope, “all I need to do is give that person access to the software. They open it on their computer, they go into the Web site and dial my microscope, which has its own dedicated server … and it’s just like they have the microscope,” he says. “You can run the slide, move the slide from one end to the other—left to right, front to back—and you can survey all of the different areas in question. It’s really like you are there.”

Another feature of MedMicro is its ability to provide a “thumbnail sketch” of the entire slide on the computer screen. “From there, you can go anywhere you want,” he says. “You can click on any part of that sketch, and it will take you there.”

In short, it is almost exactly like looking through an actual microscope, and the picture is “just as good as the original,” he says. “What they have done is adopted a good microscope with good lenses and attached a good camera, which allows an engineer in any part of the world to move that stage around. That is the wisdom that they have achieved.”

Incubating the Idea
The innovation that Kassim is now utilizing had its origins at the University of Southern California (USC) in Los Angeles. It was there in the late 1990s where, according to Trestle CEO Maurizio Vecchione, the idea for the company began when its founder, Jack Zeineh, MD, was in medical school.

“He recognized the problem in pathology of effectively transitioning from an analog way of looking at samples—a way that hadn’t changed fundamentally since the invention of the microscope—into a digital practice,” Vecchione says.

He says that Zeineh and his colleagues wanted to make better use of digital technology, much like what had been done in the field of geology. “Just a few years ago in geology, virtually everything was on film,” he says. “And in today’s environment, you now have standards that facilitate the communication of images, and all sorts of image processing and enhancements to make reading the data easier.”

USC provided an incubation environment for research on the technology, and after a series of venture rounds, Trestle became its own, now public, company. “Today we like to think that if we’re not the inventors of telepathology, we’re certainly among the pioneers in the field,” Vecchione says.

As for the technology itself, Vecchione says it is just now taking hold in the market. “In the beginning, doctors were worried about whether the image quality was equivalent to that of looking at a sample in a microscope,” he explains. “Now, clinical studies and best practices have emerged that not only show that the use of the telepathology environment is equivalent, but in some cases it can actually improve the diagnostic quality because you can introduce various forms of image enhancement and computer-assisted diagnostic tools once the image is digital.”

One of the key features of the product is its collaborative ability, he says. “Pathology is a discipline where you have a built-in need to have various specialists and colleagues review the same case—especially if it’s a difficult case—for peer review or second opinions,” he says. MedMicro is then ideal for this field because not only can a pathologist look at a computer screen and do everything he or she would with a microscope, but he or she can then share this view with multiple colleagues at the same time.

Vecchione says that Kassim’s challenge of a widely spread-out medical network is not unusual. “One of the recurring themes we’re seeing in a lot of our clinical applications is where you have a medical center that is effectively the reference point for various geographically dispersed clinics,” he says. Because expert pathologists are relatively scarce, he explains, there is often a main pathology lab in a central hub, and all of the outlying clinics rely on that primary lab’s expertise.

Because this centrally located pathologist has to review all slides within a network for any diagnoses, he or she often has to travel between facilities to collect and view samples. “This introduces both a time-efficiency issue for the doctor who must spend precious time on the road instead of doing medical work, and a patient-care issue because you often have a mission-critical patient diagnosis delayed because of the pathologist’s travel schedule,” he says. “So it’s a question of patient care, it’s a question of efficiency, and ultimately it’s a question of cost on the part of the pathologist.” In short, the Trestle product allows pathologists like Kassim to “grow very long arms,” Vecchione says.

He says that the collaborative, remote capabilities of MedMicro work well, not just for rural medical networks, but for any widely dispersed health care community, even in large metropolitan areas. The Trestle product is also used by the United States Army, which has 21 installations around the world—with a hub at Walter Reed Army Medical Center in Washington. “So if you have, for example, clinics in such remote areas as Korea needing to read biopsies, today these biopsies are put on the Trestle system and are read by the experts back at Walter Reed,” Vecchione says. “That is an example of the ultimate in distributed health care provisioning.”

He says that MedMicro differs from competing products, which often incorporate a video camera instead of digital photography. “By using a video camera, you are effectively taking an instrument that is used for streaming motion,” he says. “And while a video camera is great at streaming motion, it’s not particularly good at showing high resolution.”

Vecchione believes Trestle’s approach is advantageous fundamentally because a pathologist can view a high-resolution photograph, in real time, in any region of interest. “So we end up with about three times the resolution for about a third of the bandwidth,” he says.

In addition to clinical customers, about half of MedMicro’s users are large pharmaceutical and biotechnology companies that have installed the product for drug-development purposes.

Getting Telepathologic
Outside of his lab, Kassim believes MedMicro would work very well in a remote teaching situation. “You could have one slide on a tray, and as many computers as possible could look at it—as long as they have the software,” he says.

Other, larger organizations may have other incarnations of MedMicro.

“There are systems for big research companies … that actually have a slide loader that could take up to 500 slides on different trays, and all you would have to do is pick what tray you want,” he says.

But for his needs, the system he had installed in fall 2004 has worked well so far. In Parry Sound, he wants technologists in all of the network laboratories to be able to see the same slide, at the same time. “If I want to show them something, all I have to do is call them or send them an email, and say, ‘Look at my microscope,’” Kassim says.

The installation was so fast that they had to stall the Trestle representatives so they could have more time to prep their lab, but he has been so pleased with MedMicro so far that he’s recommended it to at least four hospitals that have put it on their wish lists.

Kassim says it’s fascinating to take the old idea of the microscope and make it truly functional for today’s needs—allowing pathologists to shorten diagnosis time from days to just hours or minutes, and in the process improve health care. It also doesn’t hurt that he won’t be spending all that cash on cab fares anymore. “It saves lives,” Kassim says. “It also saves money.”

Sarah Schmelling is a contributing writer for Clinical Lab Products.