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A Journey to Pathology 3.0: From 'bricks'​ to 'clicks'​. Part 2.

Last week three papers caught my attention; in their own right, all illustrate the potentials for unlocking the creative potential of the #pathology and #laboratorymedicine. I hope that I will find time to revisit each of them in more detail. 

The first one, published in The Pathologist, is "Priming the Clinical Laboratory for Population Health" by Khosrow Shotorbani and colleagues. Khosrow's vision and passion for leveraging the laboratory diagnostic to address much broader goals make him one of the most significant contemporary strategic thinkers in our industry. With the roaring pandemic, and remembering our conversations at the ACP's "Frontiers in Laboratory Medicine" and Robert Michel's "Executive War College", I cannot avoid reading "I told you so" message between the lines. We are all being reassured that the lessons from the crisis will help us rethink how the #healthcare is organised and work rewarded. If so, the pathology and laboratory medicine can indeed hope to be at the apex of population health.

The second article "Point-of-care testing for COVID-19 using SHERLOCK diagnostic" comes from the world-class molecular engineering team at MIT McGovern Institute. Although I am far from being the expert on #CRISPR, following the developments in the field from a distance, I cannot stop admiring the bioengineering idea behind the Specific High Sensitivity Enzymatic Reporter Unlocking (SHERLOCK) technique. Unlocking the potential of CAS13, a natural bacterial antiviral defense offers not only a new diagnostic tool but also a scalable one. With no dependence on RT-qPCR equipment and a multistep fluid-handling process, a simplified, fast and likely, very sensitive method, abbreviated with a fair pinch of humour as STOP (SHERLOCK Testing in One Pot) may be deployed as a point-of-care test (#POCT). I will watch this space. This is likely to go much broader than the detection of SARS-CoV-2.

The third one is a scientific paper published in Nature Medicine. "Geospatial immune variability…" probably gives us a hint of how pathology and precision #cancer diagnostics will be practiced in a not-so-distant future. With #digitalpathology and clinical-grade computational pathology "power tools", the integration of #morphology, #omics, #imaging and a range of clinical and population data, teams comprising #pathologists, #oncologists, #scientists, #bioinformaticians#biologists and #computerscientists will be able to #precision medicine across traditional domains and on wider geography.

This links to the main topic of this article. Over the next few weeks, I will try to share my view on the future of #pathology, or #histopathology, as we usually refer to the specialty in the UK. This deliberately coincides with #dPath20, the series of webinars organised by the South Yorkshire and Bassetlaw Pathology Transformation Programme Team and our friends from the profession, academia, and industry. We aim to engage the transformational and creative potential of our profession by sharing the experience of the real-world implementation of digital and computational pathology. We are very proud that we have managed to involve enthusiastic speakers. They practice in different countries, use different software, scanner, and IT setup, but they've all "walked the digital pathology implementation walk". And although some of them may still collect vinyl records, none of them, and more to the point, no members of their teams look back to the microscope or typewriter era with nostalgia. The guest speaker at our first webinar "The Journey to Digital Pathology at The University of Montreal Hospital Centre" on Wednesday 3rd June, 15:00-16:00 BST is Dr. Bich Nguyen from The Centre hospitalier de l'Université de Montréal (CHUM). Colleagues from Quebec, in collaboration with TribVn Healthcare, are doing excellent work. Their endeavour spans across several organisations and hospital sites in the Montreal area. The CHUM team already has very encouraging data about opportunities for quality and productivity improvement and is not shy of accelerating use of technology to roll-out remote working during the pandemic. I have had the privilege to have a long conversation with Dr. Nguyen about the Montreal project. If I have to summarise their approach, I'd chose to describe it as pragmatic, engaged, and self-reliant.

It goes without saying that the sessions are free and that you are more than welcome to register.

I have already written about the current state of the Histopathology. Although this was mainly my account of the specialty in the UK, some aspects may be universal. The service model at present, unchanged for decades due to an absence of technologically and operationally viable alternatives, is becoming unviable due to the widening gap between demand and capacity. The workload is growing in volume and complexity. Within the means of the current service model, and with the significant shortage of pathologists, the increase in demand cannot be absorbed through enhanced utilisation of the existing human and technological resources. Besides, histopathology services are fragmented. Almost every acute trusts run an 'own' histology service – usually both the processing laboratory and facilities for reporting.

Consequently, there is a variation of clinical, operational and financial performance, for example, the inconsistent generalist/subspecialist approach with avoidable duplication of work. There is chronic underinvestment in technology and underdevelopment of the workforce. Due to this cumulative strategic debt, the profession is behind with scaling up of digital and molecular pathology and developing a modern, multi-professional workforce. In summary, the capacity to deliver the service and capability to endorse computational pathology, multi-omics, integrated diagnostic, and precision medicine are neither sufficient not strategically aligned at the system level.

My views on the various aspects and chunks of this transformation will be the topic of the forthcoming series of articles.  I think that three key enablers for jump-starting the transformation of our profession are:

1.      Migration to a digital pathology platform

2.      An advanced, end-to-end approach to talent development, to accelerate development and modernisation of medical and scientific workforce

3.      Organisational and governance arrangement to enable transformation, in particular, endorsing the #platform service model in the form of a distributed network

In summary, we need a new business and service model for Histopathology.

In recent years, many in and around the profession have bought into the 'digital pathology tech hype', thinking of it as the holy grail of Histopathology. Don't get me wrong; I sincerely believe that the transition to a digital pathology platform is a must-do for the profession and Histopathology as the part of laboratory medicine industry. It is a critical technological enabler of transformation. Since individual and organisational adaptation will take time, we better start doing it on the scale sooner rather than later. 

However, as with any "next big tech thing" approach, the focus on technology is no more than strategic myopia. Our collection of technological tools may be a permissive factor, but the implementation of technology is not a goal, it is only a means to an end. The goal is to meet the unmet needs of our users and the market by figuring out how to do things nobody could do before. In that context we need a digital pathology platform to 'shrink geography', so we can deliver an integrated diagnostic service across a wide area, collaboratively, remotely, and with time, leveraging the potential of clinical-grade computational pathology tools.

Another potential fallacy is a fixed and inward thinking approach. The inertia of many established organisations makes them every so often focusing on themselves and on things that they want to do rather than on understanding the needs of their customers and realising the opportunities those present. In this context, the implementation of digital pathology is presumed just as another change of an operating model, focusing primarily on efficiency and effectiveness. I would be the last one to say that the operations of contemporary histopathology services do not need thorough 'kanbanisation', especially when considered as through prisms of regional network integrations currently undergoing in the UK. Nevertheless, digital pathology, no matter how 'end-2-end' we may think of it, will suffice if only grafted on the introverted service model. This approach and the set of the existing 'outcome and impact measures' will likely stumble on the hurdles of the 'balance sheet' and 'net current value'-focused business planning processes.

Future service and business model for Histopathology needs to hinge on outside-in perspective and abandon organisational fortifications. We will need to deliver more and more complex stuff, and the resources will be limited. For me, the obvious way forward is to abandon the insular, linear model and move to a platform network model for Histopathology: a distributed network model enabled by digital pathology... 

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