Considering digital pathology for your lab?
Learn the top 10 reasons to adapt or ignore digital pathology, and the solutions to make the transition to digital successful.
Digital pathology has harnessed a lot of attention over recent years, promising labs the benefits of a faster workflow, improved diagnostics and cost savings. However, the transition to digital pathology is fraught with challenges, stemming from a complicated transition from a microscope-based workflow to screens and servers. Learn more about the limitations, benefits and workarounds for pathology labs seeking a digital footprint.
Limitations of Digital Pathology
1. Cost
Existing digital pathology systems can be very expensive, with high-capacity scanners costing as much as $300,000 per system. Add in IT, storage, personell, computers and the fact that multiple systems are needed, and the cost very quickly reaches an upfront price tag of millions of dollars.
2. Workflow
Comparative studies on the issue of workflow efficiency and speed, including the most comprehensive study to date by Dr. Matthew Hanna at Memorial Sloan Kettering, have demonstrated a 19% decrease in workflow efficiency[i] when using scanned images for primary diagnosis.
3. Clinical Benefit
Digital pathology provides pathologists access to computational pathology toolsets, which can help provide a more reproducible diagnosis. However, 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 clinical value of digitizing and storing slides.
4. Footprint
The transition to digital is generally associated with high-capacity whole slide scanners, rather large systems that can take up some expensive real-estate in the lab.
5. IT
The transition to digital is generally associated with high-capacity whole slide scanners, rather large systems that can take up some expensive real-estate in the lab.
6. Data Storage
The transition to digital is generally associated with high-capacity whole slide scanners, rather large systems that can take up some expensive real-estate in the lab.
7. Diagnosing on a Screen
The transition to digital is generally associated with high-capacity whole slide scanners, rather large systems that can take up some expensive real-estate in the lab.
8. Regulatory
The transition to digital is generally associated with high-capacity whole slide scanners, rather large systems that can take up some expensive real-estate in the lab.
9. Down Time
Like all technology, there is a problem with downtime. Yet with digital pathology, the problem can be much more complicated, involving issues related to servers, cables and firewalls. The simplicty of placing a glass slide under a microscope is a major benefit which is being given up on the switch to digital.
10. Real-time consultations
The transition to digital is generally associated with high-capacity whole slide scanners, rather large systems that can take up some expensive real-estate in the lab.
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 fit into the position of 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 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, these codes 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 on use of digital tools per number of slides, there are economic disadvantages for adapting digital pathology.
Speed Advantages of the Microscope vs the Workflow Disadvantages of Digital Pathology
The speed in which a pathologist places a slide under the microscope at a 4X, examines the specimens for any suspicious areas of interest, and if necessary, zooms into a 10X or 20X for closer examination, can simply never be matched by viewing on a screen.
While there are comparative studies on the issue of workflow efficiency and speed, including the most comprehensive study to date by Dr. Matthew Hanna at Memorial Sloan Kettering which showed a 19% decrease in efficiency[i] when using scanned images for primary diagnosis, the reason for this slowdown should be further explained.
Dr. Matthew Hanna authored the most extensive study on the use of WSI in pathology
The obvious reason, as mentioned by Johns Hopkins pathologist Dr. Alex Baras,[ii] “is that the optics of a microscope are superior to a screen, moving the slide around is easy, and there are preset zoom levels. Looking at images on a computer is like navigating around Google Maps with a keyboard and mouse — you need to move the mouse around in a clunky way and you find yourself having to continuously zoom in and out.”
Yet further examination of the advantages and disadvantages of digital pathology versus the microscope will show that the ergonomic position of the microscope, with the pathologist looking down at the sample, combined with the optical quality image, depth perception and the human eye-brain connection, enables the pathologist to immediately, and very much sub-consciously, focus solely on the relevant area and screen out irrelevant data. The screen-based view, which is a flat, two dimensional image, apparently requires the human eye and brain to more closely examine a larger area, leading to a slower sign out time.
Rakefet Ackerman, a researcher of behavioral science at the Technion University in Israel, is an expert in the difference in studying between printed and screen text. In her 2011 study titled “Metacognitive Regulation of Text Learning: On Screen Versus on Paper”, she examines why humans are more adapt to studying from a book instead of a screen. One could only imagine if the words were switched to read a microscope and pathology image.
“Despite immense technological advances, learners still prefer studying text from printed hardcopy rather than from computer screens. Subjective and objective differences between on-screen and on-paper learning were examined in terms of a set of cognitive and metacognitive components, comprising a Metacognitive Learning Regulation Profile (MLRP) for each study media. …. Under fixed study time (Experiment 1), test performance did not differ between the two media, but when study time was self-regulated (Experiment 2) worse performance was observed on screen than on paper. The results suggest that the primary differences between the two study media are not cognitive but rather metacognitive — less accurate prediction of performance and more erratic study-time regulation on screen than on paper. …”
Dr. Rakefet Ackerman authored a study comparing meta-congnitive regulation of screen versus text learning
Advantages of AI in Digital Pathology and Scanning
One answer digital pathology via WSI can provide is the use of AI for triaging cases. The question to be asked by hospitals is if the business model of pre-screening H&E slides is compelling enough to justify the investment?
Short of triaging cases with the use of AI, the transition from microscope to screen may actually be a major step backward, as the optimum meta-cognitive regulation for the pathologist could be hard-wired to the optical view of the microscope. This could be a clear example of the age-old adage in engineering, that “just because something can be done, doesn’t mean it should be done.”
“Engineers like to solve problems. If there are no problems handily available, they will create their own problems.”
Cost Advantages and Disadvantages of Digital Pathology
Spending in healthcare has increased dramatically over recent years, in many instances an unfortunate outcome of the excessive profits that were being raked in by the large hospital systems. As New York Times contributor Dr. Elizabeth Rosenthal wrote in her Sept 1, 2019 article,” It would be unseemly for these nonprofit medical centers to make barrels of money. So when their operations generate huge surpluses — as many big medical centers do — they plow the money back into the system. They build another cancer clinic, increase C.E.O. pay, buy the newest scanner (whether it is needed or not) or install spas and Zen gardens.[i]”
The cost of going fully digital in pathology reaches millions of dollars, and one only has to visualize the workflow to see that there are extra and unnecessary steps and resources in the process.
To demonstrate this point, consider this schema from an MSKCC study recently published showing how scanning was used for large scale digital pathology consultations during Covid-19 lockdowns[ii]. This setup may be necessary in the event of pandemic where pathologists don’t come to the hospital, but it’s not the normal situation.
Compare the above schema to the existing workflow, and it is clear that there are extra & unnecessary costs associated with the equipment, trained staff, and data storage. The reason for these extra costs, is that digital pathology via slide scanning does not answer the fact that the raw data is the glass slide, and thus an inappropriate technique for digitizing the pathology workflow.
“The first rule of government spending: why have one when you can have two for twice the price?”
What Advantages Does a Pathologist Need from Digital Pathology
Integrating digital pathology can bring value to pathologists, the healthcare system and patient health. 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
- Telepathology
- 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.
