New telecommunication technologies, especially the Internet, may change this situation favorably. The economical and easy communication between people all over the world is a fact and is available to anyone, be it a pathologist or not. It is not per chance that the first virtual meetings have been those elaborated with this specialty, at least within the Hispanic-speaking community (García Rojo 1998), that pathologist list-serves are presently some of the most active or that permanent specialty-specific communication channels such as text-conference are being developed (Coma et al, 1998) (http://bio.hgy.es/uninet; http://amba.rz.charite.hu-berlin.de/telemic).

The repercussions of this new order of communications are now evident. These are some of the consequences:

From the teaching point of view, there are a great number of digitized resources, both in static and interactive form. For a few years we have had abundant on-line resources on the Internet. Those worth mentioning are the educational systems based on web environments by the Department of Pathology, University of Utah, Salt Lake City. USA (Klatt y Dennis, 1988); "AnatpathWeb" by Hôpital Necker in Paris (Fournet et al, 1996) accessible at http://www.anapath.necker.fr; "WebReport" by the Section of Medical Informatics, University of Pittsburgh, PA, USA (Lowe et al, 1996), "Wellpath" by the School of Medicine at the University of Oviedo (http://www.conganat.org/iicongreso/conf/001/index.htm), etc.

The possibilities of research are being progressively enriched thanks to the Internet. Access to different databases which are being added to the Internet and updated constantly are contributing to this enrichment.

Since 1980, the French pathologists at ADICAP (Association pour le Developpement de l'Informatique en Cytologie et en Anatomie Pathologique) have created a common language code for routine applications and have also developed a communication bridge with images with the support of several industry software providers. This code has permitted the development of a data bank with 30,000 hystopathologic images -with coded data and clinical information- accessible to pathologists through a browser. The goal is to reach an international agreement on standards and to facilitate the exchange of imagery.

There are other available databases with necropsies (Berman et al. 1996; Moore et al 1996) and cytologies. The sister laboratories of an Ontario Laboratory (Canada) have centralized a cytology database that registers 60,000 monthly cases and clinical histories automatically. The system works on a private network based on Internet standards (Golabek et al 1997).

The patient Care with telepathology, in other words, the remote morphological exam of hystological slides with the intention to perform a diagnosis is in fact one of the most creative fields within the specialty.

The interest in telemedicine stems from the 1990s. Ever since, there has been a continuous development of techniques such as acquisition, compression, transmission and interpretation of digitized imagery (Okumura et al. 1997). This opens up a new horizon in Medicine, especially in cases like those in Pathology where the diagnosis is based mainly on morphological data.

VTelepathology is based on transmission of images or video to distant places, ranging from the basic post office mailing system where a pathologist sends cases to be consulted on in an envelope, to the most sophisticated system consisting of a remote controlled microscope with a diagnosable case on a slide, connected via the Internet. The latter type of systems is designed to be used by hospitals without a specialized staff pathologist, even for intraoperatory biopsies.

Video cameras connected to microscopes are very familiar to most pathologists. Further advances in technology enables direct digitalization. Combining these digitized images and using the Internet opens the door to multiple possibilities. For example, in those cases where there seems to be a doubt in the diagnosis outcome, instead of sending the slides to one expert, several experts around the world can be consulted at one time (Furness 1997). The idea is as simple as transmitting the images through email, DCC, etc while conferencing via video, audio or text-conference, the result being a multiple expert contribution to the diagnosis.

In one case, the evaluation of the concordance between the diagnosis obtained by traditional methods and those by selecting a number of images viewable on a TV screen while two doctors communicate, had a Kappa concordance coefficient of .26 (SE = 0.06) (Allaert et al, 1996).

Transcontinental consulting through the Internet of doubtful cases in pathological surgery between Italian pathologists and J. Rosai have shown a high degree of concordance between the diagnosis performed on transmitted morphological images and the diagnosis on the hystological slides (Eusebi et al, 1997).

These are some of the results of validity studies made on remote diagnosis. In Cytology, several authors compare the diagnosis done locally through a microscope with that of selected digitized images (Della Mea et al, 1997). Da Silva et al. (1997), obtain kappa concordance indices of 0.91 on the cytology of 106 consecutive serum extravasations received in their lab. The Department of Pathology, University of California, Davis, Medical Center, Sacramento, USA, evaluated the concordance of remote and local cytological diagnoses on mammary aspirations. Two different pathologists examined the static images and the respective clinical data on a hypertext document. The degree of concordance between both pathologists was 90.5%, but only a 66.7% concordance was reached when conventional observation through microscopy was utilized by the same pathologists (Galvez et al, 1998). The discordant cases in a 100.00% and 85.7% respectively were due to suspicion more than to a definitive diagnosis. The conclusion is clear: the evaluation of electronic imagery indicates that, at least, the possibility of diagnosis is the same as that of direct microscopic observation.

Authors of the Department of Pathology, University of Udine (Italy), have developed a number of studies about diagnosis in hystopathology. Specifically, an analysis on gastrointestinal pathology consulting, with a kappa concordance index of 0.79, and 15% of diagnosis errors (Della Mea et al, 1996); in benign and malign pigmentary lesions with a diagnosis agreement of 79% between the local and remote pathologists (kappa = 0.58, P = 0.002) (Della Mea et al, 1997); comparing results on 155 frozen section samples, the diagnoses of local pathologists on paraffin embedded samples and the diagnoses of remote pathologists via imagery from the frozen section samples gave them the following results: 4 of them were considered insufficient for an accurate diagnosis while in the rest of the cases the diagnoses from the remote pathologist coincided with the definitive diagnoses produced by the local pathologist in 96.7% of the cases, even when the images were selected by young pathologists or by medial students in practice (Della Mea et al (1998).

There is an array of telepathologic equipment on the market which allows diagnosis to be performed on frozen section samples of intraoperatory biopsies, in medical centers where a pathologist is not available. The images are transmitted through digital telephone lines.

VIn Japan, the experiment on this system with the first 117 biopsies from 100 patients resulted in: the average diagnosis time being 13 minutes, ranging from 2 minutes to 42 minutes and the average number of transmitted images being 6.2 with the range between 2 and 11. The diagnosis was correct in 109 of 117 biopsies (93.2%) and was improper or erroneous in 8 biopsies. The conclusion is that better slides, a higher experience and care and a more fluid communication with the surgeon would permit the reduction of these errors (Adachi et al. 1996).

Steffen et al (1997), in the Chirurgische Klinik, Spital Oberengadin, in Switzerland, are transferring digitized frozen section images obtained with a video camera and a computer, connected to the Institut of Pathology at the University Hospital in Basel through a modem and a phone line. The results of the telediagnosis throughout almost 4 years, compared to the definitive diagnosis done on paraffin embedded samples in 96 cases are: a correct diagnosis in 89% of cases, where the malign diagnosis presented a sensibility of 92% and a specificity of 100%.

The results are even more satisfactory when several methods are applied to the lesion, objective of the remote diagnosis. For example, by combining remote studies on cytology, pathology, conventional radiology and mammograms such as those performed in the School of Medicine, University of La Laguna, Canary Islands, Spain (Roca et al, 1996). Similar cases have been reported by these and other authors (Weinberg et al, 1996), who infer that telepathology will be available to any pathologist with a computer, a video capture system for microscopic images and a phone line to access the Internet. All this done with a simple local phone call.

It seems difficult to accept that the possibility of digitized image diagnosis is real, especially when there is a lack of that type of experience. But any pathologist with access to the Internet can verify it personally. In the Institute of Pathology, Charite Medical School, Humboldt University of Berlín, Germany, work is being made with a remote controlled microscope handled through a web browser. It consists of an automated microscope, with a CCD camera attached to it and connected to a computer which functions as an Internet server. Any Internet user can access this server at http://amba.rz.charite.hu-berlin.de/telemic and control the microscope through a Java-supported browser. The system also has a chat channel where comments on the image or details on the case can be discussed. The image quality is optimum. (Wolf et al, 1998).

Observing the present situation, and the foreseeable future, it is evident that the implementation of new technologies require clarification and the adoption of protocols which will define any malpractice liability.

ETHICAL AND LEGAL IMPLICATIONS

At an expert panel in the International Academy of Cytology about "Diagnostic Cytology Towards the 21st Century" pondering the development of telecytology to be used as a diagnostic, teaching and consulting tool, and the ethical and legal implications derived from them, merged on to the following consensual agreement: "Computer hardware standards for optical digital imagery will continue to be driven mainly by commercial interests and non-medical imperatives, but professional organizations can play a valuable role in developing recommendations or standards for digital image sampling, documentation, archiving, authenticity safeguards and tele-consultation protocols; in addressing patient confidentiality and ethical, legal and informed consent issues; and in providing support for quality assurance and standardization of digital image-based testing. There is some evidence that high levels of accuracy for telepathology diagnosis can be achieved using existing dynamic systems, which may also be applicable to telecytology consultation. Static systems for both telepathology and telecytology, which have the advantage of considerably lower cost, appear to have lower levels of accuracy. Laboratories that maintain digital image databases should adopt practices and protocols that ensure patient confidentiality. Individuals participating in telecommunication of digital images for diagnosis should be properly qualified, meet licensing requirements and use procedures that protect patient confidentiality. Such individuals should be cognizant of the limitations of the technology and employ quality assurance practices that ensure the validity and accuracy of each consultation. Even in an informal tele-consultation setting one should define the extent of participation and be mindful of potential malpractice liability" (O'Brien et al, 1998).

On the other hand, the technical quality of image transmission is improving steadily and, above all, it is influencing pathologists' needs, with the definition of acceptable chromatic varieties (Doolittle et al, 1997), the development of image compression formats which facilitate a better transmission of archives(Phillips et al, 1996), or software which controls the quality of cytopathology (Rashbass & Vawer, 1996).

TOWARDS THE THIRD MILLENIUM

The surge of new advanced techniques is not always accepted favorably. In a survey made between all 256 members of the Austrian Society of Pathology based on general aspects of telemedicine, telepathology of frozen section samples or expert consultation, videoconference technologies, tele-teaching and tele-work had a response level of 46%. In general the pathologists declared that they were "afraid" of making mistakes through remote diagnosis and would not easily accept the alternative to the traditional method. A high interest on videoconferencing exists for clinico-pathologic sessions. Tele-learning and tele-work are observed as welcomed additional techniques but only as a complementation to traditional methods (Mairinger et al. 1998).

We are reaching the end of the millenium, and there is a sense of change in many things, including the way pathologists will work. We have to make an effort to get rid of our fears because it is proper for pathologists to be at the forefront of Medicine. Aller (1997) envisions the future pathologist's workstation: next to the microscope, the computer with a word processor, electronic mail, web browser, bibliographical databases, statistical analysis, image analysis, survival ROC curves and speech-synthesis systems. Is this not an attractive image?

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