The Hardest Part of Digital Pathology Isn't Digital

Dr. M. E. de Baca:
Welcome to CIPI Connections, the podcast of the College of American Pathologists' Council on Informatics and Pathology Innovation. Here, we connect you with the leaders and committees shaping the future of pathology. I'm Dr. M. E.de Baca, Chair of the College of American Pathologists’ Council on Informatics and Pathology Innovation, also known as CIPI. In this episode, we're joined by two members of the Digital and Computational Pathology Committee, Dr. Jordan Olson and Dr. Meredith Herman. The committee is leading the development of a Digital Pathology Implementation 101 Guide, and together, Drs. Olson and Herman will explore what works, what doesn't work, and what they've learned from digital pathology implementations at their own institutions.

Dr. Jordan Olson:
So hello and welcome. I'm Dr. Jordan Olson, the Chief Medical Officer of HNL Lab Medicine and the Chair of Pathology of the Lehigh Valley Health Network. And I'm here with Dr…

Dr. Meredith Herman:
Meredith Herman, Pathology Resident at the University of Michigan.

Dr. Jordan Olson:
And we're here to talk to you about digital pathology and the implementation. Meredith, do you want to tell us a little bit about your background with digital pathology?

Dr. Meredith Herman:
Absolutely. As a trainee at the University of Michigan, I was in the middle of transitioning between glass slides to full-on digital pathology workflow. I've seen a lot of trials and errors, and I've seen a lot of success in the process. And I'm curious to talk to Dr. Olson about his work and implementation and his laboratory of how they transitioned to a digital pathology workflow.

Dr. Jordan Olson:
About three years ago, HNL Lab Medicine was very curious about digital pathology. We did our investigation. We realized that there would be a lot of improvements that could be made, not just in logistics, not just in lifestyle, but our entire soup to nuts organization could be transformed by going to digital. We had a champion in our organization, a pathologist, Dr. Sajad Malik, who really built a lot of expectations and excitement among our pathologists and our technologists with digital pathology. So we began to build a business case and then implemented about two years ago. We quickly realized that our initial plan to do a phased rollout was not as efficient as it could have been. So we went and pivoted quickly to a big bang rollout and we were scanning a hundred percent of our slides about a half a year after we started our implementation. We've really enjoyed going digital, enjoying the benefits of improved logistics, improved turnaround times, and improved quality of life for our pathologists. Dr. Herman, you want to talk about the implementation at University of Michigan? 

Dr. Meredith Herman:
Absolutely. It, you know, you're speaking to a lot of the challenges with implementation in a laboratory space, and they are very common across all different settings. And, you know, kind of piggybacking off of what you discussed, there were a lot of strong champions in our department who were the digital pathology gurus, and they were involved from start to finish. So I'm speaking from a trainee perspective. They had basically set a timeline, like you said, you know, setting a clear vision and timeline for what this would entail. And the goal was probably one to two years for a full transition. At a large academic institution that sees a lot of transfers and consults and in-house cases. You can imagine that would be quite a large endeavor. And it was. And I think a lot of it came down to having strong champions who were selecting the right software, the right scanners, and of course getting the right funding to make sure that would happen, as well as the training and the personnel who could help with that transition. And it was. People were very much on board. I'd say 90% of people were optimistic, but 10% were not so optimistic. 

So we kind of face a generational divide with people being apprehensive and cautious and then others being more open to just going straight digital. So there's a lot entailed with trying to get people on board, people being optimistic and continuing on a positive attitude through a process that is quite stressful and, you know, disruptive to our usual work life, you know, workflow. So, you know, kind of we will talk more about that as well. But within two years, one and a half to two years time, we have gone fully digital on basically all of our services. I think people have started to see the benefit. And as a trainee perspective, we can talk more about, you know, the benefits as an educational perspective. But we have seen miraculous transformation in our workflow adaptation, as I was probably trying to say both simultaneously. And then also, you know, how that affected our diagnosis and overall workup of our cases. So Dr. Olson, you know, we talk about change management. And as a trainee, that word is very vague. And for the listeners who are tuning in, you know, what does change management mean? And I think for those who are trying to grasp what this entails, you know, how do you go about working with different people and getting everyone on board and on the same page in regards to this digital pathology change? Because people don't like change. It's really hard to convince people to do things that they're not used to doing. So how do you approach that? How did you guys walk through that?

Dr. Jordan Olson:
So I think that's a really great question because change management is at the heart of any digital pathology implementation. We can talk about scanners, we can talk about image management systems, we can talk about AI, all those things are important. But if you don't get the pathologists, if you don't get the technologists, if you don't get everyone involved in the surgical pathology process to buy in, you're not gonna have a successful implementation. So we started early, first building interest, building excitement, telling the story of what digital pathology is, so folks come with a baseline of information and a baseline knowledge. That was done through grand rounds, informal conversations, and interesting case conference demos. Once people were familiar with digital pathology, then we needed to start messaging the with them, the what's in it for me or to each group, to each stakeholder. And each of these were unique. The histotechnologists needed to understand what scanning would do for them, right? It could make their lives easier, huh? The distribution desk, their life changed quite dramatically. How is their life going to be different? And how is it gonna be better once we've gone digital? The pathologists, obviously, you have to explain hey, with digital you can do XYZ. And it has to be something that's speaks to them, not just a vague, well, we'll be more efficient. No, it's a you can work from home, or you can go home earlier if you're faster. Or a we'll be able to implement AI and give you a better quality or help you to a better quality diagnosis. All of those things speak to different constituents, and all those things have to be mesh messaged very thoughtfully. Now, one of the questions I have is the University of Michigan has trainees. What's in it for a trainee with digital pathology?

Dr. Meredith Herman:
I think that's an excellent question, Dr. Olson. And it's a hot topic right now for a lot of medical students applying to residency and thinking about, well, what's going to happen if we don't have glass slides anymore? What does it look like to get your education through a digital platform? And you know, from an educational perspective, I think there's a lot of benefit to having virtual slides, our digital slides. You know, we've done virtual slide education through different platforms for our own board preparations and sharing of unique rare cases. But as a trainee, like you mentioned, workflow is significantly smoother. We're not sorting through stacks of slides, we're not losing slides or things aren't missing mysteriously. Things are already cataloged and organized succinctly in our system. It's linked up with our reporting software. So we use SoftPath and Sectra. People use Beaker and et cetera. So I think there's been a seamless dialogue between our reporting software and the digital slides directly. We're able to preview our cases much more quickly because we're not spending time on administrative grunt work, so to speak, you know, organizing and trying to find the 100k slides that are coming out at different times. We're much more efficient in getting our cases done. We're also able to annotate and write notes on each individual slide. And I found that was the most beneficial aspect of the educational experience because I'm able to communicate directly. This looks like a granuloma, this looks like a weird, ugly cell, this is a mitoses, versus sitting there at my microscope trying to dot a slide with a big pen and accidentally over dot and dot over the pen, you know, over the mitoses.

So I feel like we're much more able you're more easily able to articulate our education understanding of diseases and what findings we're seeing. And at the same time, the attendings can be on their computers in their office, right down the hall or across the campus. And I can instantly message them and say, hey, what do you think? Should we do some additional stains and workup? And we can simultaneously discuss without having to track them down and you know, navigate around meetings. So I feel like things have been much more smooth sailing than they were in the glass slide way. So kind of going back to, you know, stakeholder groups that you were discussing, you know, the different people that are involved in the slide process, you know, what did you find most challenging in that process to align everybody and get their buy-in? I know you talked a lot about, you know, deliberate teaching and guidance of staff and trying to build excitement, but you know, what were the, you know, top, what was the top challenge that you encountered in that entire experience?

Dr. Jordan Olson:
My top challenge actually turned into an opportunity to more rapidly roll out digital pathology than we originally expected. When we first went live, we had almost a nine-month to a year slow phase-in approach to rolling out digital pathology. We were going to scan different subsections, different specialties, and only a portion of the slides. Our technologists quickly identified that that was a fairly inefficient way of doing it. And quickly, the what's in it for me for our histotechnologists became a we're gonna have a unified workflow and we're gonna go to 100% digital, basically within two months of starting to scan our first slide. Because they saw a unified workflow as a real win, it was going to be simpler for them, it was going to allow them to file slides faster and basically eliminate multiple steps. That quickly drove adoption by our technologists. The other stakeholder group that we really drove adoption with was our pathologists. And our pathologists were very traditional, but they had a lot of interest in digital pathology. And that was really driven by some evangelist champions that we had. However, once we started going digital, everyone went digital at their own pace. And it wasn't until we started saying, yep, the regulations allow work from home, just like our radiology colleagues, two days a week, were we able to really drive adoption because almost everyone saw that as a huge win.

Dr. Meredith Herman:
You're saying a lot of great, you know, takeaways here, you know, about like what's in it for me? What, you know, everyone needs to be on that same side. You know, what is the benefit of doing all of this extra work? What is the benefit of adding in an additional step to scanning slides, to getting storage and software? I think that's a really great key takeaway is can clearly communicating that to every person involved in the process. And I think, like you said, you know, they you probably had to expedite it because, you know, the longer it dragged on, you know, the more issues came up and you just kind of had to jump right in and do it. And I think every place does things a little bit differently and every group is a little bit different. And that kind of leads me to my next question for you is, why is it difficult to apply a one size fits all for digital pathology? You know, every place has their own timeline. But, you know, it'd be easy to say, you know, just do this, it's gonna be successful and easy flowing and for every single person. So why is it difficult to apply a one-size-fits-all approach?

Dr. Jordan Olson:
I love that question. And the answer is simple. It's because people are involved. So people aren't one-size-fits-all. And every group has its own culture, every group has its own requirements, and every group has its own unique way of doing things. And when you look at digital pathology, it's very flexible. So it can meet the needs of multiple groups, it can meet the needs of multiple pathologists, but you have to account for that, right? Not everybody is co-located in one site, not everybody is spread out across 15 sites like we are. By looking at the uniquenesses of each group and looking at the strengths that each group has, you can really tailor your implementation for efficiency gains. The other piece is every group has a different willingness to embrace change. So if you're in a group that is very unwilling to embrace change, you may be looking at an implementation that goes much more slowly, or an implementation that is more of only replacing portions of the workflow with digital. If you're at a group that can move very quickly or has a reason to change because of workflow concerns, because of geography concerns, because of workforce concerns that can really push your implementation faster or in a different direction.

Dr. Meredith Herman:
I think that really hits the nail on the head with everyone is different. Everyone comes in with a different perspective. And it's important for everybody to approach it from the personal level and getting people on board. And I think this is really great advice. And every group is going to have to approach it at their own pace that makes sense for their own practice. So, you know, leading off of that and the challenges that every place might encounter during this implementation, an implementation guide was created through the College of American Pathologists. And I would love to talk more about that with you and kind of what the idea was behind that. I guess could you briefly touch on the initial motivation to creating that guide and how is it meant to be used in practice?

Dr. Jordan Olson:
So the College of American Pathologists, Digital Pathology and Computational Pathology Committee, or the DCPC Committee, realized that there was a need to answer many of the common questions that were often being brought up to early adopters of digital pathology. Questions like what scanners should I buy, what monitors are the best, what image management system makes the most sense are common in folks who are starting to look at digital pathology. What we wanted to do is put together a guide that not only answers those questions, but also helps people through the entire digital pathology journey from acquisition to post-Go lab governance. So we wanted to put together a guide, and we did, that helps walk folks through acquisition, identifying the problem that they want to solve. We wanted to walk people through drafting a requirements document and determining the return on investment. We wanted to talk quite a bit about change management and making sure we message how digital pathology is going to improve the pathologist's practice to all the stakeholders involved. We mentioned validation, as it's one of the key components of implementation. And we have a great section on ergonomic considerations for digital pathology. It's not as simple as putting a monitor and putting a mouse in someone's hand. When your workflow changes to be completely computer driven, it changes the way you want to think about your workspace. We talk about training, cut over, go live, and then we talk about governance and sustaining that digital pathology once we're live with it. I feel it's a really comprehensive guide, and it's a guide that talks at a level that a general pathologist who is thinking about digital pathology will really enjoy. In the guide, we talk a lot about ergonomics, and I think that's a really important piece that often gets overlooked. As we become more and more dependent on the computer and less on the microscope, what are some of the key takeaways that you learned in the digital pathology implementation to protect our bodies?

Dr. Meredith Herman:
Absolutely. I love this question because as we have implemented digital pathology in at University of Michigan, I've seen a lot of colleagues who have had to adapt their workstation to ensure comfortability when they're at the microscope and we're spending or at the digital screen now as we've transitioned and we're spending significantly more time looking at the computer screen. So a few things that kind of came to my mind when I was crafting this ergonomics section was well, how, you know, what kind of equipment are we using? What kind of mouse are we using? And there's a ton of different styles and everyone has their own preference. So how do we make sure that we're protecting our wrists from carpal tunnel and making sure we're comfortable with repetitive movements? How do we protect our posture and our lower backs, you know, from sitting in a chair all day? You know, what can we consider as far as, you know, the actual furniture we're sitting in? And how do we think about the computer screen setup? How are we going to position the scopes or the sorry, the screens so we're not straining our necks? So there's a lot that goes into thinking about how we're positioning every part of our body to make sure we are doing the best job we can still for our patients when it comes to microscopic diagnosis. So just a few things, and you know, I'm sure there's a lot more we will learn as we move forward, but those are just a few of the things that I thought about when putting this guide together.

Dr. Jordan Olson:
Absolutely. So looking back on it, what's the one key lesson that you have taken away from your digital pathology journey?

Dr. Meredith Herman:
That's a really good question. I'm gonna ask you that back. I think the biggest thing is to be open-minded and flexible. There's gonna be a lot of challenges that come up with the process. Being patient is also very key. So those are a few of the key lessons, but you're going to encounter some inconveniences with some scanning issues, or you might have, things that come up with slides not being scanned properly, or something went awry in the process, and just being flexible and patient and working with your team to figure out why those things happen so they don't happen again. And, you know, I think it's just a persistent attitude you have to keep having every single day until it's fully implemented. So, Dr. Olson, I'll ask you the same question back. You know, what are the key lessons and takeaways you've gained from this experience?

Dr. Jordan Olson:
So I think the most important piece is that you know digital pathology, while it's a technology question, it's really more of a people question. And being successful with digital pathology really just depends on the alignment of your folks in your laboratory, communication with every stakeholder from the start of the workflow to the end of the workflow, and adaptability and making sure that folks are willing to change, understand the change, and understand what it's going to do for them as something they can look to when, like you said, things go wrong, things take longer than they should, implementations get delayed. We want to make sure people have a North Star to look at as we implement and more so as we use digital pathology every day. So again, I want to give a big plug for the Digital Pathology 101 Guide. I think it's a great resource for any pathologist as they start thinking about their digital pathology journey.

Dr. M. E. de Baca:
Thank you, Dr. Olson and Dr. Herman, for sharing your experiences with us. For those listening, the Digital Pathology Implementation 101 Guide is now available for download. Check it out in the show notes of this episode. And thanks for joining us for insights, updates, and the people beyond the innovation. This has been CIPI Connections, where ideas meet action in pathology.