WHITE PAPER

Lean on Digital Pathology

Diagnostic Workflow Challenges
in Anatomic Pathology

Abstract
The construction of a pathological diagnosis is the time, space and place in which cellular imaging, clinical informatics and the cognitive skill of a pathologists
intracranial neural network combine to make a prognostic or predictive statement as to the likely outcome for a given patient. The tools that surround and
support this diagnostic time, space and place are critical to the success of the work. When we focus on the environment of a pathologists diagnostic work
activities, the structure and processes of that environment have changed only slowly over the past several decades. The digital laboratory information system has
certainly been a significant change and pathologists have adapted their diagnostic information workflow from paper to a computer screen. The core of the
process that is the review and interpretation of cellular images has, however, changed little. Pathologists still assemble cases and view them under a microscope
in much the same way as was done 50 years ago. The intensity of the activity is certainly much greater, but the review process is much the same. The Digital
Pathology Imaging revolution, using whole slide images (WSIs) as a surrogate for glass slides offers the possibility of greater efficiencies in workflow. Methods to
evaluate the comparative costs of analog pathology vs. digital pathology workflows are not yet charted. This paper offers some thoughts on the use of Lean
process mapping in conjunction with activity based cost accounting to make these critical comparisons.

John E. Tomaszewski, MD
Pathology and Anatomical Sciences
State University of New York at Buffalo

Introduction
The efficiency and effectiveness of a clinical
laboratory of anatomical pathology is the product
of hundreds of pre-analytical, analytic and postanalytic steps. If any of these steps should fail in a
serious way, the outcome for patient care could
be poor. This is particularly true for those steps in
the process that are related to a pathologists
work. This is the segment of the anatomical
pathology workflow in which cognitive activity
intersects with technical process. The
construction of a pathological diagnosis is the
time, space and place in which cellular imaging,
clinical informatics and the cognitive skill of a
pathologists intracranial neural network combine
to make a prognostic or predictive statement as
to the likely outcome for a given patient. The tools
that surround and support this diagnostic time,
space and place are critical to the success of the
work.
When we focus on the environment of a
pathologists diagnostic work activities, the
structure and processes of that environment have
changed only slowly over the past several
decades. The digital laboratory information
system has certainly been a significant change
and pathologists have adapted their diagnostic
information workflow from paper to a computer
screen. The core of the process that is the review
and interpretation of cellular images has,
however, changed little. Pathologists still
assemble cases and view them under a
microscope in much the same way as was done
50 years ago. The intensity of the activity is
certainly much greater, but the review process is
much the same.
Categories of a pathologists diagnostic work that
impact diagnostic efficiency include: (1) managing
the work queue; (2) receiving and sorting of slides;
(3) fetching of clinical history, and prior
radiological and pathological studies for
correlation with histopathology and interval

comparison; (4) slide review including the physical

activity of passing slides across a microscope
stage and viewing across magnifications; (5)
constructing a report; and finally (6)
documentation and communication of the final
report.

Process Management Tools in Anatomic

Pathology: Lean
Lean is the production process improvement
system used by the Toyota Motor Corporation.
Lean is derived from the management principles
of W. Edward Demings. Lean is effective in a
culture that encourages workers to continuously
identify and eliminate waste. Lean is a system of
continuous quality improvement that, through the
identification and elimination of waste, seeks to
re-design the work environment and create a
more efficient work process.
The re-direction of the workplace culture often
takes many years, however, the adoption of tools
and structures that support the development of a
Lean culture is within the reach of anatomic
pathology laboratories seeking to improve their
efficiency. Systems to capture defects, craft
corrections through a plan-do-checkact iterative
process, and communicate and educate all of the
lab workers on the workings and outputs of the
new processes can begin to shift the attention of
everyone in the lab to the continuous reduction of
waste.
Fundamental to starting this journey of
continuous waste reduction is the establishment
of the current state processes through the
creating of a process map. A process map can
cover broad aspects of the entire value stream in
an anatomic pathology lab system or it can cover
only a targeted segment. A process map may be
high level or it may be detailed and granular in
content. A current state process map is the base
upon which changes that seek to reduce waste

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are documented and tracked. The segments of a

process map are the scaffolding upon which
measurements of waste and the cost of waste are
framed.

When evaluating the total cost of a laboratory

service both the cost of the error/waste free
component and the cost of preventing
error/waste must be taken into account.

Activity Cost Accounting

The Digital Pathology Paradigm

Activity based costing or cost accounting (ABC)

is a method that charts activities in a process and
assigns the cost of each activity according to its
actual consumption of resource. This cost
includes all of resources needed to accomplish
that activity. ABC assigns fixed cost and variable
cost (direct unit based or overhead) to each
activity. The cost of labor, supplies, equipment
and space are common types of costs. Through
this accounting process, an organization can have
a more exact understanding of the resources that
it allocates to activities that are then mapped to
the output of a product or service.

The designation digital pathology has many

aspects. One feature is the replacement of glass
slides by virtual whole slide images (WSI) and
their access through a pathology picture archiving
and communication (PACS) system. Another
aspect of digital pathology is the idea that a digital
representation of a glass slide is a pixel matrix
and a target for computation. Machine vision
tools can extract quantitative histological image
(QHI) metrics from WSIs and these data can be
used either alone or in combination to aide in
diagnoses. For example, QHI extracted from
immunohistochemical stains can transform the
qualitative interpretation of labels into a numeric
evaluation. Digital pathology also refers to the use
of WSIs as a tool for annotating and
communicating information. Taken in the
aggregate, these features of digital pathology
define a new system for practice and translational
research in pathology.

ABC methods can be complex and costly to

administer. Lean accounting seeks to eliminate
particular cost allocations rather than apply
complex methodologies for resource allocation.
Lean accounting is a snapshot of selected cost
functions across a process. Lean accounting, not
surprisingly, works best in a lean manufacturing
environment and has been useful in healthcare
environments.

The Cost of Quality

The total cost of creating a diagnosis in anatomic
pathology is the sum of the costs of the error and
waste-free activities plus the cost to find, correct
and prevent error and waste. Carlson et al (ref)
when writing about the cost of laboratory services
offer the equation below:
Cost per unit of product or service = Cost of an errorfree and waste-free product or service + Cost of
quality (costs to find and correct errors + prevention
costs)

Is There an Opportunity for Workflow

Efficiency Using Digital Pathology?
The value stream of making a diagnosis in
anatomic pathology clearly extends across preanalytic, analytic and post-analytic phases and
includes everything from specimen collection to
communicating a report. There is a segment of
this value stream however that focuses heavily on
the primary activities of the diagnostic anatomic
pathologist. Categories of these activities include
1) managing a work queue, (2) receiving and
sorting slides, (3) retrieving pertinent history, (4)
slide review(s), (5) report construction and (6)
communication and documentation of the
findings to the responsible clinicians. These
activities are detailed in Table 1. The efficiency
challenges in each of these pathologists

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diagnostic workflow categories are somewhat

different. In several (managing queue, fetching
information, constructing reports and
documentation) there is a primary emphasis of
pathologist work activities within information
systems. On the other hand, in an analog world,
the processes of receiving and sorting slides, slide
review and fetching prior histopathological
studies for comparison are largely challenges of
materials management.

processes and gaining efficiencies by leveraging

the automation inherent in digital pathology are
intriguing. The digital pathology environment, in
fact, offers the possibility of turning the cellular
imaging based diagnostic product into something
that has eluded it for generations; i.e. a precise,
quantitative, cost effective tool for the pathologist
to contribute to the personalized predictive
modeling revolution. Before these opportunities
are realized, however, the efficiencies and cost
savings of the digital pathology processes will
need to be documented. Moreover, the digital
pathology process will need to show value over
the current analog system in both cost and valueadded domains. How can a comparison between
analog and digital systems be performed?

Many anatomic pathology laboratories are

contemplating a transition from an analog
diagnostic environment to all-digital diagnostic
processes. The possibilities of stream-lining these

Table 1
Managing Work

Receiving and

Queue

Sorting Slides

Fetch

Review

Construct

Documentation and

Report

communication of the
final report

Query Assigned

Receive H&E

Retrieve pertinent

Work

slides

clinical history

First review

Abstract history

Document all slides used

to pathology

in case

report
Sort Cases by

Check H&E

Retrieve pertinent

Importance

slides against

pathology history

Second review

Coding

microscopic

records
Open Case

Enter
description

Sort H&E slides

Retrieve pertinent

Consultant

by case

radiology history

review of case

Enter diagnoses

Billing

QA and QC

importance
and review
logic
Check for

Obtain special

Retrieve pertinent

Review referred

Choose

Pertinent

study slides

lab history

case with

appropriate

consultant

synoptic

History
Availability

template

Order Special

Sort special

Retrieve pertinent

Special study

Complete

Verbal conversations with

Studies

study slides by

radiological and

review

synoptic

clinicians

case

endoscopic

template

images for
concordance
Order

Retrieve pertinent

Slide

Obtain and

Consultation

prior pathology

annotations

incorporate

slides for

Critical results call backs

consultant

comparison

report

Image

Quantitative

Report on

Analytics

image analysis

special studies

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A Proposal to Use Lean and Activity

Based Cost Accounting to Evaluate the
Efficiency of Digital Pathology
A comparison of analog and digital pathology
environments should take into account all of the
sequential activities across the diagnostic value
stream that focus on a pathologists work. This
should be done in both the analog and digital
domains. Process maps should be constructed for
those activities that reside in either analog or
digital domains. The digital domain will replace or
eliminate some types of work and will create
opportunities for new value added work. For
example, the use of computer algorithms to
create quantitative image data for use in decision
support is a value-added feature of the digital

pathology environment but not of the analog

pathology world.
All costs in each activity should be measured
including variable per unit costs and fixed costs.
An annotation of costs as waste/error free work
vs. work done to fix or prevent error/waste will
allow a comparison of the cost of quality between
analog and digital domains.
An example worksheet for the focused activity of
slide review is given in Table 2. This worksheet
assumes a digital pathology environment and
focuses on a single segment of the diagnostic
value stream, i.e. the review of WSIs by a
pathologist.

Table2: Process Map and Activity Based Cost Accounting Worksheet for a Pathologists Review of Slides
--------------------------------------------------------------------------------------
First Review

Second Review

Special Study
Review

Consultant
Review of Case

Review of
Referred Case
w/ Consultant

Slide
Annotations

Quantitative
Image Analysis

Variable
Labor Cost

$ cost of
review time
per unit of
service

$ cost of
review time
per unit of
service

$ cost of
review time
per unit of
service

$ cost of
consultant
fee

$ cost of
review time
per unit of
service

$ cost of
review time
per unit of
service

Variable
Supply Cost

$ cost of
supplies per
unit of service

None

$ cost of
supplies per
unit of service

None

None

None

Fixed
Equipment
Cost

$ cost of
using
equipment
amortized
over case
load
$ cost of
space to
support
activity
$ cost for
general and
admin
overhead
allocated to
activity

$ cost of
using
equipment
amortized
over case
load
$ cost of
space to
support
activity
$ cost for
general and
admin
overhead
allocated to
activity

$ cost of
using
equipment
amortized
over case
load
$ cost of
space to
support
activity
$ cost for
general and
admin
overhead
allocated to
activity

None

$ cost of
using
equipment
amortized
over case
load
$ cost of
space to
support
activity
$ cost for
general and
admin
overhead
allocated to
activity

$ cost of
using
equipment
amortized
over case
load
$ cost of
space to
support
activity
$ cost for
general and
admin
overhead
allocated to
activity

$ cost of time
to use
algorithms
per unit of
service
$ cost of
algorithm use
per unit of
service
$ cost of
using
equipment
amortized
over case
load
$ cost of
space to
support
activity
$ cost for
general and
admin
overhead
allocated to
activity

Fixed Space
Cost

Fixed General
and Admin
Cost

None

None

Total Cost
% Error/
Waste Mgmt.

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Some of the activities and costs in this worksheet

are unique to the digital pathology environment
while other activities would be the same for a
worksheet addressing the analog pathology
environment. The replacement of an office
microscope by a WSI digital reading cockpit is
envisioned, so equipment costs between analog
and digital systems would be different. Supply
costs between digital and analog systems are not
anticipated to be substantially different in this
segment of the value stream; however, in the
digital pathology domain there would clearly be
an additional upstream cost for scanning. A major
question is whether or not the digital pathology
environment decreases the time cost for review
of slides. If reading an electronic version of a glass
slide can be made more efficient than the process
of mounting a slide on a stage then the digital
pathology domain will be seen as advantageous.
If that is not true then the shift to an all-digital
environment will be problematic. Finally, when
comparing costs, one must recognize opportunity
costs for value added services that may be
resident in the digital pathology world and not in
the analog pathology world.

References
Zarbo, RJ. Creating and sustaining a culture of
continuous process improvement. Am J Clin Pathol
138:321-326, 2012
Carlson RO, Amirahmadi F, and
Hernandez JS. A Primer on the Cost of
Quality for Improvement of
Laboratory and Pathology Specimen
Processes. Am J Clin Pathol 138:347354, 2012
Kaplan RS, Porter ME. How to solve the cost crisis
in health care. Harvard Bus Rev. 89:46-61, 2011.

By aligning value stream activities across analog

and digital domains a like to like comparison can
be made. By using activity based cost accounting
more accurate costs can be assigned to each
activity. Combining lean process approaches and
activity based cost accounting offers a
manageable yet objective and robust method for
evaluating the costs and benefits of analog vs.
digital pathology systems.

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One North Dale Mabry Hwy. Suite 600 Tampa, FL 33609 | 813-570-8900 | inspirata.com