DICOM adoption has helped make Michigan’s previously standalone digital pathology system part of the clinical enterprise imaging solution, where it’s integrated with radiology, Ob-gyn, and cardiology. Now, “We are part of any service or department that uses the medical image for diagnosis. And technically that means using DICOM format for diagnosis,” Dr. Yousif says.
The radiology department’s experience was an important factor in the pathology department’s adoption of its digital diagnosis workflow. What made the project successful was that pathology didn’t implement de novo the PACS product chosen (Sectra, made by Swedish firm Sectra AB), Dr. Balis says. Sectra, which is a contraction of “secure transmission,” “already was the enterprise’s vendor-neutral archive for images across the entire Michigan Medicine health system. We were just adding on a relatively small incremental module, which is pathology, and they had very good features for pathology. The storage, the PACS communication, the cloud-based aspects—all of that was already worked out by radiology.” That made it possible for pathology to focus on using the image management platform “to get cases signed out efficiently and quickly, with all the information you need locally available,” Dr. Balis says.
Eventually, the department’s storage of digital pathology data will be entirely in the cloud. “We’re not pure cloud yet,” he notes. “We have a lot of on-premises solutions still, because the size of a typical whole-slide image is large and therefore the computer needs to be near the stored data to allow for rapid image retrieval times. Therefore, for the time being, our primary storage is on premises.”
Use of a picture archiving and communication system-driven workflow, instead of the laboratory information system-driven workflow, is one of the keys to pathology’s new workflow. “This is the first time we are partnering with radiology and others to utilize the PACS,” Dr. Yousif says.
A longstanding obstacle to this kind of integration has been the proprietary nature of digital pathology components, he notes. “Making the contract with one vendor, you are stuck. You are locked with that vendor,” which will provide the scanner, server, and image viewer, “which can only work with one vendor.”
“If you want to do any collaboration”—for example, if one vendor provides only bright-field scanning but not immunofluorescent or polarization scanning—“each vendor has its own proprietary format. To go fully digital, you need to digitize all those aspects; you cannot just scan,” Dr. Yousif says.
“This is the setback. This is the problem we are living with on a daily basis,” he adds. “Right now we scan all these standard, one-by-three-inch slides. But you need a specialized scanner to scan those really large slides, and that means another vendor with a different proprietary format. On top of that, we have frozen section slides that are difficult to scan from the beginning. If one vendor you are working with does not have the capability of manual scanning, to add multiple focal areas for the scanner to start scanning in different planes, then your scanner is stuck. You are always going to have a blurry image from frozen sections.”
The problem is the lack of a standard format, Dr. Yousif says. Instead, the laboratory may use TIFF, BIFF, Mirax, SVS, or another format. “There are maybe 15 of these formats at the moment,” he says. In theory, if all of them used DICOM, that would solve the compatibility issue, and that is how it has worked at Michigan Medicine. “Right now, we have around 14 scanners from four different vendors, but all of them are now using the DICOM image format. So this literally solved the entire problem.”