DigiPatICS: Digital Pathology Transformation of the Catalan Health Institute Network of 8 Hospitals—Planification, Implementation, and Preliminary Results

[Individualization and standardization in head and neck pathology]

Individualization and standardization are seemingly contradictory requirements in medicine. In the treatment of head and neck cancer, both terms have a direct influence on diagnostic procedures, which are usually carried out in pathology institutes. The current article examines the conflicting requirements arising from various technical analyses, regulatory requirements, structural changes due to digitalization, and the advent of personalized medicine. On the one hand, the goal is to promote interdisciplinary exchange by understanding the challenges and, on the other, to provide the otorhinolaryngologist with a practical understanding of the common and current pathological diagnostic tests. Using pathology as an example, it can be shown that standardization of procedures ultimately serves to improve individualized treatment. At the same time, however, the following challenges are also apparent: despite comprehensive regulations and a laboratory environment with digital support, standardization is very time consuming and costly. If similar standardization approaches are to be implemented in an operative environment such as, e.g., ENT surgery, the effort involved can be expected to be equivalent or higher due to the human factor.

Implementing digital pathology: qualitative and financial insights from eight leading European laboratories

Digital Pathology (DP) revolutionizes the diagnostic workflow. Digitized scanned slides enhance operational efficiency by facilitating remote access, slide storage, reporting and automated AI image analysis, and enabling collaboration and research. However, substantial upfront and maintenance costs remain significant barriers to adoption. This study evaluates DP's financial and qualitative value, exploring whether the long-term financial benefits justify investments and addressing implementation challenges in large public and private European laboratory settings. A targeted literature review, semi-structured interviews, surveys, and a net present value (NPV) model were employed to assess DP's impact on clinical practice and laboratory financials. Qualitative findings validate the key benefits of DP, including optimized workflow, enhanced logistics, and improved laboratory organization. Pathologists reported a smooth integration, improved training, teaching, and research capabilities, and increased flexibility through remote work. Collaboration within multidisciplinary teams was strengthened, while case examination efficiency and access to archival slides were notably improved. Quantitative results indicate that DP demonstrates strong financial potential, achieving cost recovery within 6 years. DP investment results in a 7-year NPV of + €0.21 million (m) driven by increased productivity and diagnosis volumes. Although the high upfront costs for scanners, training, and system integration pose a significant barrier to the adoption of DP, larger institutions are better positioned to leverage economies of scale. This study underscores the importance of sustained financial support to cope with the initial investment and regional collaboration in driving widespread adoption of DP. Expanding reimbursement policies for pathology procedures could significantly reduce financial barriers.

Digital Pathology Displays Under Pressure: Benchmarking Performance Across Market Grades

Digital pathology (DP) has transformed the practice of pathology by digitizing pathology glass slides, thereby enhancing diagnostic capabilities. In contrast to radiology, studies comparing the efficiency of DP monitors are limited. This work used a stress test that simulated DP sign-out in practice to evaluate the performance of medical-grade (MG) and consumer off-the-shelf (COTS) displays. Four displays, including three MG and one COTS, were assessed for luminance, contrast ratio, accuracy, and image uniformity. Key metrics, such as luminance uniformity and maximum brightness, were evaluated during a 1-month period that simulated use to reflect an 8-h work day. MG displays outperformed COTS in critical parameters, even though consumer displays were satisfactory for diagnostic purposes. Image uniformity exhibited the most significant variations, with deterioration noted over 2.5% for all displays during the test period. This study compared different types of displays for DP and highlights the importance of regular calibration for maintaining display performance when using DP. Further research is recommended to define validation protocols, including the impact of display aging on DP accuracy.

Crossing the Andes: Challenges and opportunities for digital pathology in Latin America

The most widely accepted and used type of digital pathology (DP) is whole-slide imaging (WSI). The USFDA granted two WSI system approvals for primary diagnosis, the first in 2017. In Latin America, DP has the potential to reshape healthcare by enhancing diagnostic capabilities through artificial intelligence (AI) and standardizing pathology reports. Yet, we must tackle regulatory hurdles, training, resource availability, and unique challenges to the region. Collectively addressing these hurdles can enable the region to harness DP's advantages-enhancing disease diagnosis, medical research, and healthcare accessibility for its population. Americas Health Foundation assembled a panel of Latin American pathologists who are experts in DP to assess the hurdles to implementing it into pathologists' workflows in the region and provide recommendations for overcoming them. Some key steps recommended include creating a Latin American Society of Digital Pathology to provide continuing education, developing AI models trained on the Latin American population, establishing national regulatory frameworks for protecting the data, and standardizing formats for DP images to ensure that pathologists can collaborate and validate specimens across the various DP platforms.

A 25-Year Retrospective of Health IT Infrastructure Building: The Example of the Catalonia Region

Over the past decades, health care systems have significantly evolved due to aging populations, chronic diseases, and higher-quality care expectations. Concurrently with the added health care needs, information and communications technology advancements have transformed health care delivery. Technologies such as telemedicine, electronic health records, and mobile health apps promise enhanced accessibility, efficiency, and patient outcomes, leading to more personalized, data-driven care. However, organizational, political, and cultural barriers and the fragmented approach to health information management are challenging the integration of these technologies to effectively support health care delivery. This fragmentation collides with the need for integrated care pathways that focus on holistic health and wellness. Catalonia (northeast Spain), a region of 8 million people with universal health care coverage and a single public health insurer but highly heterogeneous health care service providers, has experienced outstanding digitalization and integration of health information over the past 25 years, when the first transition from paper to digital support occurred. This Viewpoint describes the implementation of health ITs at a system level, discusses the hits and misses encountered in this journey, and frames this regional implementation within the global context. We present the architectures and use trends of the health information platforms over time. This provides insightful information that can be used by other systems worldwide in the never-ending transformation of health care structure and services.

Design, Implementation, and Analysis of an Assessment and Accreditation Model to Evaluate a Digital Competence Framework for Health Professionals: Mixed Methods Study

BACKGROUND

Although digital health is essential for improving health care, its adoption remains slow due to the lack of literacy in this area. Therefore, it is crucial for health professionals to acquire digital skills and for a digital competence assessment and accreditation model to be implemented to make advances in this field.

OBJECTIVE

This study had two objectives: (1) to create a specific map of digital competences for health professionals and (2) to define and test a digital competence assessment and accreditation model for health professionals.

METHODS

We took an iterative mixed methods approach, which included a review of the gray literature and consultation with local experts. We used the arithmetic mean and SD in descriptive statistics, P values in hypothesis testing and subgroup comparisons, the greatest lower bound in test diagnosis, and the discrimination index in study instrument analysis.

RESULTS

The assessment model designed in accordance with the competence content defined in the map of digital competences and based on scenarios had excellent internal consistency overall (greatest lower bound=0.91). Although most study participants (110/122, 90.2%) reported an intermediate self-perceived digital competence level, we found that the vast majority would not attain a level-2 Accreditation of Competence in Information and Communication Technologies.

CONCLUSIONS

Knowing the digital competence level of health professionals based on a defined competence framework should enable such professionals to be trained and updated to meet real needs in their specific professional contexts and, consequently, take full advantage of the potential of digital technologies. These results have informed the Health Plan for Catalonia 2021-2025, thus laying the foundations for creating and offering specific training to assess and certify the digital competence of such professionals.

Digital pathology structure and deployment in Veneto: a proof-of-concept study

Nowadays pathology laboratories are worldwide facing a digital revolution, with an increasing number of institutions adopting digital pathology (DP) and whole slide imaging solutions. Despite indeed providing novel and helpful advantages, embracing a whole DP workflow is still challenging, especially for wide healthcare networks. The Azienda Zero of the Veneto Italian region has begun a process of a fully digital transformation of an integrated network of 12 hospitals producing nearly 3 million slides per year. In the present article, we describe the planning stages and the operative phases needed to support such a disruptive transition, along with the initial preliminary results emerging from the project. The ultimate goal of the DP program in the Veneto Italian region is to improve patients' clinical care through a safe and standardized process, encompassing a total digital management of pathology samples, easy file sharing with experienced colleagues, and automatic support by artificial intelligence tools.

Digital transition in pathology lab: a survey from the Lombardy region

Objective

Digital pathology is an opportunity to revise the routine and old artisanal workflow, moving to standard operating procedures, quality control and reproducibility. Here the results of a survey promoted by the Coordinamento della Medicina di Laboratorio (CRC Med Lab) of the Lombardy region in Italy are reported to shed light on the current situation of digital adoption in the country.

Methods

The survey composed of 58 questions was sent to 60 pathology laboratories. The results were collected and most significant answers were reported and discussed.

Results

Answers were received from 57 (95%) laboratories, a minority organized in spoke-hub networks (16%) with a centralized processing phase (11%). Hybrid manual/computer-assisted traceability was prevalent (36%), with QR/barcode labeling starting within the pathology lab (23%). Different laboratory information systems (LIS) were employed, mostly with alert functions and/or multimedial file attachments (56% and 46%, respectively). The majority opted for a semi-automated tracking management (44, 77%) and 18 centers (32%) were partly digitizing the routine (¾ scanning < 25% of slides). Whole slide images were retained for 3.7 years in average; in-house blocks/slides archiving was still preferred (30, 53%), with 1838 (±1551) and 1798 (±1950) days (5 years) internal permanence for blocks and slides that are stored in out-source (mean turnaround time for return on-demand 3.7±2.1, range 1-10 days).

Conclusions

The advantages of digital pathology must be balanced against the challenges faced in the structural revision of the pathology workflow. This regional scouting can represent the foundation to build an efficient and connected digital pathology system in the territory.

Transforming diagnostics: The implementation of digital pathology in clinical laboratories

Digital pathology (DP) has emerged as a cutting-edge technology that promises to revolutionise diagnostics in clinical laboratories. This perspective article explores the implementation planning and considerations of DP in a single multicentre institution in Canada, the University Health Network, discussing benefits, challenges, potential implications and considerations for future adopters. We examine the transition from traditional microscopy to digital slide scanning and its impact on pathology practice, patient care and medical research. Furthermore, we address the regulatory, infrastructure and change management considerations for successful integration into clinical laboratories. By highlighting the advantages and addressing concerns, we aim to shed light on the transformative potential of DP and its role in shaping the future of diagnostics.

How many more slides to go until we fully adopt digital cytology?

Two‐liner/synopsis: The digital cytology hub (DCH) has been established under the umbrella of the Cytopathology journal. DCH will help bring about the crucial changes needed to make digital cytology the way of practicing cytology in our laboratories.

Combining graph neural networks and computer vision methods for cell nuclei classification in lung tissue

The detection of tumoural cells from whole slide images is an essential task in medical diagnosis and research. In this article, we propose and analyse a novel approach that combines computer vision-based models with graph neural networks to improve the accuracy of automated tumoural cell detection in lung tissue. Our proposal leverages the inherent structure and relationships between cells in the tissue. Experimental results on our own curated dataset show that modelling the problem with graphs gives the model a clear advantage over just working at pixel level. This change in perspective provides extra information that makes it possible to improve the performance. The reduction of dimensionality that comes from working with the graph also allows us to increase the field of view with low computational requirements. Code is available at https://github.com/Jerry-Master/lung-tumour-study, models are uploaded to https://huggingface.co/Jerry-Master/Hovernet-plus-Graphs, and the dataset is published on Zenodo https://zenodo.org/doi/10.5281/zenodo.8368122.

Cutting-edge technology and automation in the pathology laboratory

One of the goals of pathology is to standardize laboratory practices to increase the precision and effectiveness of diagnostic testing, which will ultimately enhance patient care and results. Standardization is crucial in the domains of tissue processing, analysis, and reporting. To enhance diagnostic testing, innovative technologies are also being created and put into use. Furthermore, although problems like algorithm training and data privacy issues still need to be resolved, digital pathology and artificial intelligence are emerging in a structured manner. Overall, for the field of pathology to advance and for patient care to be improved, standard laboratory practices and innovative technologies must be adopted. In this paper, we describe the state-of-the-art of automation in pathology laboratories in order to lead technological progress and evolution. By anticipating laboratory needs and demands, the aim is to inspire innovation tools and processes as positively transformative support for operators, organizations, and patients.

Invisible for a few but essential for many: the role of Histotechnologists in the establishment of digital pathology

Digital pathology (DP) is indisputably the future for histopathology laboratories. The process of digital implementation requires deep workflow reorganisation which involves an interdisciplinary team. This transformation may have the greatest impact on the Histotechnologist (HTL) profession. Our review of the literature has clearly revealed that the role of HTLs in the establishment of DP is being unnoticed and guidance is limited. This article aims to bring HTLs from behind-the-scenes into the spotlight. Our objective is to provide them guidance and practical recommendations to successfully contribute to the implementation of a new digital workflow. Furthermore, it also intends to contribute for improvement of study programs, ensuring the role of HTL in DP is addressed as part of graduate and post-graduate education. In our review, we report on the differences encountered between workflow schemes and the limitations observed in this process. The authors propose a digital workflow to achieve its limitless potential, focusing on the HTL's role. This article explores the novel responsibilities of HTLs during specimen gross dissection, embedding, microtomy, staining, digital scanning, and whole slide image quality control. Furthermore, we highlight the benefits and challenges that DP implementation might bring the HTLs career. HTLs have an important role in the digital workflow: the responsibility of achieving the perfect glass slide.

[Digital transformation of a routine histopathology lab : Dos and don'ts!]

The implementation of digital histopathology in the laboratory marks a crucial milestone in the overall digital transformation of pathology. This shift offers a range of new possibilities, including access to extensive datasets for AI-assisted analyses, the flexibility of remote work and home office arrangements for specialists, and the expedited and simplified sharing of images and data for research, conferences, and tumor boards. However, the transition to a fully digital workflow involves significant technological and personnel-related efforts. It necessitates careful and adaptable change management to minimize disruptions, particularly in the personnel domain, and to prevent the loss of valuable potential from employees who may be resistant to change. This article consolidates our institute's experiences, highlighting technical and personnel-related challenges encountered during the transition to digital pathology. It also presents a comprehensive overview of potential difficulties at various interfaces when converting routine operations to a digital workflow.

Digitization of Pathology Labs: A Review of Lessons Learned

Pathology laboratories are increasingly using digital workflows. This has the potential of increasing laboratory efficiency, but the digitization process also involves major challenges. Several reports have been published describing the individual experiences of specific laboratories with the digitization process. However, a comprehensive overview of the lessons learned is still lacking. We provide an overview of the lessons learned for different aspects of the digitization process, including digital case management, digital slide reading, and computer-aided slide reading. We also cover metrics used for monitoring performance and pitfalls and corresponding values observed in practice. The overview is intended to help pathologists, information technology decision makers, and administrators to benefit from the experiences of others and to implement the digitization process in an optimal way to make their own laboratory future-proof.

Engaging European society at the forefront of cancer research and care: How discussions at the 5th Gago Conference on European Science policy led to the Heidelberg Manifesto

European cancer research stakeholders met in October 2022 in Heidelberg, Germany, at the 5th Gago conference on European Cancer Policy, to discuss the current cancer research and cancer care policy landscape in Europe. Meeting participants highlighted gaps in the existing European programmes focusing on cancer research, including Europe's Beating Cancer Plan (EBCP), the Mission on Cancer (MoC), Understanding Cancer (UNCAN.eu), and the joint action CRANE, and put forward the next priorities, in the form of the Heidelberg Manifesto for cancer research. This meeting report presents all discussions that shed light on how infrastructures can be effectively shaped for translational, prevention, clinical and outcomes cancer research, with a focus on implementation and sustainability and while engaging patients and the public. In addition, we summarize recommendations on how to introduce frameworks for the digitalization of European cancer research. Finally, we discuss what structures, commitment, and resources are needed to establish a collaborative cancer research environment in Europe to achieve the scale required for innovation.

Stromal tissue segmentation in Ki67 histology images based on cytokeratin-19 stain translation

Purpose

The diagnosis and prognosis of breast cancer relies on histopathology image analysis. In this context, proliferation markers, especially Ki67, are increasingly important. The diagnosis using these markers is based on the quantification of proliferation, which implies the counting of Ki67 positive and negative tumoral cells in epithelial regions, thus excluding stromal cells. However, stromal cells are often very difficult to distinguish from negative tumoral cells in Ki67 images and often lead to errors when automatic analysis is used.

Approach

We study the use of automatic semantic segmentation based on convolutional neural networks (CNNs) to separate stromal and epithelial areas on Ki67 stained images. CNNs need to be accurately trained with extensive databases with associated ground truth. As such databases are not publicly available, we propose a method to produce them with minimal manual labelling effort. Inspired by the procedure used by pathologists, we have produced the database relying on knowledge transfer from cytokeratin-19 images to Ki67 using an image-to-image (I2I) translation network.

Results

The automatically produced stroma masks are manually corrected and used to train a CNN that predicts very accurate stroma masks for unseen Ki67 images. An F -score value of 0.87 is achieved. Examples of effect on the KI67 score show the importance of the stroma segmentation.

Conclusions

An I2I translation method has proved very useful for building ground-truth labeling in a task where manual labeling is unfeasible. With reduced correction effort, a dataset can be built to train neural networks for the difficult problem of separating epithelial regions from stroma in stained images where separation is very hard without additional information.

Digital pathology implementation in a private laboratory: The CEDAP experience

Introduction

The transition to digital pathology has been carried out by several laboratories across the globe, with some cases described in Portugal. In this article, we describe the transition to digital pathology in a high-volume private laboratory, considering the main challenges and opportunities.

Material and methods

Our process started in 2020, with laboratory workflow adaptation and we are currently using a high-capacity scanner (Aperio GT450DX) to digitize slides at 20×. The visualization system, Aperio eSlide Manager WebViewer, is integrated into the Laboratory System. The validation process followed the Royal College of Pathologists Guidelines.

Results

Regarding validation, the first phase detected an error rate of 6.8%, mostly due to digitization errors. Phase optimization and collaboration with technical services led to improvements in this process. In the second validation phase, most of the slides had the desired quality for evaluation, with only an error rate of 0.6%, corrected with a new scan. The interpathologist correlation had a total agreement rate of 96.87% and 3.13% partial agreement.

Conclusion

The implementation and validation of digital pathology was a success, being ready for prime time. The total integration of all laboratory systems and the acquisition of new equipment will maximize their use, especially with the application of artificial intelligence algorithms.

Digital pathology world tour

OBJECTIVE

Digital pathology (DP) is currently in the spotlight and is rapidly gaining ground, even though the history of this field spans decades. Despite great technological progress, the adoption of DP for routine clinical diagnostic use remains limited.

METHODS

A systematic search was conducted in the electronic databases Pubmed-MEDLINE and Embase. Inclusion criteria were all published studies that encompassed any application of DP.

RESULTS

Of 4888 articles retrieved, 4041 were included. Relevant articles were categorized as "diagnostic" (147/4041, 4%) where DP was utilized for routine diagnostic workflow and "non-diagnostic" (3894/4041, 96%) for all other applications. The "non-diagnostic" articles were further categorized according to DP application including "artificial intelligence" (33%), "education" (5%), "narrative" (17%) for reviews and editorials, and "technical" (45%) for pure research publications.

CONCLUSION

This manuscript provided temporal and geographical insight into the global adoption of DP by analyzing the published scientific literature.

Measuring the Digital Skills of Catalan Health Care Professionals as a Key Step Toward a Strategic Training Plan: Digital Competence Test Validation Study

Background

Despite Catalonia being an advanced region in terms of digital health adoption, the “Forum for Professional Dialogue” identified the need to improve information and communication technology (ICT) competences as one of the present and future challenges for health care professionals (HPs).

Objective

We aimed to validate the digital competence test developed ad hoc for this study and to measure the digital competence level of Catalan HPs to establish their current level as the baseline for designing a strategic training plan.

Methods

An exploratory observational study was conducted based on a voluntary survey where sociodemographic, professional and digital tool knowledge, digital tool use, and training needs data were collected and based on the score obtained from a digital competence test developed ad hoc. The digital competence test consisted of 2 “real-life scenarios” with 7 and 11 questions.

Results

In total, 803 HPs, of whom 612 (76.2%) were women, completed the survey between June 28 and July 16, 2021. Most participants self-rated their digital competence level as either intermediate (384/803, 47.8%) or basic (357/803, 44.5%). The mean score in the digital competence test was 22.6 (SD 4.3). Therefore, most participants displayed a basic level of digital competence. The internal consistency of the digital competence test was 0.66, and the discrimination index of all questions was ≥0.2 for all items except for 1 question.

Conclusions

This exploratory study highlights the need to improve the digital competence of HPs working in Catalonia, with special effort being made to provide training according to the specific needs of the different HP profiles. The results have informed the Health Plan for Catalonia 2021-2025 and lay the foundations for the development and deployment of a framework program for the digital competences of HPs. The developed digital competence test shows acceptable consistency for the objective pursued, although improvements are needed to fine-tune its accuracy.