Although most pathology departments have not yet made the transition to digital, many are actively evaluating the business case. Why?
Most countries today are experiencing high pressure from the increase in cancer cases, which has resulted in protracted waiting times for diagnosis and treatment. At the same time, the more advanced diagnosis and treatment methods being adopted are significantly increasing the survival rate among cancer patients, and have been doing so for the past few decades. These advancements as well as the growing demand for cancer care are straining healthcare budgets to a point that is no longer sustainable.
Moreover, patients are becoming more demanding, increasingly seeking care providers with a proven track record of fast and high-quality care. With more transparent statistics becoming available, we will most likely see an increased flow of patients to top-performing institutions—in other words, if you can’t offer fast and accurate care, you will lose patients and your source of income. We also see that many countries are incorporating new national legislation to reduce waiting times. One example is the standardized cancer pathways in Sweden, where waiting times for five common cancers have been regulated since 2015 and an additional 14 cancer types during 2016. Both these trends challenge healthcare providers to improve the quality and efficiency of their cancer care.
Pathology plays a significant role in improving cancer care quality and waiting times. Pathologists not only diagnose biopsies, but also play a crucial role in the treatment, prognosis and follow-up of patients. A report from the UK National Health Service (NHS) states that “protracted decision making in pathology accounts for 41% of delays in cancer diagnosis, and is a leading cause of patient safety incidents”. In addition, a large Swedish investigation from 2012 concluded that in order to meet the rising demand for shorter waiting times in a cost-efficient way, the adoption of new technology such as digital pathology is necessary.
A quantification of the cost savings of digital sharing
A transition toward digital pathology requires an investment that often needs to be preceded by an approved business case quantifying the true cost savings of going digital. The list of benefits of adopting digital pathology can be long and the business case complex, which may be problematic when creating one. However, an appealing business case doesn’t need to be complex; it can be created by keeping things simple, focusing on the short-term benefits that come with digital sharing and minimizing treatment errors.
Decreasing costs of sharing
For example, the reduced costs associated with savings made in logistics and administration of glass are fairly easy to monetize. Let’s say 30% of a total of 30,000 annual cases need to be sent to subspecialists outside the hospital. The costs for transportation would average at least USD 2 per glass, resulting in a freight saving of USD 18,000 annually. In addition, the administrative costs of packaging and labeling would most likely be the salary of one secretary, at an annual cost of USD 50,000.
Decreasing costs by minimizing treatments errors
The benefits of shortening waiting times are hard to quantify, but the cost savings of minimizing treatment errors have been estimated in several studies. For example, treatment errors can significantly be reduced by sending digital slides to the most appropriate subspecialist instead of using in-house generalists. In a study conducted at the University of Pittsburgh , the costs for undertreatment and overtreatment for breast and melanoma cases (based on insurance numbers) were calculated. These numbers were extrapolated to other cancer types, which resulted in a cost of USD 21,500 per treatment error. The prevalence of treatment errors can be found in many articles, including a study from the MD Anderson Cancer Center which estimated that among 2,718 reviewed cases, there was a discrepancy between the original pathology report and the subspecialty final report in 25% of the cases. 6.2% of these resulted in a major discrepancy affecting the cancer treatment. By applying these numbers for a hospital with 30,000 cancer case biopsies per year and with a malignancy rate of 35%, the cost of interpretation errors leading to treatment mistakes would average roughly USD 14 million annually (30,000 x 35% x 6.2% x USD 21,500).
Showing that digitizing pathology can reduce treatment errors therefore provides a very important and powerful reason for making an investment in digital pathology. One proven way to improve the quality of healthcare is to conduct a subspecialty pathologic review of patients with cancer before initiation of therapy. This means that in the best possible scenario, pathology cases should be reviewed by a subspecialist with the correct expertise and experience for a specific case. Allocating the right cases to the right subspecialists not only increases the accuracy of diagnosis, the experts are also the ones who can diagnose a case within their subspecialty with the highest efficiency. This is a benefit that became obvious when radiology was digitized.
However, as most pathology departments today still haven’t transitioned to a digital workflow, the sharing of physical glass with subspecialists involves shipping the glass or, in some case, the pathologists travelling to the glass itself, which results in longer waiting times. The high pressure to keep lead times short is forcing many healthcare providers to review as many cases as possible using in-house generalists instead of sending the cases to the most appropriate subspecialist. This keeps lead times down, but at the expense of the accuracy of diagnosis, most likely resulting in a growing number of instances of both undertreatment and overtreatment, which is tremendously expensive for the provider. Accordingly, the goals of reducing lead times and improving quality through the use of subspecialists appear contradictory in an analog workflow using glass for review. Reducing the allocation to subspecialists outside the hospital to keep lead times short has a negative impact on quality. Digital pathology would enable healthcare providers to share the right case with the right pathologist while also reducing the waiting time, and at the same time increase the accuracy of diagnosis and minimize treatment errors and their associated costs and patient suffering.
Knowing about the other benefits adds extra arguments on top of the business case
By quantifying the savings in treatment errors due to improved quality, reduced logistics costs and reduced administration associated with shipping of glass, one can conclude that digital sharing alone is enough to justify the investment in digital pathology. Yet these estimated savings do not include the shortened lead times resulting from a digital workflow, as mentioned earlier. Nor have other benefits, such as time savings in the MDT, case reviews, etc., been taken into consideration. Moving from a cost focus to revenue, reducing lead times will also most likely lead to a more attractive care provider from a patient perspective, enabling revenue to be increased thanks to the ability to handle more patients with the same resources.
Efficient sharing justifies digital pathology
Digital pathology provides benefits such as shorter waiting times while at the same time achieving higher diagnosis precision by allocating cases to subspecialists. Most pathology departments are in the early stages of adopting a digital workflow, but the missing piece of the puzzle often involves creating a business case and securing funding. Basing the business case solely on the benefits of digital sharing of images will keep it simple and easy to discuss. It will show the potential savings in reduced treatment errors, logistics and administration, which probably will be enough to justify the investment in digital pathology. A necessary and positive consequence is also the shortened waiting times for patients—meeting patient demand and regulatory enforcements, and making the care provider more attractive.