CAP Article from April

[TheCritic]

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Pathology in the Digital Age

I know we've talked about this topic to some degree in the past, but this article raised my level of interest in this topic. I can't see any reason why I could haven't a sweet a** flat screen in my office one day to look at slides with.

 

[trent05]

The author makes a bold statement by saying "I beg to differ and am prepared to predict that digital pathology is the way of the future and will become as established and routine over the next three to seven years as the autoanalyzer and automated cell counting." I don't think it will happen in the next 3-7 years, but maybe 15 to 20. From the demos I've seen, the big problem is not resolution but of memory storage.

 

[yaah]

I agree - as it is now you still have to prepare the slide by normal methods, then have it stained, then SCAN it, then do all the stuff with looking at it on the screen. You can skip everything after "have it stained" and just look at it, it takes far less time and effort. Now, eventually people will streamline the process and centralize it, but I don't think it will really be a helpful technology in many practices for awhile. Where it will help most is for big major labs who can send out images to all the experts instead of delivering slides. I think Bostwick already does this.

I should also add, I have seen these technologies and I still prefer looking at it under the scope. I see more and it is easier to manipulate. That may change, obviously.

 

[mlw03]

my question would be speed - could images really be scanned that quickly? for off-site reading of slides, could that massive amount of data be sent quickly enough to make this practical for outside expert opinion? and could the viewer "move" the slide around quickly (ya know how when you move a google earth image it gets fuzzy for a few seconds and then refocuses? that would get annoying if looking at 200 "slides" a day)?

on a related note, if this technology eventually comes to fruition, doesn't that make outsourcing that much easier? if you can send the data to the expert at University of XXX, you can send it to Kirachi or Mumbai just as easily, where the pathologist probably makes far less than their American counterpart.

 

[LADoc00]

my question would be speed - could images really be scanned that quickly? for off-site reading of slides, could that massive amount of data be sent quickly enough to make this practical for outside expert opinion? and could the viewer "move" the slide around quickly (ya know how when you move a google earth image it gets fuzzy for a few seconds and then refocuses? that would get annoying if looking at 200 "slides" a day)?

on a related note, if this technology eventually comes to fruition, doesn't that make outsourcing that much easier? if you can send the data to the expert at University of XXX, you can send it to Kirachi or Mumbai just as easily, where the pathologist probably makes far less than their American counterpart.

Im testing a new software system that is crazy. About 100x better than Aperio IMO. When it does get out there, it will change everything. I wasnt a believer until a few weeks ago when I got ahold of it.

The front end is completely automated. The slide is loaded, scanned and uploaded to the web via robots. The image resolution is mind boggling, from low pow. 2x down to 100x oil immersion and best of all you only data store those jpeg frames that highlight your bottom line Dx. The glass is stored at some off site.

dont PM me for the name, I cant say anything more.

 

[TheCritic]

.......The front end is completely automated. The slide is loaded, scanned and uploaded to the web via robots........

You've got to listen to me. Elementary chaos theory tells us that all robots will eventually turn against their masters and run amok in an orgy of blood and the kicking and the biting with the metal teeth and the hurting and shoving.

 

[mlw03]

You've got to listen to me. Elementary chaos theory tells us that all robots will eventually turn against their masters and run amok in an orgy of blood and the kicking and the biting with the metal teeth and the hurting and shoving.

isn't that the plot of a will smith movie? in any case, it's crazy to think that the technology in the article is apparently a lot closer than i would have thought. if what LA is describing can be done affordably and allows equal diagnostic capabilities to traditional microscopy then that would be very cool.

 

[Neddy]

on a related note, if this technology eventually comes to fruition, doesn't that make outsourcing that much easier? if you can send the data to the expert at University of XXX, you can send it to Kirachi or Mumbai just as easily, where the pathologist probably makes far less than their American counterpart.

A bit of a scary idea that. Still, I think it would be more likely to play out the way "outsourcing" in radiology has - the radiology professional assocs have enough power to ensure that all films are eventually read by US - certified radiologists, so the outsourcing gets used more as an additional tool for US radiology practices, rather than as competition. I wouldn't be surprised if high-volume technical services (e.g. cytology screening) started to be done via outsourcing, but I think it will always be an American pathologist signing out on the bottom line for the forseeable future.

 

[DrBloodmoney]

There's no market for nighthawk services for pathology. So that worry about outsourcing/ Pathologists in Australia worry is overblown.

Bandwidth, bandwidth, bandwidth, and storage. These are the major problems with this - once you conquer the turnaround time problems scanning in your whole surgical pathology run (which the tech is nowhere near yet). The only reason that radiology is going digital is because their MRI/CT machines capture all of the images digitally now. Slides are going to be analog for a very long time.

 

[LADoc00]

There's no market for nighthawk services for pathology. So that worry about outsourcing/ Pathologists in Australia worry is overblown.

Bandwidth, bandwidth, bandwidth, and storage. These are the major problems with this - once you conquer the turnaround time problems scanning in your whole surgical pathology run (which the tech is nowhere near yet). The only reason that radiology is going digital is because their MRI/CT machines capture all of the images digitally now. Slides are going to be analog for a very long time.

I TOTALLY agreed with you before a few weeks ago. Since about 1985, I have had a somewhat hobby-like interest in digital images, image compression and data storage and I didnt think it could be done but I was wrong. HOW it is being done, I have no idea. It seems to defy what I have seen with other vendors like Aperio (which is slow, clunky but still marginally operational) by being lightning fast with insane resolution. Im getting a Denzel Washington "Deja Vu" like feeling when I use it.

 

[CameronFrye]

I TOTALLY agreed with you before a few weeks ago. Since about 1985, I have had a somewhat hobby-like interest in digital images, image compression and data storage and I didnt think it could be done but I was wrong. HOW it is being done, I have no idea. It seems to defy what I have seen with other vendors like Aperio (which is slow, clunky but still marginally operational) by being lightning fast with insane resolution. Im getting a Denzel Washington "Deja Vu" like feeling when I use it.

Sounds very cool and could definitely be a useful tool. Although the technology may be around the corner, I still can't see massive outsourcing of routine specimens becoming an issue anytime in the foreseeable future. However, I could definitely see this technology used for consultations.

 

[SLUsagar]

Sounds very cool and could definitely be a useful tool. Although the technology may be around the corner, I still can't see massive outsourcing of routine specimens becoming an issue anytime in the foreseeable future. However, I could definitely see this technology used for consultations.

agreed. We've used it in the past while at the VA to get free AFIP consults from a few scanned slides.

 

[mlw03]

There's no market for nighthawk services for pathology. So that worry about outsourcing/ Pathologists in Australia worry is overblown.

Bandwidth, bandwidth, bandwidth, and storage. These are the major problems with this - once you conquer the turnaround time problems scanning in your whole surgical pathology run (which the tech is nowhere near yet). The only reason that radiology is going digital is because their MRI/CT machines capture all of the images digitally now. Slides are going to be analog for a very long time.

i'm not sure what this term means. can you explain please?

excellent point about how radiology is digital because the imaging technology went there on its own because that's how the engineers thought it best to capture the images.

 

[TheCritic]

i'm not sure what this term means. can you explain please?

excellent point about how radiology is digital because the imaging technology went there on its own because that's how the engineers thought it best to capture the images.

A poem to explain:

At 3am in the morning the ER doctor needs a radiograph read.
The radiologist is fast asleep, snug in his bed.
The radiologist in Australia (nighthawk service) reads the image and makes a diagnosis.
Aren't you glad you don't have an acquired phimosis?

Sorry if you actually do.

 

[mlw03]

ah... very nice explanation the Poe himself would be proud of. i gotcha though - there's far more overnight need for imaging studies than there is a need for 2am review of a sigmoid polyp.

so american ER docs will base major decisions on non-US licenced physicians' readings of films? that sounds mighty risky. "i'm sorry ma'am, but your husband died while on the table for an appendectomy it turns out he never needed because the foreign radiologist misread the CT scan" - i dunno how that would hold up in court. this argument is part of why i'm not afraid american pathologists are gonna be squeezed out by outsourcing. i can't imagine american surgeons and internists making major treatment decisions based on a pathology report from a doctor who's never passed US exams. while i have no doubt that foreign pathologists can be just as competent as american ones, it's just too undefendable in a lawsuit, i would think.

 

[trent05]

The nighthawks in Australia are US boarded radiologists. The whole outsourcing scare is way out of proportion, especially when they try to include path in the near future. Come on...

 

[CameronFrye]

A poem to explain:

At 3am in the morning the ER doctor needs a radiograph read.
The radiologist is fast asleep, snug in his bed.
The radiologist in Australia (nighthawk service) reads the image and makes a diagnosis.
Aren't you glad you don't have an acquired phimosis?

Sorry if you actually do.

Yeah, currently, outsourcing of radiology is driven by radiology groups who have chosen to forgo some income to avoid call. Overnight pathology services are so rare, there is no demand for such a service.

The real threat to radiology (and perhaps pathology) would be cost-driven outsourcing. However, I don't see this being a very serious threat (even for radiology). Our society is too litigious at the moment, the thought of outsourcing healthcare to "inferior" foreign doctors would get people in an uproar, and a majority of clinicians like to have someone they can interact with when they have questions or when problems arise. Heck, just check out the backlash that has occurred against outsourcing of call centers.

 

[CameronFrye]

The nighthawks in Australia are US boarded radiologists.

Yep. Someone can correct me if I'm wrong, but I believe non US boarded radiologists cannot currently read those studies (or perhaps insurance companies just won't pay for it).

 

[yaah]

Yep. Someone can correct me if I'm wrong, but I believe non US boarded radiologists cannot currently read those studies (or perhaps insurance companies just won't pay for it).

If I am correct, the other thing about nighthawk services is that they always have a disclaimer so that if they miss something, you can't blame them financially or whatever. And every study they read is "preliminary" so it has to be read again by the local radiologist in the morning. I may be wrong about the first part, but I'm pretty sure about the latter.

 

[CameronFrye]

If I am correct, the other thing about nighthawk services is that they always have a disclaimer so that if they miss something, you can't blame them financially or whatever. And every study they read is "preliminary" so it has to be read again by the local radiologist in the morning. I may be wrong about the first part, but I'm pretty sure about the latter.

Yeah, that sounds about right.

 

[TheCritic]

The nighthawks in Australia are US boarded radiologists. The whole outsourcing scare is way out of proportion, especially when they try to include path in the near future. Come on...

So do radiologists get incentives to relocate or are these docs already there? How does that work?

 

[LADoc00]

If I am correct, the other thing about nighthawk services is that they always have a disclaimer so that if they miss something, you can't blame them financially or whatever. And every study they read is "preliminary" so it has to be read again by the local radiologist in the morning. I may be wrong about the first part, but I'm pretty sure about the latter.

true. they are all in "prelim" status coming from NightHawks. Technically, NHs sign nothing out when on call.

There would be zero market for this in path. I dont want to explain it, but trust me. The thing I would worry about is the fact it might be used by clinicians to client-bill.....a very big worry in fact.

 

[pathstudent]

true. they are all in "prelim" status coming from NightHawks. Technically, NHs sign nothing out when on call.

There would be zero market for this in path. I dont want to explain it, but trust me. The thing I would worry about is the fact it might be used by clinicians to client-bill.....a very big worry in fact.

I talked to a gastroenterologist who said that their group, which currently has their own histo lab and two pathologists, next plan, when it can be done, is to let go of their patologists, make the slides in their lab and have them read in India and then bill the insurance company for the pathology. I asked him if he worries about a drop in quality and also if he wouldn'r rather know who is reading his slides, and he pragmatically replied, "Sure, but if it puts an extra 50k in my pocket a year...." and then shrugged his shoulders.

These groups of physicians aren't super greedy or evil. They are just using common sense.

Medicine was once a genteel profession where altruism and collegiality were the highest principles. Now medicine has nothing to do with medical care to benefit others. Medicine is a way of making cash. Even in academics, this has become the case.

 

[TheCritic]

"Sure, but if it puts an extra 50k in my pocket a year...." and then shrugged his shoulders.

These groups of physicians aren't super greedy or evil. They are just using common sense.

Common Sense? Are you serious? So are you just talking about this specifically, or do you think any way to alter your practice to increase profit is common sense regardless of the impact on patient care? Is this you?

 

[CameronFrye]

I talked to a gastroenterologist who said that their group, which currently has their own histo lab and two pathologists, next plan, when it can be done, is to let go of their patologists, make the slides in their lab and have them read in India and then bill the insurance company for the pathology. I asked him if he worries about a drop in quality and also if he wouldn'r rather know who is reading his slides, and he pragmatically replied, "Sure, but if it puts an extra 50k in my pocket a year...." and then shrugged his shoulders.

These groups of physicians aren't super greedy or evil. They are just using common sense.

Medicine was once a genteel profession where altruism and collegiality were the highest principles. Now medicine has nothing to do with medical care to benefit others. Medicine is a way of making cash. Even in academics, this has become the case.

It's human nature that people will try to bilk as much money from the system as possible. However, (even though it's ridiculously slow and cumbersome) the system (medicare) eventually cracks down on these loopholes. When Medicare first appeared, there were a lot of people in healthcare who made huge fortunes (you had a new payer who always paid up and didn't ask too many questions). The govt eventually cracked down, and this self-referral nonsense will probably meet the same fate. However, a lot of these crackdowns go too far and will probably end up burning honest labs. For example, instead of eliminating the pod labs, they'll just knock back the reimbursements on TA's (in the case of GI) or BCC's (in the case of derm).

 

[pathstudent]

Common Sense? Are you serious? So are you just talking about this specifically, or do you think any way to alter your practice to increase profit is common sense regardless of the impact on patient care? Is this you?

Yeah collegialism and altruism are dead. It is all about billing. It is why pathologists started their own outpaient labs the last couple decades. It is why clinicians are opening their own subspecialty surgery centers and hospitals. Everyone wants those lucrative patients, those lucrative procedures those lucrative biopsies. No one wants the sickest of the sick, or the longest most difficult procedures or the complex path specimens.

Can you blame the gastroenterologists? They can have their patient's and do their biopsies and send them to some path group or they can send the tissue to their own lab and hire some dumb**** right out of residency to read them for 250K a year or maybe even send them to india and pay 50k to have them read and bill a couple million for it to split amongst themselves.

What would you do? Scenario A or Scenario A with an extra 100K a year.

Medicine used to be medicine. Now it is a business.

 

[Gyric]

Your GI friend is of course welcome to do whatever he wants but he should realize that when one of his screening colonoscopy patients comes back with a T3 tumor he will get crucified in court ... like end of career, drawn and quartered ... we can count on the lawyers in this at least.

I can see the expert witness now (an American pathologist of course) ... "so I looked at the biopsy you interpreted as normal, in cooperation with your esteemed colleague in India, and well there are a few normal cells present, but it is a wonder you found them in between all of the CANCER."

 

[pathstudent]

Your GI friend is of course welcome to do whatever he wants but he should realize that when one of his screening colonoscopy patients comes back with a T3 tumor he will get crucified in court ... like end of career, drawn and quartered ... we can count on the lawyers in this at least.

I can see the expert witness now (an American pathologist of course) ... "so I looked at the biopsy you interpreted as normal, in cooperation with your esteemed colleague in India, and well there are a few normal cells present, but it is a wonder you found them in between all of the CANCER."

Well they are willing to have their path read by guys right out of training whichi is probably more dangerous than having it read by experienced pathologists in another country.

 

[mlw03]

Well they are willing to have their path read by guys right out of training whichi is probably more dangerous than having it read by experienced pathologists in another country.

at least the newbie will be american trained and certified. everyone makes mistakes, but when the reason behind the mistake is to increase one's profits, i think that's what would get you burned in court. i agree with gyric - at least the lawyers are serving some good purpose for us in this situation.

 

[trent05]

The bottom line is that even if the technology were available to have the slides digitally read in India, the doc in India would have to have a state license in whichever state the biopsy was taken. So where is the threat? Why would a pathologist who is licensed in the US want to live in India and charge less? The real threat is in having too many residency positions in pathology and the oversupply of newly minted pathologists. Due to the oversupply of new path grads the private groups are able to abuse them and underpay them for their work, never give them partnership, while in the meantime profiting off of them. What is the difference between being used for profit by a clinician, fellow pathologist, or an MBA. There is none and that is why the pod labs and path mills are able to exist. I would gladly take 250 from a GI doc over 180 from a path group.

 

[yaah]

What worries me is how medicine is becoming more and more of a hunt for profits. Obviously in every business one should have the opportunity to make money and share in the fruits of difficult labor, but I fear medicine is going to go down the route of the hedge fund operation, i.e. operated and controlled from afar, profits siphoned off, problems dealt with locally and not by those taking the profits. It is very easy to spin something the way you want it to be perceived. As in, if you were to potentially outsource pathology to India, you talk about the years of experience, high volume, etc etc. Not to worry though, I'm sure we'll continue to get plenty of lectures about teamwork, synergy, Lean techniques, and the like.

Despite the fact that I own mutual funds, I am actually pleased that the stock market is tanking currently, because it means the never-ending quest for more credit has its drawbacks.

I agree that eventually politicians will stand up against relentless profiteering and market manipulation within healthcare, but it's going to be a slow, gradual process, with changes only likely occurring following crises.

 

[pathstudent]

I would gladly take 250 from a GI doc over 180 from a path group.

In a resasonable path group you should be making 360-400k in 2-5 years.

Don't get suckered into taking the higher amount in the short term.

 

[pathstudent]

What worries me is how medicine is becoming more and more of a hunt for profits. Obviously in every business one should have the opportunity to make money and share in the fruits of difficult labor, but I fear medicine is going to go down the route of the hedge fund operation, i.e. operated and controlled from afar, profits siphoned off, problems dealt with locally and not by those taking the profits. It is very easy to spin something the way you want it to be perceived. As in, if you were to potentially outsource pathology to India, you talk about the years of experience, high volume, etc etc. Not to worry though, I'm sure we'll continue to get plenty of lectures about teamwork, synergy, Lean techniques, and the like.

Despite the fact that I own mutual funds, I am actually pleased that the stock market is tanking currently, because it means the never-ending quest for more credit has its drawbacks.

I agree that eventually politicians will stand up against relentless profiteering and market manipulation within healthcare, but it's going to be a slow, gradual process, with changes only likely occurring following crises.

One thing that could save pathology, would be to have CMS slash the reimbursement for TC. This would screw a lot of pathologists who own their own histo labs, but it take down the AP parts of quest/labcorp and all the pod labs. Hopefully they will make the TC basically a break-even thing for your average lab.

 

[Trenchcoat]

LADoc00:

What are the approximate file sizes of the scanned images?

Does it store one jpeg for each level of magnification (i.e. separate files for 2x, 4x, 10x, 40x, 100x) or is it one file with proprietary computer scaling to show detail?

Can you manipulate the images while viewing (i.e. rotate, color-balance, mark a location on the image for future reference)?

Can you tag images with more information than is contained in standard jpeg EXIF metadata?

What about alternative inputs to a mouse (digital pens, touch screens)?

Can you make screen-shots and save to memory cards on the fly?

Can you manipulate the files with standard photo imaging software or only the proprietary engine?

Is there integration with other widely-used applications (Powerpoint, Photoshop, Outlook) for seamless movement of images?

Does the software have plug-in architecture?

These are some features that will probably speed adoption.