You don’t know it yet, but if you’re skeptical about digital imaging
or even admit to being a technophobe, there’s a nearly 50 percent chance
you’ll have a change of heart in the next three or four years. At least,
that’s one plausible inference from CAP TODAY’s recent survey of anatomic
Even some who now regard digital imaging as a gimmick or a useless frill
in pathology could shift their thinking. That’s because the technology
is well beyond being the "next new thing" and on its way to being firmly
embedded in the laboratory, the survey suggests.
In answer to the survey’s lead question—Does your group currently
capture one or more images of the histologic sections associated with
surgical pathology cases...?—34 percent of the pathologists who
responded said yes, their group captures such images to store or integrate
Of those saying no, 12 percent said they would consider deploying an
image capture system within a year, and 35 percent estimated within one
to three years. "A picture montage greatly enhances our reports," was
a typical response.
On the other side, 50 percent insisted there was no chance. In answer
to the question of when they would adopt such a system, said one: "Never,
if I can help it."
Nevertheless, that still suggests digital imaging is conforming to a
classic technology adoption curve—the formula that has accurately
mapped the adoption of tools like VCRs, cell phones, and DVDs, says Bruce
Friedman, MD, professor of pathology at the University of Michigan Medical
School and director of pathology data systems for the University of Michigan
"The general rule," he says, "is about one-third are early adopters,
and they’re willing to tolerate the inconvenience and technical challenges
of the technology. The questionnaire results reflected this." (This would
correlate, he notes, with the technology enthusiasts, visionaries, and
some of the pragmatists as defined by Geoffrey Moore in Crossing the
"What it means," Dr. Friedman continues, "is we’ve got ten through the
easy part, and I’d predict about a third will hang back for a brief period
and wait until the technology has proven itself, and a third are uncomfortable
with change in general and will be very reluctant to adopt this new technology.
The way these adoption curves move, it’s probably taken six or seven years
to get the first third of people to adopt, and my guess it will be two
or three years for the next third to come around."
Dr. Friedman told CAP TODAY he found the questionnaire results, which
ranged all over the map, to be a fascinating collage. "As I was looking
at the survey write-up, I thought of the ad line, ’Certs is a candy mint.
No, Certs is a breath mint.’
"People in pathology look at digital capture, storage, and retrieval
in different ways and to accomplish different goals. Some people look
at it and say, ’Is this a means to enhance the quality of my small biopsy
or tumor reports?’ Some look at it and say it’s great for recording gross
images of specimens.
"Others say it’s great for teaching conferences, and others say it allows
me to acquire and publish more information about a case, understanding
that an image is just a different type of information. Different people
come up with different reasons why they want it."
And why they don’t. The question, "Why haven’t you adopted it yet?" brought
a flood of negative descriptors, among them "time-consuming," "nonreimbursable,"
"superfluous," "inefficient," "far too cumbersome for our surgical pathology
volumes," and "not clinically useful." "Worthless," was one pathologist’s
Dr. Friedman was struck by the volume and variety of these narrative
comments and said the questions in the survey "clearly struck into an
emotional vein." One commenter dismissed digital imaging as "window dressing,"
while another termed it a "relatively useless ’bell and whistle’ for the
"I would be hard-pressed to think of another technology adopted by one-third
of pathologists that another third would regard in such a dismissive way."
"I don’t really blame many of the pathologists who question the value,"
Dr. Friedman says, "because the technology for digital image capture and
publication has been very user-unfriendly in recent years, and it disrupted
the workflow in surgical pathology reading rooms."
He finds it interesting that in radiology there’s almost no debate about
the value of capturing images and making them available to the ordering
physician. "You have to ask the question, If it’s the norm in an allied
field like radiology, why not in pathology?"
"Part of the reason is surgical images do not start as digital. A paraffin
section looked at through a microscope is essentially an analog image,
the opposite of digital, so several steps are necessary to convert it
In contrast to radiology, pathology also has a sampling issue, he admits,
because a paraffin block and a paraffin section contain millions of images.
"But I believe it is really important in diagnostically challenging cases
to present in the report those key images on which the diagnosis was based,"
he says. "When reviewing such a report years later, it’s a relatively
simple matter to reconstruct the decision process of the pathologist signing
Lack of reimbursement should not be an issue, in his view. "A number
of pathologists commented on the survey, ’Well I don’t get reimbursed
for image capture and publication.’ But radiologists don’t get reimbursed
either for that specific component of the consultation process. It’s part
of the process they accept, and many clinicians place a high value on
being able to review the radiology images themselves. And I believe the
same is true in surgical pathology."
And he says dismissing digital imaging in surgical pathology as "marketing"
isn’t wise: "It’s a weakness of our specialty that we don’t always convey
to clinicians the value of our services. Then we complain we’re not adequately
appreciated by them."
"My own view," Dr. Friedman adds, "is that a report with one or more
images, microscopic or gross, is a higher-quality report than one that
does not have images for complex and challenging cases. And I feel in
a relatively short period, the quality of reports will be judged in part
on the basis of whether relevant images are included."
Still, he knows that some pathologists’ doubts about digital imaging
are not ill-founded. "Capital is scarce for most pathology departments
and health care in general, and there are a tremendous number of financial
reasons for reluctance to adopt new technology, particularly one such
as imaging without a very favorable return on investment.
"If a pathologist is not extremely enthusiastic submitting a capital
request, he may assume, a priori, that hospital administrators will turn
it down. And it is also very easy for administrators to turn down early
technology, particularly if they don’t see additional revenue." For the
most part, imaging systems are an additional expense and not a revenue
generator, so they have to be justified on the basis of clinician satisfaction
with a higher-quality report, he says.
Technical issues too can set up roadblocks, the survey revealed. One
pathologist reported that problems with image integration into Cerner
AP reporting had prevented the adoption of digital imaging, while for
another hospital inadequate computer storage capability of the LIS and
hospital information system was an obstacle.
On the other hand, just plain embarrassment could be an incentive to
make the leap into digital imaging. One respondent who now uses digital
image capture only for teaching said his hospital was considering expanding
"Since we don’t incorporate gross and microscopic photos in our reports,"
this pathologist said, "the clinicians always point this out when we get
reports from some small city in Mexico that does have gross and microscopic
images in its reports (most of good quality and in color)."
Thirty-five percent of pathologists using digital image capturing said
in the survey that integrating images into reports has been successful
and cost-effective. But even more (42 percent) cited success in using
images for conferences or teaching. Fourteen percent listed documentation
of gross images.
The respondents’ descriptions of how they are using the technology showed
a shift from recent years, Dr. Friedman says. Small biopsies and tumor
cases were cited often, as was gross imaging, while skin cases and cytopathology
were cited less frequently.
The popularity of skin biopsies as a favorite use for digital imaging
has dropped as a percentage of total use, he says. "Images of skin biopsies
launched the technology, and now they’re being supplanted in popularity
by small biopsies and use of images for gross tumors."
Cytopathology also ranks at the bottom in terms of popularity. "This
reflects, I believe, a lag on the part of cytopathologists in appreciating
the value and importance of images in the report, but I look for that
to start climbing."
It’s no surprise, he says, that the greatest use is for tumor cases.
"Gross images of tumors are very, very important in selected cases. And
one of the nice things about capturing a digital gross image is that the
digital image can then be used to indicate where tissue has been sampled
as a substitute for the crude line drawing on a piece of paper." Such
paper drawings, traveling with the case, he notes, can be a source of
As one of the respondents pointed out, there is tremendous potential
for correlations between positive cytopathology cases and subsequent definitive
surgical procedures, Dr. Friedman says. For example, with a history of
a positive Pap smear, "when you do, say, a uterine resection, you could
then correlate the image of the previous positive Pap smear with an image
of the uterine tumor."
But the value of images goes beyond direct patient care. From a clinical
research perspective, he says, "the presence of clinically relevant pathology
images in databases would be extremely valuable when cases are retrieved
And finally there’s the value of pathology images for patient education—the
opportunity for the clinician to sit down with the patient and have a
discussion about the results of surgery.
"The patient can’t recognize the tumor," Dr. Friedman says, "but the
image might help the clinician in explaining, for example, that there’s
a tumor in the resection margin or in a lymph node; therefore, we have
to treat you with chemotherapy or radiation therapy."
Asked how they deployed their system for capturing images, 49 percent
of the respondents said they had an internally developed system. Only
eight percent said the system came from their current laboratory information
system vendor, while about a third (35 percent) obtained a system from
a different vendor.
"One would think the LIS vendors, since they had already installed the
system in a department, should have been on top of this emerging technology
and made it available as an easily used feature in the LIS," Dr. Friedman
Why isn’t that the case? "Perhaps the LIS vendors didn’t understand the
technology, or it didn’t integrate well with their technology, so they
didn’t offer it." Or, he speculates, "They didn’t see there was sufficient
demand from customers for it, or perhaps the technology is so challenging
that specialized vendors had to evolve to develop it as best-of-breed
Most laboratory information systems have been managed by clinical pathologists
because such a large percentage of information generated in the laboratories
comes from chemistry and hematology. "It may be that LIS vendors did not
see sufficient demand for imaging modules because they were interacting
primarily with clinical pathologists."
In teaching and conferencing, digital imaging has enthusiastic converts.
"We do use digital image capture extensively to teach and conference,"
wrote one pathologist, who added, "I don’t know how we got along without
it in past years. I recently had a biopsy case that came out on a Tuesday
and I integrated that same case in a lecture I gave on Wednesday at 8:00
Walter H. Henricks, MD, director of laboratory information services and
surgical pathologist at the Cleveland Clinic Foundation, told CAP TODAY
his hospital, too, is poised to have pathologists use digital imaging
to create their own collections, and most specifically for residency,
medical school education, and tumor board purposes.
Using primarily Diagnostic Instruments’ Spot Insight camera, "we’ve phased
in digital photography for the microscope over the last one to two years,"
Dr. Henricks says it’s important to distinguish digital imaging’s educational
purposes (teaching, conferences, or tumor boards), quality assurance,
and personal educational collections from putting images in reports.
"To me, that’s a whole separate realm of behavior, goals, usage, and
results compared with putting images in reports. A lot of people wouldn’t
argue with the value of using digital imaging in a big center where you
can load images on a network, show them in conferences, and use them for
teaching. There are all kinds of obvious benefits."
"But when you start talking about putting images into reports, it’s very
Yes, it is. One pathologist surveyed wrote, "Pictures are not representative;
they are misleading for most nonpathologists, and can be misinterpreted
by others." Another respondent who sized up digital imaging as "marketing
fluff" commented: "Who is going to look at it—a surgeon who couldn’t
tell myocardium from onion root cells? Try signing out 90 to 100 complex
cases a day. Leave the picture taking to Michael Moore."
Dr. Henricks, who is a founding member and former president of the Association
for Pathology Informatics, sympathizes with some pathologists’ concerns.
"The pro side is that this adds value and helps some clinicians communicate
with patients. It serves as good patient education. Referring physicians
like to see photos in reports, it jazzes up reports, and the commercial
reference laboratories have this capability."
"The flip side is, What purposes does it really serve? I think groups
have to ask. When you really look at what it does for patient care, I’m
not convinced of its value."
As one survey respondent wrote, "We’ll probably end up doing it because
it’s progressive, but the medical justification for the extra time, expense,
and overhead remains to be proven."
Moreover, Dr. Henricks says, some pathologists are concerned that photos
in reports can be misleading. "We’re dealing with field selection, and
you can’t always encompass an entire case in one or two microscopic fields."
"I’ve seen referred cases of very nice reports with very beautiful photos,
but the diagnosis was incorrect. The most important thing is the accuracy
of diagnosis and staging information if there’s a tumor."
Dr. Henricks is a skeptic on how likely clinicians are to use images
in talking with patients: "I find it hard to believe that most clinicians
will sit down to explain a picture they themselves may not understand.
Also, it kind of diminishes us to say we can sum up the work we do in
pathology in a single photograph."
Installing digital imaging to survive competitively, however, is understandable.
"It might be required for survival for some practices," Dr. Henricks says,
if the group’s client base is at risk of migrating to other laboratories
that provide this capability or if it wishes to compete for new business.
His own laboratory plans to implement the technology to have it available
for competitive reasons.
When asked why they had implemented digital imaging, the largest number
of respondents said because of "interest in the technology." But that’s
a vague answer. The second largest answer was more specific: pressure
from clients, Dr. Henricks points out. "Competition from from reference
laboratories might be one of the single biggest drivers for groups to
put images in reports." Only 17 percent cited a desire to capture more
detailed information about cases.
"So they’re looking at what competitors are offering, the sales and marketing
departments perceive competitive advantages, and that’s what’s driving
it. None of the answers really say it’s going to improve patient care."
Dr. Henricks sees himself as "a bit of a contrarian" on some digital
imaging issues. "I’m not saying we should go backwards, but we should
decide whether the investment of time and money in digital imaging in
reports is justified. And I think there will be more valuable applications
of digital imaging in the future, such as whole-slide digitization," he
"Now that LIS vendors are becoming more progressive, you can buy systems
to integrate images without any need for an external interface. It could
be that some respondents built their system before this was possible."
Those using digital imaging only for tumor boards, conferences, and presentations
are not going to use the LIS to capture images, he adds. "They will be
putting together their own cameras and databases. And that’s something
else to consider as we migrate toward electronic medical records."
Telepathology is a separate issue from the digital imaging cited in the
survey, he notes. There’s a definite value to telepathology, which is
diagnosis at a distance using some type of imaging technology in real-time
or in consultation.
But he and Dr. Friedman suggest digital imaging is likely to have a much
larger impact. "My own belief," Dr. Friedman says, "is that for the most
part, except for some specialized markets, telepathology is not a big
"For rural areas that are understaffed, yes, and for large hospitals
or medical centers there is some movement of images around the institution,
but most pathologists who need to can walk to the specimen and see it
their way. So the market for telepathology will always be a niche—but
the market for diagnostic image capture, storage, and retrieval will be
Pathology information systems are now frequently sending reports through
interfaces to other systems, especially in the hospital. "But those interfaces
typically don’t handle images at this time," Dr. Henricks notes.
"It’s not that medical record systems can’t handle them, but its means
of transfer might not prove feasible for images. In the future, though,
I think we will be seeing pathology images in the EMR as well."
He is not referring to a universal standard electronic medical record,
but to individual institutions’ systems that were formerly called hospital
information systems but are now more full-featured and include medical
orders, laboratory orders, and the results from those orders.
"They’re the mechanism through which a lot of laboratory pathology reports
are transmitted to physicians, and physicians often access them through
some type of electronic system."
To facilitate that access, it’s important to find ways to standardize
image exchange, he says. "Sharing of digital imaging is viewed by many
as a significant part of our future, and a first piece is to develop specifications
for a digital imaging exchange system so images can be transferred regardless
of how they were obtained." This standardization is one of the key objectives
of the Association for Pathology Informatics (www.pathologyinformatics.org)
and its Laboratory Digital Imaging Project.
Survey respondents were likely to report that response from clients has
been positive. About 70 percent said the system they had adopted was either
very acceptable or acceptable. Said one: "Clinicians love it, and they
are now so used to it they demand it."
However, there is no unanimity on the question of what clinicians prefer.
"Clinicians are not asking for images on reports; they want timely reports,"
one pathologist wrote. Another said the impersonality of relying on digital
imaging is a drawback: "One-on-one interactions have been preferred at
our academic center."
In Dr. Henricks’ view, there is some validity to what the holdouts are
saying. "Sometimes people do digital imaging just for the sake of doing
it. It’s something that has some value and is worth considering, but departments
have to look at what are the reasons, what are the benefits versus the
costs, and are they justified."
For example, as one pathologist explained, there is frequently just not
enough time to shoot photographs. "It does impact pathologists’ workflow
to stop and select fields and take pictures," Dr. Henricks agrees.
Don’t be too quick to dismiss those who are hesitant to adopt digital
imaging, he advises. The survey’s respondents shared thoughtful reservations
about why it may not be right to rush headlong into the technology.
Nevertheless, he sees strong signs that resistance to digital imaging
is softening. "Years ago, people just didn’t want to adapt. But we’re
now well beyond the stage where people are afraid to use it."
Anne Paxton is a writer in Seattle.