How We Are Going Digital

Cellular pathology services in Wales were under pressure, with a national shortage of consultants, difficulties in recruitment, and an ever-increasing workload all adding to a recognized service sustainability risk. Rapidly advancing technology offered a potential solution to the problem in the form of digital technology. Could this technology be implemented nationally?

In the past, the very idea of going digital would have been met with a healthy dose of skepticism, but because digitization of glass slide preparations had reached a sufficient level of quality, efficiency and effectiveness, we believed digital pathology was ready for realistic consideration – with the potential to further integrate the software interface with the Wales Laboratory Information Management System (WLIMS), which would allow us to report cases within an all-digital environment. This combination of factors encouraged us to begin investigating digital pathology’s potential for NHS Wales Diagnostic Cellular Pathology services.

An all-digital cellular pathology service is attractive for a number of reasons. First, it eliminates many of the time-consuming steps involved in physically transporting microscope slides to consultant cellular pathologists locally, externally, and for multidisciplinary team (MDT) review. Second, case reviews and external expert opinions can be performed electronically – and in real time – increasing access to additional diagnostic expertise and thus precision. Third, remote consultant MDT attendance through video conferencing is improved by the inclusion of images, resulting in the potential for greater subspecialization and shared working across NHS Wales.

One step at a time

Following the 2013 modernization of the Cellular Pathology service in North Wales – which centralized three cellular pathology services onto one site – Betsi Cadwaladr University Health Board (BHUCB) successfully bid for capital to procure a digital cellular pathology service, which was installed in March 2015. However, medical staffing and other service constraints prevented the necessary verification process for clinical use. More resources were needed, so another successful bid was submitted to the Welsh Government in November of 2015, on behalf of the National Pathology Operational Managers Group, to fund a national program.  Our plan? Two phases: verification, followed by national implementation.

In January of 2016, we agreed membership of the Efficiency through Technology Fund Digital Cellular Pathology Programme Board, drafted a program timeline, and held initial discussions with procurement colleagues. A month later, we held the inaugural Programme Board meeting and circulated a list of nationally agreed items for procurement of clinical workstations to health boards for purchase, we also identified Consultant Histopathologists participating in the verification exercise for each health board and a project team at Betsi Cadwaladr. Finally, we were ready for the verification exercise, which officially began in April 2016.

The good and the bad

The positives of the verification were that staff communicated well, used national procedures and protocols provided by BCUHB, and were enthusiastic about the verification program.

The negatives were system issues that could not be quickly resolved because of differences in local health board IT policies that resulted in delays to the verification process and frustrations in colleagues. Some of these issues and frustrations were alleviated by implementing a weekly audio conference with colleagues at Leica – our equipment supplier – which helped to resolve some of the system issues.

The changes in working practices experienced were handled well by colleagues which in part were due to robust procedures provided by experienced colleagues in BCUHB and an overall enthusiasm to ensure that the verification phase reached completion.

Just over a year after the verification stage began, the final statistical analysis was presented to the Programme Board, the Meeting of Welsh Histopathologists, and the Welsh Scientific Advisory Group Symposium. Our results were very promising when compared with other international studies of digital pathology, particularly in terms of concordance and accuracy. The Programme Board agreed to recommend to the NHS Collaborative Executive Group to proceed with a full rollout of digital technology – and the Chief Executives agreed to move to the second phase of the program: implementation.

Lessons learned

During the course of the verification phase, we learned a few valuable lessons that we’d like to share with other pathology services looking to make the same move.

Information governance protocols are vital – establish them early on in the program as they are essential for sharing digital images!

A national information technology lead would have been helpful. Although we identified local IT leads early on in the program, we did not select a national lead for the verification phase – and we think this added to difficulties we experienced with conflicting work practices between local health boards’ IT departments. For the implementation phase of the program, we will be including a national IT lead as an essential role.

Discrepancy meetings between colleagues in North and South Wales were identified as a key part of the program at an early stage. These discrepancy meetings were held between colleagues if there was a difference between results reported on glass slides and those reported using digital image. The importance of these meetings has been highlighted by clinical colleagues to discuss the variance in results, reach concordance, and additionally as a valuable peer review. We recommend that anyone undertaking a similar transition to digital implement these meetings as well.

The way forward

Cellular pathology services across South and West Wales are currently being reviewed through a separate process; the outcome of which is likely to be a service model similar to that of North Wales – namely, a reduced number of centralized sites providing service in the future. We still need to further consider the impact of digital technology on that service model, but we expect approximately the same number of slides generated, so scanner capacity should not be significantly affected. The main impact of the technology is most likely be increased flexibility for pathologist reporting – a benefit by any measure!

Given the possibility of a centralized service model for South and West Wales, part of our implementation phase involves procuring a digital pathology solution for those regions based on their activity and medical workforce profiles. The tender specification for the Betsi Cadwaladr system would serve as the initial basis for this procurement. Additionally, we can use the shared learning and national verification work from the North Wales project to inform the implementation of the South and West Wales system, meaning that the system could be deployed immediately after procurement. Within three years, the entire NHS Wales Cellular Pathology service could be entirely digital – and given the success of our initial verification phase and the benefits we’ve seen thus far, we’re looking forward to full implementation.