An in-depth review of the often overlooked and unspoken advantages and disadvantages of digital pathology versus microscopy
“In 90% of instances I don’t need you, and in 10% I don’t trust you.”
Taught to a young marketing professional by an older pathologist at a tradeshow, the 90/10 rule of pathology states that in 90% of instances the pathologist doesn’t need any digital pathology assistance in reaching a diagnosis, and in the remaining 10%, that digital help wouldn’t be of any clinical value.
This statement, which typically generates laughter and nods of agreement when told to pathologists, leaves one to question the advantages of digital pathology, and forces one to ask if the disadvantages of the transition to digital pathology outweigh the benefits.
The 90/10 rule leaves us to question… Are existing digital pathology solutions providing true clinical and economic value for pathology labs?
AN HONEST LOOK AT PATHOLOGY, AND THE ADVANTAGES & DISADVANTAGES OF DIGITAL
Very little has changed in pathology. For over 100 years, pathology has been practiced in almost the exact same method, earning it the distinction of being the most subjective science, and stubbornly disconnected from the digital health revolution.
The stalwart of pathology is the glass microscope, an analog device of glass and light, and a relic of the pre-digital era when there was no concept of digitally correlating patient information with diagnostic results or using AI to automate the workflow. Yet today, where computational methodologies and remote consultations have become a must-have for practitioners, there is validity in questioning the role of the old microscope in pathology, and seeking digital technologies to improve quality and efficiency of care.
How does this push to rid the microscope from the pathologists’ desk work with the many pathologists who prefer the microscope?
Moreover, at a time when the discussion on the benefits of digital pathology is taking place in every pathology lab, even the most forward-thinking labs like Memorial Sloan Kettering – which has a standard operating procedure of scanning all slides – still have microscopes on the desk of their pathologists?
Overstated Value of Digital Pathology? Or… Misunderstood Advantages
As in many arguments, both sides may be correct. The value of digital pathology today is likely greatly overstated, stemming from an approach that uses brute force to solve the problems of subjectivity and low reproducibility.
Alternatively, digital pathology can bring cost savings, improvements in care and enhanced levels of lab efficiency, yet likely only when done in a manner that takes into account the unique workflow and characteristics of pathology.
When understanding why pathology is different from other diagnostic sciences, it becomes clear how correct the 90/10 rule is and where the disadvantages lay. And at the same time, how digital pathology can play an important role in improving workflow and standard of care.
Cost Reduction | Time Savings | Clinical Enhancement
Comparing the Key Advantages and Disadvantages of ARM in Digital Pathology
Quantitative vs Qualitative – Digital vs Analog
Pathology is considered the most subjective science, with reasons being that the majority of specimens examined are qualitative in nature, complimented by a myriad of issues relating to pathologist training, population characteristics and other factors.
Unlike a blood or urine sample which produces a quantitative result, the typical cancer biopsy will have around 20 slices stained with H&E. Examined by a pathologist, these slides are a qualitative (yes/no) to the presence of cancer. Following this examination, the lab may continue on to quantitative testing with specialty stains like IHC and ISH.
According to 2017 CMS data[i], 88305, the code associated with H&E, was billed just short of 20 million times. Compared to 88360 and 88361, codes associated with semi-quantitative and quantitative IHC that were billed nearly 500,000 times, making up just 5% of the pathology workflow!
Further drill down of the 88360/1 testing will reveal that not all of these slides require computer assisted quantitative tools. If for example the standard of care is based on a 15% cutoff for expression of a HER2 IHC sample, then the computer assisted tools would primarily be of value in borderline instances where the semi-quantitative approach may be mistaken.
As the overwhelming majority of pathology slides are qualitative in nature, and the overwhelming majority of the pixels on slides are of no clinical, educational or training value; pathologists must ask what is the economic and clinical value of digitizing and storing slides.
Based solely on use of digital tools per number of slides, there do not appear to be economic advantages for adapting digital pathology. However, it is the borderline and difficult cases, albeit small in number, where the use of computer-assisted diagnostic tools and remote consultations can be of life-saving value.
What Advantages Does a Pathologist Need from Digital Pathology
Integrating digital pathology can bring value to pathologists, the healthcare system and patient health in certain instances. The key to success is the method of delivery.
Advantages that Digital Can Bring to Pathology
- Computer assisted diagnosis with digital image analysis and/or AI
- Automating and/or speeding up auxiliary tasks such as sign-out or reporting
- Library of comparative images
The Advantages for Digitizing the Microscope
Augmentiqs was founded on the belief that the advantages of the microscope cannot be surpassed, and we must complement these advantages in place of supplanting them.
Augmentiqs bridges the existing microscope with digital pathology, transforming the existing microscope into a platform for the deployment of digital pathology applications – directly from the existing pathology workflow. In so doing, we maintain the microscopes:
- Speed of viewing specimens
- Superior image quality
- Ability to adjust the microscope’s fine and coarse magnification
- Depth perception & eye-brain connection
- Avoidance of computer-vision syndrome
To bridge the benefits of digitization with the glass slide, Augmentiqs introduced to the world the concept of microscope-based digital pathology. Our novel approach for multi-directional communication between the microscope and PC, including augmented reality microscopy (ARM), brings to pathology labs the benefits of digital pathology at a fraction of the cost and complications common to whole slide scanners.
By attaching Augmentiqs to a conventional microscope, Augmentiqs permits pathologists to rapidly execute image analysis for stains such as Ki-67 directly from the microscope’s stage, as well as real-time consultations with geographically remote colleagues. But more important, Augmentiqs is an on-demand solution for digital pathology, meaning that the use of the system is only when the pathologist decides to use the technology, thus achieving the best of microscopy and digital capabilities.
Augmentiqs is a microscopy-centric approach to digital pathology, providing pathologists a stream-lined and cost-efficient method for realizing clinical and workflow enhancements. By connecting the microscope to the computer, Augmentiqs supports and strengthens the advantages of the microscope for workflow and primary diagnosis, while improving efficiency with the introduction of pathology software applications.
By functioning as a platform for real-time software deployment and informatics within the microscope, Augmentiqs allows pathologists immediate access to imaging, analytical software, telepathology, LIMS integration and other digital pathology applications.