As I am approaching the age of 60 and getting ready to retire and return with a reduced workload, I remember the times when I started my career in cellular pathology 36 years ago. I am from the generation of cellular pathologists who started with a setting that lacked computerised information systems, or computers at all, in their diagnostic or research practice. Errors in typing, when proofed, must be corrected by a ‘Tipp-Ex’ or be totally retyped. Searching for previous reports was done manually on large bound volumes of reports for each year. Computerisation of the written part of our practice and ease of its access and search has dramatically improved productivity. The technology that digitises the image part of our practice offers enormous benefits in selected settings.
My exposure to digital pathology (DP), like many, has started in the educational and quality assurance domains. It was looked upon as an inferior adjunct but would not replace the real slide experience. However, in the diagnostic domain, my first scientific conference discussion about this topic was part of the College of American Pathologist seminar in 1999 titled ‘The Virtual Pathology Lab, from the Autopsy to Data-opsy’. The outline of that vision felt like Sci-Fi at that time. My first chance to engage with this concept in the real world was through the LDPath Group/London in 2013. The concept envisions a cellular pathology laboratory where a team of receptionists, biomedical scientists, pathologists, managers, secretaries, transport/posting staff, and clinicians can cooperate to produce a pathology report without being based in one place. This demands a laboratory information management system (LIMS) which is available to all these professions online from any location and whole slide imaging (WSI). No couriering or posting of slides to the pathologist an no returning of slides to the lab are required. Once filed, if the need to send away material for a second opinion or MDT review, just sharing of digital links is all what is needed. In addition, the design of this process adopts all the principles of Lean/Sigma working to avoid many of the post-analytical incidents. For example, the instantaneous email of the report to the clinician upon authorisation avoids the problems of lost or misfiled paper reports and cuts 1-2 day from turnaround time of procedure to sight of the report. It also ensures that the clinician gets a notification that a result is ready prompting action. Also the use of an App to inform the clinician about their list of outstanding cases and what stage each biopsy is at proves very helpful in reducing phone inquiries.
Another very useful gain from integrating DP and LIMS is the ability to quickly seek multiple second opinions from a large cohort of experts at the touch of a button. Second opinions are instantaneously documented and usually are returned either the same day or the next day in most cases.
Through this concept, I started reporting from my home office in Surrey on material that had been procured in Hertfordshire or Essex. The same material was entered into LIMS in central London, processed in Dorset, and upon authorisation, delivered instantaneously to clinicians’ electronic mailboxes, wherever they are. This also means that if I or the clinicians are travelling outside the country to a conference, the use of an Ultra-HD/Retina-Display laptops would allow for this process to be uninterrupted. Using all the above, I am able to achieve a turnaround time of 95% within 2 days and 98% within 3 days. Requesting additional work is done online with notifications by email to the pathologist when this work is ready. MDT’s are also possible virtually (even before Covid).
After building close professional relations with a delightful group of clinicians over 16 years in Surrey, I needed to relocate to a new part of the country, the beautiful region of north Wales. Traditionally I would have severed all my professional relationships in the private sector with such a move, however using digital pathology these were maintained.
I have moved to north Wales for several reasons, most important of which is the presence of a DP setup in its NHS Lab. The challenges and the use of DP in this setup are different. North Wales is a geographically wide region. It had three cellular pathology labs at Wrexham, Bodelwyddan, and Bangor which were amalgamated into one lab at Glan Clwyd Hospital/Bodelwyddan. Delivering MDT services to each of the three hospital teams using the conventional method would require travelling 180 miles/week for the three dermatology meetings alone. Considering that there are 29 different weekly MDT’s, the availability of digitised slides allowed the full participation of the cellular pathologists in these meetings remotely, thus saving enormous amounts of pathologist time, travel costs, and carbon footprint.
In my current post, I am delighted to have the colleagueship of an excellent dermatologist based at Wrexham Maelor hospital who has been fully trained in dermatopathology. Centralisation has denied this colleague the chance of popping in and discussing the histology of interesting cases with a pathologist at a multiheader microscope or the ability to examine his own patients’ slides. DP has allowed us to have an arrangement where he and all consultant dermatologists and SpR’s are able to request digitisation of the slides of any patient. Consequently, this case can be examined by the clinician for multiple purposes. This includes in addition to diagnostic purposes; postgraduate education, use for the inflammatory skin clinicopathological conference, or for the monthly joint-clinic where clinicians from the three hospitals meet to discuss difficult or rare cases. In addition, I have noticed that giving dermatologists with special interest in dermatopathology unlimited access to our slides has proved to be one of the best quality assurance and diagnostic skill improvement methods. This is because of the emails or phones that I consequently receive from the dermatology team. For example, where the histology report did not match the clinical picture, I receive clinical photographs of the lesion(s) with excellent detailed clinical summary. Then ping-pong discussions develops by email where we eventually reach to a better assessment of the biopsy in most circumstances. The atmosphere of discussions is luckily cooperative rather than negatively critical.
The presence of the DP platform on an all Wales level allows for pathologist from any region to examine digitised slides from any other other region without the need to post these slides. This can provide the ability to seek second opinions or perform routine central reviews at a much faster rate. For example, this feature has speeded up the contribution of the ‘Haematologic Malignancy Diagnostic Service’ to our local haematology MDT. This service is geographically centralised in Cardiff and Swansea, and DP has cut approximately 2-3 days of delay due to packing, posting and booking-in before examination.
All cellular pathology departments receive slide sets for patients where a second opinion or review for MDT discussion is required. Normally these slides are given a local accession number to document the opinion or the review involved. Consequently these slides are returned to source. In order to keep a record of the morphology on which our opinion is based, we keep a digital copy of each slide set we receive before posting it back.
Finally, Covid has challenged many of our educational activities such as the ability to meet for the ‘Interesting Cases/Variances/QA’ and the ‘Black Box’ meetings. Discussions at the multi-head were not safe, therefore we resorted to digitise all the slides involved in these meetings and we linked thereafter through Microsoft Teams. This has allowed us to keep social distancing rules and added the ability to include in these meetings members of staff who are either self-isolating or working from home. Presenting macroscopic images or clinical images is a feasible adjunct and to these meetings. An additional bonus is the ready access to Medline database or Google Scholars live while the meeting is proceeding. This allowed for many of the uncertain facts or arguments to be immediately checked and mostly resolved. Also, where there are heated discussions, the presence of the feature of ‘raising hand digitally to speak’ has almost completely eliminated the simultaneous and side talking which happens inevitably in a physical multi-head microscope discussion. We intend to continue this format even after Covid is over.
As for challenges, one of the problems we face in NHS Wales is the inability to give access to our server for colleagues outside Wales due to stringent computer security and confidentiality concerns. In the future, having a transferable ‘common file format’ and encryption may allow for sharing our cases to a wider circle. Finally, the process of digitisation is an additional step over and above routine cellular pathology preparations, and the adoption of a fast scanning system that requires minimal or no human input beyond filling a rack and loading it to the scanner is essential in order to avoid delays of delivery of slides to pathologists.
In summary DP has revolutionised and improved my practice significantly and therefore it is highly recommended in particular settings considering the cost of this technology.
Dr Essam Raweily 11/08/2021
Dr. Essam Raweily
MBBS, FRCPath, FIAC, Dip Dermpath
Dr Rawaily is a Consultant Cellular & Dermatopathologist based at Betsi Cadwaladr University Health Board. He is currently the clinical Lead of Pathology/ North Wales. His main publications can be seen at: Google Scholars: Dr Essam Raweily’s publications