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Diagnostics Digital and computational pathology, Technology and innovation, Profession, Histology, Microscopy and imaging

A Roadmap to the Future

We are one of the first laboratories to move to a fully digital histology workflow – and possibly one of the first to have made a case for doing so. It seems to me that very few people in the pathology world believe that such a business case can become possible. LabPON has made the transition, though, and among the many things I gained from that is a certainty that the long-term benefits outweigh the costs.

Getting off the ground

Our first business case was based on assumptions – which is what you have to do when you’re trying to pioneer something new and nobody is sure what to expect. We made some calculations and took some educated guesses, but there was no way to be certain until we actually implemented our plans. Now that we’ve gone fully digital, we know what needs to be done to get there. That’s why, in 2015, we started a new flow analysis – one that, when we finish at the end of this year, should be accurate, informative, and lead to a much stronger business case for digitization.

There are two components in a business case for digitization. The first is logistics. It’s no challenge to demonstrate that there are clear logistical advantages to digital pathology. You don’t have to go through your physical archives anymore; you don’t need a secretary to manage your storage and filing systems; and you can save money by optimizing your staff and space requirements.
The second component is diagnostic time – and there are also benefits to be had here. I am sure that when we finish our flow analysis, we’ll be able to show that digital diagnostics, including viewing slides digitally, is faster than the microscope. I think that, based on our preliminary results, a combination of the logistical and time-based benefits might allow pathologists to do their diagnostic work faster. That means you increase both capacity and efficiency. Not only that, but I think that – at least in part – the quality of digital diagnostics is actually better than that of slide-based work. If our final analysis confirms these preliminary results, then that’s big money – and big benefits for pathologists.

Finding funding

Fortunately for me, LabPON is a non-profit organization. We’re not part of a hospital, nor are we private – which means that we don’t have to build a very detailed business case in order to obtain financing for a new project. So at the beginning, we calculated the investments we thought we would need – things like new scanners and digital storage – and explained the profits, not just in terms of financial benefits, but also quality improvements and increased flexibility.

Our laboratory works for four different hospitals in the area, and our pathologists travel a lot. They attend multidisciplinary meetings, examine frozen sections, and do all sorts of things that traditionally require their physical presence. But as a result, they’re sometimes stuck at the hospital for several hours in between tasks – a waste of time for them and a waste of resources for us. But now, with digital pathology, they can do their diagnostics remotely from the hospital, or even from home. It creates a lot more flexibility, as well as improving the quality of the diagnostics, both of which factored into our initial “business case.” That message was what originally drove us to consider digital pathology, and strong enough to convince the board of its value!

A leap in logistics

In my laboratory, a glass slide has a long journey to complete. Once it’s finished and the coverslip is placed, a technician checks the lab management system, assigns the case to a specific pathologist, and takes the slides on a walk through our three-floor building to its destination. When the pathologist is finished with the cases, the slides are taken back to the archive. This happens five or six times a day, and we have two or more multidisciplinary meetings a day that also require the retrieval of slides from the archive. It takes a lot of people – and a lot of time – to accomplish all of that moving around. With digital slides, this transportation of physical slides is not necessary. The pathologist can simply enter a number into the image management system and see the corresponding slide. That saves so much time and effort that we actually need fewer personnel – in our case, we can reallocate a secretary and a technician to other work, just by eliminating those unnecessary logistics.

The work doesn’t just get faster with digital technologies; it gets more convenient, too. When I’m preparing for a multidisciplinary meeting and need to refer to a particular slide, I have to go through a folder full of slides, check them, read the patient’s reports, locate the ones I need, and write up the cases and slides to be discussed – all while using the microscope as a reference. But digitally, I open the case in the lab management system, which is fully integrated with our image management system, and I can see the whole-slide images and reports on my screen right away. And when I’m in a meeting and someone brings along an extra case for advice, I no longer have to say, “Sorry – this is new to me and I don’t have any information with me.” Instead, I can just log in remotely from the meeting room, look at the slides for that particular case, and then provide an opinion. I use the technology when I’m working on cases in the laboratory, too. For example, if I encounter a lymph node with potential metastasis and I’m not sure whether or not the tissue has the morphology of the patient’s primary tumor, I no longer have to ask my secretary to retrieve the primary tumor slides from the archive. Instead, I open the case in the lab management system, juxtapose the old and new images on the screen, and compare. What used to take me minutes now takes me seconds!

Most people think that the biggest investment will be the scanner or the software. That’s not true. One of the biggest investments is the transition period.

Words to the wise

Before pathology labs begin the digitization process, it’s vital to establish a good flow analysis. Why? Because most pathologists think that the only part of the flow that needs to change is the part after the slides are ready to be scanned. But that’s not true. To make the jump from microscope to digital, there’s a high likelihood that you will need to change multiple aspects of your workflow. That can be difficult to understand if you haven’t actually transitioned yet – but we certainly changed a lot of things in the early part of our flow. From the information in the lab management system (which has to be linked to the image management system) to the protocols we use in the cutting room (which now minimize the number of slides needed per case to save on storage and scanning time) and the stains we use for immunohistochemistry, many things are different.

So you need to make sure you’ve done a good flow analysis before you begin. You also need to make sure your laboratory has a good network – because if it’s slow, you’ll lose time – and that involves checking everything from cables to switches.

The laboratory will need an image management system that can be fully connected to the digital pathology system. You also need to make plans: how much digital storage will you need? How long will you keep digital files? How many scanners will you need to handle your highest workload? And ultimately, the answers to all of those questions will lead you to your roadmap and business plan.

One thing to remember, though: most people think that the biggest investment will be the scanner or the software. That’s not true. One of the biggest investments is the transition period. That’s when you have to sustain duplicate logistics – slides and digital files – but you can’t overlook its importance. Pathologists need to learn to trust digital images, and they need to have glass slides to check if they want to verify that the image was captured well and they’ve made the right diagnosis. During the transition period, pathologists will naturally work slower as they check both types of image, and you’ll need more personnel because you have additional logistics. What if you don’t have the personnel – or the money? You can’t skip the transition period altogether, but you can make it shorter. How? With a good flow analysis and a good roadmap.

That’s my secret in a nutshell. If you want to make a good business case for digital pathology, you have to plan ahead. Figure out what you want your digital laboratory to look like, what changes you need to make, and where you need to spend your money (on both direct and indirect costs) – and when you have the answers to those questions, you should be able to make a smooth transition and get a good return on your investment.

In a nutshell...

  • In the long-term, digital pathology’s benefits outweigh its costs; it simplifies logistics, saves time, and allows pathologists to work more efficiently
  • Before going digital, it’s vital to establish a good flow analysis and roadmap to make the transition short and seamless

Alexi Baidoshvili is a pathologist and project director of the digital pathology team at LabPON, The Netherlands.

Read more:

The Doubting Dollar
By Luke Perkocha

Part of a Larger Whole
By Marcial García Rojo

Techniques in Transition
Michael Schubert interviews David Snead

A Business Case for Common Sense
By Liron Pantanowitz

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About the Author
Alexi Baidoshvili

A pathologist and project director of the digital pathology team at LabPON, The Netherlands.

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