Irenee Nshimiyimana, a Butaro Hospital laboratory technician, uses the telepathology system
to photograph slides he has produced in the lab.

When you only have two pathology laboratories in a country of 10 million people, clinicians often have to make treatment decisions without pathology results. This was the case in Rwanda, until BWH joined with other organizations to reduce turn-around times and ultimately build capacity in the country’s pathology labs.

Getting Started

The first step of this process occurred when Partners In Health (PIH) opened Butaro Hospital and devised a system to reduce their specimens’ turn-around time. Pathology technicians at Butaro packed specimens in the luggage of volunteers and PIH staff flying back to Boston, along with appropriate documentation.

When the specimens arrived in Boston, they entered the routine specimen flow of BWH’s Pathology Department. Specimens were sliced, stained and studied pro bono by BWHers, who then faxed reports back to Rwanda. While this provided rapid diagnostic turn-around for more patients, specimen transport was not evenly distributed throughout the year and there was still plenty of room for improvement.

One of these improvements was setting up a coordinated tracking system to log samples as they traveled across the ocean and track their results. Meanwhile, BWH partnered with Dana-Farber Cancer Institute, PIH and the Rwandan Ministry of Health to procure equipment and establish a functioning pathology laboratory at Butaro.

After the laboratory was established, Danny Milner, MD, pathologist and assistant medical director of Microbiology at BWH, and Jim Pepoon, HT(ASCP), director of clinical operations in Pathology at BWH, spearheaded an initiative to train Butaro’s pathology technicians to turn specimens into blocks and slides.

Going Virtual

Looking ahead, the team saw that the next step was to couple the pathology technicians’ new skills with new technology to improve turn-around time.

Coincidentally, Dave Shulman, MD, now an intern in the Boston Combined Residency Program in Pediatrics, with a strong interest in global health, was just beginning his medical school pathology rotation at BWH. Shulman met with Milner and decided to take on this telepathology project, researching USB microscope cameras that could take still images of slides, as well as software to enable remote viewing of these images.

Shulman traveled to Rwanda in February 2013 to get the software up and running, and telepathology cases began trialing in March.

The initial step in telepathology is for pathology technicians at Butaro to turn specimens into slides, photograph them, and upload the pictures and short case histories to a password-protected site on the Internet.  When new content is uploaded, the site automatically sends an e-mail notification to pathologists at BWH as well as a handful of pathologists volunteering at other institutions. The pathologists log in, review the uploaded content, and post their opinion on the diagnosis. Clinicians in Butaro then log in, see these comments, and use them to create a treatment plan for patients.

An additional feature of telepathology is that pathologists can use it anywhere in the world. While most pathologists volunteering with telepathology are based at BWH, some are based in Europe, and this difference in time zones means that a volunteer is almost always available to offer a reading.

Looking Ahead

Telepathology will not completely eliminate transport of samples to Boston, since some samples will still need more detailed work-ups than are currently available at Butaro. However, many times cases are easy to diagnose using telepathology, enabling clinicians to receive a diagnosis and promptly begin treatment.

The ultimate goal is to have a permanent Rwandan pathologist at Butaro who could use telepathology for consultations as needed. The Human Resources for Health program, which BWH participates in, is helping make this aspiration a reality by helping train the next generation of Rwandan pathologists.

Telepathology is currently operating in a trial phase, and specimens are being read virtually as well as physically sent back to BWH, to ensure the results correlate.

“Telepathology is a key component in the expansion of pathology capacity in resource-poor settings,” said Shulman. “It allows for improved access to pathology services and more comprehensive medical care for the underserved, including cancer care.”