Special report: Pathology
It does sometimes feel as though the Carter recommendations to consolidate pathology services came from another era. But there are signs that the shift is starting to happen.
Over the past year or two, a number of health economies have signed contracts and begun the move to ‘hub and spoke’ working.
The idea is to create ‘cold’ hubs handling routine work, including work from GPs, and ‘hot’ spokes handling specialist, urgent or out of hours work, all supported by a central database allowing doctors to access results wherever they are.
Examples up and running include South West Pathology and The Pathology Partnership in the East of England. Then there are the more recently announced collaborations in Bristol and Essex. Soon, there will be many more.
New ideas, new IT
One focus for industry in the years since the second Carter report in 2009 has been to adapt laboratory information management systems to multisite working.
Many of the new networks have moved to a single LIMS, including Bristol, Essex and Surrey’s recent expansion to include Frimley Health NHS Foundation Trust – all Clinisys sites.
Kent Pathology Partnership has proposed that its sites should migrate to the CSC Apex systems used at East Kent Hospitals University NHS Foundation Trust.
As Donald Saum, business development director for Clinisys, says: “Most of our implementations now are multisite. That’s been driven by trusts merging or as a result of trusts creating networks. As a business we have made sure our products support multisite operations.
“That means a greater ability to identify at which sites requests are being generated, then tracking and monitoring movement of the sample around the network, as well as optimising the workflow.”
His key words are scaling and flexibility. “A network might not start as a network, so systems need to be designed so that they are scalable and flexible. That’s been a big focus for us – making sure systems can expand and support further growth.”
The generic challenge, he says, is interoperability. “You have to integrate into the multiple systems in different hospitals, systems such as the patient administration system and the order comms systems. We have now embedded Orion’s Rhapsody integration engine into our LIMS.”
Interoperability is key
Professor Tim Helliwell, vice president for learning at the Royal College of Pathologists and a consultant histopathologist in Liverpool, agrees that interoperability is key.
“There are definitely still some significant IT problems in getting efficient and effective communications between organisation and compatibility between lab IT on one side and the electronic patient record on the other,” he says. “We are getting there but it is taking a lot longer than we had originally hoped.”
In Leeds and Bradford, the LIMS-EPR interfaces are now being built. Now the health community is leaning towards a single electronic health record that, from the narrow pathology point of view, would be an enormous help, he says.
Ed Harris, product manager for Sunquest’s ICE order comms system, says clinical commissioning groups have begun to exert considerable influence in the area of pathology.
“We are really seeing now that the consolidation is not being driven just by pathology but also seeing the influence of CCGs and how they commission services,” he says.
He cites their influence on East of England’s TPP and on North London, where the combined CCGs plan to commission a range of services including pathology from five trusts, using ICE as the common order comms system.
Driving innovation and co-operation
Both Harris and Saum say that there is a new era of communication among suppliers – something that is likely to continue as new digital technologies come on stream in pathology.
One example of these technologies is virtual or digital histopathology – creating digital images of tissue slides to be viewed on a computer screen instead of under a microscope.
It is a development that has the potential to streamline the way slides are viewed and reported on. Take away the need to move a physical slide from one place to another and the world opens up, with the potential for a slide to be seen from any location.
A number of UK sites are developing this. University Hospitals Coventry and Warwickshire is currently pioneering a series of proof of concepts (see case study) with GE Healthcare.
GE Healthcare is also working with Imperial College Healthcare NHS Trust, University College London Hospital NHS Foundation Trust and in North East England.
In Leeds, a Virtual Pathology project led by Leeds University is working with Sunquest CoPath. Salford Royal Hospital has just completed a pilot with Sectra.
So, Clinisys is working proactively with GE Healthcare and other providers to make sure that when virtual pathology becomes a reality, the LIMS is ready to integrate the solution and support the workflow and restructuring of histopathology.
Recently, the company announced a partnership with Mawell’s Picsara imaging solution, which will provide an integrated image management solution within the LIMS.
Says Saum: “This technology is coming of age and we need to be ready to enable users to get the best value out of it regionally, nationally and perhaps internationally. We need to explore how this works in a hub and spoke model, and how you provide information to clinicians.”
Sunquest, meanwhile, is exploring similar issues with pathology IT providers Ventana and Aperio, now owned by Leica.
Not too fast…
There is some excitement around digital pathology, but Professor Helliwell is cautious. Work here and in North America suggests that 95% of slides can be safely read in virtual format. “The problem is we do not know which are the 5% that can’t be read safely,” he says.
It is also tricky to create the business case – especially in those departments that have already undergone significant transformation work and so released potential efficiencies.
The expensive pieces of kit are the scanner and the image storage system and these would need to be in located where slides are made, for viewing elsewhere.
That places the expense not in the university hospital centres but in the district general hospitals. “We are looking at a business case that is cost neutral,” says Professor Helliwell.
James Boys, vice president for international sales at Sunquest, says there is another limiting factor. “There has been quite a pushback in this area. Part of it is a traditional view about the microscope. Part of it is histopathologists worrying about their jobs.”
Professor Helliwell again agrees that take up may prove problematic but hopes that a new generation of pathologists will be more amenable to digital solutions.
He is working with the Royal College of Pathologists on virtual training tools that will start to familiarise trainees with the technology.
Other drivers for transformation
If digital pathology is on the horizon, then just peeping over it are other applications that will start to digitise pathology. Portals for patients with long term conditions to view their pathology results, for example, or new tools in genomics.
Here Sunquest is partnering with Partners Health, a US group that includes Harvard and MIT, and is talking to NHS partners about collaboration.
NHS England set the agenda a year ago with its report Digital First: Clinical Transformation Through Pathology Innovation. Out there, a wide range of partners is working together to make it happen.
Last month, University Hospitals Coventry and Warwickshire NHS Trust announced a new ‘Digital Pathology Centre of Excellence.’
It is a joint development by the trust, Coventry and Warwickshire Pathology Services, the University of Warwick, and Omnyx LLC, which is itself a joint venture between GE Healthcare and University of Pittsburgh Medical Center.
The partners have been developing a series of proofs of concept around digital pathology – digitising tissue slides and viewing them on a computer screen rather than under a microscope.
They want to develop digital pathology to point where it can be used in the NHS, backed up with the right research, and to develop advanced tools that will take histopathology into a new era.
Sara Dalmasso, GE Healthcare’s general manager for digital pathology solutions, says digital pathology offers a number of benefits. For a start, slides will no longer have to be physically moved to the specialist reading them.
“Carter started to talk about sub specialisation,” she says. “With digital slides, you can start to push slides to wherever the specialists are.”
It becomes easier to get second opinions, and opens up the possibility of computer-assisted analysis, such as tumour grading, which could have huge benefits for patients.
But is a digital slide and a computer image as good as a physical slide and a microscope? Work by the centre is beginning to prove the case.
Over the past year, 3,014 cases have been viewed both digitally and on a microscope to ensure there are no discrepancies between the two.
David Snead, University Hospitals Coventry and Warwickshire consultant clinical pathologist and clinical service lead, says: “Becoming a centre of excellence for digital pathology is fantastic for the trust.
“This project has been five years in planning and implementation, and it is wonderful to see it coming to fruition. It is really good news for our patients, as we will be able to offer even better care to them than ever before.”
But he admits this is just the start. “We have a fascinating journey ahead of us as we start to implement the powerful tools that we have helped to develop,” he says.
Dalmasso adds: “They are really leading the pack here in the UK. We want to support them with the right tools and to do the research that will prove this technology works.”