In the last 15+ years, I have had the opportunity to be involved in many informatics projects, from LIS builds to digital pathology (DP) implementations, to the creation of a novel integrated reporting workflow that combined disparate radiology and pathology data. In many of these projects, it really did feel as if we were breaking new ground and exploring where no one had been before. Even with our LIS implementation, when we had questions for the vendor about what other institutions had done in similar situations, we were usually given the unsatisfying answer, “all institutions are different,” and were left to discover things on our own. While this is true and workflows due to environmental, clinical workload or staffing differences are often unique to institutions, there is certainly opportunity to share experiences to develop collective knowledge throughout our industry.  After these projects were completed (or completed to the point of operational launch), we could not help but reflect on how we could have done things differently (or, rather, how we could have done things better). Many of our errors were not necessarily intuitive, but all had the benefit of increasing our knowledge.

 

A common starting point for many projects happens when institutional leadership (with fear of missing out) tells the anatomic pathology director, “We need to go digital. Go get a scanner!” Of course, without actually starting with a sober needs assessment, you are already on the wrong foot. Another very common starting point is buying a scanner to support tumor boards. This seems like a great idea. If the slides are scanned, they will be much easier to find, and the presentation to our clinical colleagues will look much more snazzy, right? What’s not to love? Well, not so fast. Scanned slides work wonderfully for conference preparation and presentation if the slides are already scanned and organized for easy retrieval. But if your workflow requires the slides to be retrieved, scanned and then reviewed in between the tumor board case list distribution and the conference, this fancy new digital workflow is actually introducing a time consuming and technician dependent process without perhaps adding significant value to the process already in place. Indeed, by introducing a scanning step to your tumor board preparation workflow, you are reducing the time available to submit a case and developing a technology reliance that could easily fail if there is a scanning error or untimely login error. This can be a little embarrassing if just last week you told your colleagues the cutoff time to submit a pathology case for tumor board will be brought forward to accommodate this expensive new digital system. Sorry! Of course, when you have the opportunity to learn this lesson it can really provide insight on not only how a complete DP solution can do wonders for your workflows, but an incomplete solution may be worse than no solution at all. If your group has bravely invested resources and explored the digital pathology-verse and find yourself wishing you could ask for a Mulligan, you’re probably in good company.

 

To avoid this pitfall, along with a needs assessment, a comprehensive standard operation procedure (SOP) of the end-to-end workflow from case list submission to image organization to image viewing is essential to close the loop on implementation of DP for tumor board support. Furthermore, if your institution has already invested in a vendor-neutral archive (VNA) software for image management, it may already provide the solution for image management and presentation. If so, depending on the functionality of the VNA, this could significantly reduce the start-up costs and complexity of dipping your feet into the DP world.

 

Having made enough of these errors of both omission and commission over the years, I have developed a few general principles on how to go about avoiding them in the future. Many concepts are universal, and some are very specific to a project. First and foremost, any substantial project should begin with a needs assessment, followed by a comprehensive business plan that addresses exactly what you are trying to do and who will be doing it. This will be where you discover the return on investment (ROI), which may include both financial and non-financial benefits. As best you can, you should try to get input from all operational stakeholders, these include department and institutional leadership, IT leadership, pathology faculty and histology staff. In some institutions, the IT leadership will be split into many teams, such as LIS support, network team, IT security, EHR team, and so on. An IT project manager is essential to bring all these stakeholders together. Your belief of what is technically possible may be very different from your IT project manager’s idea of what is technically practical. If you can avoid paralysis from over-analysis, you’re off to a good start. A coherent business plan can also help you overcome possibly the greatest challenge of getting your project started, securing funding.

 

Thereafter, your challenges will come in three forms:

  • Technical
  • Regulatory/compliance
  • Social

 

If, earlier, you involved the appropriate stakeholders in the business plan development (and secured the necessary funding), the technical challenges should be surmountable. Fingers crossed. Your next challenge will be regulatory and compliance. Again, proper business plan development should anticipate and avoid most of these challenges. Nevertheless, sometimes your compliance team may introduce an obstacle you could not foresee and will compel you to take a different approach. In my prior position, we had purchased a Leica LV1 and a remote image viewing software platform to support our frozen section service. However, in between purchasing the software and installing it, the software had been hacked, and our IT compliance overlords withdrew permissions to use it. There was no getting around this issue, and we were forced to develop another solution. Compliance and regulatory challenges cannot be avoided or ignored, but they should not be showstoppers. Some creative thinking with your team usually finds an alternative solution. The last challenge, which, in my opinion, is actually the hardest to overcome, is the “social engineering” that may be involved with your group to generate positive engagement with this new technology. There are, of course, various ways to encourage adoption of new technologies (such as DP) that are beyond the scope of this blog, but suffice to say, if this issue is not carefully considered and if forethought is not applied to this potential problem, the mysteries of passive-aggressive behavior can absolutely kill your project.

 

All the errors we discover in our DP journey can be somewhat difficult to document and share in published literature, but they may make for a useful roundtable or panel session at a meeting. Ultimately, by sharing our more regrettable experiences with the wider community in an open and safe venue, our mistakes can be educational and avoidable, rather than expensive and repeatable.

 

W. Dean Wallace, MD, FCAP

Professor of Pathology 

Keck School of Medicine of USC