Anne Paxton
April 2025—Unprecedented moves with a lot of moving parts is how Jessica Wang-Rodriguez, MD, of the Veterans Health Administration describes a transition to digital pathology the size of the VHA’s.
It’s a mission that has become necessary, Dr. Wang-Rodriguez says of the large-scale digital pathology transformation. She is executive director of the VHA National Pathology and Laboratory Medicine Program Office, Washington, DC, and professor of pathology at the University of California, San Diego.
With 170 VHA medical centers and 1,193 outpatient clinics (of varying complexity) extending from the 50 states and the District of Columbia to Puerto Rico and Guam, the demand for VHA anatomic pathology services is strong while record retirements and other staff attrition have stretched staff thin, she says. The VHA’s 576 pathologists working in the 111 laboratories processed 419,000 AP cases within the VHA between September 2024 and March 2025.
While many VHA facilities, particularly those in urban areas, are well connected with available specialty-trained pathologists and have an academic affiliation, others in rural settings have no pathologists onsite.
“We realized the time is right to bring digital pathology into the VA,” Dr. Wang-Rodriguez says.
To date, 51 of the 111 anatomic pathology laboratories are in various stages of implementing the FDA-approved high-throughput Philips digital pathology systems.
Dr. Wang-Rodriguez’s program office, in addition to spearheading the national telepathology/digital pathology program, oversees the National Enforcement Office, which administers the VA’s more than 1,060 CLIA licenses and employs agents who inspect laboratories.
The national digital telepathology program began about two years ago, after large-scale market research to ensure the VHA could secure funding to support the sites with FDA-approved, high-throughput scanning equipment and image management systems as well as local servers that would have to be built, Dr. Wang-Rodriguez says. “We started small with a pilot with the first six sites, with collaborative agreement by their facility leadership to ensure adequate space, informatics, and IT support.” Later, additional sites and VISNs (Veterans Integrated Service Networks) self-funded their participation and joined in the pilot. “The hope is that more sites will adopt digital pathology when they see its benefit and as local resources become available,” she says.
To validate the systems, national standard operating procedures were put in place for each site, using the CAP’s validation guideline. “We go above and beyond in the validation plan because we have every site contributing cases and open the access for pathologists to review each other’s cases through each other’s servers,” she says.
The quality metrics are the scan rejection rate, re-scanning rate, and turnaround time. “We wanted to find out if the workflow of incorporating the extra step of scanning the slides would bring delays,” she says. Regulatory accreditation requirement review was essential because the scanned images would be used for primary diagnosis. “We also work with our VHA information technology and privacy office to make sure those requirements are met.”
Some VHA laboratories are using digital pathology for primary diagnosis. Others are doing secondary consultation and specialty-specific virtual tumor boards, “but the goal is to eventually move toward digital sign-out for primary diagnosis,” Dr. Wang-Rodriguez says. Real-time intraoperative frozen section diagnosis and rapid onsite evaluation for fine-needle aspiration are other long-term goals to be achieved by 2028.
Despite its scale, the program so far has been streamlined and productive, Dr. Wang-Rodriguez says. But far from simple. “We have to standardize a lot of processes, beginning with a national standardized labeling policy for accession and configuration of barcoding cases to set up a structured database with help from VHA IT and biomedical engineering.” Also needed: building physical servers to store digital images locally with the plan to move to an enterprise cloud server to make all images a part of medical records, and working with various vendors on the equipment, barcodes, and AP tracking software and hardware.
“These are pretty unprecedented moves in digital pathology transformation at the VA,” Dr. Wang-Rodriguez says.
For the pilot project, the image format, which is proprietary and vendor-specific, must be standardized. She views the DICOM (Digital Imaging and Communications in Medicine) format used in radiology as a model for digital pathology. “I’m hoping that in the future state, there’s enough push to standardize pathology’s digital image format” to one like DICOM, “so it can be read by viewers anywhere. That’s the holy grail,” she says, “to have that universal viewing system. We also want to make sure we can navigate multiple specialties’ images simultaneously, not just pathology but also radiology or GI or other clinical images to make higher-quality, informed diagnoses.”
Once images are digitized, incorporating artificial intelligence data computation and image analysis is also important, she says. “There aren’t that many AI tools in pathology that are FDA-approved for diagnostic pathology, and we would certainly like to see more of that.” Integrating the AI applications with the image management software is also essential, so it’s not cumbersome to use and to ensure the safety and security of digital information transmission.
Enterprise cloud imaging is a must to be able to integrate the images within the electronic health records, and the goal is to have every provider in the health care system able to access records of all the patients they care for across the geographical barriers. The huge file size of those images rules out placing the digital images in the EHR currently.
“So this is a large undertaking. There are a lot of moving parts,” Dr. Wang-Rodriguez says. “But I do think this is going to be a huge return on our investment.”
Darius K. Amjadi, MD, JD, is chief of Pathology and Laboratory Medicine Services at the Charles S. Kettles VA Medical Center in Ann Arbor, Mich.
When he joined there in 2021, a Leica Biosystems Aperio digital slide scanning system had already been set up by his predecessor, Stephen Chensue, MD, PhD. A smaller VA hospital in northern Indianapolis often needed consultation or other services it couldn’t provide in-house. “So Dr. Chensue created a kind of small network between the two sites, which meant we already had some infrastructure and experience doing this.”
The pathology IT vendors have the ability to read the different proprietary files or convert to the radiology DICOM format, Dr. Amjadi says. “There’s pressure on all the scanner manufacturers and software vendors to move toward something like DICOM. Once you have that, it’s just a matter of being able to safely transmit the data and find ways to protect the personal information of the patients.”
Radiology has accomplished that, and the Ann Arbor VA’s academic affiliate, the University of Michigan Medical School, where Dr. Amjadi is on the neuropathology faculty, stores radiology, dermatology, cardiology, ultrasound, and pathology together on its image management system. A “specialty-agnostic” system is preferable, in his view, over an image management system specific to pathology.
When Dr. Amjadi’s group volunteered to have the scanners installed first, “we kind of worked through some of the bugs.” One example: “The screens on our monitors are gigantic,” and didn’t easily fit in spaces as expected, so they improvised large cardboard cutouts approximating the monitors’ size to ease layout-related decisions.
One obstacle is that the VA does not have a seamless medical record integration. “If a patient comes from a different VA, we have to register them in our VA. We’re trying to find ways of leveraging our size and our expertise” to address this problem, Dr. Amjadi says.
Coming up with a standardized slide labeling system was a challenge. “We had to make sure we were using the same nomenclature,” meaning that at times “we may need five different label printers to make sure they work on all the different scanners.” For local site image storage, “we have large servers and drives that we can store the images on, but the goal is to have a cloud-based network.”
He expects that real-time high quality diagnostic digital pathology will soon become a reality at his VHA site. “Everything is validated, we’re ready to go, but we are waiting on our national SOPs. We want something we can just roll out and have things as seamless as possible between the different sites.”
One of Dr. Amjadi’s goals is to create a system that is reproducible outside the VHA. “The eventual goal is to be like radiology, so we can exchange images with anyone anywhere, collaborate on research and diagnosis, and not just make health care better for veterans, but make it better for everyone.” Being a large client, he notes, can sometimes lead vendors to do what is good for everyone.
The digital pathology conversion project at WJB Dorn VA Medical Center in Columbia, SC, differs from the national VHA pilot program, says Jailan Osman, MD, MSc, chief and clinical medical director of WJB Dorn’s Pathology and Laboratory Medicine Services.
Her contract with Philips for use of its high-speed digital pathology scanner predates the national VHA project, and many challenges had to be met, Dr. Osman found. One was how to integrate the WJB Dorn system with the national VHA network and meet government network security requirements with a contract that differs from the national pilot contract. “I was thinking: Am I going to be able to store my lab’s data in the national storage iCloud or do I have to create my own iCloud?” In the end, she was able to link her data with the national iCloud and found it worked well.
Digital pathology at the WJB Dorn VA is FDA approved for primary diagnosis. “We did a comparison study between the original slides and the digital slides for multiple cases with different diagnoses, and it worked very well. We are ready. But we are waiting for the SOPs to be signed by national. For the time being, we do consultations with our scanned cases, we do education, and we do tumor boards.”
Her advice for other pathologists within the VHA: “Don’t do what I did if you want to introduce digital pathology. It’s much easier to be in a national pilot study.” If you want to get your own contract, it’s not impossible, she tells them, but expect challenges. “From my experience, when in doubt or if you have questions for a new laboratory procurement, contact your local biomedical IT, which can work with security, area managers, and so on.” Something she would do differently next time: “I would not go straight to telepathology without having a digital platform in the AP department. I would bring in the digital before I go with the telepathology.” (Within the VHA, telepathology refers to the application of digital tools to share and interpret diagnostic pathology, beyond the confines of a designated laboratory site.)
When it is fully implemented, the broad-scale use of digital pathology for primary clinical diagnosis will be an important advance, in Dr. Osman’s view. “To be able to use digital pathology for primary clinical diagnosis is reimagining what is possible in disease detection and prediction, and it’s also using a large, diverse data set to build a powerful artificial intelligence model in pathology.”
A model Dr. Wang-Rodriguez foresees too. “Different histologic changes in morphology are now being coupled with genomic testing, other molecular biomarkers, and immunohistochemistry,” she says. With that information, she adds, more data can be generated, not only for diagnosis but also prognosis and treatment. “It will aid the physician and their patient with outcome studies.” It’s one reason she sees universal digital pathology as all but inevitable.
“Definitely, within the decade, it will be impossible not to have digital images in a pathology practice,” she says.
Anne Paxton is a writer and attorney in Seattle.