College of American Pathologists
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Why digital imaging leaders forge ahead

September 2003
Eric Skjei

If there isn’t already a digital-imaging system in your laboratory, there probably should be one soon. This technology is steadily making the transition from an infrequent add-on used here and there by pathologist enthusiasts and early adopters to a powerful tool for not only clinical diagnosis and consultation but also education, documentation, quality assurance, and cost control. Digital imaging even includes digital microscopes (Nikon’s CoolScope, for example), electronic “staining” of slides, and digital analysis of the specimen, including its DNA distribution.

“We now know that we can create digital images that can be better than chemical-based photography and that offer significant advantages in terms of the ability to manipulate, store, retrieve, and analyze information, including information that isn’t available to the naked eye,” says Mark Tuthill, MD, division head of pathology informatics at Henry Ford Hospital, Detroit. “This is a huge step forward.”

Right now, digital imaging is probably used most often to take still pictures of gross specimens. “It’s cost-effective, user-friendly, and much more efficient for all parties involved,” says Michael Becich, MD, PhD, director of the Center for Pathology Informatics at the University of Pittsburgh Medical Center, Shadyside. Dr. Becich, a pioneer in whole-slide digital imaging, is a founder of Interscope Technologies, which manufactures a whole-slide digital-imaging system. The company recently won an Air Force contract to demonstrate and implement a telepathology system. “The Air Force can’t recruit and retain pathologists at all of their locations,” Dr. Becich explains. “Obviously, they can process the tissues and provide the slides, but they cannot keep enough high-quality expertise in all locations where it’s needed.” Interscope’s digital-imaging system will fill that gap.

Digital imaging is also slowly making its way into pathology reports, though it’s still the exception rather than the rule. In most labs where digital imaging has made its debut, especially in community hospital settings, it has been driven by the lab’s desire to make reports more attractive and effective. In these cases, digital imaging’s introduction is often fueled by a few pathologists and other laboratorians with a strong interest in the technology.

One fan is Eric Schubert, MD, a pathologist at Memorial Hospital, Chattanooga, Tenn. “I actually enjoy making reports with images,” Dr. Schubert says. “I enjoy the process, and I’m not the only one. There are others here who have the same attitude.” He estimates that perhaps five percent of his lab’s reports now include images, but he expects that percentage to rise. The technology offers the lab a way to sell its services to existing clients and new prospects, Dr. Schubert points out.

“I think the big bang for your buck in imaging is in marketing. We’re a hospital-based group, but we do actually try to get a lot of outside accounts, serving community-based docs.”

Memorial Hospital is one of the many places where digital imaging is actively used at the gross stages of the laboratory process. “We do a lot of gross images, and in fact we go to the OR fairly often and take pictures of the organs in situ,” Dr. Schubert says. This includes taking pictures of the radiographs that are typically hanging up in the OR during the operation. “We’ve had surgeons say it’s really neat when they get a report from us and they can see not only the diagnosis but also a picture of the radiology, a picture of the gross, and a picture of the microscopic views,” he says. “It’s great to be able to put all those modalities into one report.”

Commercial products are steadily infiltrating the imaging market. Tamtron, a division of Impath, began offering this year an imaging module that is integrated into the company’s AP PowerPath product. Tamtron has been working closely with the Department of Pathology at the University of Washington, among others, for about the past 18 months to develop and implement the module, which is scheduled to go live this fall as part of a version upgrade.

“We’ve been using it a fair bit in the test mode and really like it a lot,” says Rodney Schmidt, MD, PhD, associate professor of pathology and director of medical informatics at the university. “In fact, it’s so nice that that’s one of my prime motivators for getting the whole package into production soon.”
The imaging module is a tightly integrated extension of the core product, he says. “Basically there’s one window that has several tabs for different types of information relating to a case, and what they did with imaging is just add another tab onto that,” he says. “So it’s still a very case-centric approach to design.”

If the pathologist has already taken images and associated them with the case, they show up on the imaging tab. If not, he or she can click on a camera icon above the tab to bring up a window with a live feed from the camera. The pathologist frames the shot and, with the click of a button, acquires the image and associates it with the case. There’s also an opportunity to add information, such as a legend or a different name for the image.

The image is stored in the database at high resolution. “You then have the option of including a particular image in the report,” says Dr. Schmidt. “If you choose to include it, the software in the background automatically makes a lower-resolution image that is appropriate for printed output and puts that lower-resolution copy in the report.” The high-resolution image is retained in the database for later use in, say, a PowerPoint presentation or manuscript.

The use of images in reports, Dr. Schmidt says, is likely to be “very much dependent on the particular pathologist and the particular type of case.” Some want to collect pictures for conferencing or for additional documentation purposes, but not necessarily for the report. “At the time that you do the gross you can be taking pictures and they’re saved right with the case so they’re available for reference, but they wouldn’t necessarily go into the report,” he says.

The system accommodates different cameras. The method that is least bound to a specific camera uses a Twain image-capture interface for Windows operating systems. This interface accommodates any camera that is fully Twain-compliant. Alternatively, the system allows importing and exporting of images to and from the file system. Regardless of the method, image acquisition usually involves only a few clicks of the mouse.

Dr. Schmidt himself prefers “one of the consumer-level Olympus cameras” for gross photography.

“Those cameras are nice because they produce the equivalent of a video output through a separate cable to the video card in the computer. You can see the real-time view right on the computer monitor to frame everything. You click the button and the camera automatically takes the picture and downloads it into the database.” The integration is smooth, Dr. Schmidt says, and the cameras are relatively inexpensive and becoming high resolution.

The system takes gross and microscopic pictures. “Both types appear on the tab at the time you take the picture, and you can specify whether it’s a gross photo or a photomicrograph,” Dr. Schmidt says. “If you specify it as a photomicrograph and then click the check box to include it in the report, it automatically lands in the microscopic description section of the report.” The user doesn’t have to manipulate the image in any way—that’s handled automatically. “From my point of view, that is the real key to this product because it’s all about workflow,” says Dr. Schmidt. “The easier you make it for the user to get a good-looking report, the more usable it is.”

How quickly will digital imaging replace film? Dr. Schmidt is optimistic: “I expect us to be eliminating film for gross photography probably within two months of going live.” The timeline for photomicroscopy will depend in part on how many cameras Dr. Schmidt deploys. “If we have only one in the department, the transition to full digital will be pretty slow, because no one wants to get out of their chair and wander over to the imaging station,” he says. “But we’re going to be deploying cameras on most pathologists’ desks, so I’m expecting the transition time to digital to be relatively fast.”

In other environments, digital imaging has already become a mainstream workflow tool to help pathologists handle large volumes of cases. “Just the other day I did 200 cases, and I imaged every one and looked at the gross images of every one,” says Steve McClain, MD, director of dermatopathology and director of pathology informatics at the Albert Einstein College of Medicine/Montefiore Medical Center, NY. “So we’re talking about getting this technology to a very fast level, to a level where it doesn’t impede the process—it enhances it.” Images, he says, are a new form of pathology documentation. “We can now document the entire process, from the time the requisition and the specimen enter the system to the time when it’s grossed and cut, to slide histology, surgical pathology, cytology, second opinions, and an array of other consulting and educational uses, including autopsies,” he says. “It’s limitless.”

What makes this kind of digital imaging possible? Dr. McClain points above all to the use of bar codes. “We bar code everything, each requisition, each specimen bottle, every slide,” he says. “The use of bar codes to make imaging, image recording reliable in terms of identification is a critical step because putting the wrong image in the report doesn’t help anyone and may well lead to a disaster or an error,” he says. Without bar coding or some other form of automated, reliable identification system, he adds, digital imaging is going to have limited application in health care.

Henry Ford Hospital, too, uses digital photos for some documentation and hopes to do more. Dr. Tuthill is now shaping a next-generation system. “We want to create a digital-imaging system that will not only do the photo documentation function we’ve already been doing but will provide for images that are stored in such a way that we can do ad hoc and post-acquisition analysis on them,” he says.

“If you’re going to do this type of work effectively, these images can’t be just stored as files sitting on a single hard drive, times 20 pathologists,” Dr. Tuthill adds.

Think about searching the Internet, he suggests. If you undertook a search and all you got back was the result from one server, then found you had to search again on a second server, then a third, and so on, you’d soon give up. “We need to have an integrated imaging database that supports not only the photo documentation, education, and research components but also supports the diagnostic components of using digital imaging,” Dr. Tuthill says.

Such a database has to be integrated with the other clinical information systems from which clinicians and others draw information. For example, the image database needs to be integrated with the anatomic pathology information system, Dr. Tuthill says. Otherwise, users have to find the case, search for the image, tie the two together, and send them out for review. The process must be smoother and simpler than that.

Integration with other clinical information systems also means reducing the number of times images have to be replicated, which saves money. “When the surgeon goes to look at the pathology report and he wants to see the image of this surgery, we want him or her to be pulling from the same image database to see that image,” Dr. Tuthill says. “We’re really looking for an integrated imaging database that works across all our clinical information systems and allows the pathology images, once they’re acquired and released, to be viewed by those we have decided should have access to them.”

Along with bar codes and image databases, digital imaging relies on “fast networks and good interconnections to information systems,” says Yukako Yagi, PhD, director of technology management at University of Pittsburgh Medical Center, Shadyside. UPMC is developing a decision-support system to help pathologists interpret image information, and the center has already implemented a DVD jukebox storage system for its images. In short, this is a process that requires a complex web of tools.

To become truly mainstream digital imaging will have to prove itself capable of helping control quality and costs. And it has the potential to do just that.

“I’m going to tell you a secret that’s only about a hundred years old,” Dr. McClain says. “And that is that the key to reducing errors is to be able to correlate the gross with the microscopic.” Dr. McClain uses a system developed at Montefiore Medical Center that allows him to scan a bar-coded slide at the microscope and instantly view the relevant digital gross images. This could, of course, also be accomplished with traditional film-based photography, but the process would be prohibitively cumbersome.

Comparing gross findings with microscopic findings, says Dr. McClain, provides answers to basic questions such as: Do we have the lesion? Have we cut enough slides? Should we go back and cut more? Are the margins free? “Sometimes the margins are clearly involved in the gross, but that’s not reflected in the report text,” Dr. McClain notes. “A single glance oftentimes at my gross images shows that the margins are free—it’s pretty obvious.”

This kind of simple comparison also highlights other errors, such as a mislabeled slide or specimen. And the potential for error reduction is significant. “When we talk about reducing errors by an order of magnitude, by a factor of 10, so your accuracy goes from 99 percent to 99.9 percent, we’re talking about very significant kinds of quality steps,” Dr. McClain says. And it is efficient: “Reviewing gross images adds maybe four seconds to my process, so we do it in every case now,” he says.

“Quality is going to be a big driver,” Dr. Becich agrees, “because there are too many medical errors out there, and reducing them is going to require everyone’s best efforts.” But within pathology, quality assurance too often depends on self-regulation, Dr. Becich says. “You’ve got your own pathologists reviewing their own material, dictating whether something is right or wrong,” Dr. Becich points out. “There’s a natural conflict of interest.”

“The right way to do quality assurance,” Dr. Becich continues, “would be for institution A to be the quality assurance officer for institution B.” But think about how that happens now: “You have to grab a bunch of glass slides, bundle up a bunch of pathology reports, and send them to another place. We’re nervous enough about doing that internally because we lose slides every time we pull them from the files and put them on somebody’s desk,” he says. “Moreover, after the diagnostic stage the slides become of secondary importance because everyone is focused on signing out the stuff that’s coming through the door. And that’s why we lose things.”

On average, he says, if you could examine major medical centers with large slide archives that run many conferences and tumor boards and provide consultations, you would find about “20 percent of the slides missing from the files.” And when the slides can’t be found, what happens? “We go back and do another cut, and there’s a cost associated with that.” And that’s just for biopsies and large resections. “You lose a cytology slide and it’s gone forever, so in these cases, where you only have one precious sample, a digital imaging quality assurance step becomes even more important,” he says.

In contrast, in a system in which the quality assurance is driven by whole-slide imaging, the original slide doesn’t have to be removed from its file. “You take the digital image, you distribute it to two or three places, and they can take two months, three months with it, and nothing ever gets lost,” Dr. Becich says. “You still get a complete report, and the slide image and the report stay together.”

Dr. Becich’s group sees 27,000 surgical specimens a year at UPMC. Of those, 9,000 are shipped to two other hospitals in the UPMC system. Keeping track of all that traffic is a massive job. “Wouldn’t it be nice to be able to share those 9,000 cases just by clicking and sending, by creating an automatic rule in the LIS that says, ‘Take these 50 cases, go out to the database, grab the digital images and the reports, and drop them into these pathologists’ workflow queues?’” says Dr. Becich. “That’s the direction we’re headed in in QA.”

If eliminating slide transfer and unnecessary recuts saves time, and if time is money, what is the return on investment?
“Our own studies, involving Interscope and interns from Carnegie Mellon University, found that the ROI on a digital-imaging system—for post-diagnostic use only, meaning conference support, quality assurance, slide sendouts, internal consultative activities—was 18 months,” Dr. Becich says.

Not much time at all.

Eric Skjei is a writer in Stinson Beach, Calif.