Transporting a patient’s sample by courier so that it can be seen at another hospital is a reality that faces pathology departments today. It is a consequence of the analogue nature of how pathology functions, something that also means this crucial discipline, which underpins patients’ diagnoses, often works in relative isolation to other parts of healthcare.
But an historic reliance on slides and microscopes that restricts the flow of information and opportunities for collaboration, could soon be about to end in a move that will change how pathology departments function and place the discipline at the heart of the healthcare enterprise.
Pathology is widely expected to be the next big digitisation in the UK’s NHS, something that is equally applicable in many parts of the world. It is inevitable. In fact it is happening now.
Many pathologists no longer wish to transport samples in jiffy bags. They want the means to function regionally and they want to be able to quickly access the visual information they need, wherever their location, in order to carry out their diagnostic function which is in increasingly high demand by clinicians across the hospital environment.
Pathology is embarking on a transformative journey through digitisation, one which will help it to modernise, address diminishing resources and respond to the modern day call for integrated, sustainable and joined-up healthcare. And modern technologies mean that barriers to adoption can now be overcome.
Why does pathology need to digitize?
There are a huge range of benefits that can be achieved through digitisation and the business case is very strong. So, what are these benefits?
Regionalising pathology workflows
Departments now have a strong desire to regionalise their workflows. In fact, in many cases a distinct lack of resource and skillsets in pathology is already forcing hospitals to regionalise work. But at present hospitals have very little or no means to support this. It is the reason pathology departments must today resort to couriers or even the back of taxi on some occasions, to move samples where they are needed.
Digitising pathology offers the very real means to solve this challenge and to allow work to be regionalised, improving workflow balancing through the sharing of digital images. It would mean that not every hospital needs to have a particular sub-specialist, such as a neuropathologist. Instead hospitals could much more easily access a sub-specialist at another site when needed.
Such a collaborative approach also allows for ready access to peer review and to quickly draw in a second opinion when needed.
Collaboration within hospitals—maximising the value of MDTs
At present in some instances pathologists do not display slides during multidisciplinary team (MDT) meetings and instead present their own assessments and conclusions. Displaying slides may not be convenient or even practical. But failing to share this basic information with clinical colleagues is counter to the nature of MDTs, which exist to foster collaboration and gain input from the best of different disciplines in order to achieve the best outcomes for patients.
Pathology can improve this important clinical engagement by easily displaying digital images in MDTs.
Reduced costs—access to sub-specialists, accurate diagnoses.
Digital pathology can reduce costs in a number of ways. It means that images are sent directly to sub-specialists, or other hospitals, without any lead time or costs for glass transportation or handling. This also removes the risks of slides being damaged or lost.
In addition, greater access to sub-specialists than a pure reliance on in-house generalists, can increase the accuracy of diagnosis significantly. This can ensure treatments for patients are optimised.
Speed of reporting
The process of reporting can become much faster as the need to manually handle slides is eliminated.
The use of image analysis algorithms means that the reviews can be more consistent, reducing variation in quality.
Access to historic information
Access to historic samples and referrals is also made much easier through digital pathology.
Greater intelligence, analytics and unprecedented pathology performance measurement
From a business perspective there is significant benefit to understanding how pathology is working locally and regionally.
Intelligence is important. With a digital solution the NHS will be able to measure outputs and performance of services. It can look at the volume of images analysed, the speed, the quality of service provided by an individual hospital, or by an individual pathologist, turnaround times, and how effective they are. Key performance indicators can be set locally, regionally or nationally. Performance can be measured against this and quality can be benchmarked against other hospitals.
This is an opportunity to improve, for hospitals to identify where they are doing well or falling down, or to see where an individual needs training or assistance. But without this intelligence, pathology is missing a key opportunity to improve and to avoid potential problems having an impact on the patient.
Patient access and a key missing part of the patient record
Digitising pathology can enable patients to access their own imaging and information. Breast cancer or skin cancer patients, for example, who have access to their medical records can see reports with imaging information, post-surgical photographs and pathology results. That information can give patients the power to drive their own healthcare. This is a big part of the patient record that is missing without digitisation in pathology.
Making pathology an attractive career path
Some pathology departments are embarking on digitisation to attract young people into the profession. At present the discipline is not always seen as a progressive, exciting area by people entering the healthcare profession. However collaboration enabled by digital transformation has the potential to make it a far more engaging environment.
Remote reporting—enable home working
There are benefits for those already firmly into to their pathology careers. Some pathology departments are choosing to embark on the transformation at least in part to allow their staff to work remotely. Remote reporting offered by digitisation means that pathologists can work from multiple locations and have an improved work-life balance.
A common problem for pathologists is to develop neck injuries as they progress through their careers, due to time spent at the microscope. Pathology departments in Sweden, for example, have chosen to enter into digitisation in order to improve ergonomics for staff.
Education and training
The ability to share digital images makes training much more practical and can be far more effective than having multiple students standing at a microscope.
Overcoming obstacles, avoiding pitfalls—making the transition a reality
This is a new journey for many departments, one that has many clear benefits as well as pitfalls. But there are places where pathology can look to ensure the transition takes place smoothly. Although a very separate discipline with its own needs, radiology embarked on its digitisation journey some 15 years ago in the NHS and even further back elsewhere. Many of the lessons learned here can offer guidance.
Technology—fast access to images, previous challenges overcome
Radiology departments are no longer confined to the inefficient viewers and software provided with scanners. This is one barrier to entry that has already been overcome. Off-the-shelf technologies can now enable departments to access images several times faster. Departments no longer have to rely on the software supplied with their scanners, which can be complex, difficult to support for the hospital’s IT department, slow and lack interoperability.
Workflow centric solutions on the other hand, now enable departments to access images very quickly and independently of the pathologist’s workstation. Significant time savings are also made through automatic retrieval of previous examinations for the patient concerned, and simple mark up of case rounds. It also means that specialists can easily access images outside of the department.
Inward looking and dead-end solutions may be restrictive
To maximise the potential of digitisation, departments should avoid solutions that are not interoperable. Some early pioneers have chosen solutions that lock them in with a specific vendor, restricting an ability to scale to regional and national collaboration. Instead of simply looking to solve immediate problems, pathology must look beyond the department to the wider enterprise and to other hospitals across their region or even their country. This is fundamentally about integrated healthcare.
Anticipating access demand
Some departments have not given full attention to the level of access digitisation will entail. They are considering some groups which will need to access information, but haven’t necessarily considered the scale at which access to pathology imaging will be necessary. For example, some have not taken into account the need for patient access. This will be inevitable and is a key part of many government policies on healthcare.
Data security and system back ups
Some departments contemplating digital pathology have yet to consider basic requirements, such as data security. Some have so far not envisaged what happens when the system goes down and are still reliant on the microscope as a back-up. Consultation and collaboration with the IT department is essential.
Digital pathology in practice—it is happening now
A world first in Sweden
Sten Thorstenson, a senior consultant pathologist at Linköping University Hospital, began using digital technology to review histopathology samples as early as 2006. However, as far back as 1999, he attempted to reduce the amount of time pathologists were spending traveling between Kalmar and Västervik. He began using a frozen section scanning procedure for patients undergoing surgery in Västervik and digital telepathology technology to send the images to the reviewing pathologist in Kalmar, eliminating the need to have a pathologist on site. By 2008, he and his colleagues became the first in the world to begin implementing digital pathology across the entire department, with parallel access to microscopes and slides.
Since January 2014, he has performed his reviews exclusively with digital technology, without using paper referrals or slides and microscopes. He presents primary diagnoses to the pathology department at Linköping University Hospital, but works from home in Kalmar, more than 200km away.
A range of benefits are being realised by Dr Thorstenson’s team. Pathologists no longer need to spend lengthy amounts of time at a microscope. Reviews are more consistent, with fewer variations in quality between experienced and less experienced pathologists. Earlier samples and referrals are easier to access and the risk of samples being difficult to locate has been reduced.
Improvements are still being made. A new viewer, in use since April 2014, allows access to images two to three times faster than with a previous scanner image viewer.
“Digitisation has created entirely new opportunities for cooperation between clinics,” he says.” Not least of all, better diagnostics can be achieved through access to sub-specialists. Provided you are using a good, fast image viewer combined with a suitable human interface device, such as a 3Dconnexion mouse, the pathologist can also save time since less time is spent preparing samples—switching slides in the microscope, selecting the right lens, focusing, etc.—in a digital review than when using a conventional microscope.”
Pioneers are now emerging in the UK. Salford Royal NHS Foundation Trust has recently completed a pilot programme to embark on a journey of digital pathology.
We are facing repeated calls for a joined-up approach around patient care, which now requires the ability to seamlessly share information that follows the patient. Combined with the resource pressures faced in pathology and the many opportunities that come with digitisation, there is a growing recognition that the discipline must modernise and move into the digital era.
Digital pathology not only presents a strong business case, but is a business requirement into the future to support the sustainability of the discipline at the heart of the enterprise.