Laboratory accreditation must-haves

CAP Today

January 2010
Feature Story

There are CAP Laboratory Accreditation Program requirements for telepathology in the laboratory general checklist. Telepathology is defined in the checklist as the practice of pathology in which digitized or analog video or still images are viewed and the interpretation is part of a formal diagnostic report or the patient record. The preamble to this section of the checklist specifies that it applies to primary and frozen section diagnoses, formal second opinion consultations, or ancillary techniques that involve image interpretation. It could apply to remote robotic telemicroscopy, real-time video microscopy, and, of course, to whole-slide imaging use for remote consultation.

Here are the laboratory accreditation requirements:

1. There must be a method in place to ensure that patient and image identification match. The note to this requirement says verbal methods are acceptable, so it does not have to be a fancy electronic system. But you have to have a procedure for how you do that for telepathology.

2. The pathologist must have access to the pertinent clinical information at the time of case review, whether it be on paper or in an electronic medical record or maybe the clinical history in the AP LIS.

3. There need to be policies for the appropriate, intended use of the equipment so that all pathologists understand they’re not supposed to use that remote microscopy system that was set up for frozen sections to make primary diagnoses on soft tissue consults.

4. There need to be training procedures for the users of the system.

5. There must be some allowance for including digital pathology in the department’s overall quality management program.

6. There must be procedures in place to ensure that sites using telepathology provide reasonable confidentiality and security and conform to HIPAA requirements.