Digital Slide Imaging: Is Outsourcing Coming Next?

This article appeared in PathologyToday, published by ASCP and written by its president, Dr. John S.J. Brooks.  Normally when I see such a title – the implication of whole slide imaging as a no-brain gateway for outsourcing and its implications to pathology practice in this country, I am left to ponder who would think this.  That biopsies and surgical specimens obtained in US Labs are seamlessly going to be scanned and read overnight by a pathologist in India or Australia (presumably for less money but with equal or greater quality, right?).  Nonetheless, I am left sending e-mails and replies to authors to tell them about cost, technology obstacles, file sizes, market need, relevance, medico-legal issues, reporting, quality assurance, market need (yes – I said this twice – because there is no market and no need).  Still ponderers of such thoughts warn that I should get a medical license in India to sign out cases from the US if I want to keep my job.  They tell me to look at radiology – NightHawk in particular as a business model for outsourcing pathology.  The simple reply is that pathology obviously is not radiology, there is no need to sign out hernia sacs at 2 AM somewhere as much as there is the need to have competent, board certified radiologists (US born and trained, credentialed at hospital receiving care, etc…) somewhere to read chest X-rays, CTs and MRIs at 2 AM.  Most notably, these files start as a digital format, obviating the need for conversion to a digital data set and the sizes are much, much smaller for any particular study.  Consider the time to scan a 60-slide breast case, scan, upload, transfer, download, view and report.  You get the idea.

In any case, Dr. Brooks has very poignantly and succinctly nailed this one in the below article, available at on the ASCP website (Download pathology_today_jul07.pdf).  It should be mentioned that both ASCP and CAP have organized task forces to look at these issues.  As Dr. Brooks points out, I do not think there is an immediate threat, but rather an opportunity to incorporate these new technologies into our clinical business practices.

Modern life has its peculiar paradoxes: the cell phone and the personal digital assistant (PDA) are but two examples of the double-edged swords of life in the fast lane (Is there a slow lane? Can I get on it?). Cell phones make it easy to speak to anyone anywhere, but the problem is that anyone can also reach you anytime and anywhere. PDAs are the same—only with e-mail.

For pathologists, the ability to create digital images from microscopic glass slides is now a reality, complete with depth of field and the same “two edges” as cell phones and PDAs. Until recently, the profession has been preoccupied with all the potential good this new process could lead to: use in education of residents and medical technology students, in clinical conferences for patient care, and in telepathology for either education or expert consultation. The ability digital imaging gives us to detect and compare previously unrecognized cell and tissue detail for diagnosis has great potential to improve the diagnostic process. Finally, the ability to diagnose digital images—“slides”—at home is a (pleasant?) possibility.

On further reflection, other implications come to mind. Will this wonderful technology turn on us like a double-edged sword? Will all histology slides be imaged and sent to far-off places for interpretation? Will anatomic pathology services also be outsourced? If so, how soon would this become truly feasible? Anxious pathologists worry that “This is right around the corner!” This sense of immediacy reflects the fact that radiologic images are already being electronically transported to places like Australia for interpretation.

However, what has happened in radiology differs from what might happen with pathology. The lack of night-time radiologic coverage across a spectrum of Xrays, MRIs, and CT scans was previously the rule in many hospital settings. There was both a need and demand for services that were not, for good reasons, able to be covered by radiologists in the U. S. Currently no such unmet demand for pathology services exists.

The Society has been focusing on this issue since it was first identified in 2005 by the first ASCP Task Force on the Future of Pathology and Laboratory Medicine, which I had the privilege to chair. Because of the weighty array of topics confronting us, ASCP has created a second Task Force on the Future to follow up on key issues.

The outsourcing potential for digital imaging is a multifaceted problem, one that is on the minds of the best Information Technology leaders in Pathology. As a first pass (and as a non-IT person), I suggest this particular “threat” requires a lot to happen before digital outsourcing affects us directly. For example, each site producing slides would have to purchase the equipment to scan all slides. Capital would need to be invested. Digital imaging requires huge amounts of memory and has related delivery issues. And, our currently familiar and comfortable microscopic approach to using traditional slides will need to change before the profession is ready to adapt to reading and making diagnoses directly from a computer screen.

Then there are the legal concerns—credentialing, licensing, malpractice coverage for those in distant lands tailored to potential lawsuits in this country, state by state. Also, will the American public allow this? A final diagnosis rendered by a pathologist remains much more definitive than the typical radiology report. Finally, the driving forces behind this sort of change would likely differ from those that drove change in radiology, because we have adequate coverage of AP services now; the driver may be financial—i.e., cheaper services. Suffice it to say that, unlike other threats that are

clearly immediate, the outsourcing of anatomic pathology diagnosis through digital technology is at least some years away. In the meantime, let us all continue to focus on how to best approach the future, not by preserving past practices, but by embracing change and trying to influence it as it comes. We must change to adapt, and this is made all the more clear by what is now happening with outpatient biopsies. For the first time in my life as a pathologist, I confess to being quite concerned about our future, unless we confront, head-on, the serious immediate issues facing us, such as where and how biopsies should be diagnosed and whether there is merit in a common repository for patient material (previously called our system of local laboratories, which has served America’s patients very well).

Those are my thoughts for this month. Please don’t hesitate to contact me with your thoughts at president@ascp.org.

ASCP President’s Message

John S.J. Brooks, MD, FASCP