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Journey to Pathology 3.0: From 'bricks'​ to 'clicks'​-'PathCoin'​

Two days after the excellent presentation by Bich Nguyen about the Montreal #digitalpathology journey at our first #dPath20 Webinar, I was thrilled to discover a new article in the Archives of Pathology and Laboratory Medicine. A letter by Juan Retamero and colleagues: "Microscope? No, Thanks: User Experience With Complete Digital Pathology for Routine Diagnosis" is timely, relevant, and very reassuring. It comes from one of the first teams in Europe with the credibly long track record of successful digital pathology transition.

Now, we may need a photo finish to establish whether the team from Granada University Hospitals, University Hospital Utrecht, or LabPon was the first to complete transition (I sincerely apologize if I have missed someone) but that is beyond the point. We all understand that this is not about popping up a proverbial champaign bottle at the '100% digital' party, but about the grit to endure the journey across 'the adoption chasm' and about gaining and sustaining traction. The healthcare sector scrapyard is full of brilliant and innovative pilots; not so many can say that they master scaling up and maintaining the change. This is the main reason why we are bringing to you #dPath20 Webinars. We want to learn about the implementation of digital pathology from those "who have walked the digital pathology walk" and are willing to share with us their insights, data, and tips and help us move faster and more effectively. 

Our next speaker on Thursday 25 June 2020, 13:00-14:000, will be Juan Retamero himself! We expect a useful, practical, insightful, and entertaining talk about the experiences from Granada and a few other centres where Juan's expertise made a difference. This Webinar will be supported by the media team from Bradford University and moderated by Samar Betmouni and me. Last Wednesday we had ~200 participants, so please look for #dPath20 on LinkedIn, Twitter, or Facebook to book your place as soon as the link goes live in a day or so. Although we expect that the majority of participants will be from the UK, this is an open invitation - we will be pleased to host colleagues from every corner of the world. The journey from 'bricks' to 'clicks' is the global journey of our profession.

The teams from Granada, Utrecht, and LabPon have managed to sustain the change, we have the opportunity to read their account on the pages of Archives and Histopathology. Irrespective of geography and the inherent organisational differences all three unequivocally passed the most rigorous digital pathology field test - the test of time. They showed that high-volume, multicentre, routine diagnostic work can be delivered on the digital pathology platform. Pathologists who endorsed digital pathology would not dream to go back to microscopes.

Also, there is an explicit message that, once the digital platform is operationalised, there is a scope for improving efficiency. This is before we even considered the future benefits of clinical-grade #AI and other #computationalpathology tools. And this is probably the most contentious issue for pathologists in many organisations. Especially if the austerity and Net Present Value-driven approach to investment make the viability of a digital pathology business case depend on the increase in pathologists' productivity. 

Again, the question is not whether a digital pathology platform can enable the pathologists, "the most expensive resource within the system", to be more productive or not. The question is, how do we leverage the digital pathology 'power-tools' to do so in a safe, clinically effective, patient-centric, fair, and accountable manner. Technology is only the enabler. It is up to us to develop business models, processes, skills, governance concepts, and tools to take advantage of the existing and emerging technological and scientific advances. One aspect of this debate is about understanding what does the performance-enhancing, 'end-2-end digital pathology platform' looks like. Another one is about assessing and quantifying pathologists' productivity.

The latter is the main topic of this post. The pathologists in the UK may have an excellent starting point. Most colleagues from the UK will be very familiar with the RCPath Guidelines for Staffing and Workload; if you do not practice in the UK it is the topic worth exploring. The Royal College Guidelines have evolved. RCPath points are more accurately capturing safe and optimal workloads adjusted for the current state of technology and operational design in the majority of the subspecialties. Version 5 of the Guidelines will soon be ratified, and the RCPath Working Group is committed to their continuous development.

Although the saying is that "the Devil is in detail", with the RCPath points, "the Devil is in the concept". The details will be 'elbow grease' for sure, especially when it comes to IT integration, but the results will follow.

In addition to quantifying performance activity for resource allocation, by virtue of its design, RCPath point lends itself well to become the UK histopathology currencyPathCoin. In that context, it can prove to be pivotal for simplifying and building confidence around contractual and financial arrangements and, ultimately, for decreasing transactional costs. PathCoin is much needed to support the scaling-up of histopathology and helping it evolve as the platform economy. Conceptually, if we think of the RCPath point as PathCoin, as with any currency, there are two critical elements for its successful application: (1) trust and (2) an exchange system.

Every currency depends on trust, and trust is a two-way street. Both histopathologists and employers need to believe in the credibility and applicability of RCPath Guidelines. Credibility is not whether the RCPath points are perfect or not. It is about using them with integrity as the profession and as individual professionals. It is about trust that the RCPath set the codes 'right' and that we code 'rightly'. As per the later, in addition to our good intentions to code properly, we all need to have a skill to do so, tools to do so, a method to develop and teach these skills, and a method to audit our compliance with the standards. We would expect accountability from any financial system in any firm. As per applicability, it is also about designing and setting up software and translation tables to facilitate coding and enable maintenance, as the practice and Guidelines change, and the operations scale-up. Therefore, our end-2-end digital pathology platform will need to have reliable performance management and accountancy subsystems.

The concept of an exchange system is equally important. Again, the question is not if the RCPath point is a 'perfect' currency or not. There is no perfect currency. Guidelines will change. They will always be about the best attempt to describe and quantify a fair and safe workload at a particular moment in time. In a way, they are a 'snapshot' of the practice. The function of the exchange is to continuously monitor the system and keep it up to date in a consistent, transparent, and accountable manner so that it can quantify the evolving reality of our practice across the whole range of our subspecialty streams. As I've mentioned, the RCPath Guidelines are now in their 5th iteration. I'm following closely for over a decade, and they are getting better. The good exchange system is about this constancy of purpose. However, I think that two key areas need particular attention.

First, a few-year refresh-rate is way too long to capture the increase in the evolving complexity of the workload in our profession. The 'complexity creep' is asynchronous and significantly varies across the subspecialties and geography, mirroring the variability and change in clinical practice. A good exchange needs to be able to capture, explain, and address these variations and fluctuations accurately and promptly. This is critically dependent on a consistent and continuous acquisition and review of reliable data. It will be challenging, but if we crowdsource ideas and remain fully engaged, we will be on the top of it.

Second, as we already mentioned, there are, and there will be expectations for productivity improvement, i.e. histopathologists may be challenged to report "more cases per unit of time" or "absorb the increase in complexity". Some of these challenges can be addressed by the work described in the previous paragraph and adjusted in an evidence-based manner. However, we need to be particularly clear about expectations that will stem from the belief that new digital technologies will help us get rid of the range of wasteful tasks. Hence, they may help us free up time for productive reporting or provide tools that will enable us to do more within the same time and at least to the same quality standards. The paper from Granada and the last week's Webinar provide a credible claim that it is possible. More will come when clinical-grade computational pathology tools go mainstream. A good exchange system should be able to provide a reality check so the expectations of all stakeholders in the conversations can be realistic, specific, and based on evidence. If the change is needed, it could then be precise, appropriately planned for, and resourced.

Also, a team that develops an exceptionally good operationalisation of the exchange system should not limit its ambitions to set thresholds or ceilings. In this context, it should aim to help to explain and quantify the ways that leveraging particular technologies and changes in working practices could influence quality and productivity standards. An outstanding team would aspire to do it beyond the boundaries of its turf; I would not be surprised to see the new players in this domain challenging complacent incumbents or doing excellent work across their own geography. During these suboptimal times, plenty of countries with less money and much worse healthcare options have performed far more successfully than advanced economies. Therefore, there is very little guarantee that the post Covid19 ecosystem will reward incumbents wedded to status quo.

If you plan to read one #Covid19 related article this week, a short but to the point perspective: "False Negative Tests for SARS-CoV-2 Infection — Challenges and Implications" in NEJM is as good as anything. It is a great reading companion to BMJ's "Interpreting a COVID-19 test result" probably by now read 'backward' by the audience in the UK.

Also, do not miss on a very practical instruction manual "Optimising home internet connections and WiFi" by Roland Hanbury on SlideShow. Homeworkers will need their Swiss knife and this is a great primer. 

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