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Enabling Personal Digital Microscopy The Rise of Digital Pathology Why Digital Technology Can Solve the Challenges of the Pathology Department A Digital Revolution Size Matters: Small, Digital Microscopy Could be the Missing Link Digital Pathology and an Artificial Intelligence Future

Published by Global Business Media

SPECIAL REPORT: ENABLING PERSONAL DIGITAL MICROSCOPY

SPECIAL REPORT

Enabling Personal Digital Microscopy The Rise of Digital Pathology Why Digital Technology Can Solve the Challenges of the Pathology Department

Contents

A Digital Revolution Size Matters: Small, Digital Microscopy Could be the Missing Link Digital Pathology and an Artificial Intelligence Future

Foreword

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Tom Cropper, Editor

The Rise of Digital Pathology

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Liron Pantanowitz, Vice Chair for Pathology Informatics at University of Pittsburgh Medical Center Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor Tom Cropper Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated.

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A Long History of Digital Pathology Benefits of Digital Pathology What Has Been Standing in the Way? Integrating Technology The Mindset Barrier Making it Work The Future

Why Digital Technology Can Solve 7 the Challenges of the Pathology Department Tom Cropper, Editor

Older Patients and More Complex Cases The Search for Solutions Why is Adoption So Slow?

A Digital Revolution

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Jo Roth, Staff Writer

Financial Considerations Complexity and Integration Image Format Attitudes of Pathologists and Administrators Convincing the Doubters

Size Matters: Small, Digital Microscopy Could be the Missing Link

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Jo Roth, Staff Writer

Bright Future, Difficult Present Smaller and More Portable Devices Making New Technology Work

Digital Pathology and an Artificial Intelligence Future

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Tom Cropper, Editor

Image Quality Artificial Intelligence Evolutions for the Future

References 15

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SPECIAL REPORT: ENABLING PERSONAL DIGITAL MICROSCOPY

Foreword

I

t is 20 years since the first commercial whole slide

complex workflow patterns hold health services back

imaging devices became available, but digital

from truly embracing digital technology.

microscopy is still struggling to gain a foothold.

One solution, as James Butler discovers, could be

Practicalities stand in the way of adoption, but

to move towards smaller and more compact personal

smaller, personal digital microscopy promises to

digital microscopes. He looks at how smaller devices

provide a link which solves many of the problems.

such as the Grundium Ocus aim to overcome some of

Personal digital microscopes are small enough

the key barriers to adoption. While many scanners are

to fit on top of a desktop and can scan and share

large, expensive and unwieldy, these are affordable,

images quickly between different participants. In our

portable and capable of integrating seamlessly with

opening article Liron Pantanowitz of the University

other systems.

of Pittsburgh Medical Center explains how they are

Finally, we look to the future. Although barriers may

using digital microscopy to connect pathologists in

exist in the short term, the future definitely belongs to

different locations among their community hospitals.

digital – and with new developments in 3D imaging,

We will then look at the evolving nature of pathology.

data collection and AI, the possibilities are exciting.

Demand for services is predicted to increase rapidly,

Digital transformation may be a key element for health

but the sector faces a recruitment crisis. Digital

services in general, but nowhere could it be more vital

technology provides an option which can empower

than in busy pathology departments.

teams of pathologists to cover much more ground.

Even so, as Jo Roth discovers, adoption is not as fast as it might be. Concerns about cost and the challenge of integrating new technologies into

Tom Cropper Editor

Tom Cropper, has produced articles and reports on various aspects of global business over the past 15 years. He has also worked as a copywriter for some of the largest corporations in the world, including ANZ Bank, ING and KPMG.

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SPECIAL REPORT: ENABLING PERSONAL DIGITAL MICROSCOPY

The Rise of Digital Pathology Liron Pantanowitz, Vice Chair for Pathology Informatics at University of Pittsburgh Medical Center At the University of Pittsburgh, we’re seeing how digital pathology can save time, money and improve outcomes for select use cases.

Digitising data and sharing it online is crucial for facilitating collaboration between teams in multiple locations, but putting this data online inevitably puts it at risk

D

IGITAL TECHNOLOGY has long promised to deliver substantial improvements in the way pathology is delivered. For various reasons, though, uptake has not been as rapid as it could be. Financial constraints, practical obstacles and pathologist mindset which often sets itself against the development of digital technology have all combined to hinder its progress. However, at the University of Pittsburgh Medical Center, we’ve been finding novel ways in which it can deliver the overhaul in pathology that many people might argue is long overdue.

In this world of digital pathology, many things are possible. Digital images can be used to offer primary diagnoses, second opinions, quality assurance, sharing, image analysis, AI, education and conferencing. It is revolutionising the delivery of telepathology and analysis as well as aiding the development of research, archiving and academic publications. With technology continuing to evolve and develop, it also offers exciting prospects for the future especially in areas such as artificial intelligence and machine

learning. These are all avenues that have been successfully explored by the team at Pittsburgh.

A Long History of Digital Pathology Digital pathology is often portrayed as being something new, but that’s not the case. It’s easy to forget that this technology has been with us for many years. Our team has been using it – to various degrees – for more than 20 years.

It is now 20 years since the first commercial whole slide imaging devices were made commercially available and, in that time, users have built up an extensive body of evidence demonstrating their value. National guidelines have been drawn up. In 2017 the FDA endorsed the technology for primary diagnosis in surgical pathology, so this is definitely not a trend, it isn’t just a fad – it is a technology which is mature and has been proven to work. It looks like it is here to stay for the long term. What’s more, the latest technology is identifying ways to overcome some of the most stubborn and enduring barriers to adoption.

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Benefits of Digital Pathology

In 2017 the FDA endorsed the technology for primary diagnosis in surgical pathology, so this is definitely not a trend, it isn’t just a fad – it is a technology which is mature and has been proven to work

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This has enormous benefits when teams are working remotely. With conventional microscopy, slides must be shared physically. This might not be much of a problem when users are based within the same hospital; they can simply pass a slide over from one person to another, but this has significant problems for an integrated organisation such as ours which has pathologists working remotely. Slides cannot always be sent by courier, which slows the entire process down, especially if they have to travel across oceans.

This is why digital microscopy is so important.

It allows you easily to send and share images remotely and get results from experts sooner.

It is having enormous benefits in our work at Pittsburgh. Our hospitals are divided into academic urban and community hospitals.

Many of our community hospitals have intraoperative consults performed using robotic microscopy by specialists, especially in the realm of neuropathology. We have several neuropathologists that can handle these consults remotely. For this we use small footprint scanners to perform live robotic reviews that can also offer whole slide imaging for rendering second opinions to improve quality.

This device is perfect for a number of reasons.

Firstly, it is small, which means it can easily fit into a frozen section suite. It is also relatively more affordable than a large high capacity scanner.

What Has Been Standing in the Way? Those barriers are a combination of practical, financial and psychological. Financial constraints mean administrators will be wary of investing in new technology unless there is a proven return on investment. However, it is not the cost of the equipment that holds the process up as much as the expense and work involved with finding qualified people to operate it. You could compare it to buying a brand-new bus but being unable to find anyone to drive it.

Digital technology can also create a number of security concerns, not all of which are easy to resolve. Digitising data and sharing it online is crucial for facilitating collaboration between teams in multiple locations, but putting this data online inevitably puts it at risk. Digitisation will increase the quantity of highly sensitive information which hospitals will be handling. There is a pressing obligation on all healthcare providers to ensure that data is securely managed and shared in an appropriate manner.

At the University of Pittsburgh Medical Center, our security team complete extensive testing on any new device to ensure it is safe to use.

Knowing that adequate measures have been put in place provides important reassurance.

Integrating Technology Just having the technology in itself will not always be enough to guarantee success. Some organisations have an approach in which they will only use equipment which has received FDA clearance, so if there is a component which does not have this, you may find yourself waiting for new equipment to be cleared for use or having to use it off-label. Devices can also be locked-in making it impossible to add on or substitute other equipment. For example, a device may require a specific monitor in order to function properly.

Without the ability to bolt on a cheaper, generic model, you may see costs pushed upwards.

The great strength of new technology is its ability to integrate operations. Our team uses a lab-centric approach in which everything is managed and processed in a single place.

Our whole slide images are readily accessible to end users via the lab information system. If different systems are not integrated effectively, they will be working separately and be unable to communicate effectively. Processes will take longer and be more difficult to manage, which can impact how staff view innovations.

The Mindset Barrier Poor integration can exacerbate another important barrier – mindset. Innovation is often met with resistance from the people who are expected to use it, and in healthcare this assumes a number of different forms.

If devices are not integrated, workflows will be fragmented, which can increase the amount of time it takes to perform certain tasks. This results in a backlash against the technology from the very people who will be using new equipment in their daily routines. They were promised a device which could improve performance, reduce their workloads and be quicker to operate. If they instead find something which takes more time and adds to their workload, they will react negatively.

SPECIAL REPORT: ENABLING PERSONAL DIGITAL MICROSCOPY

The idea of higher productivity levels, though, is not always welcome. Imagine a new device which can increase the number of scans that a pathologist can process. Suddenly he or she is presented with the prospect of daily workloads which could be about to rise significantly.

They may even see it as a threat. Wherever new technology finds ways to speed up work-flow and enable individuals to increase their workloads, it is only natural to worry that this may see headcounts fall. Many people will be happy to see others adopt the technology but will be reluctant to do so themselves for fear of the threat it could pose to their own jobs. In order to engage with those on the front line, we need to reassure them that this is a solution which will be a help rather than a threat or a hindrance.

Comfort using the technology is often influenced by just how confident people are in their ability to use the systems. If you are experienced and have spent years viewing images and making diagnoses, you will likely be confident of your ability to do so regardless of the modality – i.e digital or glass. Junior consultants, meanwhile, might struggle a little more. If they have been trained to look at these challenging cases down microscopes, they might be less confident of their ability when it comes to viewing images on a screen.

Making it Work Successful and widespread adoption will be about much more than just what the technology can do. There is a wealth of evidence showing the benefits digital pathology can deliver. However, success will only truly come when health services work out how to overcome the barriers and implement it effectively.

It’s an arduous journey we’ve experienced ourselves in Pittsburgh. Initially, we chose a topdown bottom-up approach in which everyone was asked to adopt it. This can sometimes be counter-productive. People do use it, but the compulsory nature of the implementation can provoke an adverse reaction. Instead, we have now adopted a more consultative approach in which we provide the capability, but do not make adoption compulsory. We are there to provide help and support to people as and when they choose to use it. This is a relatively easy approach and meets with less resistance.

Progress is incremental and we don’t have a situation in which everyone is overwhelmed.

Individuals adopt the technology as and when they want to, rather than because they have been forced. Coupling digital pathology with suitable AI apps to improve diagnostic quality is a good use case.

As an academic medical center, we see different benefits through our use of digital pathology.

This is where the field is heading and most new students and trainees today want to get involved.

If we didn’t use it, we would probably not be able to attract the best people. We find that millennials who are very tech savvy see this as a key attraction. They want to be involved with forwardthinking organisations which are embracing the latest techniques and technologies. The same may be true in the wider workplace. A hospital which is tech-savvy will be a more attractive option for the best graduates.

If devices are not integrated, workflows will be fragmented, which can increase the amount of time it takes to perform certain tasks

The Future So, where might this go in the future? Technology is moving forward quickly and has the potential to go in a number of different directions. One WWW.HOSPITALREPORTS.EU| 5

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Digitising data and sharing it online is crucial for facilitating collaboration between teams in multiple locations, but putting this data online inevitably puts it at risk

of the most highly publicised has been artificial intelligence, which is something we have been investigating. One system which we have been looking at closely uses an algorithm to detect prostate cancer. It scans images and highlights suspect areas.

A number of the questions we’re posing revolve around when it should be used. Some people prefer to use AI technology after screening their H&E slides to back up assessments or identify areas which might have been missed. Others might prefer to get the AI results before they see their scans. They can then look at an image without the AI and compare it with one that displays the heat map applied. This can speed up the diagnostics and turnaround times.

We are also building up a scanned database of images and this has a lot of direct and indirect benefits. If you want to look at a prior

case now you can quickly pull up those digitally archived biopsies.

This database can also help in the setting up and testing of AI. To get a deep learning system working, you might have to build up a database of scans to validate and calibrate an app. With a database like our we will be ready to go.

Digital pathology may not be new, but it does represent the future. Technology is evolving rapidly which will improve turnaround times, diagnosis results and efficiency. Problems of money, mindset and implementation still present obstacles, but the technology is increasingly finding ways around them.

Liron Pantanowitz is vice chair for pathology at Pittsburgh medical centre includes digital imaging and pathology. A large hospital system with many partners.

There is a wealth of evidence showing the benefits digital pathology can deliver. However, success will only truly come when health services work out how to overcome the barriers and implement it effectively

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Why Digital Technology Can Solve the Challenges of the Pathology Department Tom Cropper, Editor Rising demand and recruitment challenges pose serious problems for the future of pathology. Can digital technology provide the answer?

P

ATHOLOGY FACES many challenges.

Trained pathologists are thin on the ground, demand is rising and money is tight.

Digital pathology offers a way for health services to continue improving outcomes for patients and satisfying the rising demands on their services.

Many of these challenges stem from society’s success at treating diseases. In the developed world, people are living much longer, but the body has not yet evolved to function as well in later years as it does in its youth. One of the key issues is our ability to control our own DNA which, according to recent studies, declines beyond the age of 55. Until this point our bodies are extremely good at repairing damage to DNA, but beyond it more and more cells will be replaced by mutations. A group of cells starts to develop within the body whose DNA is slightly different than those around them, which increases the likelihood that they will become cancerous1.

Older Patients and More Complex Cases One of the results of this is that the number of people with cancer and other diseases associated with later life is expected to increase rapidly over the coming decades. So too is demand for pathology services and that could place infrastructure under strain because research suggests pathology departments may struggle to keep pace. A study by Cancer Research UK identified a 4.5% year on year increase in the number and complexity of histopathology requests since 2007/08 with the majority of these being for cancer screenings. This, the charity warned, could lead to a severe crisis over the next five to ten years as demand outstrips supply2.

Already, departments are struggling to keep up. A workforce census in the UK, run by the Royal College of Pathologists showed that only 3% of NHS histopathology units had enough staff to meet growing demands3. This shortage, as a

report by the BBC discovered, was leading to serious delays in the diagnosis of cancer cases4.

Rising demand comes at a time when colleges are struggling to produce enough pathologists to replace those reaching retirement age. A report into trends within graduate medical education found that, although the number of pathology programs and positions has increased since the 2001 to 2002 academic year, this increase is lower than that of graduate medical education5.

Moreover, many pathology sub-specialities have declined in population adjusted levels. A looming gap in pathologist numbers poses a significant problem for health services.

The Search for Solutions To solve the problem, the report argued, more attention must be focused either on graduate education programs or new technology. The former option is difficult. A shortage in trained pathologists is nothing new; there is always going to be a limit on the number of pathologists who can be found and trained at any one time.

Somehow, health services will need to make the best use of the resources available to them and, for this, new technology will be key.

The Cancer Research UK report recommended increased focus on digital pathology to address some of the sector’s most pressing challenges.

Digital pathology has recently progressed from a technology which was on the margins to one which is becoming increasingly common in both hospitals and academia.

Digital microscopy scans digital images from slide-mounted tissue sections which are normally examined under a conventional microscope.

These can be accessed via secure servers by digital pathologists based anywhere in the world.

In many ways this is very much a theme of the moment. Digital technology is being hailed as a potential solution to a number of the problems facing health services and is expected to grow rapidly in the future. According to a study

Digital pathology has recently progressed from a technology which was on the margins to one which is becoming increasingly common in both hospitals and academia

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In the developed world, people are living much longer, but the body has not yet evolved to function as well in later years as it does in its youth

published by Allied Market Research, the digital pathology market is expected to grow from $3,323 million in 2016, to $8,668 million by 2023, growing at a CAGR of 14.8% between 2017 and 20236.

Why is Adoption So Slow?

Digital pathology has progressed from a niche idea to one which is becoming an increasingly common feature of pathology departments.

Even so, adoption has been relatively slow and regionalised. Many innovators have been forced to accept losses on their investments.

So, what is changing?

The conversation has turned towards value-based healthcare. Spiralling budgets and finite resources encourage health services to investigate options which get the best results from the limited resources available to them.

This attitude shines a light on the drawbacks of conventional microscopy. The need to share slides manually can lead to delays if they can’t be sent by courier or have to be sent internationally.

This can cause errors and increases reliance on trained pathologists.

Traditional microscopy requires a microscope to view a glass slide. It shows only one side and one field of view at a time. If a pathologist wishes to view another side, he or she must remember the information from the first slide.

Digital pathology, meanwhile, can view slides side by side on a computer. It can use software to help with analysis and quickly scan and share images with remotely-based teams. Digital images can be integrated easily into a lab data storage system which allows for further learnings, analysis and education.

Given all that, it is perhaps surprising that digital pathology hasn’t advanced further than it already has. The evidence shows that it works and delivers lasting value. The obstacles are familiar in the form of cost and practical implementation but, as we’ll see elsewhere in this Report, overcoming them is far from straightforward. Much will depend on how technology is integrated with existing systems and the attitudes of pathologists and administrators.

Digital pathology has recently progressed from a technology which was on the margins to one which is becoming increasingly common in both hospitals and academia

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SPECIAL REPORT: ENABLING PERSONAL DIGITAL MICROSCOPY

A Digital Revolution Jo Roth, Staff Writer Digital technology is revolutionising the world of pathology, but implementation can be fraught with difficulties. Smaller and more portable devices could be the answer.

D

IGITAL TECHNOLOGY has been shown to have significant benefits in the world of pathology. It has built up an impressive body of evidence proving its effectiveness, so why are adoption levels slower than we might expect?

The reason, to borrow a quote from the movies, is that there’s a difference between ‘knowing the path and walking the path.’ In other words, even if administrators understand the benefits, they still see a host of obstacles standing in their way.

civilian, such as the need to operate around the world and in remote areas7. These workflow assessments can be challenging and administrators may be reluctant to implement innovations until they have a clear and definitive argument for their use. They are looking for guidance and support in identifying how best to go about introducing innovations into their departments.

Financial Considerations

Another problem will be the format in which images are seen. In other words, it’s the difference between a digital image and a glass slide. Pathologists who are accustomed to the latter might be worried about the former. They may not fully trust the clarity of the image or feel that they may pick up details by viewing glass directly which they might miss via a digital image.

There may be lessons to be learned from the world of radiology where CT and MRI scans can deliver extremely high-quality images, but these are often still viewed in black and white. An expert’s capacity to make an informed decision will be affected directly by the quality of the image presented to them.

The act of scanning a slide, therefore, does not create a bottleneck, but the way in which that image is shared could. Poor image quality will hinder pathologists in making effective diagnosis.

Although most uses show that this is not the case, the attitude persists, which is another problem for people attempting to sell new devices.

Attitudes of Pathologists and Administrators Any new technology meets with resistance, especially where conventional systems have been perceived as doing an adequate job. Attitudes from managers and from pathologists themselves can obstruct wider adoption. In many cases, it may be a fear of innovation. If individuals have become accustomed to working in a certain way, they may react against any new technology for which they have to learn new skills or practices.

A 2015 study into the barriers and facilitators of digital pathology found that the number one response was a lack of familiarity with digital slides8.

The most obvious of these is money. The argument, as so often, is between innovators, who will point to savings from greater efficiency, more accurate diagnosis and the avoidance of unnecessary operations, and fiscal conservatives who will point to the upfront cost.

That expense is significant. Although the cost of digital pathology has fallen in recent years, it still represents a considerable outlay. If administrators are struggling to balance tight budgets, they will think carefully about any new expenditure.

Long-term savings will run up against short-term expense and, in many cases, the latter will win.

Buyers will need to see a clear return on their investment and unfortunately, thanks to complicated workflows, that can be difficult to quantify. Metrics can be imprecise and unreliable which undermines trust in the product as a whole.

So, if a seller is attempting to promote a solution to an administrator, he or she will need to be able to demonstrate a clear, verifiable and fast return on investment.

Complexity and Integration Complex workflows also make it difficult to integrate new systems. Any new technology will be disruptive and may have problems integrating into that particular workflow. Each implementation will need to take account of the goals and needs of pathologists together with the infrastructure requirements. These will be unique to each individual environment.

For example, a report into the use of digital pathology in the military found that military pathology had very different requirements to

Image Format

Digital technology has been shown to have significant benefits in the world of pathology. It has built up an impressive body of evidence proving its effectiveness, so why are adoption levels slower than we might expect?

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If a seller is attempting to promote a solution to an administrator, he or she will need to be able to demonstrate a clear, verifiable and fast return on investment

‘It just takes a bit of getting used to, open it up, zooming in and out and going round. And sitting at a computer screen as opposed to looking down a microscope.’

The concept of digital reporting can also be off-putting for some users as another interviewee explained.

“I can’t imagine someone who’s so used to this as me would want to change my routine work to a digital way of reporting.... Because, yeah, I’d be relearning a lot of diagnostic skills but wouldn’t have the time to do it. I wouldn’t see any need to do it.”

Convincing the Doubters That last point is an important one to bear in mind, because it represents one of the key obstacles to making the buying decision. Adapting to digital microscopy represents a big change –

one which pathologists may not feel they have enough time for. It’s a big ask, especially if they do not see a pressing need for the technology.

Although most pathologists may be reluctant to openly admit it, there may be a sense in which this technology represents a threat. Digital technology’s promise is that it will improve turnaround and allow more work to be performed by a smaller number of pathologists. Adopting this technology, they may worry, could see workloads, which already feel intimidating, rise even further.

Understanding, addressing and overcoming these fears could be the key to accelerating the adoption of digital technology in pathology departments and ensuring it truly can become more widespread in pathology units. By doing so, it can become an extremely valuable tool in the fight against the key challenges facing the world of digital pathology.

Any new technology meets with resistance, especially where conventional systems have been perceived as doing an adequate job.

Attitudes from managers and from pathologists themselves can obstruct wider adoption

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Size Matters: Small, Digital Microscopy Could be the Missing Link Jo Roth, Staff Writer Digital pathology is seen as the future by many people, but uptake is slower than might be expected. Could smaller and more portable devices be the answer?

D

IGITAL PATHOLOGY often feels like a product of the future which should be already here. Whether it’s the initial cost, hostile attitudes from managers, a lack of human resources or resistance from professionals, it still struggles to overcome a number of hurdles. However, smaller and more portable digital microscopy devices could prove to be the missing link which solves most of these problems.

Bright Future, Difficult Present It’s hard to deny that digital pathology has a number of issues. In general, attitudes to the concept are relatively positive, but practicalities stand in the way. Cost is an issue; budgets are tight and any upfront investment will need to be justified. Although digital pathology can be shown to have numerous long-term cost benefits, managers will still wonder if they can shoulder the short-term expense. However, practical considerations are often even more important.

New technologies need to be integrated into complex workflows and function with existing infrastructure. They will need qualified people to work with them and, in a world in which digital pathologists are at a premium, developing the necessary human resources presents a significant problem.

Even so, all these challenges are outweighed by the longer-term imperative to get more from existing pathology teams. A survey from the Journal of Clinical Pathology demonstrates the scale of the challenge. It found that 58.5% of institutions had identified digital pathology as a high or highest priority, with improved efficiency, turnaround times and collaboration among the most common advantages.

However, funding for initial outlay, software, staff and pathologist training were thought to be the biggest barriers9. There is clearly interest, the report concluded, and usage is likely to

increase in the future, but potential buyers are still seeking guidance on safe and sustainable implementation. The answer to this problem is to shape technology in a way which overcomes its key barriers to adoption and one way to do that is by making everything smaller and more portable.

Smaller and More Portable Devices According to tech firm Grundium, smaller portable digital microscopes can bridge many of the gaps in the process and its Ocus portable digital microscope aims to do just that. Where many other digital scanners are large and prone to picking up interference from other machines, the Ocus weighs just 3.5kg and can go anywhere.

Its compact and rugged design means it is not just bound to a desk but can be taken outside the hospital and used in the open air. Deployment and set up only takes five minutes and it can be used with relatively little training. This, its makers say, gives it a number of key advantages: 1. C ost: A smaller size comes with a lower cost. Devices can be purchased for each pathologist, in theatres or in academic settings.

2. S ize: A compact design means it is not bound to a desk but can go anywhere. It is designed to be used on desktops and in tight spaces, or easily transported by road, sea or air.

3. E asy to use: Conventional slide scanners are much larger and confined to a single location which makes them dependant on having qualified personnel in that location.

The Grundium Ocus, on the other hand, has been specifically designed to be easy to use.

Operators only need a little training and set up is quick, which reduces reliance on trained and experienced personnel.

4. M obile: Images can be quickly scanned and sent to other pathologists in different locations.

5. E asy integration: If new digital technologies require a substantial overhaul of existing

The ability to work with a browser means slides can be quickly and easily shared by professionals in any location. Images are held securely with end-to-end encryption to ensure the safe and secure transfer of images

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A survey from the Journal of Clinical Pathology demonstrates the scale of the challenge. It found that 58.5% of institutions had identified digital pathology as a high or highest priority, with improved efficiency,

systems it can make their implementation difficult or prohibitively expensive. Grundium’s Ocus, meanwhile, has been designed to work with numerous file formats, which makes it easier to work with whatever is presently in the department.

A key ingredient in its implementation is its browser-based software which has none of the compatibility issues other software might suffer from and can be implemented easily into any legacy system. The ability to work with a browser means slides can be quickly and easily shared by professionals in any location. Images are held securely with end-to-end encryption to ensure the safe and secure transfer of images.

Making New Technology Work Grundium’s marketing material is shaped very much with both the buyer and seller in mind. For the buyer, it offers an excellent piece of technology

which can be used in many different situations.

For the seller it is a great app which overcomes many of the key objections of buyers.

All too often, innovation is designed with a view to what technology can do but not how it will work with what is already in place. It is tempting to design a system from scratch which visualises the perfect operating environment, but that fails to account for what buyers want. They are not starting from scratch but moving on from existing systems and infrastructure.

When a technology fails to gain the traction it needs, the root cause is often down to how it is being sold to the target audience. Those which are successful take the technology and design it in a way which removes the key barriers to purchase. By doing so, they change the conversation around digital pathology from a technology for the future to one of the present.

turnaround times and

All too often, innovation is designed with a view

collaboration among

to what technology can do but not how it will

the most common advantages

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work with what is already in place

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Digital Pathology and an Artificial Intelligence Future Tom Cropper, Editor The future of pathology is digital and it’s opening up a wealth of opportunities in advanced technologies such as AI. But how can health services access that future.

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HE WORLD of venture capital has seen the rise of a new buzz phrase in recent years: digital due diligence. Technology has transformed the world of business so completely that, from an investor’s perspective, a business which has failed to adapt quickly enough may be doomed in the future – even if everything looks good in the present. Because its competitors are moving forward quickly, they will soon find it impossible to compete and so – no matter how great the finances look – they will keep their hands in their pockets.

The same is true to an extent in healthcare.

Digital technology is transforming every part of the landscape. Private companies are delivering innovations, governments are actively supporting its uptake and patients are accessing services with digital platforms at every opportunity. In all these areas, the obstacles and opportunities sound very familiar.

Digital innovation normally holds out the prize of efficiency gains, costs savings and faster turnaround times, while the main obstacles involve initial start-up costs and the difficulty of integrating new systems with old.

As we’ve touched upon in this Report, digital pathology is not without its challenges, but most of these are short term and practical in nature.

It’s a question of affording the technology and managing the integration with legacy workflow processes. The future appears to be very definitely digital and the further we move into the future, the wider the possibilities become.

Image Quality The first step into digital pathology came with 2D digital imaging. These systems have relatively recently been granted approval in most major territories and involve viewing slides in a traditional two-dimensional view.

3D digital pathology attempts to add new layers by stacking slides on top of one another to produce images with much more depth and detail. New solutions promise to section

tissue mass at a micron level, stain it and then examine it under a digital microscope. It allows vastly more data to be stored because the entire tissue mass is being examined.

This data is incredibly important as it puts much more information in the hands of pathology teams, which will lead to improved decisionmaking, analysis and even improved artificial intelligence and machine learnings which can help to process all this information.

Artificial Intelligence A report into the use of life science technology within the UK’s NHS, states that pathology is ripe for innovation as data creates opportunities to change the way care is managed. Tools, such as artificial intelligence (AI), argues the report, will be ‘increasingly important’10.

“Systematic digitisation of pathology images could be readily established providing substantial efficiencies in the pathology service within the NHS,” states the report, “allowing the system to become increasingly virtual and reducing the need for every hospital to have the full on-site set of pathologists.”

Digitisation and data will be crucial in this as it paves the way for AI algorithms to provide insights which are not currently available using conventional approaches.

The technology is in the developmental stage, but the growing amount of data within healthcare systems is making it increasingly viable. Until relatively recently, AI was a great idea for the future – it was easy to get excited about the potential of algorithms to unveil hidden information, but the capacity simply was not there. The big stumbling block has been data – namely that there isn’t enough of it - but that is changing.

As a society, we have become incredibly adept at producing data. The vast majority of data ever produced came into being within the past few years and studies suggest that the amount of data we capture could increase ten-fold in the next ten years11. In the realm of microscopy,

Data is incredibly important as it puts much more information in the hands of pathology teams, which will lead to improved decisionmaking, analysis and even improved artificial intelligence and machine learnings which can help to process all this information

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Those which have progressed further with digital microscopy will represent more attractive destinations for the best and brightest talent

digital technology is making a huge amount of data viewable and shareable.

At the University of Pittsburgh Medical Center, clinicians are building up a library of digital images which could become an increasingly useful resource in the creation of AI. Those images will be vital in helping to develop effective algorithms which can aid pathologists in their diagnoses.

One such system is already being pioneered in which an algorithm can be used to identify potential problems within images. This can be used in two ways – either prior to screening, in which case pathologists will be given insights which can guide them in their observations or afterwards, in which case pathologists can use it either to confirm or correct their initial assessment.

Momentum is gathering behind the technology as it starts to demonstrate its effectiveness.

Speakers at a recent conference pointed to a number of studies which showed that AI could exceed the performance of experts. One of these comes from the Massachusetts Institute of Technology (MIT) where researchers are using a machine learning system to detect whether breast lesions identified in a biopsy might turn out to be cancerous. According to its study, the machine correctly identified 97% as malignant.

Researchers believed that such levels of accuracy could lead to a reduction in the number of unnecessary surgeries by more than 30%12.

Evolutions for the Future Many of these technologies are unproven and, while there have been a number of projects demonstrating the potential of AI in digital microscopy, this technology is still developing.

Several studies have been held in ideal lab conditions – achieving realistic metrics which could be repeated in a daily clinical setting to help build a body of evidence.

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Likewise, AI will need robust and reliable algorithms to deliver effective and accurate insights. A start up at the University of Toronto has recently raised US$1.5million to develop such improved algorithms. These algorithms can be used to distinguish between cells which may be cancerous and those which are simply growing normally. They can be enhanced analytics tools and build upon the effectiveness of devices which are already available.

The pieces of the jigsaw are falling into place.

Innovation in one area such as data is facilitating further developments in advanced concepts such as AI, which brings us back to the concept of digital due diligence. This is something which is already happening in the world of business.

Even if an executive doesn’t see the need for digital technology, they have to consider making their move because, if they don’t, they risk becoming uncompetitive.

For all the impediments to digital adoption, this is where pathology is going. Whether it’s a hospital or academic institution, having the best technology available not only impacts the quality of treatment but also its attractiveness to potential students and employees. Each will want to be working in places which are at the cutting edge of development and are delivering the very best care possible. Those which have progressed further with digital microscopy will represent more attractive destinations for the best and brightest talent.

This is a sector with enormous potential and one which can address some of the key challenges impacting pathology departments. As studies have already shown, diagnosis can be improved, reducing the number of costly operations; additionally, the limits to pathologist numbers can be overcome by automating processes and making images more mobile.

SPECIAL REPORT: ENABLING PERSONAL DIGITAL MICROSCOPY

References: We Lose Control of our DNA From the Age of 55: http://sciencenordic.com/we-lose-control-our-dna-age-55

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Testing Times to Come? An Evaluation of Pathology Capacity Across the UK:

https://www.cancerresearchuk.org/sites/default/files/testing_times_to_come_nov_16_cruk.pdf 3

College Report Shows UK Wide Histopathology Shortage:

https://www.rcpath.org/discover-pathology/news/college-report-finds-severe-staff-shortages-across-services-vital-to-cancer-diagnosis.html 4

Pathologists Shortage Delaying Cancer Diagnosis: https://www.bbc.co.uk/news/health-45497014

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Trends in Pathology Graduate Medical Education: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881980/

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Digital Pathology Market Predicted to Reach $8,668million by 2023: https://www.alliedmarketresearch.com/press-release/digital-pathology-market.html

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Needs and Workflow Assessment Prior to Implementation of a Digital Pathology Infrastructure for US Military and Airforce: http://bit.ly/2Gt5tuw

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Barriers and Facilitators to Digital Pathology: http://eprints.whiterose.ac.uk/86602/1/MEDINFO2015_HistopathologistInterviewsFINAL.pdf

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Digital Pathology Access and Usage in the UK: https://jcp.bmj.com/content/71/5/463

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Life Sciences Industrial Strategy:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/650447/LifeSciencesIndustrialStrategy_acc2.pdf 11

What Will We do When the World’s Data Hits 163 Zettabytes?

https://www.forbes.com/sites/andrewcave/2017/04/13/what-will-we-do-when-the-worlds-data-hits-163-zettabytes-in-2025/#2b442da8349a 12

Artificial Intelligence Helping to Detect Breast Cancer:

https://healthcare-in-europe.com/en/news/artificial-intelligence-helping-to-detect-breast-cancer.html

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Notes:

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