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Digital pathology matchmaking: people, pixels

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Karen Titus

February 2019—Digital pathology is many things. One thing it’s not is a one-night stand.

As laboratories contemplate using digital pathology for primary diagnosis in the wake of the FDA’s approval nearly two years ago, it’s become abundantly clear that while digital pathology might seem to promise easy pleasure, it’s actually as complicated as keeping multiple spouses happy. Think Jacob, Rachel, and Leah. Think “Big Love.”

Whatever your reference, you better (to quote the Queen of Soul) think.

Dr. Anil Parwani and Dr. Wendy Frankel at OSU Wexner Medical Center, where pathologists are using digital pathology at their own pace. “Technology should not be used as a reason to change people,” Dr. Parwani says. “People should change themselves and use the technology they’re most comfortable with.” (Photo courtesy of Jodi Miller)

Think about the questions and worries of top executives. Think about pathologists and their workflow. Think about the influence of IT. And then keep thinking. As several experts recently told CAP TODAY, buy-in doesn’t happen once, with one group of people. It is, instead, a perpetual wooing.

David McClintock, MD, associate chief medical information officer, Michigan Medicine, Ann Arbor, recalls being in meetings with pathologists who, “when push came to shove, went from, ‘Yeah, we support this,’ to ‘Why are we doing this?’ to ‘We support it’—all at the same meeting. There’s a real internal struggle with them,” says Dr. McClintock, who is also director of digital pathology, associate director of pathology informatics, and associate professor of pathology, Department of Pathology. That’s not to say Michigan isn’t interested in digital pathology, including for primary diagnosis. “But,” he cautions, “you shouldn’t anticipate that everybody understands it” simply because they’ve been hearing about it.

Even when people come on board with little fuss, they may still want an escape hatch. The Ohio State University Wexner Medical Center has taken a deep plunge into digital pathology—Anil Parwani, MD, PhD, MBA, vice chair of anatomic pathology and director of both digital pathology and pathology informatics, estimates that about 90 percent of the institution’s pathologists use digital slides for some type of application, including primary diagnosis, research, education, or consults. Yet even now he hears their fears: of new technology; whether it will help them do their work; poor image quality; being slowed down; unease with looking at a monitor. It’s as if they dread entering a bad, 1950s marriage, telling Dr. Parwani, “I’m going to be trapped forever.”

Though they are divided by a state line (and a storied football rivalry), Drs. Parwani and McClintock have much in common as they shepherd their colleagues and institutions along the digital pathway. Both presented at the Association for Pathology Informatics workshop at OSU last December, and in follow-up interviews with CAP TODAY they spoke further on what makes the field both unnerving and exciting.

When Dr. Parwani, who is also professor of pathology and biomedical informatics, arrived at OSU in July 2015, the institution’s leaders had already given their first, crucial blessing to build an expansive digital pathology program. Primary diagnosis was on the horizon, and the need for improved technology was obvious. Wendy Frankel, MD, the Kurtz chair and distinguished professor, and chair, Department of Pathology, laid the groundwork. One of her objectives (and likely a selling point) was in fact to hire someone with the expertise and knowledge to put the grand scheme into practice.

Enter Dr. Parwani.

Dr. Parwani’s first step was to map out the expedition, so to speak. What was OSU doing digitally at the time, and what did it want to be doing in 2016, 2017, 2020, 2025? That led to a series of questions: What did they hope to accomplish by using digital? What clinical applications did they want to use? Did they want to pursue primary diagnosis? Or should they focus on other areas, such as consultations, image analysis, and/or artificial intelligence? What about remote frozen sections?

Once they put primary diagnosis in their sights, they had to look at the prerequisites. One was barcoding and tracking of glass slides, which OSU lacked. Dr. Parwani and his team spent some nine months setting this up.

At the same time, they planned simpler projects that would be steps along the primary diagnosis path. That included remote frozen section coverage. OSU has several off-site hospitals; in addition, frozens are done in the main on-site OR, but with pathologists working out of an office some 10 minutes away, “It’s disruptive to their day to leave everything, go and do a specialty frozen, and go back to their office,” Dr. Parwani says.

Once barcoding was in place, they purchased a small scanner to facilitate digital remote frozens. The results have been striking—“It took off,” Dr. Parwani says—with pathologists making fewer specimen identification errors. It also sharply reduced the need for travel. They then purchased another scanner for another hospital, where they started offering FNA services remotely.

These smaller steps set the stage for large-scale scanning protocols. Scanners would be crucial, of course, and Dr. Parwani and colleagues went through an RFP process to figure out the best choice for primary diagnosis. They also selected a workflow management system. “We actually looked at how much it would cost if we built some of the software ourselves,” before deciding to use multiple vendors. “They have different applications,” Dr. Parwani explains. “We also realized that not all vendors can provide hardware and software for everything. So we did a best-of-breed approach.”

As things continued to unfold, he continues, “We spent a lot of time validating small scanners, training the technicians, training the pathologists. We expand the protocols when we buy a scanner, and we follow the CAP guidelines for validation.”

Again, the small steps soon led to bigger ones. Because the only whole slide imaging system currently approved for primary diagnosis is a closed one (Philips IntelliSite Pathology Solution), that made it harder to integrate with the other pieces. “Throughout the whole process of implementing digital pathology, we worked closely with many, many vendors on these issues [of] compatibility and interoperability,” says Dr. Parwani.

Perhaps the biggest step of all was focusing on performance for pathologists. “You want the ability to review images in their office to be a very good experience,” Dr. Parwani says. “It should not be an experience where the images are pixilated or out of focus—that would have killed things.”

It turns out Dr. Parwani had smoothed the way by picking up small but crucial endorsements early on. Thanks to the success of those first, incremental steps, “We had some buy-in from a few pathologists who were willing to try primary diagnosis,” which OSU went live with in March 2018.

As it embraced digital, OSU elevated the meaning of the word “multitasking.” During the run-up to primary diagnosis, they were also scanning and archiving older slides—seven to eight years worth of all cancer cases. The goal was to barcode them, link them to the LIS, and make them available for clinical work, education, and research.

Dr. Parwani’s excitement is palpable. “For the first time, we were able to see the value of not having to pull glass slides anymore.”

The archive now contains 1 million digital slides. “Suddenly, the game has changed for us. We are connected to the information that’s needed.” Pathologists no longer need to wait for someone to pull slides from an archive, nor do they need to deal with slides that are, like Netflix DVDs, dusty, old, and possibly broken. This is particularly helpful for OSU’s extensive clinical trial work. Transactions that once took hours if not days now occur within minutes, says Dr. Parwani. “We simply send an email with a link to the slide.” He says that earlier in the day, in fact, he spent a mere five minutes accessing three cases from 2014, for patients who were now undergoing new treatments and molecular testing.

Dr. Parwani concedes he had mixed feelings when they began tackling the archive. “We thought this would happen, but I wasn’t optimistic at the time that we would be able to scan so many slides and be able to have enough cases in the archive to implement this. I wasn’t optimistic about performance at this scale.” This was the rare public works project that went better than planned. “If I knew two years ago that we’d have a million cases scanned, and that the performance would be so good . . . ,” he marvels. “But I didn’t want to oversell it.”

Before this, pathology was huddled in its own silo. Now, he says, “We are a clinical system.” By that measure, it has also “become a system that cannot go down.” They store every image in duplicate, at two different sites. Another backup can be created, if needed, within 30 minutes.
This big leap has made pathology the largest user of digital storage in the medical system. “We’re not talking about terabytes anymore; we’re talking about petabytes.” In a sense, pathology is a campus giant, not unlike the Buckeyes football team. “Yes, yes we are,” Dr. Parwani says with a laugh. “People know who we are now.”

At Michigan, Dr. McClintock, who is API’s immediate past president, is likewise working to raise the profile of digital pathology. For years the institution has used digital pathology in education. And its Kidney Precision Medicine Project, an NIH-funded endeavor, includes developing tools for digital analysis and slide viewers for digital pathology. “But this is on the research side,” says Dr. McClintock.

If OSU has pursued a big bang approach to digital pathology, Michigan might be embarking on a Socratic stroll. As he and his colleagues consider clinical applications, including primary diagnosis, Dr. McClintock finds himself asking an increasingly complex series of questions to figure out next steps.
The lengthy courtship has been complicated by a reinvention of Michigan’s Department of Pathology, which included moving all AP laboratories to an off-site facility. (See “For one laboratory, a workflow transformation,” CAP TODAY, June 2018.) In the process, glass slide handling was made much more efficient, Dr. McClintock says. One example: While it used to take up to two hours to have slides delivered, it now happens in 15 minutes.

Michigan’s experience has shown an alternative to taking aim at glass houses. Why not pull a Philip Johnson and add more glass? Michigan’s new setup includes multiple sign-out rooms whose construction allows for easy collaboration, Dr. McClintock says. “There are glass walls in between these sign-out areas,” which makes it easy to see nearby colleagues and request help. Consider it a triumph of person over pixel.

At Michigan, making it easier to use glass slides has made Dr. McClintock’s job harder. “I have some work to do to figure out, what are those true-use cases” that justify a move to digital pathology? Moreover, the university is looking to build a new clinical tower, which means (among other things) belt-tightening overall. “You have to show how you can save money at the same time you’re going digital, which is going to cost money and typically doesn’t have an obvious return on investment.”

‘You can skip the
FDA process if
you want. But then you’re putting risk on your institution.’
David McClintock, MD

Dr. McClintock, naturally, has kept abreast of what his counterparts are doing in Columbus. “They have a good plan—it made sense for OSU to do it in the way they’re doing it.” But the outcome has many sitting on the edge of their seats. “We’re all waiting with bated breath to see how it works out for them. If it works: What did you do and how can we do it?” Dr. McClintock says with a laugh, before adding, “If it doesn’t work: Oh, wow, good thing we waited, because, God, look at what you did.”

If you’re a college football fan, it would be easy to put a competitive spin on matters—two great powerhouses going head to head, guided by different game plans. What will bring the goal closer: three yards and a cloud of dust, or a high-flying aerial game? Each has risks. “That’s not to say Anil’s doing anything wrong,” Dr. McClintock says, thus scuttling any comparisons between Woody Hayes and Bo Schembechler. “But you don’t know how it’s going to play out.”

The point is not to dismiss digital, nor to champion one scheme over another. Rather, Dr. McClintock’s experience is a reminder that when it comes to adding digital pathology, each institution has to decide for itself what it needs.

While the growth in storage consumption is seen as a point of pride at OSU, Dr. McClintock thinks about storage and sees only questions. How long will digital slides need to be stored? The current thinking is 10 years, he says, unless the glass slide is retained. “But until you get that first court case” involving a discrepancy between glass and digital, and a crucial piece of information isn’t available, that unknown is worrisome. “What’s going to happen?” Dr. McClintock asks.

Dr. McClintock keeps up a steady stream of questions as he considers the wider field of digital pathology.

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