The physical logistics of converting to digital presented challenges.
The area to scan digital pathology slides was small, Dr. Yousif says. “Then we studied the entire infrastructure for scanning and decided to use a separate room and we built that room to be a little closer to the main lab. Then someone has to send us those glass slides and then we digitized. That was the plan more than 18 months ago.” However, they then decided to visit multiple labs that already moved to a digital workflow. “And we asked, ‘What is the single thing that if you wanted to redo this, you would do for your lab?’ And they said, ‘I wish I could put my digital pathology scanner within histopathology or within the wet lab.’”
So Michigan Medicine decided to switch from the histology lab infrastructure installed in 2018 in an offsite location. “We said we want to remodel to have the digital pathology lab with 13 to 15 scanners in the center of the lab. So we relocated these scanners to make it efficient. The slides are distributed from staining direct to the scanner, then sent to the back counter for distribution without interruption, without interference or multiple floors or handling. And that’s helped us have extra space for different microtomy specimen devices” and streamline the entire workflow.
Hiring multiple FTEs to do extensive quality control is a necessity, Dr. Yousif says. “At this moment we are performing 100 percent QC for every slide. Every slide will have multiple stages of QC: a QC stage on the scanner, then a QC stage on the PACS, and then a QC stage between the block and the glass slide, just to make sure the entire tissue being captured, the entire area, is not out of focus.”
All this QC means manual labor and added costs, but Dr. Yousif predicts that QC artificial intelligence will soon help, made possible by DICOM. “With an AI application, it can tell you even before you take the slide from the scanner that slide number two in the rack or number five in the scanner has issues and you need to re-scan that slide.” This isn’t feasible with a proprietary format other than DICOM, Dr. Yousif says. “This is available because DICOM provides you all this metadata or granularity of detail to find that slide.”
The histotechnologists love this feature, he adds. “You have to provide tools or data to help your histotechs. We created dashboards for them because the visualization is important for the scanning histotech as well as for the other histotechs.” This way, they can say, “‘Oh, I see from the dashboard that scanner number one is done with staining so I need to pick it up.’ It tremendously improved workflow to have the dashboards provide this notification.”
He advises anyone with doubts about advancing their digital pathology to take a look at sites where it is working. “Visit multiple sites that have success stories.
Communicate with them; learn from their mistakes. Then the first thing is to try to communicate with your colleagues from radiology, from their imaging department, because they might have a solution for you.”
When he and his colleagues presented their plan to radiology, “they had no idea about pathology. We educated them and they helped us.” Now “we are part of their system. So when we hire additional FTEs, they are helping radiology, and their FTEs are helping us.”
Second, he advises putting DICOM into the contract with any vendor so the vendor is responsible for paying for all the conversion, all the migration. “Then the vendor is committed from now on.”
His third piece of advice is to use what is called a unified platform. “For example, think about what’s called X-driven workflow or a platform or digital cockpit that can help pathology.”
Finally, Dr. Yousif says, an important question is how to make your digital pathology information available to the patient and clinician. “We are living in this bubble by ourselves and sharing all this knowledge for patient care. So if my patients right now wanted to transfer the care from Michigan Medicine to another institution, different state, or even a different country, how can I make it efficient by sending the data so the receiver can read it? Again, with DICOM, because everyone understands the standard, they don’t have to install another application or work with that vendor to decipher that format. You send the data in an encrypted way to the other institution and they should be capable, to be honest, of reviewing those images.”
His hope is that at the end of 2025 the department will be fully digital for all surgical pathology services. “By that time I’m hoping we barely distribute any glass slides because [for now] we have this hybrid workflow.” The different services are pleading with him not to send any more glass slides, he says. “Pediatric, renal, medical—that’s literally what they have said.”
Nevertheless, building a digital pathology workflow also has to take into account the capability to pull slides, Dr. Yousif says. “In the PACS-driven system, we have built all the customization that can enable the pathologist to request glass slides if they need to.”
The new workflow includes a backup plan for disaster recovery, ensuring continuity in the event of system downtime. Another PACS allows images to be saved for just seven days. After that, “we purge it from the backup PACS because you don’t need it because the main one is already archived.”
At some institutions, he says, the likely backup plan is to distribute glass slides during downtime. “And that’s fair enough, but we need to change this mindset. I want to provide everything I can in order not to go back to the glass slide.”
Dr. Yousif asks colleagues at other institutions if they’re able to provide their images to their clinicians. “There is a lot of fear about doing that, but sharing our knowledge and our images with clinicians and with patients directly is a patient care and patient satisfaction-enhancing opportunity,” Dr. Yousif says. “The interaction allows the clinical team to more precisely tailor treatment regimens and, similarly, allows the patient to better understand their own disease process.”
From the experiences gained from piloting trials at Michigan, Dr. Balis says, “we know it is highly impactful and beneficial when patients get the opportunity to review their histology with a pathologist. It’s not standard practice at all yet. It’s something we aspire to do. But from the limited examples we have, we know it works.”
Anne Paxton is a writer and attorney in Seattle.