The use of technology has overcome significant challenges in the modernisation of pathology services across North Wales, particularly in respect of geographical constraints and population base
Muhammad Aslam MBBS FRCPATH
Clinical Lead Histopathology
David Fletcher PhD FIBMS C.Sci
Directorate General Manager
Betsi Cadwaladr University Health Board, Bangor, UK
The Betsi Cadwaladr University Health Board (BCUHB) is the largest single health organisation in Wales, and is responsible for providing community, hospital and mental health services, and overseeing primary health care services for a population of around 680,000 people in North Wales, together with providing some services to residents of North Powys and parts of Cheshire and Shropshire.
The services are provided from three acute hospitals: Ysbyty Gwynedd (YG) in Bangor; Glan Clwyd Hospital near Rhyl (YGC); and Wrexham Maelor Hospital (YMW), along with a network of community hospitals, health centres, clinics, mental health units and community team bases. We employ approximately 16,000 staff, and also coordinate the work of 191 general practitioner (GP) practices, and National Health Service (NHS) services provided by dentists, opticians and pharmacists across the region.
BCUHB was established on 1 October 2009 as a part of the Welsh Government One Wales reform programme for the NHS in Wales, bringing together three acute and several community hospitals, along with six primary care commissioning area units as a single provider. The reconfiguration provided great opportunity for closer working together by multiple organisations in the north of Wales to provide best possible and specialist care for our patients.
The greatest constraint, similar to any mixed urban/rural population, is geographical – presenting confounding issues in respect of having adequate critical mass to support sub-specialist care provision while maintaining acceptable access times for the majority of patients.
For Pathology services across North Wales, a single managed service was created to replace the three individual hospital-based departments. With the relatively low requirement for direct patient access to laboratory-based Pathology services, the opportunity existed to re-provide these services in a more specialist, concentrated form. During the period 2010–2015, several business cases were approved and implemented, to support this vision, providing new/refurbished premises, specialist laboratory equipment and IT technologies to improved both quality and performance of essential investigations and tests.
Location of BCUHB Acute Hospitals in North Wales.
Cellular pathology in North Wales
For Cellular Pathology services, the outcome of this major reconfiguration was a merge of the three small cellular pathology departments into one single managed central laboratory based in Glan Clwyd Hospital site near Rhyl; a new, purpose-built laboratory and accommodation for up to 12 medical staff and their secretarial teams. The service operates principally from the Glan Clwyd site, with currently sample reception, mortuary, and minimal consultant/secretarial accommodation and facilities remaining at the Ysbyty Wrexham/Ysbyty Gwynedd sites. The new single Cellular Pathology service annually processes:
- 44,000 histopathology requests
- 5000 non-cervical cytology requests
- 50,000 cervical cytology requests.
However, the provision of clinical services for patients remains locally based at each hospital, with over 25 multidisciplinary team meetings scheduled each week. To fully modernise the services provided and handle the workload and geographical challenges, it was envisaged at earliest stage to rely on modern digital technologies (in addition to consolidation alone) as follows:
- A new Laboratory Information Management System (LIMS; Intersystems Trakcare Lab) has been installed as part of an all-Wales Pathology implementation
- New digital dictation system ensures full end-to-end IT connectivity is achieved across the BCUHB Cellular Pathology Service with minimal need for staff to move between sites
- Macroscopic digital photography system and digital faxitron for breast specimens are under process to be installed and linked with digital microimages and LIMS
- Blocks and slides barcoding and digital labelling system installed
- Provision of barcode reader to the consultants who can scan individual slide and request form to report
- A new automated H&E stainer/coverslipper (Dako Coverstainer) was installed in 2015 to ensure consistent, high-quality slide preparations
- The immunohistochemistry service is fully automated, using two Roche Benchmark XT analysers, including all breast marker work and third Benchmark ultra
- Video-conferencing facilities system installation in a separate room to provide global North Wales link for the multidisciplinary team (MDT)
- Video-conferencing facilities system in a large seminar room, which is currently used as managerial cross site meetings, candidate interviews and teaching purposes
- Q-pulse, a laboratory quality assurance software installation, is carried out (a new application for accreditation under UKAS standards for the entire Cellular Pathology service will be made in 2016).
Consolidation of Cellular Pathology services to a single location provides significant benefits in respect of critical mass, for example, efficiency and sub-specialisation. However, the distance between acute hospital sites (35 miles), the need for transporting slides for MDT meetings/specialist review, and necessary slide tracking issues would add significant time to result turnaround times and also create a significant increase in laboratory workload.
In addition, there is a critical medical consultant workforce shortage within Cellular Pathology across the UK, and this is also currently the case across North Wales, exacerbated in part due to retirements and the relocation of services; this had resulted in extreme imbalance in the capacity and the workload.
To maintain services reliance on locum agencies and outside providers was the only short-term option but that increased lab work further in terms of tracking and relying heavily on logistics, increasing the risk for specimen losses and damage in transportation. The number and location of MDTs also result in significant movement and tracking of slides. To develop specialist reporting and internal/external case review further increases transportation and associated risks and increase in additional gain in lab workload.
Digital pathology
To manage these issues and to run the Department on Lean principles, the need to move towards digital pathology was paramount. A digital pathology solution was expected to contribute across a number of areas. The solution would help in the MDT reviews, similar to a PACS radiology-like solution, whereby the consultant could review the case in their office digitally and present on the screen. Across site frozen could be performed without a consultant needing to be present at the site. Outsourcing of work could be completed without transporting slides, removing issues with tracking. Internal review on individual cases by colleagues in the trust or elsewhere in the country could be carried out quickly and without significant secretarial and laboratory input.
It was also considered that outsourcing some of the MDT would be possible, without additional pressure on the lab staff. Digital pathology also provides a great potential contribution towards teaching and training, as North Wales, serving a population of more than 600,000, provides exposure to plenty of varied pathology which could be used across the country for training purposes.
The vision of the organisation to see beyond the traditional solutions and look into future has helped cellular pathology to challenge the three centuries old method of microscopic reports, to be replaced or supported by digital high definition screen reviews and reporting.
In 2013, the Welsh Government made capital available though a competitive ‘Health Technology Fund’ to introduce new technologies into clinical service that were not previously provided. Subsequently, a business case for the implementation of a complete digital pathology system for North Wales Cellular Pathology was proposed as a valid bid to this fund. The case was justified to the Health Board by explaining the above challenges and providing best possible solutions, taking into account estimation of increased services demand in future, and greater reliance on cost efficiency to save money while continuing to provide best quality diagnostic work.
The understanding that digital pathology would help to maintain UKAS ISO standards, fulfil KPIs for RCPath standards, and improve the turnaround time in surgical reporting, convinced the board to support the bid.
Following several rounds of scrutiny, the bid supporting the introduction of Digital Pathology across North Wales was approved, the principal proposed benefit being the instant availability of diagnostic quality images from digitised microscope slides, eliminating logistical delays and improving reporting times.
- In April 2015, following a robust procurement exercise, Leica Biosystems’ Aperio Digital Pathology system was installed; including a high-capacity automated slide scanner, three smaller semi-automated slide scanners and 12 consultant workstations, consisting of a high power base station/graphics card and two high resolution monitors.
- In order to bring the new system into diagnostic use, verification of the new technology in comparison with existing methodology is necessary. This represents a significant piece of additional work, for which additional short term funding was secured in late 2015. With the potential for the digital pathology system to be fully integrated with the new national LIMS system, there is also scope for a potential future all-Wales digital Pathology service. Consequently, a national project group has been established to complete the verification process, permitting engagement from Cellular Pathology clinicians from other Health Boards in Wales.
- Currently the project team is working hard to complete the digital verification study in 2016, in order to make the system for routine diagnostic reporting usage available as soon as possible. The implementation of digital pathology is an ongoing process with the largest challenge seen in IT support. The target is to acquire all the data, identify any discrepancies, and make the results available by the end of 2016. Following this, there will be a transition to more and more reliance on digital reporting rather than microscopes. Before starting the verification process, 3 x 20 teaching cases were produced from a random collection of reported anonymous cases, and the glass slides and digitally scanned images were made available to review, in order to set individual consultant thresholds. Additional teaching sets for large resection cases are in process. The verification study is led by the all-Wales project, and involves a team of consultants, scientists, IT personals and managers.
- The system produces high resolution images, which will be manipulated through bespoke software (Aperio eSlide Manager), and will be integrated with the LIMS.
- Office-based video conferencing facilities form part of each consultant workstation, allowing a broader range and faster speed of access to microscopic images, and are intended to enhance collaborative working (for example, MDT), case referral, and research and development.
- Frozen sections facilities on all the three sites, after verification of digital reporting frozen services, will be provided offsite on the hub by consultants digitally.
Conclusions
The modernisation of Cellular Pathology services across North Wales has evolved from three small DGH-based services, each with relatively low resilience, to a larger, single centre operating from modern premises and equipment.
Whilst bringing together all of the expertise into a single location brings significant benefits, it also creates new dilemmas – principally arising from the wide geographical area served and dispersed population base. Modern digital technologies (Digital Pathology) are currently being deployed to solve these problems, and it is expected that complete modernisation through digitisation of the service will occur over the next 18 months.
