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Inside the Lab Technology and innovation, Digital and computational pathology, Software and hardware, Microscopy and imaging

The Future of Digital Pathology

Although some doubters remain, the value of digital pathology is increasingly recognized around the world – especially in this post-pandemic era. Digital enthusiasts Jonhan Ho and Sylvain Mailhot review the current state of play and how digital adoption can be encouraged.

Digital pathology is, by now, indisputably the future of the field. Although some are still reluctant to accept its place in the lab – and despite its slow adoption in many institutions – the digital slide image is slowly replacing the glass slide on the microscope’s stage. The flexibility, accuracy, and potential to deploy ever-improving informatics and image analysis tools make digital pathology an attractive option. But significant hurdles remain nonetheless – the initial expense, disrupted workflows, and altered infrastructure required for implementation prevent many labs from accessing digital pathology’s full potential.

However, the onset of the COVID-19 crisis at the start of 2020 only served to highlight some of the key benefits of digital systems. Those institutions with digital pathology enabled their pathologists to better manage workloads and diagnose from the comfort – and safety – of their own home. Regulatory issues can hamper digital adoption – but, as we adapt to the practical consequences of the pandemic, medical and regulatory communities are increasingly analyzing ways to combine slide digitization and the benefits of remote diagnosis. To learn more about the current state of play and where things are headed, we spoke to Jonhan Ho and Sylvain Mailhot, two pathologists with digital experience.

Time for change
When Jonhan Ho first saw a whole-slide image during his pathology residency, he was blown away. “I knew that one day we would all be making diagnoses routinely with digital pathology,” he says. At the same time, though, he was growing frustrated with the cumbersome medical software on offer. “I was incredibly frustrated with how much time we wasted clicking unnecessary buttons. I felt at the time that we had a unique chance to influence the future of pathology software for decades to come.” One vision for the future led to imperfect pathology workflows forced by bad software; the other to happy and inspired pathologists at work – and Ho wanted to do everything in his power to make the latter a reality.

With the rise of the pandemic, his aspirations were timely. “COVID-19 has really hastened the need for remote learning, and we have shifted all of our teaching to whole-slide images,” Ho explains. But, as education becomes increasingly democratized, he noticed a glaring absence – a platform for doctors, especially pathologists, to share their knowledge. To solve that problem, Ho created KiKo – an acronym for “knowledge in, knowledge out.” There, pathologists share collections of whole-slide image cases paired with videos and other forms of content. And KiKo is taking off. Recently, the platform hosted its first global digital dermatopathology grand rounds, in which dermatopathologists worldwide shared cases and traded their best tips and tricks.

We are no longer chained to the location of the histology lab.

“Digital pathology empowers the pathologist,” says Ho. “We are no longer chained to the location of the histology lab. On top of that, digital pathology opens up a whole new set of informatics and image analysis tools that we are just now starting to create.” He cautions, however, that not all digital pathology software offers a good user experience – and that it’s important to impress upon vendors the importance of having dedicated user experience designers on their team.

But is now the right time for a move to digital? Ho thinks so. “Hospital systems will save money with digital pathology by decreasing errors and dynamically distributing workloads,” he says. “I am hopeful that, because the pandemic has highlighted the need, regulatory agencies will be more willing to allow pathologists to adopt digital pathology.”

Ho’s Top Tip: “Garbage in = garbage out. To get good, clean images, the histology lab must put out good, clean slides.”

Demonstrating digital desirability
After Sylvain Mailhot first experienced digital slides during the Laval University virtual slide telepathology project, he realized its unlimited potential and was sure that the field would be fully digital within five years. Why? “You have immediate access to colleagues anywhere on the planet. You can transfer them the files and quickly obtain a second opinion,” explains Mailhot. “It can also be difficult to physically locate slides when required, so being able to access them immediately on a digital system saves a lot of time.” Mailhot also believes that digital pathology is more ergonomic than the traditional setup, with digital slide viewers offering a more comfortable working experience than sitting hunched over a microscope.

The major obstacle to digital pathology is the resistance of the pathologist.

But why has digital pathology not been embraced fully across the field as Mailhot anticipated a decade ago? “Based on my experience working with digital slides and discussions with others across Canada and the US, the major obstacle to digital pathology is the resistance of the pathologist,” he says. Mailhot believes that, for digital adoption to succeed, the number of pathologists who are interested in, and enthusiastic about, digital pathology must reach a critical threshold. He acknowledges that there can be stumbling blocks when it comes to digital implementation – but none are impossible to overcome. “There is a lag between the production of the slides and the digital image when scanning your own slides, so it’s important to devise a system for prioritizing important slides,” Mailhot explains. “There will also be times when you are disappointed with the quality of the digital image, which is why we manually pre-scan all slides to detect any out-of-focus areas.”

It’s partly thanks to digital pathology that Mailhot’s lab has successfully adapted to the challenges of COVID-19. With no on-site work permitted during lockdown, the ability to diagnose cases digitally meant that pathologists could operate from the safety of their homes. Mailhot also highlights the workflow benefits in the event of illness. “If one pathologist cannot work, I can immediately resend the slides to a different pathologist on the system. Before, I would have had to go into their office to physically retrieve and redistribute the slides.”

Given the current rate of adoption, how does Mailhot propose to convince the doubters that digital pathology is the way forward? “Some pathologists have the misconception that digital slides will never look as good as glass under a microscope – and that they take more time to navigate. To prove that this isn’t the case, it’s important to show these people digital slides on a high-quality screen using an advanced system to demonstrate image quality and ease of use.” Once people are on board, Mailhot believes the second step to successful implementation is to work closely with the IT department. It’s not only a question of having a great image, he says, but also of having sufficient storage and network facilities to support a seamless digital system.

Once the early promise of AI is realized, pre-screening slides into categories will save both time and money.

Although the transition to routine digital diagnosis can be costly for institutions at the outset, Mailhot believes that the long-term savings make it worthwhile. Consolidating digital slide production to one site, distributing slides digitally, and improving slide organization will all save money and time in the long run. “Looking further into the future, I think that sophisticated artificial intelligence (AI) tools will force laboratories to go digital,” says Mailhot. “Once the early promise of AI is realized, pre-screening slides into categories will save both time and money.”

After scanning slides and diagnosing them digitally for many years, Mailhot believes that institutions like his have a key role to play. “Labs that have already made the transition will build up experience and expert knowledge – and they need to make sure they pass it on to others to increase digital pathology’s value and to help with the transition.”

Mailhot’s Top Tip: “I think people have misconceptions about digital pathology. I would advise everyone to try it. Look at slides using a high-quality screen, computer, and scanner, and I think you’ll love it!”

Jonhan Ho is Assistant Professor of Dermatology and Pathology and Director of the Dermatopathology Unit at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Sylvain Mailhot is Medical Director at PathAssistant Laboratory, Moncton, New Brunswick, Canada.

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About the Authors

Michael Schubert

While obtaining degrees in biology from the University of Alberta and biochemistry from Penn State College of Medicine, I worked as a freelance science and medical writer. I was able to hone my skills in research, presentation and scientific writing by assembling grants and journal articles, speaking at international conferences, and consulting on topics ranging from medical education to comic book science. As much as I’ve enjoyed designing new bacteria and plausible superheroes, though, I’m more pleased than ever to be at Texere, using my writing and editing skills to create great content for a professional audience.


Luke Turner

While completing my undergraduate degree in Biology, I soon discovered that my passion and strength was for writing about science rather than working in the lab. My master’s degree in Science Communication allowed me to develop my science writing skills and I was lucky enough to come to Texere Publishing straight from University. Here I am given the opportunity to write about cutting edge research and engage with leading scientists, while also being part of a fantastic team!

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