Ring the Changes

King Whitney Jr., personnel thought leader, said, “Change has a considerable psychological impact on the human mind. To the fearful, it is threatening because it means that things may get worse. To the hopeful, it is encouraging because things may get better. To the confident, it is inspiring because the challenge exists to make things better.”

Will 2024 bring big changes to your pathology lab? Perhaps it’s the year you’ll go fully digital – or introduce an automated sample reception system. Maybe NGS will move in house or you’ll select an AI algorithm to assist with some specific task.

With new systems come new processes to develop, new software to learn, and more time spent at computers. And it’s fair to say that’s not everyone’s bag. So, once the project has the green light and the install date is set, how do you bring the laboratory team on board with the change?

We posed this question to Giovanni Lujan, Director of Digital and Computational Pathology at Ohio State University (OSU). Falling very much into the “confident” category of the Whitney quote, he was hired by OSU in 2019 to help manage the transition to a 100 percent digital pathology workflow.

How (or why) did you become a digital pathology expert?
 

Back in 2016, when people were really beginning to talk about digital pathology, I started going to all the conferences and networking with people in the field. I wanted to know more. But there was no training available and very little literature. However, I picked up that Europe was more advanced in the digital field than the USA – so I set off for Europe!

The trip was self-funded initially, but eventually I received some sponsorship from vendors. I went and visited laboratories in places like the Netherlands and Spain. I learned all I could from them and saw pathologists, with my own eyes, signing out cases digitally. This was unheard of in the States. So I returned home super excited to try to achieve the same, and I was lucky enough to be hired by OSU.

Why do you think the OSU team were early adopters?
 

Because of the vision of our Chair, Wendy Frankel. She wanted to bring the center forward and was aware of digital pathology, but needed help from someone with the right “technology savvy” to make it happen. And so Anil Parwani joined the team as Vice Chair, bringing around 20 years’ experience with digital technologies. With the combination of Frankel’s vision and Parwani’s dream, OSU’s digital laboratory became a reality. In fact, Parwani was the first pathologist to sign out a case digitally in the US in March 2018. After some initial sluggish adoption, Parwani, knowing of my interest and enthusiasm, hired me as “fresh blood” to create some momentum around adoption of new technology.

What sort of resistance did you experience when implementing the change?
 

The main objections were: I’m very good at what I do, I’m very fast and efficient, and I don’t want to go back to being slow. So I didn’t see a fear of technology – more a fear of disruption to the workflow.

What were the other obstacles to digital implementation?
 

The main obstacle was the guidelines. In the labs I visited in Europe, the protocols came from the centralized governments – and pathologists were obliged to follow them. In the States, each institution issues its own guidelines for service provision and won’t implement new systems without the approval of the pathologists.

We can enforce a set of guidelines, if they have been approved by the US regulatory bodies as the standard of care. But digital pathology is not yet the standard of care. So the institution can’t make the use of digital pathology compulsory – it’s the pathologist’s choice.

How were the team brought on board with the changes?
 

We started with training. Everyone in the department received training. And I started meeting with every pathologist individually, so we could have one-to-one conversations to address any concerns. Next, I started asking people to be less dependent on their glass slides – to try working digitally for a full day, maybe two days, to see what happened.

In my division, nearly everybody jumped on the bandwagon almost immediately. And our colleagues in neuropathology were already using the systems to a large extent, so their expertise was established.

And then, in early 2020, the pandemic hit.

By that time, everybody was trained on the digital systems and we were preparing for a big upscale in digital sessions. The university issued everyone with laptops with VPN incorporated and started to ask doctors to manage their patients from home. We followed the example of radiology, which is a speciality more akin to pathology. The radiologists had all been working digitally for more than 20 years, so they just carried on at home.

Immediately we saw a benefit – you don’t have to be in a lab to be a pathologist, you can do it from home or wherever you are. The only problem was the regulations for signing out cases from home – we needed to gain licenses.

The College of American Pathologists and the Digital Pathology Association took on the advocacy with the regulatory bodies – the US Centers for Medicare & Medicaid Services (CMS) and the Clinical Laboratory Improvement Amendments (CLIA). Sure enough, within days, a temporary guideline was issued that allowed signing out from home. The guideline was extended, and recently modified to allow sign-out from home as long as the home address is registered with a CLIA-certified organization.

Once that was in place, we had 100 percent adoption of digital pathology in our group of 60 or so pathologists (around 40 in the main hospital and 20 in other locations). The exceptions are those pathologists who sign out certain subsets of cases that have not been amenable to transition due to technical differences, like bone marrow counts, renal immunofluorescence and cytopathology slides. We are diligently working with them to bring them up to speed now that the technology is catching up.

Throughout the process, what have you learned about change management?
 

Information is key. We can’t just propose a change and expect the end users to jump on the bandwagon right away. We need to demonstrate that the processes for quality assurance and sign-out are equivalent whether performed digitally or with glass slides.

I keep on top of the literature and keep the pathologists informed of all the research, so they can see it for themselves.

And finally we need to spread the word – share the success story. We had around 12 abstracts accepted from our division by the United States and Canadian Academy of Pathology congress 2024. And we made the covers of two magazines in the last quarter.

What skills do you think are important for change managers?
 

I think anyone can find a way. Change management can be taught or, in my case, learnt by trial and error. You need to have a clear goal, to accept that people won’t be forced to adopt change, and to share the success stories. Sometimes having an expert in change management brought in to assist may be helpful or, at least, the person spearheading the transition should have knowledge of the obstacles and how to overcome them. One of the most important lessons I learned is that you cannot alienate the pathologists, even those who are vocal about their disdain of the new technology. Sometimes those become your best allies down the road. 

And you need passion! You need to live completely in that world, to have plenty of experience, and to talk with passion about that experience. If there’s no passion, it won’t happen soon enough.