Going Digital: Can Everything In Pathology Be Consolidated?

With digital transformation at the top of the healthcare agenda, it can be easy to think that technology can solve the problems the laboratory faces. Just digitize and then everything becomes easier, faster, and better connected – right?

That’s certainly a possibility. As managing director in an imaging company engaged in regional digital pathology programs around the world, I could describe plenty of real-world benefits digitization can deliver. From being a precursor to the application of artificial intelligence to supporting faster diagnoses and allowing instant access to opinions and reporting capacity from pathologists who might be many miles away, digital pathology has enormous potential. And, as pathology services remain under pressure to restructure, regionalize, and consolidate, digitization provides a means to help reshape structures in which services have been historically isolated in a single organization.

The challenge is that technology cannot do any of this successfully alone. Unless people with decision-making authority give rigorous thought to appropriate service design, workflow, clinical strategy, and the intricate requirements of different specialties, the chances of realizing digital pathology’s service-transforming benefits are slim.

When digital could be damaging

A recent conversation I had with one cellular pathologist challenged my own thinking on the subject and reminded me about the dangers of viewing technology as a solution in itself.

Luisa Motta is a pathologist and strong advocate of the potential for digitization to really help a discipline faced with an insurmountable workload and massive resource pressures – especially as much of the existing workforce approaches retirement and recruitment of new clinical graduates proves challenging. Nonetheless, Motta is rightly concerned that digitization and service consolidation could be hugely damaging if not approached correctly.

The creation of regional pathology hubs and pooling of scarce resources has long been an ambition in healthcare worldwide. For example, Lord Carter made a strong case for consolidating pathology services to “improve quality, patient safety and efficiency” in his 2008 independent review of NHS pathology services in England (1). As regional approaches now start to emerge, for Motta – and, I suspect, many other pathologists – the thought of being moved from the hospital to a business park off a motorway is unsettling. And it’s not because they aren’t willing to work as part of a regional network; it’s not a protectionist approach to their own hospital’s resources; and it’s not because they are resistant to change. It’s because they want to defend a vital mechanism of communication between the pathologist and the clinician – a relationship that is instrumental in decisions about patient care.

Don’t sever the links

To alleviate such concerns, those leading transformation need a detailed understanding of how different pathology specialties operate and interact with clinicians as part of the clinical, surgical, or patient pathway. They need an accurate understanding of the profiles of different hospitals. They need to make sure they protect knowledge networks for which geographical proximity is important. And they need to ensure that relocation and consolidation of resources does not detract from service value, improvements, research, or the ability to discuss individual patients.

Consolidation and transformation must follow clinical strategy – and that may vary from one hospital or region to the next. Some regions, for example, may have hospitals with responsibility for specialist pathways and areas of highly complex surgery. For specialist pathologists like Motta, the idea of moving pertinent pathologists outside the hospital makes no sense, because having consultants close to the lab promotes discussion. In these complex areas, consultants actively visit the lab to see the surgical specimen – not just a slide or image – before it is dissected and discuss it with the pathology team. This act is difficult to replicate through a report on a digital image sent from a business park…

In more straightforward reporting cases that rely only on slides, relocation is less of an issue. But in specialist pathways and complex surgery, some pathologists are concerned that digital transformation could sever links and take them out of the clinical conversation. And, in some cases, if the clinical dialogue is damaged and the service becomes less effective as a result, pathologists worry that the service itself could be taken over by another provider. As Motta told me, “We cannot consolidate to the detriment of patients or the development of the service. Patients could be put at risk if we can’t discuss things that are pertinent to the case.”

Of course, most pathologists recognize the very restricted financial envelope of organizations like the UK’s National Health Service (NHS), and the consequent need to save money. But the primary driver should not be financial gain. The bigger opportunity is to use digital pathology to achieve regionalization that allows quicker access to specialist opinions as part of the first report, rather than making consultants – and patients – wait for review after review after review.

For many pathologists, the main reason to consider transformation should be to eliminate duplication. In some systems, pathologists may refer reports from one to the next, making patients wait weeks for a diagnosis. The real opportunity is to streamline pathways and develop a workflow that adopts the principle of getting it right the first time.

Don’t apply a single strategy

How can we make this happen effectively? Success relies on having the right strategy to address the requirements of different services both locally and regionally, so that we don’t end up in a situation where physical backlogs are converted to digital backlogs. Used properly, digital pathology enables the development of bespoke solutions to solve the clinical issues that a specific pathway in a specific region may be experiencing. If you understand the workflow and the pathway, and have gone through individual pathways to identify duplication, you can make informed decisions about where pathology labs need to be created, consolidated, or retained, and how they can be connected via digital pathology to ensure optimal use of resources – particularly workforce.

Motta cautions that some people focus too much on how many labs are needed and the cheapest way of creating them, rather than paying attention to workflow and pathways. Instead, she advises, ask what makes sense, what doesn’t, and what the best system would look like.

She also believes that consolidation can be overdone to the point where benefits start to become risks. Sensible consolidation is determined by the development of bespoke solutions (centralist or federalist models) based on a deep understanding of the unique characteristics and requirements of patients and services in a specific geographic area – including how patient care is delivered and shared across organisations. The result should be streamlined patient pathways with minimal or no duplication, increased quality and sustainability, and avoidance of unwarranted variations in care. Centralist models that remove histopathology from tertiary hospital services and don’t streamline pathways are problematic because they are not patient-centered and create inefficiencies in the larger ecosystem.

The impact of histopathology in patient care (even tertiary care) cannot be easily measured; value-based histopathology is a poorly developed topic with only rudimentary metrics and data. However, a working environment that facilitates informal interdisciplinary communication is good for patient care. Geographical proximity creates spaces for spontaneous communication. Meeting someone unexpectedly offers an opportunity to discuss interesting or challenging cases, quality improvement ideas, and more. These interactions are essential at a tertiary care level, where knowledge generation is an important responsibility in which histopathology plays a key role. Spontaneous interactions are also opportunities for ad hoc education of colleagues, including the new generation of health care professionals. Given the general lack of understanding of our role in patient care ( which leads to misinformed policymaking, a lack of funding, and effects on service development and patient care), our visibility goes hand in hand with influence and survival.

There is an optimum consolidation point that allows you to work with partners to produce an initial report that is timely, accurate, complete, and allows the patient to move to the next part of the pathway. A deep understanding of the regional workflow – in particular, which specialties can be removed from the hospital and which cannot – is essential.

Do we have the right leaders?

Many of the people currently leading transformation understand its intricacies. As digital pathology begins to move beyond discussions on whether digital images are as effective as microscopes and slides and focuses on the reality of transforming services so they can cope with demand and better serve patients, informed leaders will be key to making such transformations work. But there can be no room for complacency; in large and complex institutions like the NHS, we must continually challenge leadership structures to ensure that they have the necessary knowledge, skills, and commitment.

This need has not gone unnoticed. Matt Hancock, the UK’s health and social care secretary, alluded to in a January 2020 keynote address on the urgent need for modern technology (2) – and it is understood from the ground up. Laboratory medicine professionals need to play a leadership role at this time of substantive transformation to ensure they are understood and heard. Motta believes that pathologists are still not necessarily represented at boards and in salient papers that describe workforce requirements in cancer pathways. And, where this is the case, the status quo needs to change. Pathologists who are singularly focused on addressing the immediate backlog of reporting also need to be given scope to play a crucial role in policy-shaping and decision-making at the national, regional, and local levels. They need to be able to change the conversation from one where technology is seen as the answer to one that seeks conscientious analysis of how we can improve pathways – before we use digital pathology as a tool to get there.

As Motta said, “Digital pathology is like any tool – including dynamite. In the right hands, it can be really useful. In the wrong hands, it can be quite destructive. Some managers think that installing digital pathology will solve all their problems without even modifying or adapting patients’ pathways. That’s not going to work.”