Telepathology and Digital Image Analysis

Vol. 19 • Issue 5 • Page 24

In the not-so-distant past, our radiology colleagues went through a digital evolution and revolution similar to that which pathology and lab medicine finds itself. Almost overnight hard, hand-held x-rays and films thrown up onto a dark room light box became images on computer screens, now standard practice and standard of care. Similarly, in lab medicine, entire microscope slides can now be transformed into whole slide digital images, viewable on almost any computer or screen. These images are far from still or static; rather, one can move a microscopic digital image as they would a routine slide, with the ability to zoom in and out with a simple computer mouse.


Multiple hardware and software companies have strategically invested considerable sums into the digital pathology realm with an eye to improving and advancing routine diagnostic healthcare, education and research. For many years, simple video streaming has been used in hospital and lab settings to “beam” an image from one set of trained eyes to another. The Internet and slide scanning technology affords the opportunity for those same images to be available instantly anywhere. Many of the strategic planners and developers are working full bore at the task of making the technology user friendly and readily accessible.

In Clinical Practice (Px), a not-for-profit professional networking portal for the global pathology community, brings the field of pathology into the digital age with Web 2.0 features designed to promote exchange of pathological cases, ideas, knowledge, information, products and services. Through Px’s telepathology capabilities, pathologists can stay connected with their professional network and members to collaborate on cases to gain a second opinion.

(Read more about in the June 2009 issue of ADVANCE for Administrators of the Laboratory: The healthy number of industry entrants into the ring of development has rapidly pushed the pace at which these technologies will be used in practice settings. Among the major players are: BioImagene, Hammamatsu, Olympus, Leica, Nikon, Aperio and GE.

Each company’s system has its own benefits, including proprietary software systems, speed of scan, rapid technical support and repair, and Z-axis scanning. BioImagene, for example, has an image viewer that allows for easy remote access to images and excellent customer support. The most successful company, however, will be the one that designs the system for the pathologist from the practitioner’s point of view rather than from the engineer and designer’s perspectives. Collaborative efforts will lead to success.

Regulatory Issues

The diagnostic image scanning and tissue images are carefully undergoing scrutiny and are in the midst of FDA approval processes. The current positive feedback from those trials will further validate that the future is now. At issue is whether primary digital diagnosis is as accurate as microscopic diagnosis and whether diagnosis is repeatable among pathologists when that diagnosis is made from a digital image. The FDA has approved digital diagnosis of some specific subsets of analysis, such as HER2 image analysis.

Digital Advantages

Pathologists embrace this feedback and must carefully consider all options. It’s clear, though, that this automation presents numerous advantages. Digital slide scanning, for example, minimizes barriers to pathology expertise. Experts around the world will now be available at the click of a mouse to view difficult cases and confirm diagnostic impressions without time delay and, hence, treatment delay. Underserved nations may now be better served. The Western world pattern of outsourcing in many sectors of the economy will be reversed as the vast intellectual capital in our practitioners will be sought and insourcing of diagnostic care will shift to where the expertise resides.

The quality of the imaging is also improved. From a general practice point of view, slides are viewable up to 40x with great clarity. Competition and Moore’s law will quickly close any existing gaps that the end user may find. Moore’s law states that computer speeds and computer storage improve logarithmically over time. Competition in this area will accelerate these improvements.

An overlooked advantage is that the technology allows for vastly improved ergonomics in day-to-day practice. Many pathologists experience shoulder or back discomfort by the end of a long diagnostic microscope day. With digital slides, images can be viewed on a large, high definition screen, eliminating the need to lean or hunch over. Improved comfort within the work setting inevitably improves productivity.

Digitization of slides also presents the ability to archive vast amounts of diagnostic and research material, which can allow for cross institutional collaboration with major research and teaching databases. Digital data will be more readily available for those researching difficult or orphan diseases.

Financially Feasible?

Is the cost to adopt digital microscopy inexpensive yet? The short answer is no, but consider this: The cost of not entering the digital realm may catch many labs off guard and by surprise, as contracts and expert microscope slide work may be repositioned in the market place. The technology certainly holds the possibility of shifting the current lab practice paradigms altogether. Those who adopt the technology will be strategically positioned for survival. Centers of diagnostic excellence will be those who can enter into the market of treatment of patients anywhere and everywhere with instant technology. In the realms of radiology, those who did not change were essentially forced out of the marketplace through retirement or attrition.

Personal Perspective

As a subspecialized board-certified dermatopathologist with a busy and growing practice, I have had the opportunity to use digital microscopy while at lectures, meetings and conferences to provide seamless, non-delayed care to distant patients back home. Imagine the possibility of viewing consultation work on your smart phone, laptop, iPad, etc. when you are away from the office to keep patient care on track. The technology exists to allow that current procedure and from my experience it works. The brave new world is indeed here. The future is now. The digital pathology revolution is intriguing, unique and exciting.

Dr. Cole was trained at the Mayo Clinic, Minneapolis, and in New York City with Dr. Ackerman in skin pathology. Dr. Cole is board-certified in anatomic pathology, clinical pathology and dermatopathology, has medical licenses in 15 states and runs a free standing, independent, local, regional and national dermatopathology service known as Cole Diagnostics Inc. in Boise, ID.