College of American Pathologists
Printable Version

  Feature Story


cap today

Zooming into the future— digital pioneers forge ahead

February 2002

Karen Southwick

After nearly two years of work, the six-member pathology staff at Memorial Hospital in Chattanooga, Tenn., is including digitized images in its reports.

The community hospital uses still cameras to capture gross images and video cameras to capture microscopy. "The system is up and running, but it’s not complete. We’re just embellishing our reporting with imaging," says Eric Schubert, MD, a staff pathologist at Memorial and champion of its digital imaging project.

Memorial’s pathology reports and images are printed rather than transmitted electronically. Ideally, Dr. Schubert says, "We’d like to fully integrate what we see with what we say—to share our view of the disease process with the clinicians who provide the treatment." And the pathologist’s findings would be captured and conveyed quickly, easily, and seamlessly to the requesting clinician.

While that hasn’t happened yet, several trends are merging to move digital imaging out of the ranks of exotic technology and into day-to-day use. First is the continuing fall in the prices of digital cameras and other hardware needed to capture electronic images. Second is the availability of powerful software and networks that can store and transmit images, which are far more complex than text. And third is the push by pathology information system vendors such as Cerner DHT and Tamtron Corp. to offer add-on imaging modules.

"Over the next two years, images will become commonplace in pathology reports," predicts J.P. Fingado, vice president and chief operating officer of Cerner DHT, Waltham, Mass. The first wave of users will be the academic institutions, which want to be on the leading edge, and commercial labs, which seek to gain a marketing advantage by offering illustrated reports.

To date, however, most digital imaging efforts have been customized solutions developed by devout believers in the technology. There is no standardized system comparable to radiology’s PACS (picture archive and communications system) for storing and indexing pathology images. Vendors estimate it can cost an average-size pathology group $50,000 to $100,000 for an entry-level imaging system, including digital cameras and software. That price climbs for higher-resolution cameras and bigger groups. Finally, digital imaging requires significant changes in pathology workflow, which makes busy and conservative professionals uneasy.

Nonetheless, the trend toward digital imaging in pathology seems inexorable. Laboratories can eliminate film and save money, and they can make images available online for whoever needs them. Digital images are more accessible to more people, which makes the technology of particular interest to researchers. And as other medical professions, including radiology (the leader), cardiology, and surgery adopt digital images, pathology won’t want to be left behind.

Fletcher Allen Healthcare, an academic medical center affiliated with the University of Vermont College of Medicine, has been experimenting with digital imaging for two years. "We’ve kept on track with our goal of inserting images into pathology reports," says J. Mark Tuthill, MD, medical director of pathology informatics at Fletcher Allen and assistant professor at the College of Medicine.

"Four digital image-capture stations have been deployed, and digital cameras are deployed in the surgical pathology grossing area, as well as autopsy. And budget requests have been made for five more digital photomicroscope stations," says Dr. Tuthill.

Gross images, including autopsy and surgical pathology, also can be captured digitally. The resulting pictures are saved to a hard drive and can be inserted into electronic reports or printed. Many of the center’s 25 pathologists now know how to include images in their reports. Dr. Tuthill and informatics staff are training the remainder to use the in-house technology, which includes Cerner DHT’s CoPathPlus and other required hardware and software components that Dr. Tuthill assembled.

"Our pilot project was integrating images into the reports," he says. "We are doing this first in autopsy," inserting images into a CoPathPlus-linked Microsoft Word document and printing the resulting report on a color printer. Digital imaging will be rolled out to other areas, including such focus areas as prostate biopsies and dermatopathology specimens, on a voluntary basis.

"Every new system creates a new wrinkle," Dr. Tuthill says, and not everyone is eager to cope with that. But, "To my mind, adding a digital image to a report is not much different from attaching a document to e-mail," he says.

Dr. Tuthill intended originally to develop a software system for digital pathology imaging that could be commercialized, but that has not happened. "We were successful in implementing image input and output stations for the pathologists and in raising the issue to a level of concern for the hospital information technology managers and leadership," he says.

Consequently, Fletcher Allen is working on developing a hospital-wide imaging solution that would encompass not only pathology, but also radiology, cardiology, and other clinical subspecialties. The resulting system likely will be based on PACS technology, Dr. Tuthill says.

What Dr. Tuthill found is that pathology can’t go it alone in imaging; it must reach out to other image-intensive medical subspecialties. "The challenge with these systems is not just getting data in—capturing slides—and being able to view them, but finding the image once you have a large volume," he says. That requires a standardized method of indexing those images—which radiology has in PACS.

While PACS will be the basis of image storage at Fletcher Allen, pathology made its contribution too, Dr. Tuthill says. "We had to evolve some processes to reformat digital images sucked into the cameras so they could be put into reports. This has laid the groundwork for an imaging archive."

In one sense, Chattanooga’s Memorial Hospital is an unusual place to have developed digital imaging because it’s a community hospital rather than an academic medical center. Most of the impetus for Memorial’s effort has come from Dr. Schubert, for whom it has been a labor of love.

Dr. Schubert coaxed about $250,000 out of the budget gurus at Memorial to buy cameras, hardware, and software. He chose to use video cameras rather than still cameras for microscopy because he says it’s easier for pathologists to capture images that way. Still cameras are used for gross images.

Like many pioneers, Dr. Schubert had to blaze his own trail, building an interface to his Meditech laboratory information system to combine the text report with the image. Meditech, he says, "is not working in this area, so we had to develop our own system."

Pathologists must print their image-enhanced reports, but Dr. Schubert is working on an interface with the hospital information system to allow online viewing. In this effort, he is working with radiology. "As PACS develops, it’s moving beyond just radiology imaging into hospital-wide imaging," he says. Dr. Schubert believes pathology images will be integrated into PACS for storage, just like computed tomography and magnetic resonance imaging.

The ideal would be one-stop shopping, where any hospital department that uses images—including cardiology, surgery, pathology, radiology, and ER—would be able to capture and exchange images online as part of an electronic medical record. "But there are huge barriers. All have their own systems and workflows and use different modalities for getting images," he says.

Although the technology can support such a system, political barriers remain. "I don’t think anybody is doing this yet," Dr. Schubert says. "It will first show up in academic medical centers within the next two to three years."

Pathology does have a role to play, he adds. "In the hospital, pathologists are very comfortable with computers, with imaging technology, and with searching for information." The challenge is to combine those competencies, enlist other hospital departments, and prod laboratory and hospital information system vendors into adding digital imaging modules.

One of the furthest along in developing cutting-edge digital image systems for pathology is InterScope Technologies of Pittsburgh, which just sold its first system to UPMC Health System-Shadyside, part of the University of Pittsburgh medical system.

Michael Becich, MD, PhD, chair of the pathology department at UPMC-Shadyside, is working on a process called whole-slide imaging, which virtually no one else has attempted to integrate fully into pathology workflow. "Mike is a trailblazer," says Cerner DHT’s Fingado.

Dr. Schubert says he himself is not attempting whole-slide imaging because of the difficulties involved. "Dr. Becich’s approach is pretty elegant," he says. "You can’t get a whole-slide view looking into the microscope, so you have to have a specialized machine."

UPMC-Shadyside will be a test site for the whole-slide system from InterScope, a privately financed, for-profit firm of which Dr. Becich is chairman and cofounder. "We’ve raised a significant amount of venture capital to develop and commercialize our breakthrough system to capture whole slides," Dr. Becich says. "We’re going into beta testing at UPMC with a plan to do clinical trials beginning this summer."

Most imaging systems mount "a camera on a stick," which takes digital snapshots of whatever the pathologist is viewing under the microscope, Dr. Becich says. Somewhat like a strobe light, InterScope’s system uses an optical light source that flashes repeatedly, as well as a robotic device that scans the anatomic pathology slide, to capture multiple images. A software-management program then combines all the images into a single picture in about 10 minutes.

Thanks to a new round of funding, development has accelerated. "By March, we will have an instrument that will provide a whole-slide image in considerably less than 10 minutes," Dr. Becich says. "You can view the image on a regular PC. Picture your PC as the lens of the microscope now integrated into a flat panel display. You can zoom in and zoom out using your keyboard or mouse."

UPMC-Shadyside will use the InterScope technology for education and research. Until the Food and Drug Administration approves the device, based on the ongoing clinical trial, "pathologists will not be making primary diagnoses from our images, instead they will be using them for retrospective case review, quality assurance, and other research and education uses," Dr. Becich says. InterScope’s technology interfaces to CoPathPlus, allowing the images to be labeled via standard bar coding.

"The first place we’re positioning this in pathology is in post-diagnostic review," Dr. Becich says, so the pathologist can avoid the cumbersome process of finding and retrieving slides. "Ten to 20 percent of the time you go to find the slide and it isn’t there," he says. "Someone else has it, or worse, it is lost, missing, or broken, which requires recutting and restaining the case." Instead, the pathologist can review archived cases electronically.

Quality assurance procedures, which require random review of five to 10 percent of pathology diagnoses, are time-consuming and costly for pathologists, Dr. Becich adds. "Our system makes it much easier to share and compare diagnoses to make sure they’re right, and to do retrospective random review of cases."

Furthermore, oncologists and other clinicians will be able to sit down at their computer, look at the images, and confer with the pathologist by phone or videoconferencing, rather than set up a face-to-face meeting.

Dr. Becich anticipates completing the clinical trial this year and receiving FDA approval in 2003. At that point, "we can offer a complete set of images for primary diagnostic purposes," he says. Dr. Becich expects the price to be competitive with that for outfitting a pathology department with individual cameras for each microscope.

"We have 50 interested clients," says Dr. Becich. "Our problem is not finding clients but manufacturing the devices." The first market is academic medical centers, then large reference labs and pathology practice groups. InterScope will start selling the system commercially this year for R&D applications. The system is integrated solely with CoPathPlus, but InterScope plans to build relationships with other vendors.

The first version of the system requires that each slide be loaded manually. The robotic device then takes over the scanning. In an upgraded version, hundreds of slides can be loaded at once, "and the robotic system will scan these overnight," Dr. Becich says.

One barrier to adoption of this technology is that no standards exist for whole-slide imaging. Dr. Becich says he and InterScope are working with federal agencies, the Radiology Society of North America’s Integrating the Healthcare Enterprise initiative, and the Association for Pathology Informatics to develop a standard.

CoPathPlus developers have been working with thought leaders like Dr. Becich to produce their imaging module, called PICSPlus, which is now being rolled out commercially.

The product took about two years to come to fruition, Fingado says, but the technology can acquire images, print them in a readable format, and store them. "The hardware has become much cheaper and much faster," he adds.

PICSPlus is a "full imaging system for the anatomic pathology lab," Fingado says, and it handles microscopic and gross images. (It does not do whole-slide imaging.) The module, which integrates seamlessly with CoPathPlus, is designed so the pathologist still does the report as a single workflow. "It recognizes when you’re taking gross versus microscopic images and places them in the correct location of the report automatically," Fingado says.

Pathologists can take multiple images and select which ones to include in the report, saving the others for research. Images are stored in repositories and tied to the pertinent report. Each report can be printed or transmitted online in a Web-like environment.

Fingado cautions that image databases must protect privacy the same way written reports do. "Not only do you need to protect the images from unauthorized use, but, for privacy purposes, you must treat the image the same way you would a diagnosis," he says.

PICSPlus adheres to an open standard developed for digital cameras called Twain compliance, which is designed to support Web-based imaging. "We’ve adopted this standard so when you upgrade your camera, you can still use our system," Fingado says. "We’ve taken the risk away from the pathology department."

Digital cameras for PICSPlus can be purchased from Cerner, or the lab can use its own digital cameras. Pricing varies greatly depending on the number of cameras needed and the degree of reolution sought, he says.

About 15 CoPathPlus customers are using PICSPlus, generally academic hospitals and commercial labs. And more than half the new contracts for CoPathPlus include an imaging module. "The market for this is actually huge," Fingado says. He believes pathology imaging will follow a path similar to radiology, which "is going filmless."

Anatomic pathology system vendor Tamtron Corp., San Jose, Calif., will release its imaging module in March. Called PowerPath image management, it will integrate with Tamtron’s PowerPath pathology information system. The company has formal partnerships with LIS vendors McKesson and Siemens to integrate PowerPath, and it’s working on additional agreements.

"Our entire effort with PowerPath image management has been focused on workflow-oriented image capture," says Steve Tablak, Tamtron’s president and chief executive. "We want to make sure we don’t turn the pathologist into a complex photographer."

The module will capture microscopy (though not whole slides) and gross images. Tablak says pathologists writing a report need only click on a tab folder, which contains images acquired earlier, to drop an image into the report. The camera is mounted on top of the microscope and takes images as the pathologist views and selects them.

The images and reports are stored in a database and are accessible directly from a patient’s record. "This gives the pathologist the ability to include images in the report," Tablak says. However, for clinicians accustomed to receiving faxed reports, "this complicates delivery," he concedes, because color images don’t fax well. Tamtron offers a second add-on that can transmit the results online, including images. "The clinician in a doctor’s office can click on the link and look at the report and the images," he says. Viewing the image with the patient is also an option.

Tablak sees two barriers to rapid adoption of imaging technology. The first is workflow. Pathology labs "are very high-volume, high-turnaround," he says. "Will people be willing to spend another four or five minutes capturing an image?" Since the pathologist probably will want to handle image selection, "our whole focus has been to allow pathologists to immediately capture an image as they view it," he adds.

The second barrier is storing and retrieving enormous amounts of information, particularly if whole-slide processing becomes popular. "You wind up with a gigantic file for each slide," Tablak says. "Are you going to put those files on your networks and have people sharing them?"

Tablak is a bit more cautious than Fingado in predicting widespread use of pathology imaging. By selling PowerPath image management within Tamtron’s customer base of 300 hospitals and reference labs, "we’ll get a good demographic reading of who will be using this technology," he says.

Over the next two years, Tablak expects academic institutions to be the first adopters because of the cost savings they can achieve by replacing film with digitized material. His personal opinion, however, is that "the slide is going to be with us for a very long time."

Karen Southwick is a writer in San Francisco.