Digital imaging not picture perfect—yet
You tell us. Are these dreams or nightmares? Fiction or fact?
Electron microscope images instantly available for review. Malpractice
attorneys with Web sites dedicated to images from errant pathologists.
Pathologists who preview images via the Internet using a system
that costs nothing. Pathologists who want images in their reports
and are told the cost will be as high as $550,000. Technologists
in Beijing, grossly overpaid at $200 per annum, screening "digital"
slides from managed care patients living in northern California.
Digital imaging for pathology is not a whirring gizmo in a Jules
Verne novel. Its advance is being delayed only by the niche-stature
of the information technology market for pathologists. But it was
clear at the Advancing Pathology Informatics, Imaging and the Internet
(APIII) conference, held in Pittsburgh last October, that digital
imaging is now feasible. The caveat: It’s not as easy as setting
up a new iMac.
"The major downside to this technology is the fiscal implications,"
says J. Mark Tuthill, MD, assistant professor of pathology at the
University of Vermont. "This technology moves so fast that if you
move too fast, you may buy something that’s already obsolete. This
is where expertise comes in. Don’t go it alone."
Dr. Tuthill does not believe that pathologists need to become
code-writing hackers or photographers. Instead, he says, physicians
must only understand their own computational needs and know enough
to talk to the information systems people who build digital-imaging
There’s more good news. Digital imaging is a fairly typical technological
advance for which huge cost savings theoretically are possible.
This savings comes not just from processing film, but from storage
and education, and consumables and turnaround time. As with computers
in general, the field is also benefiting from plummeting prices
for key components—in particular, digital cameras, which once
cost as much as $20,000—which intensifies interest in the
The complicating factor is that, for now, incorporating digital
images into an existing medical practice or laboratory information
system appears to be about as easy as transforming a 1976 Ford Pinto
into a 2000 Formula One racer. No doubt it can be done. But it’s
still rare enough that one needs to pay attention to the early adopters—those
happiest out in the high-tech garage. The recent APIII meeting had
such individuals in spades.
Two such individuals are Alvin Marcelo, MD, and Paul Fontelo,
MD, MPH, of the National Library of Medicine, who, fittingly, offered
an electronically posted abstract.
Dr. Marcelo, a surgeon, and Dr. Fontelo, a pathologist, are part
of the NLM’s Office of High Performance Computing and Communications.
They decided to test whether compressed digital images were as good
as noncompressed digital images. Why make a distinction? Because
compressed images can be sent across the Internet—even between
countries—far more quickly, especially if large numbers of
images are involved.
Besides changing the way the image is created, the JPEG compression
process shrinks the image files from a megabyte to one-tenth that
size. For their paper, Drs. Marcelo and Fontelo asked colleagues
in Chicago and Cincinnati to read representative shots of the same
case at different magnifications. The investigators then compared
how the readers fared with the compressed JPEGs versus the noncompressed
BMP images. (JPEG files are inexpensive to create, manipulate, and
archive, even on slow, archaic computer networks.)
The results were surprising. "There are no significant differences
between noncompressed BMP and compressed JPEG images in areas of
acceptability for diagnosis, accuracy of diagnosis, confidence level,
and overall image quality," Dr. Marcelo and his coauthors wrote
in their abstract.
That means low-paid physicians in other countries could acquire
images from the United States quickly, diagnose them properly, and
relay their findings back to the United States via e-mail. Once
the legal issues were resolved-and this is nothing more than forward-looking
speculation-there would be no scientific or clinical reason why
a well-trained pathologist in Moscow could not stare deeply into
a 14-inch computer screen and do just as good a job as a colleague
in Peoria. The time difference between the two countries might even
be an advantage, allowing 24-hour coverage.
Indeed, programmers in India already do large amounts of high-level
work for U.S. corporations, and it may be wishful thinking to presume
that cost-obsessed U.S. insurance companies would never hire similarly
bargain-priced labor in other countries.
Certainly no one from the business sector who attended the APIII
meeting expected pathology to be federally exempted from the digital
winds blowing across change-resistant industries such as finance,
travel, or retail shopping.
But Dr. Marcelo soberly refuses to be drawn into any such hypothetical
scenarios. He sticks closely to the facts: "JPEG would be an acceptable
format for exchanging pathology images. Before this paper, there
had been no randomized material on the use of compressed images
in pathology, [though] there have been a lot in radiology." This
paper, he told conference attendees, is just one step in the process
of rigorously ensuring telepathology won’t create more problems
than it solves. Says Dr. Marcelo: "Telepathology is a developing
science; its implementation, at present, is best left to local advocates."
Two strong local advocates were present in Pittsburgh, as it happened,
with dramatically different stories about the nascence of digital
imaging. At the risk of understatement, both have colleagues less
comfortable with computers than themselves. Neither reported banishing
film or printers from their practices. Nor were they willing to
say digital imaging is as easy as logging onto America Online. But
glimmers of the future may be buried in the remarks of both.
Eric Schubert, MD, staff pathologist at Memorial Hospital, Chattanooga,
Tenn., gave presentations on two successive days-and by his own
admission, at the time of his comments in Pittsburgh, his colleagues
in Tennessee had not quite given him the go-ahead. The reason for
that soon became clear: This is not easy.
Dr. Schubert is part of a group of five pathologists who handle
30,000 cytologies and 40,000 clinical specimens annually. "We’re
overworked," he bluntly states. "That’s why I’m trying to put this
system in place. I’m losing a lot of hair, gaining a lot of weight,
and I can’t remember my kids’ names. That’s where I’m at." He is
also chairman of his hospital’s information systems steering committee,
however, and well-positioned to see what is happening as other specialties
wrestle with the digital future.
Dr. Schubert thinks the exclusion of images from pathology reports
is curious. "Ever see a pathology textbook without any images in
it? I haven’t. This is a very visual field," he says. As he and
others point out, many photographic costs, for the moment invisible
because they are embedded in a variety of personal and group budgets,
will inevitably be wrung out of the medical dollar once digital
imaging is fully adopted in a decade or two. At one academic center,
Dr. Schubert recalls, his colleagues estimated they were spending
$30,000 to $60,000 annually on film processing for medical meetings
Says Dr. Schubert: "The cost I quoted didn’t even include storage,
personnel, or camera costs-just film and processing. So in the very
beginning of our project, we got seed money from the hospital based
just on that argument alone. And then there is the obvious argument
that Kodachromes are hard to catalog, keep track of, are easily
lost, and are expensive to duplicate."
But his first forays to save money by going digital were not promising.
He slowly worked his way through the list of laboratory information
systems vendors published annually in CAP TODAY and found, to his
chagrin, that not all could incorporate images into reports. He
discovered that some were not knocking themselves out to bring information
systems for pathology into the 21st century. He recounts one call.
"I say, ’Hello! I’ve got a check for $77,000. Can I put images into
your system?’ And the answer is, ’What?’" His audience laughs.
Dr. Schubert is quick to note that he was not considering the
cheapest possible package. That might cost as little as $6,000 and
include items bought not from traditional hospital vendors but from
mass-market retail outlets such as Best Buy or Amazon.com. A digital
camera ($300), microscope attachment ($700 to $1,300), image databasing
software ($50), color inkjet printer ($300), PC/video projector
for conference room ($3,000), CD-ROM writer ($400), and Zip drive
($150) might all be on his suggested shopping list for cash-strapped
departments. Buying these items is painless and relatively safe,
with mistakes easily corrected as better, newer models emerge.
The real trick, Dr. Schubert adds, is linking these products with
the rest of a practice or hospital. Some of the pressing needs?
"Multiple capture stations, probably utilizing video input [which
is much faster and simpler to use on a routine basis]; image capture
software that is actually user-friendly; departmental support for
color printing; hospital support for image-based reporting [customized
hospital information system]; and an interface between image capture/database
software and the laboratory information system or, better yet, a
laboratory information system that actually directly supports images
for capture, database, and reporting. This last item is the current
Holy Grail in this field," says Dr. Schubert. "Lots of vendors say
they can do this; lots of pathologists say they want this. Yet almost
no one has actually implemented it in any real way."
Dr. Schubert continues: "I made a bunch of telephone calls and
ended up talking my way up the ranks of this company and talking
to someone who was head or VP of research and development. Basically,
I was told that if we were radiologists they might be interested
in looking at this. ’The people in pathology, they don’t even look
at microscopic images.’"
Dr. Schubert finally was able to identify about a half-dozen LIS
vendors who he thought could probably meet his needs. However, when
he budgeted in the cost of implementing a new LIS with the cost
of the new imaging hardware, the total ballooned to at least $300,000
to $500,000. His colleagues were understandably reluctant. "When
I presented this to my group, they said, ’Eric, you’ve done a nice
job here. Now go back to work.’ Clearly, there had to be another
approach because this one wasn’t flying," Dr. Schubert says.
An easily discouraged person might have given up at this point.
But Dr. Schubert persevered, electing to try to assemble his own
system. Basically, his approach was to use a stand-alone imaging
system and mesh it into the hospital’s existing LIS. This required
building interfaces to move information between the two systems
and customizing software to integrate the images into the pathology
reports. The total cost will exceed $200,000, but customizations
have been added to further enhance laboratory workflow, such as
changing the transcription platform to Microsoft Word, instituting
pathologist-driven electronic signout, and setting up an automated
report printing and faxing module.
The good news? "I expect to be more or less done [in terms of
routinely dropping images into our reports and storing these image-enabled
reports in the hospital electronic medical record] within maybe
six to nine months," Dr. Schubert told CAPTODAY in December. That
could be truly innovative.
Part of his victory, he notes, lies in finding a piece of software
that could handle all of the imaging functions and then locating
the software consultants who could connect it to his LIS. That job
could be custom-programmed by the Shams Group, database consultants
in Carrollton, Tex. The work of the Shams Group, in practical terms,
will allow the images of Dr. Schubert and his colleagues to drop
directly into the report that is sent to a referring dermatologist
Asked how fellow pathologists could locate a company such as the
Shams Group, Dr. Schubert concedes he got lucky. "My introduction
to the Shams Group was serendipitous," he explains. "I met them
through the hospital CIO. Clearly, it helps to have good relations
with the hospital information services people if you are going to
do any developmental work. I would also expect that getting involved
with user support groups for the major LIS vendors can lead to good
Consultants for any ancient or cutting-edge LIS system may be
hard to find, he observes, but they do exist on the periphery of
the ecosystem surrounding any vendor. You’re not alone.
But has Dr. Schubert’s path been so pocked with potholes and strewn
with scary prices that it will not be followed by less adventuresome
souls? He admits one politely insistent physician needs to take
the lead, and he concedes that individual could be just about anyone.
"Progress on any front is always driven by, and largely dependent
on, the perseverance of one doc who leads the charge," he says.
"If that doc is in radiology, then the hospital will implement PACS
in radiology first. If that doc is a cardiologist, then cardiology
imaging will lead. It is a lot easier to generate support for a
radiology system than a pathology system," he adds, "simply because
most clinicians are interested in seeing the radiograph. Microscopic
images tend to be seen as somewhat less relevant unless you’re dealing
with oncologists. In my environment, the hospital-based radiology
group is behind us, but the outpatient radiology group is ahead."
Another expert on hand in Pittsburgh was Dr. Tuthill of the University
of Vermont. At 37, Dr. Tuthill finished a fellowship in pathology
informatics last July, but he became comfortable with programming
in his college days, when he took a minor in computer science. As
a medical student and resident, he understood that computers could
ease the life of a pathologist a bit. He regards his programming
as not so much a hobby but as an outgrowth of his medical training.
"It comes from my realization as a medical student that all of this
information you need is on a piece of paper, and it’s locked up
in the basement, and we need it up on the fifth floor now," he says.
"It’s all tied together. Images are just one part of it."
If Dr. Tuthill had not chosen medicine, he probably could be making
a comparable living writing Perl scripts, the lingua franca of the
Web masters who create and maintain Internet sites. Does every practicing
pathologist with an interest in this area need to learn to write
Perl scripts? Nope. "I don’t know that that is possible or desirable,"
he comments. "It’s not that it’s particularly hard, but it does
get into the question of how much time do you want to devote to
More important, he believes, is being able to serve a mediating
role. "You have to be able to sit with computer scientists and technicians
and tell them enough of the specifications of the system you’re
trying to design, understanding enough of their lingo so they understand,"
he explains. "There is a role for a pathologist who has an interest
in this sort of thing to stand in between pathologists and computer
Dr. Tuthill’s programming ability, however, is not incidental
to what he’s done for his department. It’s central. The big picture
is that he’s allowed his colleagues to see electron microscopy images
immediately, as soon as they’re "scoped." The consulting pathologist
gets an e-mail saying case #12345 is ready for review; the message
includes a hyperlink to a secure Internet page that displays the
For the first stage of the project, digital and traditional 8
by 10 glossies were prepared. The future may be simpler, with only
a subset of the whole batch going to photoprocessing. Instead of
20 8 by 10 glossies per case, at a huge annual cost, the pathologists
will be able to print only those four or five essential to the diagnosis.
Notes Dr. Tuthill: "You can cut 35,000 to 40,000 bucks off your
photographic budget relatively easily. That’s just [electron microscopy].
If you look at photography in general..."
For now—this was a pilot project, with 100 electron microscopy
cases logged into the system—the pathologist reviewing a batch
of such images needs to consult a different database to learn more
about the patient. But Dr. Tuthill and his colleagues are creating
several computer programs that would allow images, text, and other
pertinent clinical information to be automatically inserted into
the same Web page at the same time. One immediate hurdle on the
way to that destination? Security.
Dr. Tuthill is already using Microsoft e-mail and database software,
which he considers hard to break into; he wants to be extremely
cautious about maintaining the privacy of patients and the physicians’
reports. "We are very concerned about security issues," Dr. Tuthill
notes. "We tolerate almost no clinical information outside of the
actual clinical systems themselves."
The foundation of Dr. Tuthill’s project—and the reason he
could finish it while handling his other responsibilities as a fellow—is
that he did not need to invent the Internet. The World Wide Web
not only does most of the work of storing and transferring information,
but also radically simplifies the process of creating computer programs.
We’re not talking about Excel or Quicken. We are talking about smaller,
nimbler Internet-based programs that can be built and tested quickly
on microbudgets. We’re talking, in some cases, about Perl scripts.
As Dr. Tuthill explains: "This is the major incentive behind the
Internet: The cost of developing an Internet application is so much
lower than developing a stand-alone application in the prior generation.
If you add to that the fact that you’ve got connectivity built in,
you’ve got another win, because inherently you have applications
that can talk to each other. You have an inherent savings there:
You do not have to program for interoperability"—that is,
ensuring that Windows users in private doctors’ offices and UNIX
users on campuses can take advantage of the same program.
The cost of Dr. Tuthill’s project? Nothing, because the department
already owned a Dell Power Edge 2200 server to hold the images.
Dr. Tuthill jokes that the University of Vermont may have turned
a profit on the project because graduate students in computer science
paid tuition to work on it. But he also makes a serious point. For
those in academic medical centers, pathology-related Internet programming
projects can be highly desirable among computer researchers because
of their real-world practicality. "Within academic communities,
these problems are of such interest that they are the subject matter
for master’s theses, for PhD theses," he explains. "These are things
that can be a part of relationships with other departments in their
Unlike Dr. Marcelo, Dr. Tuthill has no reservations about making
a few predictions. "Ten years hence, getting a pathology report
with images from a consulting pathologist, a consulting physician,
or in the patient’s actual report will be ubiquitous. We won’t consider
the fact that images weren’t always there. We’ll tell the anecdotes
about how images didn’t use to be in the reports."
If that sounds rosy, it is-and it isn’t. There is also an imperative
not to be left behind that Dr. Tuthill admits he is a bit hesitant
to discuss. "We get these requests from our physicians and from
other physicians," Dr. Tuthill continues. "They say, ’Jeez, you
don’t have images in your reports? When are they going to be there?’
This is not casual. This is, in many ways, the lifeblood to the
laboratory. Once images can be readily integrated into the report,
there will be no going back. The appeal of images in the reports
for other pathologists, for other physicians, and for the patients
themselves, is of such import that once the cat gets out of the
bag, there will be no going back."
For his part, Dr. Tuthill is tearing holes in the bag to help
the proverbial cat get out. In a year or two, he says, the team
at the University of Vermont may have ways for pathologists elsewhere
to use the same system. The Vermont computer programs may be licensed;
they may form the basis of a startup company. Every traditional
option for campus-incubated startups is under consideration.
While tight-lipped about the details, Dr. Tuthill does say: "We
are developing a couple of applications that may have market impact.
We are looking at the requirements of integrating images and the
textual information that would be in the pathology report. If anything,
we are increasing our embrace of Internet-based technology. This
is decreasing our time for development quite significantly."
One clue Dr. Tuthill does drop is that pathology may not be the
only target market. "We are looking at tools that could make a difference
not just in the lives of other pathologists, but other physicians,
other patients, other health care systems. It’s about getting this
information out to the patients’ doctors and to the patients themselves
so that they can be actively involved in their disease process,"
he explains. "By providing good communication for doctors, we provide
good information for patients. Good lab data means good patient
care. That’s what our motivation is."
Mark Uehling is a freelance writer in Chicago.