Substantial improvements in the way pathology is delivered have long been promised by digital technology. However, uptake has been slow for a number of reasons. A combination of financial constraints, practical obstacles and the mindset of pathologists have hindered its progress. However, the University of Pittsburgh Medical Center have been looking into new ways to deliver these changes in pathology that many people may argue is long overdue.
Many things are possible in this world of digital pathology. Primary diagnoses, second opinions, quality assurance, sharing, image analysis, AI, education and conferencing are all possible with digital images. The delivery and analysis of telepathology is being revolutionized. The development of research, archiving and academic publications are also being supported. Exciting prospects for the future are offered by continually evolving and developing technology, particularly in areas such as artificial intelligence and machine learning. The team at Pittsburgh has successfully explored all of these avenues.
A Long History of Digital Pathology
Digital pathology is often considered something new but this technology has been around for more than 20 years.
Benefits of Digital Pathology
When teams are working remotely this has enormous benefits, as slides don’t need to be physically shared. When users are based within the same hospital, they are able to pass slides to the next person simply. However, in an integrated organization where pathologists work remotely, this poses a significant problem.. The entire process is slowed down if slides need to be sent by courier, especially if they have to travel overseas. Digital microscopy allows images to be easily sent and shared remotely, meaning results from experts are received sooner.
The work in Pittsburgh sees huge benefits where hospitals are divided into academic urban and community hospitals. Intraoperative consults are performed in many of the community hospitals, particularly in neuropathology, by specialists using robotic microscopy. Several neuropathologists can handle these consults remotely using small footprint scanners to perform live robotic reviews. These are also able to offer whole slide imaging for seeking second opinions to improve quality.
This device is small, meaning it can fit easily into a frozen section suite. Compared to a large high-capacity scanner, it is also relatively more affordable.
What Has Been Standing in the Way?
A combination of practical, financial and psychological factors make up these barriers. Administrators are wary of investing in new technology due to financial constraints, so they need to see a proven return on investment. The cost of the equipment is one thing, but it is the expense and work involved with identifying qualified people to operate it that holds things up. It is like buying a brand-new bus but not being able to find a driver.
Several security concerns are also raised with digital technology and not all of these are easy to resolve. To facilitate collaborations between teams in multiple locations, it is crucial to digitize data and share it online. However, putting this data online inevitably puts it at risk. The quantity of highly sensitive information will increase with digitization and hospitals will be required to handle this. All healthcare providers are obligated to ensure that data is securely managed and appropriately shared.
The security team at the University of Pittsburgh Medical Center completes thorough testing on any new device to ensure it is safe to use. Important reassurance is provided in knowing that adequate measures have been put in place.
Success is not always guaranteed through just having the technology. Some organizations require equipment to have received FDA clearance before they will use it. As such, if any component doesn’t have this there may be a considerable waiting period before new equipment is cleared for use. Otherwise, it will have to be used off-label. Locked-in devices also make it impossible to add on or substitute other equipment. For example, a specific monitor may be required by a device to function properly. Costs may be pushed up without the ability to bolt on a cheaper, generic model.
The ability to integrate operations is a big strength of new technology. Pittsburgh uses a lab-centric approach where everything is managed and processed in one place. The lab information system makes whole slide images readily accessible to end-users. Inefficient integration of different systems will mean that they are unable to communicate properly. The way in which staff view innovations will be greatly impacted if processes take longer and are more difficult to manage.
The Mindset Barrier
Another important barrier, mindset, can be exacerbated with poor integration. The people who are expected to use technology often resist innovation. In healthcare, this assumes several different forms.
Workflows will be fragmented if devices are not properly integrated. This will increase the amount of time it takes to perform tasks when users were promised a device to improve performance, reduce their workloads and be quicker to operate. As such, the very people meant to use the new equipment in their daily routines may then revolt against the technology.
The first commercial whole slide imaging devices were made commercially available over 20 years ago. In that time, an extensive body of evidence has been built up to demonstrate their value. The FDA endorsed the technology in 2017 for primary diagnosis in surgical pathology. This demonstrates that this is a mature technology that has been proven to work. Furthermore, some of the more stubborn and enduring barriers to adoption are being overcome with the latest technology.
One thing that is not always welcome is the idea of higher productivity levels. A new device with the potential to increase the number of scans that can be processed presents pathologists with the prospect of significant increases in daily workloads.
It is only natural to worry that headcounts may fall when new technology finds ways to speed up work-flow and increase workloads,. Many people will happily see others adopt the technology but will be reluctant to do the same in case it poses a risk to their jobs. Those on the front line need reassuring that this is a helpful solution rather than a threat or hindrance.
People’s confidence in their ability to use the systems often influences the comfort using the technology. Those who have spent years viewing images and making diagnoses will likely be more confident in their ability regardless of whether the images are digital or glass. Meanwhile junior consultants may struggle a little more in confidence if they have been specifically trained to examine challenging cases down microscopes.
Making it Work
A technology’s ability is not the only factor in successful and widespread adoption. Evidence demonstrating the benefits that digital pathology can deliver is widespread but success can only be fully realised when health services figure out how to overcome the barriers and implement it effectively.
A top-down, bottom-up approach was initially chosen in which everyone was asked to adopt it. The compulsory nature of the implementation risks provoking an adverse reaction amongst those who are asked to use it. A more consultative approach has now been adopted where the capability is provided but adoption is not compulsory. Help and support are provided to people as and when they choose to use it. While progress is incremental, this approach meets with less resistance and doesn’t cause everyone to feel overwhelmed. Individuals are not forced into anything and adopt the technology as and when they want to. A good use case is coupling digital pathology with suitable AI apps to improve diagnostic quality.
Different benefits of digital pathology are seen by an academic medical centre. Most new students and trainees are keen to get involved in new technology and so if it were not in use then they may find it a struggle to attract the best people. In particular, millennials who are very tech-savvy see this as a key attraction. They look for forward-thinking organizations that embrace the latest techniques and technologies. The same may apply to other workplaces. A tech-savvy hospital will be more attractive to the best graduates.
There is potential to move forward in several different directions, as technology is progressing quickly. Artificial intelligence has been one of the most highly publicized. One example is a possible algorithm to detect prostate cancer by scanning images and highlighting suspect areas.
The key question for most is around when it should be used. AI technology may be used after screening H&E slides to back up assessments or to identify areas that might have been missed. Alternatively, AI results could be received before they see their scans. An image without the AI can be examined and compared with one that displays the applied heat map. Diagnostics and turnaround times can be sped up this way.
A scanned database of images is also being accumulated, which provides a lot of direct and indirect benefits. Digitally archived biopsies can be quickly accessed to look at a prior case.
The setting up and testing of AI is also aided with this database. To build a working deep learning system, a database of scans is needed to validate and calibrate an app.
While digital pathology has already been around for many years, it does still represent the future. Technology is evolving rapidly, which will improve turnaround times, diagnosis results and efficiency. Issues with costs, mindset and implementation all cause barriers, but the technology is increasingly finding ways around them.
The Grundium Ocus does away with physical slide transfers between the clinic and the lab and enables live telepathology consultations between surgeons and pathologists.
The Grundium Ocus is a monumental leap in digital pathology. It is a precision tool, and is small and affordable enough to be on every medical professional’s desk. It is truly portable and can be brought anywhere. Wireless connectivity means telepathology is now possible practically anywhere on the planet.
The Grundium Ocus is a game changing enabler of personal digital microscopy. It brings the global pool of pathology experts to you and it makes looking at sample slides convenient even off-lab.
The Grundium Ocus is your personal microscope scanner to make daily work faster and easier.
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