Going Digital

Most hospitals and pathology departments have not yet adopted a digital workflow, let alone gone fully digital. As we covered in a recent blog post, reasons for not adopting a digital workflow include the cost of the digital pathology system, required IT infrastructure, and time and monetary resources needed for training pathologists and lab staff. The outbreak of COVID-19 has made pathologists and hospitals more open to adopting new technologies for telepathology and remote sign-out. This is an exciting time for digital pathology as more hospitals are leading the way and showing how to go digital and what the benefits are in doing so. We are taking you on a trip around the globe to Spain, Italy and The Netherlands to three hospitals where they successfully implemented 100% digital pathology. Grab your passport and let’s get moving!


On our itinerary

Granada University Hospitals - Granada, Spain

Granada University Hospitals comprises two teaching hospitals located in the city of Granada and two peripheral district general hospitals serving the towns of Motril and Baza. In 2016, they embarked to fully digitize all prospective histopathology cases, and to perform all routine diagnosis on a digital basis, thus creating a fully digital multisite network. In Utrecht, The Netherlands, University Medical Centre implemented a fully digital workflow for primary diagnostics in 2015. This same year, Cannizzaro Hospital in Catania, Italy transitioned to an effective and complete digital surgical pathology workflow in the pathology laboratory.


Let’s start at Granada University Hospitals. The transition from analog to digital pathology took a total of six months (from April to September 2016), which encompassed the installation of the required hardware and software, the integration of the IT elements, the vendor training sessions, and a test phase.1 Not only is this impressive, but it shows that going digital in a timely fashion is possible. So what’s the secret to their sauce?


Granada University Hospitals found that a crucial step toward 100% caseload digitization is the integration between the image management system (IMS) and the existing clinical IT infrastructure. It is essential that both the laboratory information system (LIS) and the image viewing software vendors be involved in the integration process, and that their software be open and flexible to permit the necessary data interchange.2


They also created the role of scanning technician which fulfills three main purposes. These include:

● checking the quality of all the slides prior to being scanned

● loading the scanner

● inspecting slides upon completion (approx. 25% to 30% of all slides)


The final quality control involves checking that the:

● scanner has performed self-calibration successfully

● scanned areas include all tissue in the glass slide

● images are free from stitching or other image artifacts

● color, contrast and focus are appropriate


This attention to detail pre- and post-scanning has resulted in the overall error ratio being below 0.1%. What’s more, all of the tasks performed by the scanning technician usually requires approximately a 0.5 full-time equivalent (FTE).3


While an additional role was created, the laboratory staffing needs were reduced from 3 FTEs histotechnicians down to 0.5 FTEs. Prior to digital pathology being implemented, the analog workflows corresponding to slide sorting, case assembly and distribution to pathologists were time consuming and urgent. Because cases are automatically assembled and made available by the digital pathology system, the laboratory staff traditionally in charge of these tasks are now dedicated to other duties. After digitization, the slides are sorted before being filed, but because the digital images are already available to the pathologists, this sorting is not urgent and therefore is not as labor-intensive as that of an analog workflow.


The pathologists at Granada University Hospitals have signed out, on average, 21% more cases each year since the implementation of full digital pathology for primary diagnosis, signaling improved efficiency. This increase in caseload between 2015 and 2018 would have required a total of 29 pathologists, instead of the existing 23.4


Varying levels of pathologist buy-in is considered one challenge to implementing digital pathology. Not at Granada University Hospitals. Within 2 weeks from going live, all of the pathologists at the hospitals were using digital pathology for primary diagnosis. Why the immediate buy-in? Pathologists felt attracted to diagnosis using only digital pathology from the start, given that this provides a tidier workspace without the clutter normally associated with piles of glass slides and request forms. Additional reasons why their pathologists were willing to transition to digital diagnosis are:

● availability of digital tools for marking, measuring, and mitotic counting

● orderly disposition and immediate availability of glass slides, including those archived

● better perceived quality of low-power images

● added ease of preparing for multidisciplinary team meetings and conducting teaching sessions


This, together with the rational case allocation permitted by the creation of a fully digital multisite network, has resulted in a more productive working environment.


Cannizzaro Hospital - Catania, Italy

Next we’ll take a look at the Department of Pathology in Cannizzaro Hospital in Catania, Italy. In 2015, the department embarked on digitizing all of their histology cases using WSI and decided to start using digital slides for routine surgical pathology practice. The digital pathology system was deployed primarily to support clinical diagnostic work. However, the system was also adopted to assist with showing select cases as whole slide images in multidisciplinary team meetings or tumor boards. This hospital’s experience with the effective adoption of WSI for primary diagnostic use was more dependent on optimizing pre-imaging variables and integration with the laboratory information system than on IT infrastructure and ensuring pathologist buy-in.


Even though digital slides were subsequently validated for primary diagnosis, their laboratory supported a hybrid workflow for one year. So in addition to glass slides, pathologists were still provided with glass slides. This hybrid approach allowed pathologists to become more confident and overcome their learning curve with WSI. However, this hybrid approach did not allow pathologists and technicians to immediately benefit from all of the advantages of digitization, the most evident being a reduction in workload related to not delivering glass slides. So what led to abandoning the hybrid approach and pathologists going fully digital? Pathologists enjoyed the immediate access to review previous slides belonging to patients instead of waiting hours, sometimes days, for the slides to be located, assembled and delivered by lab technicians. Also, they liked the immediate selection of slides for running additional stains. Additional benefits experienced by the pathologists were:

● WSI were available to pathologists on the same day as slide staining

● digital slides were easier to share with colleagues for second opinions and exchange of knowledge

● evaluating and discussing pathological findings present in certain cases (e.g., the margin status of a tumor) at tumor boards on a computer monitor or conference room screen


Although Cannizzaro Hospital did not perform an accurate timed workflow analysis, a decrease in the turnaround time of histological diagnoses was apparent when just a digital workflow was applied. The average turnaround time for their cases measured from complete “stained status” of a glass slide to “digitized status” when the WSI was available was around three hours. This led to a gain of eight hours in their laboratory due to skipping the prior lengthy manual case assembly and delivery of glass slides to pathologists.5


One thing to note that is different from Granada University Hospitals, instead of a scanning technician ensuring quality control of the digital slides, the hospital’s pathologists often bear the ultimate responsibility in assuring that digital slides are of diagnostic quality. With the time and labor savings in the lab, the role of scanning technician could be created to take that burden away from the pathologists.


University Medical Centre - Utrecht, The Netherlands

Finally, let’s visit University Medical Centre in Utrecht, The Netherlands. Similar to Cannizzaro Hospital, University Medical Centre supported a hybrid workflow for one year. This decision was made to support the smooth transition and adaptation to the new digital workflow. It was left up to the subspecialty teams to decide when to abandon the glass slide routine, which was achieved for most subspecialties.


Unique to both Granada University Hospitals and Cannizzaro Hospital, University Medical Centre considered occupational injuries related to pathologists using the microscope for extended periods of time like neck injuries, shoulder pains and carpal tunnel syndrome. They used the opportunity of going digital to improve the daily ergonomics for the pathologist and reduce occupational injuries. By placing the screens at an optimal distance in a custom configuration per pathologist and placing a 3D mouse, they have reduced the number of complaints related to neck/shoulder pains and carpal tunnel syndrome.6 They received survey input from 23 individuals with various degrees of experience in pathology and various amounts of exposure to digital pathology systems. All respondents had at least 6 months of experience working with their system. Based on that survey, frequency of injuries for digital diagnostics was 23% less than for traditional microscopy.7


So what measurable benefits did University Medical Centre experience? Overall, the turnaround time decreased from 6.16 days to 5.73 days (6.94%), with the largest effect being seen in the complex cases categories. For the most complex category, the mean turnaround time decreased by 20.16%, which is almost 2 days less per case.8 The transition to digital pathology resulted in shorter turnaround times allowing diagnoses to be made faster and treatment to begin sooner leading to better patient outcomes.


Granada University Hospitals, Cannizzaro Hospital and University Medical Centre are three great examples of how to move from an analog to a digital workflow. The benefits are many including time and labor savings in the lab, more opportunity for live discussions and second opinions among pathologists and even reduction in pathologist occupational injuries. If your organization is considering going digital, we've highlighted success stories to be used as inspiration. Through their experiences, we see the different types of benefits going fully digital has to offer and can model implementation based on the examples.


Built on the vision of better patient outcomes, Instapath was founded in 2017 by engineers and scientists to enable patients to immediately know their cancer diagnosis. Our team made it our mission to develop fast and easy digital pathology technology so diagnosis can be made in minutes instead of days. To learn more about Instapath and our technology, visit www.instapathbio.com or contact us at info@instapathbio.com.


References

1-4 Retamero JA, Aneiros Fernandez J, Del Moral RG. Complete digital pathology for routine histopathology diagnosis in a multicenter hospital network. Arch Pathol Lab Med in press.


5 Fraggetta F, Garozzo S, Zannoni GF, Pantanowitz L, Rossi ED. Routine digital pathology workflow: The Catania experience. J Pathol Inform. 2017;8:51.


6-8 Stathonikos N, Nguyen TQ, Spoto CP, Verdaasdonk MAM, van Diest PJ. Being fully digital: perspective of a Dutch academic pathology laboratory. Histopathology. 2019;75(5):621‐635.


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