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Inside the Lab Technology and innovation

The Journey to Digital Pathology – Pathlab: a Case Study

This is part 1 of a 3-part series showcasing how pathology laboratories in New Zealand, Germany, and Portugal have successfully tackled the transition to digital.

New Zealand is world-renowned for its sweeping landscape and wonderful panoramic views, so it’s interesting to see this echoed by the team at New Zealand-based Pathlab, which takes a broad and comprehensive view to optimizing anatomical pathology services – for now and for the future.

“We’ve been able to invest early in technological advances to help us improve our processes and efficiencies for both our staff and our patients,” says Corinne Hill, Lead Scientist – Histopathology/Molecular Oncology at Pathlab – an anatomical pathology lab that processes more than 60,000 cases and 200,000 slides annually. 

“About the time we implemented a single-piece workflow with our integrated management system, we started to look closely at digital pathology. At the time – more than 10 years ago – digital was starting to become more robust,” Hill reflects. “Even as we focused on our then near-term goal to minimize the risk to the audit trail within the histology laboratory, we could see very early on that digital was the next advancement for our service.”

Pathlab’s Director of Anatomical Pathology Richard Massey remembers the team learning about digital pathology when it was way out on the horizon. “We had been watching it very carefully, particularly with a view to modifying our workflows and taking advantage of the increased patient safety that digital pathology could offer,” he notes. “We wanted to start with a view to gaining experience with the technology: how it actually felt to work with it.” 

The beginning of the journey – multidisciplinary team meetings

The Pathlab team initially focused on applying digital pathology to multidisciplinary team meetings (MDTs) for one service region, called the Bay of Plenty. “We integrated our digital system first with MDTs because we saw that as an easy way to get familiar with a technology without it being too onerous on the pathologists,” noted Hill. 

The team quickly learned that digital enables a different sort of work experience for a pathologist and for the clinicians with whom a pathologist collaborates. “My main experience is that, when you first start using digital pathology, like any other new skill, it takes effort and concentration,” Massey explains. “Obviously, a screen is not a microscope. There are new sets of visual and motor skills to be learnt while reporting off a screen as opposed to reporting using a microscope. There is a learning curve; however, people interpret that as being inferior – and it’s not.”

To the contrary, gains in efficiency and productivity were evident from the outset. The team saw that both the pathologists and collaborating clinicians benefited from the ability to remotely share and view images and notes. “We found that converting to digital pathology enabled us to manage the workload for meetings, and it gave much greater visibility for the clinicians as to the material we were looking at,” notes Massey.

Hill adds, “We saw that MTDs do not have to be run all in the meeting room. With this world of remote/hybrid work and social distancing or isolating because of exposures, a pathologist can still work from home and even manage an MDT across multiple sites using video conferencing tools. Pathologists used to have to walk across the carpark with piles of glass slides, which slowed us down and was very inefficient. With the digital tool, we prepare our images before we attend the meeting. It's a faster service, which provides more information to the clinician and, at the end of the day, the patient.

“Pathologists also reported satisfaction [...] to be able to effortlessly look up the previous biopsy of the resection specimen or the previous material belonging to that patient, enabling quick review and comparison. Even reviews from clinicians happen very easily with digital because pathologists just look up the patient details, open the report and review the slides, and then can immediately provide the clinician the information that they're looking for.”

The digital approach also brought increased security. “We had to look at our workflows with glass in a whole new way. Having a secure locked-down workflow for digital pathology has made it plainly apparent how vulnerable traditional reporting processes are to human error,” said Massey. “Now, with digital, you [know] you are not looking at the wrong slide from the wrong case. You are always looking at the right slide, and you are able to annotate easily.”

The halfway point – scaling up to primary diagnosis

Success with MDTs gave the Pathlab team confidence to adopt digital pathology for primary diagnosis. “We transitioned from MDTs – looking at images and sharing images – to actually being able to report those images in a safe environment,” says Massey. “To achieve that, it was really important to have specimen integrity from the very beginning of the process right up until the end where a pathologist is signing out. For that to happen, digital systems and reporting systems must be integrated.”

To enable the use of digital for primary reporting, the team created a rigorous quality control (QC) process. “A quality process makes sure that your system is safe,” explains Hill. “We created a detailed set of QC steps. For example, we conducted a full audit comparing glass to the digital image, making sure that the interface was safe, that everything matched and that the image quality on the screen was of a higher quality than the glass. It required a lot of steps to finalize, but it has absolutely been worth it.” QC actions included establishing parameters for image quality working with 4K panels for workstations, creating protocols for annotation, and developing guidance for accessing a patient’s previous images and clinical details.

First and foremost of these is optimizing image quality, asserts Massey. “We scan everything at 40 times, and that gives you equivalent resolution to 40 times on the microscope. Annotation of a high-quality image then becomes second nature. Digital measurements are highly accurate, and the measurement rulers can be left in place so that you are able to show any reviewing pathologist exactly what you are interested in. Anybody who looks at that image (and they can even be looking at it at the same time as you) can see what you’ve done.” 

Throughout the implementation process, cost was examined. “When you're putting in a new piece of technology, which on the face of it may look like it doesn't increase any efficiencies, a barrier can be the cost-to-efficiency ratio,” noted Hill. However, consider how “it's providing support for the pathologist, providing better service. It's about quality, and it is about the future. So over time, that cost is negated because you're looking at a higher-quality and more efficient service,” she advised.

The next horizon: computational pathology and AI

Looking ahead, Massey muses, “The other biggie with digital pathology is returning our images into data; the things you can do with that data are almost limitless. Assisted diagnosis is on its way. It isn’t a matter of if, but when. Our plan is to have several years’ worth of live image data available to pathologists, perhaps as much as 10 years, so that we are prepared when the time comes.”

The application of AI to digital pathology is exciting, holding the promise to not only improve the accuracy and reproducibility of diagnosis but also equip pathologists with new capabilities in prediction of therapy response and patient outcomes. There is significant potential for AI to help pathologists – and the physicians they work with – to provide better patient care.

Hill agrees and adds, “Look at what to start now so that, in the future, you’re ready for AI. We’re not quite there yet, but to get to that stage, you need the tools now so that you're ready for the next wave of technology which will come. Digital, of course, is critical to that preparation.”

When implementing digital pathology, Massey and Hill have straightforward advice for fellow pathologists: begin with a bottom-up review of all processes and then focus on – and codify – your digital workflow. “A secure single-piece workflow is vital to implementation; just buying a scanner is not doing the job,” says Hill. “You have to build a secure process around that technology. In our experience, the actual implementation of the digital component of the workflow is the final step of the whole process. It’s not the first thing you do.”

Ten years into their journey, both doctors are enthusiastic that the future is digital. “For the labs that aren't looking at digital pathology yet, it’s a matter of when, not if.”

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About the Author
Rob Monroe

Pathologist currently serving as Chief Medical Officer for Leica Biosystems and Chief Scientific Officer, Oncology, for Danaher Diagnostics. Monroe is board certified in cytopathology, anatomic pathology, and clinical pathology and holds a PhD in genetics. He has years of experience in the digital pathology space and frequently consults with pathologists around the world.

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