In terms of remote real-time telepathology software, TeamViewer was recognized as the overall best platform in terms of access, functionality, and speed. In addition, a majority of respondents would recognize the software as capable for clinical practice (rapid on-site assessment, Mohs, frozen section). Notable functionality which improved usability included simplistic design, unattended access, and reduced latency. Real time telepathology workflows are most utilized for limited resource settings, such as remote hospitals or even successfully deployed in international locations. ^[3,4] Though international connections were not tested in this study, the user experiences gleaned are portable globally. 

In terms of access, AnyDesk, MSTeams, and TeamViewer were recognized as high performers. Each tested software was compatible with iOS and Windows platforms. Functionality not tested here, but of the utmost importance includes security. AnyDesk uses end-to-end encryption to ensure that all data transmitted between devices is secure. ^[10] Microsoft Teams uses industry-standard security protocols such as TLS and SRTP to secure data in transit and at rest. ^[11] Parsec also uses encryption to secure its remote desktop connections. ^[13] Splashtop uses AES-256 encryption to secure its connections ^[12], while TeamViewer uses 256-bit RSA key exchange and AES-256 session encryption. ^[9] A functional assessment by local-regional information technology security should be performed prior to implementation to remain HIPAA compliant. 

Functionality assessment demonstrated AnyDesk and TeamViewer as superior. This is largely due to the simplicity of design and button configuration. Notably, not all users would utilize the functionality tested (screen capture or screen share), however, this simple test allowed for a deeper assessment of the menu and functionality of the software should it be required. Within clinical settings, a second remote consultation may be necessary and screen sharing would be useful for second opinion or subspecialty-based consultation. [1-4,6,8] Video recording or screen capture can be used for educational purposes such as lectures, rounds, tumor boards. [7] Each remote desktop solution offers unique features that set it apart from the others. AnyDesk offers features such as file transfer, session recording, and remote printing. Microsoft Teams offers features such as screen sharing, chat, and video conferencing. Parsec is designed specifically for gaming and offers features such as low-latency streaming and gamepad support. Splashtop offers features such as remote wake, multi-monitor support, and session recording. TeamViewer offers features such as file transfer, remote printing, and multi-platform support. These features may not be relevant for specific clinical settings, however, each institution should carefully compare available functionality. Image quality was not a comparative difference for most respondents and was not a critical factor of this study, however, was included should there be significant difference between platforms. Previous publications have shown telepathology, once validated, is a robust clinical system for clinical practice.[1-4]

Speed perception results showed TeamViewer to be superior, however, AnyDesk was a noted close second. Several comments, demonstrated rasterization times to be slower with AnyDesk comparative to TeamViewer. AnyDesk uses a proprietary video codec called DeskRT to provide a smooth and responsive remote desktop experience. [10] While TeamViewer uses high-speed data channels and optimized image processing to provide fast and responsive performance. [9] This software difference may have led to varied experiences. Splashtop and Parsec were notably “slowest” though Parsec uses its own low-latency streaming technology to provide “high-quality graphics and minimal lag”. [13] Splashtop claims to provide “up to 10x faster performance” than other remote desktop solutions, though its methodology is unclear. [12] Microsoft Teams uses adaptive bandwidth technology to optimize performance based on network conditions which may have led to variable experiences. [11]  

Within the practical assessment, an attempt to realize the actual value of the remote system was made. A comparison of currently utilized software and value within one’s own practice was made. Notably, two respondents currently utilized real-time telepathology with only one of them satisfied with the current software (MS Teams). Though that pathologist remained confident in that software (MS Teams) at the conclusion of the study, 80% of pathologists noted TeamViewer as preferred in their practice. In addition, AnyDesk was noted by two pathologists to be superior to their current software and one noted Splashtop and TeamViewer to be superior as well. When presented with pricing for each remote software, pathologists were amenable to 4 of the 5 solutions. Of note, one pathologist noted current latency relative to expense to be impractical for their current use and another suggested MS Teams as an acceptable compromise given the bundle with the MS Suite. Prior studies have suggested price as a barrier to utilization for telepathology [5], however Laurent-Bellue et al, demonstrated a similar annual expense when comparing a real time pathology implementation to pathologist time and courier costs. [6] 

Notable limitations of the study include a low number of survey respondents with individual opinions and perceptions of speed, ease, and remote internet connections. In addition, hospital-based security and firewalls were not tested in this study which may change user experiences.