Zooming into the future— digital pioneers forge ahead
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
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
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
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
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
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
Karen Southwick is a writer in San Francisco.