Digital pathology in Norway – a nation-wide conceptual study

Inger Nina Farstad MD, ProfessorDepartment of Pathology

Division of Laboratory MedicineOslo University Hospital (OUH) and University of Oslo

Health Region South-EastHealth Regions West, Middle and North

National IT service for health care (NIKT)

It´s all about the patient

“The right specimen to the right pathologist at the right time”

If …

– Pathologists can work in networks without delay and risk of losing samples

– Distant consulting on rare or difficult cases is secure

– Technical, legal and economical issues are handled in relation to these needs

19 labs in Norway, including

2 private labs in Oslo area

Remote frozen section service: a

telepathology project in northern Norway.

Nordrum I, Engum B, Rinde E, Finseth A,

Ericsson H, Kearney M, Stalsberg H, Eide

TJ.

Hum Pathol. 1991 Jun;22(6):514-8

Norway is geographically a complicated country

TromsøKirkenes

Diagnostic Pathology in Norway -Challenges

• A small and a large country (5.2 mill people, 200 pathologists)

• Some cases rarely seen• Solid tumors in children

(20-30 cases per year)• Non-neoplastic kidney-

and liver disease (<2000 cases per year)

• Neuromuscular diseases (< 100 per year)

• And other …

• Some samples need many supplementary tests• CNS tumors (HE, molecular, IHC)

• Hematopathology (HE, IHC, molecular, flow)

• Kidney diseases (HE, IF, EM)

• Other (FISH)

• Shipping parts of specimens between labs is time-consuming, expensive and carries risks of misunderstandings and loss of material

Diagnostic Pathology in Norway -Challenges (2)

Four Health regions

South-East (2.9 mill)West (1.2 mill)Middle (0.9 mill)North (0.5 mill)

The solution … Digital Pathology?

From idea to project (1)

• Applications … difficult to receive funding for infrastructure– To the Health Regions

• (South-East, pre-analysis, no funding; West, ongoing, some funding, Middle and North, ongoing and funding partly through research applications); ie four regional projects on-going

– To the Norwegian research Council• No response for projects aiming to improve health care through

improved infrastructure

• Except DoMore! (domore.no) In silico Pathology - Improving diagnosis by utilizing Big Data and software-driven automation of pathology

From idea to project (2)Seminar in Oslo April 30, 2015

Experiences from digital pathology in Canada (Sylvia Asa, Pathologist-in-chief, Toronto general hospital)

Digital pathology in Sweden: the Linköping project (Claes Lundstrøm, Project leader, CMIV)

Future possibilities for digital pathology (Darren Treanor, visiting professor, Linköping, and Senior consultant, Dep of pathology, Leeds)

From idea to project (3)The letter to the Ministry of Health, Directory of eHealth, Managing Directors of Regional Health Authorities,

from Departments of Pathology around the country

advocating

BETTER AND FASTER TREATMENT OF PATIENTS THROUGH DIGITAL PATHOLOGY

And comparing to radiology

Why is pathology not digitised the way radiology was 20 years ago?

NIKT launched the project

Start March 2016

Report to be delivered February 2017

How can we work through this?

• Asked for advice …– Visited Laboratories;

Toronto, Linköping, Utrecht, LabPon

• Invited vendors(Health South-East)

Our definition of Digital Pathology

• Scanning glass slides to obtain virtual slides, but also– Request from clinician

– Standardised work in the histopathology and immuno labs

– Integration with laboratory information and management systems

– Integration with other relevant information• Grossing images

• Radiology images

• Other laboratory information (microbiology, molecular, flow, biochemistry)

– Integration with patient administrative system

– Structured reporting

What is needed to achieve the vision- the right specimen to the right pathologist at the

right time?• Lab workflow

– Standardisation, automation

• Networks with subspecialities– Organise diagnostics within groups of pathologists trained within these areas– Back-up at other hospitals for vacancies– Expert help ”a click away”

• Technical issues– Scanners– Storage (virtual slides)– Integration– Work station

• Engaged IT architects

• Economy– Investments versus savings (in the long run)

• Legislation– Engaged lawyers

Standardisation

• Diagnose at a distance …– How many sections per slide?

– Section thickness?

– How deep into the biopsy/surgical sample?

– Image quality?

– Antibody clone/retrieval system?

• Reporting– Similar for the same type of specimen/diagnosis,

irrespective of pathologist/lab

Multidisciplinary and multisite

• MDT meeting with all relevant disciplines– Pathologist or radiologist at a distant hospital

• Communicate with collegeue at another lab (or in other region, or internationally?)

• The need for a national database … ?– Networks within diagnostic subspecialities,

regionally and/or nationally

– Legal issues

Reporting and consulting

Health Region South East and NIKT

Pathologist at Lab A should be able to access previous samples from the same patient in Lab B, or consult a collegue at Lab B with her own case

Lab A

Lab B

Technical issues

• Storage and retrieval of historical cases– Store how long?– Retrieval time (when need to see a previous case from the same

patient)

• Integrations – With patient administrative systems– With laboratory information and management systems– With images of large samples – annotations on gross specimens– With image repositories (radiology, endoscopy, molecular, EM,

FISH …)

• Work station

Structured report (national standard)

• Grossing images with annotations

• LIMS/similar for workflow control

• Virtual slides• Other relevant images (from • repository)

Pathologist´s work station: access to all relevant data necessary to make a correct diagnosis

Legal issues (Norway)

One patient – One journal

– Implies that records are available for a patient admitted to hospital even if this occurs far away from where the patient lives

– MyJournal – every patient can log in to his/her healthinformation/journal

– This should also mean:• A pathologist working with a sample should access previous samples

from the same patient regardless of which laboratory the case wasdiagnosed and consult the wanted collegue at another lab

• Lawyers work with these questions; many issues are solved

Economy

• Investments– Storage– Equipment (scanners and screens)– Integrations (”network power”)

• Drivers– Population: inhabitants > 62 years increases dramatically– Personalised medicine requirements

• Alternative costs: increased waiting times, and patients missing treatments– Health Region West: wise to invest in expensive diagnostics to ensure correct

use of very expensive treatment?

• Geneticists require storage for Big Data (whole genome sequencing)

Scenario A

Scenario B

Scenario C

Scenario D

Low Digital pathology High

Low

er

Wo

rklo

ad

Hig

her

Wo

rklo

ad

The business case?

What influences pathology services?

• Ageing population• More people survive and

live with cancer• Improved technology• Informed patients• Personalised approach• Economy• Health administration

policies

The “inverted” business case!Report to be delivered February 2017

If Digital Pathology is not implemented

• Waiting times for diagnostic reports will increase

• Patients may not receive the optimal treatment

• Costs for cancer treatment will increase disproportionately more

• Lab costs will increase

• The need for pathologists will increase even more

• Standardisation becomes more difficult

• Lack of integration with other important information to make the correct diagnosis can potentially harm patients

Line Rodahl Dokset (Project Leader, National Conceptual Study)LIDOKS@sykehuspartner.no

Arnstein Hodne (Project Leader, Digital Pathology Health Region South East)ARNHOD@sykehuspartner.no

Thanks to the project team NIKT

and to

Sabine Leh (Consultant, Haukeland University Hospital)sabine.leh@helse-bergen.no

Thank you for the attention!