Aleksandra:
Today, my guest is Kate Baker. She is a clinical pathologist and we are both veterinary pathologists. She’s a clinical veterinary pathologist. I’m an anatomic veterinary pathologist, so I look at tissue and there is a lot of tissue processing involved when I have to look at images. And Kate can look at images that are actually made on the spot in the veterinary clinic. And Kate was already a guest on my podcast, so I’m going to link to everything we have and we talked about with Kate before. But she developed an app, a digital telecytology app, Pocket Pathologist. So first of all, welcome, Kate. Thank you for joining me again.
Kate:
Thank you. I’m super excited to be back again.
Aleksandra:
Yeah. And let’s talk about this app. Before we dive into how it was made and all the nitty gritty stuff that I want to know on the digital pathology side, tell me what it is, how did you come up with the idea and let us share the screen with the app. Let’s show the guests this app.
Kate:
Yeah. While you’re pulling that up, I can go into what it is. Just a general overview. So like you mentioned, cytology is a modality, a sampling modality, that veterinarians can perform in their clinic. So they take an aspirate, a needle biopsy essentially, into a mass or a lesion of some sort, and then they can spray the cells onto the slide and stain it right there in their clinic and look at it under their microscope. So for anybody who’s listening that’s not as familiar with the difference between cytology, which is what I just described, and histopathology, which is what Alex does as a anatomic pathologist, there’s just not really any processing aside from staining in the clinic that has to be done. So it makes it a point of care test that can be done inside of the clinic.
The traditional workflow for veterinarians is they will want to sample a mass and then they will either look at the mass or the sample themselves in their clinic and try to make a decision about what they’re seeing or they’ll send it… Well, I should say, and/or because sometimes they do both, they’ll go ahead and send it to a clinical pathologist for expert review. And so trouble in the past, I should say, the challenge has been for veterinarians in some cases, there is an associated cost with sending in those slides to a pathologist to review. And there’s a huge amount of value to that because we are trained where we’ve spent years in residency, years doing nothing but this, to know exactly what we’re looking at or at least to get as far as we can in that process, so that thought process. So there’s huge value in that. But sometimes, veterinarians are just faced with situations where their owners don’t have the financial resources to do that step, or maybe they need information-
Aleksandra:
Totally because in Poland where I practiced, and that was actually a reason I pulled out of veterinary practice because you want to help the animals, you have the knowledge, you have the resources, but the owners cannot pay for that. And I don’t know, I couldn’t reconcile that. That was tough for me, so I moved into pathology.
Kate:
Yep. Yeah, it’s a huge challenge. It’s one that veterinarians are facing every day, some more than others. Some veterinarians are located in resource-rich areas where the pet owners do have discretionary income to afford those types of services but even if that’s the case, there’s still going to be situations where some owners don’t or they have to prioritize finances. It’s just the reality of veterinary medicine. Aside from the affordability standpoint, there’s also the efficiency and speed. So regardless of the availability of finances, there are cases where we really need to know information quickly. So whether this is an emergency standpoint and we’re looking at does this animal have a septic abdomen, which is an infection, for anybody listening that doesn’t know, this is essentially an infection inside of the body. And so we can get information about that.
Aleksandra:
Like emergency case. There is no time to-
Kate:
Emergency, yeah.
Aleksandra:
Wait for the diagnosis.
Kate:
Right. So having modalities that give that ability to be efficient in that diagnostic process are highly valuable. And very often, even if it’s not an emergency situation, it’s just a workflow standpoint, the veterinarian needs to get the owner to the next step so that they can keep moving with whatever they’re dealing with. So speed is never a bad thing. Of course, we want to maintain accuracy with speed, but being able to cut out that time period between sending glass slides in the mail, that ship has sailed. That’s what digital pathology in general has given us, is that ability to get realtime feedback very quickly. The difference with what I’m doing in this service is that it is… At least, as it stands now, digital pathology scanners are just still quite expensive. They’ve been around for a long time.
Aleksandra:
They are prohibitively expensive for, let’s say small business owners. It’s a great solution for big institutions, companies, but both in human medicine and veterinary medicine. If you are sole entrepreneur, so to say, I don’t know how very much that is in the human medicine, but in veterinary medicine, especially in rural areas, this is the normal thing. And you, Kate, work or collaborate with a company that actually provides scanners to veterinarians. So they don’t own them, but they can use them. How does that differ from what you have? What’s the situation there?
Kate:
Yeah, so I do contract read for, actually, several of these digital scanning services and companies as a contract pathologist. So I really love the digital pathology technology now that exists. And these… Yeah, I know. I’m speaking your language. I love it. It makes things… I mean, as a whole, these scanners, these are bench top scanners. Some are bigger than others. Size does play a role in these decisions that some of these veterinarians are dealing with because if you’re a mobile veterinarian, you don’t have room for a scanner. So there are some options that are smaller, but there’s pros and cons to all these things. Whether you’re leasing out a scanner or outright purchasing one, I think leasing is probably more common, but there’s still a monthly cost associated with that. And then on top of that, the cost of the client per sample. And I’m not saying that’s a bad thing. These things, this is cutting edge technology. It needs to be… That comes with cost, but there’s just a-
Aleksandra:
Yeah. And then you’ll have to make a business decision. Okay, do I have enough of cases that will justify this investment?
Kate:
Exactly.
Aleksandra:
And sometimes, there’s not enough cases, but you still want to provide the highest quality of care for your patients. And I guess that’s when your app comes in, but I let you continue this thought.
Kate:
Yeah. So that’s where I was seeing a problem with there was a gap. And I didn’t come up with this idea, so just off the bat, static-
Aleksandra:
You did not?
Kate:
No, [inaudible [00:07:31] I didn’t. Static telecytology is something that’s been established both in human medicine and in veterinary medicine. There have been articles written about it. What it is, basically, in its simplest form, the veterinarian or veterinary technician, the person in the clinic is looking at the slide on their microscope in their clinic and then they’re taking photos with their smartphone or their microscope camera, but a lot of times, it’s with a smartphone. These smartphones are so powerful and their camera abilities are great. And so if you’re good at holding your phone to the ocular, then you can just do it that way, or if there are some cheap attachments or even some more robust ones. Our friends over at Skoped Micro, they have this awesome attachment-
Aleksandra:
Yes. We’re going to be [inaudible [00:08:15] in the description below. It’s an attachment we both use.
Kate:
Yeah, and it helps stabilize the phone on the ocular. And so you can take photos of what you’re seeing, focal areas. I see cells over here, I’m worried about these cells, or maybe have a particular question about this group of cells or whatever. And send those via the app to the pathologist, which right now is me, but I plan to expand that over time for review. It’s a lower cost option for some of the obvious reasons. One, I mean, there’s no scanner involved. So you’re just using something that you already own, your phone.
If you decide to buy an adapter, then it’s a really low cost option under a couple $100. And you’ve got a system that you can use to get a pathologist’s opinion on your cases. You’re not going to be scanning the entire slide, at least in the form that we have it right now. Maybe in the future, I won’t say too much, but at this point, you are taking still images so there has to be some consideration about what you’re taking photos of. So usually, it’s somebody or should be somebody that has some experience with cytology. You do not have to be a pathologist. It’s just-
Aleksandra:
Just an insert here. If you want to learn more about veterinary cytology, my guest here provides excellent courses that are CE hours, everything that you need for professional education. So-
Kate:
Yes. That right there. Thank you for that. Yeah, I do. Right?
Aleksandra:
So we’re going to [inaudible [00:09:39] that in the description as well.
Kate:
Thank you. Yes. I mean, that’s where all this started for me. I started with providing continuing education courses for veterinarians, aimed towards the GP and in some cases, the veterinary technicians that’s wanting to learn more about cytology to help support that in-house review. Not to replace pathologists, I mean, we do not want to be replaced, but we understand the realities that it’s just not feasible for every case to go out to a pathologist. And so I want, my goal, my mission is to support a veterinarian.
Aleksandra:
And not every case does need to go to a pathologist because the level of expertise in veterinary clinics, especially if the veterinaries are interested in that and are putting effort into education, there is a lot of cases that they are confident in diagnosing, but there is always a certain amount of cases that you need this additional expertise, you need somebody who’s doing only this, who was trained only to do that.
Kate:
And I hear from veterinarians quite often that they feel almost ashamed or embarrassed to not know what they’re looking at. They feel like there should be some level of understanding that they have. And there is a huge breadth of experience and comfort level in cytology, just like any other area of veterinarian medicine. If you really like surgery, you’re probably going to learn more about surgery and practice it. Same can be said for cytology. The tricky thing with cytology is that a lot of schools don’t really emphasize cytology. I’m not speaking for all of them, but from what I understand of the majority of the people that I come in contact with, they just didn’t have a lot of training in school in this particular area and so they don’t feel confident. So it is never wrong to submit all your cases to a pathologist if you’re able to, but I mean, even ones that are obvious, they said, “Oh, I sent this in and it was a mast cell tumor and I’m embarrassed because I should have known that.”
No. There are people that are really good at cytology in practice and they still submit everything because they want a pathologist’s name on that report just for covering their basis and legality purposes. So it’s never wrong, but this just provides a way for those veterinarians that need a service like this, whether it be because of finances, whether it be because of remoteness. I have a couple of clinics in Alaska and one in the Yukon in Canada that use this.
Aleksandra:
No kidding?
Kate:
Yeah, that’s been one of the really cool things is seeing the different… I had a vet from Indonesia send me a case last week and a couple from Australia. So these remote areas-
Aleksandra:
[inaudible [00:12:06].
Kate:
[inaudible [00:12:07] is not possible because of their remoteness. This is really, it’s providing a solution to them, which is making me very happy. That’s what I want.
Aleksandra:
So we just need a phone if we want an adapter to put on the microscope and then we download the app, right? Pocket Pathologist, let’s look here on the screen.
Kate:
Yeah. So this is the website, the main page of the website, which you don’t ever have to even go to the website, you can just download it straight into your phone from the App Store or Android Google Play.
Aleksandra:
So I did that before our call. I already am, even though I’m not practicing veterinary medicine and the classical veterinary medicine, I’m doing research. I do direct development support for my day job, but I registered so that I could show you. So let’s go to this Pocket Pathologist and let’s see like-
Kate:
Yeah, so this is-
Aleksandra:
[inaudible [00:13:02] I have it on the phone, I took my picture. What do I do next?
Kate:
Yeah. So the screen you were just on is the main page, and then when you download the app, it’ll look like this, either on your phone or you can use it in your desktop. So this is the actual interactive app here on the desktop that we’re looking at. And I mean for this to be super user-friendly, that’s my biggest… I know how busy veterinarians are, they don’t have time to be poking around trying to figure out where things are. So right there in the middle, you’re right there at the top, submit your case. So if you want to click that, then what you do is here is just any other submission form. But again, I spent a lot of time trying to make sure that I was only asking for information I really needed because who has time to fill out a bunch of forms, super long forms I’d pass stuff that you don’t need? The patient information here-
Aleksandra:
Us, we already are in the system if we register for the app, right?
Kate:
Right. And this may change just a… And we’ll get into this a little bit too, is just because I know we’re going to talk a little bit about how we developed the app, but this registration process may change just a little bit, again, with everything in mind to make things easier for the vet. So if you’re tuning in and it looks a little different, it may look a little different in the future if you’re listening to this in the future.
Aleksandra:
It would tell us what to put in, right?
Kate:
Yeah, everything will be really easy.
Aleksandra:
Reading is the only technical requirement.
Kate:
Yep, that’s right. Yeah. Anybody can put the information in. I mean, anybody in the clinic that is. And then you scroll down and you see there at the bottom, it says ad site. And I’m think it should let you… Yeah. So then you put in the location, description and lesion, and then there’s where you put your photos in. So you can either put photos [inaudible [00:14:40].
Aleksandra:
Or you can put [inaudible [00:14:41] into the photo.
Kate:
Yep, and you can either do photos or short video clips. So if you prefer to just video as you’re moving around, you can do that too. And then you submit, you can add multiple sites. There’s a little discount if you add two sites for one animal. So at this time, one site is 47 US dollars and then a second site on that same patient that’s 37 US dollars. So we picked that price to be affordable, but still obviously value our time as pathologists and our expertise but to provide that support that makes it within reach and accessible for more pet owners, honestly. And so then once you complete that, which it won’t let you do because there’s required fields, but that’s okay because there, you see it’ll just take you to a payment screen and then you just put your payment in and then it goes to me. And then on my end of things, it pops up on my list and I look at it, I evaluate the pictures.
One of the really cool things about this that I love is that I can communicate with the veterinarian or the veterinary technician, whoever’s submitting the case directly through a chat feature. So if I look at the photos and think “I really could use a couple more at lower objective” or for whatever reason, I need something different, I can give them tips directly through the chat feature and it pops up as an alert on their phone. So they have their phone all the time, so they see it pretty much immediately and then they can respond quickly so it keeps things moving really nicely.
Aleksandra:
This is fantastic. So yeah, I want to ask you. So you do not have computer science background, any, right?
Kate:
No.
Aleksandra:
Neither do I. We’re veterinarians by trade.
Kate:
Right.
Aleksandra:
So you worked with a developer, app developer team. This is something in digital pathology that fascinates me. How did you build the bridge between your developers team to build the app that is user-friendly? How much did you need to learn from the app development, computer science side and how much did you have to teach your developers to have a good communication and a good product in the end? Tell me about this process.
Kate:
Yeah. So I started this service without really ever thinking about an app. I didn’t know what it was going to necessarily end up as. So the service itself started in WhatsApp. So I essentially beta-tested this unintentionally through WhatsApp where it was the same type of service, but you can submit photos and then I would write back. There was no formal report at that time, but at the time, it was just a conversation essentially. So it was a little out of the norm of what people are used to, but it was really helpful because they could say, “Okay, I spoke with a pathologist and this is what they said” and then we would send a manual invoice. It was all very manual and it was time consuming. So I realized people are using this, they need this service and so how can I make this easier on both us from the admin standpoint and then on them as well?
So I was talking with a friend and she said, “Have you thought about an app?” And I thought, “Well, I mean that sounds great, but I think apps are million dollars and how do I even-”
Aleksandra:
Who?
Kate:
Do I just Google app person? I mean, I don’t even know. So she actually had a friend that had a tech background and had started a company developing apps locally, which was cool too. And so we connected and they were a good fit as far as they understood what I was trying to do. It was easier to explain because I already had the service structured out in WhatsApp and so we could… And I got some good insight as to what I wanted based on beta-testing it. So we were able to have some pretty smooth conversations about it and they went through the whole process. I’ve learned a lot about app development at this point, what a wireframe is, what flow charts are and user experience and all of those, but that’s not my area of expertise and I don’t try to let it be, I just want to be able to speak the same language. So I’ve learned some of those things.
Aleksandra:
That’s my point that, especially in digital pathology, you have people coming into the team from different backgrounds and the most extreme is the pathologist and the computer scientist. But you have all kinds of different people who are in the lab, people who are in the regulated environment, quality assurance, and they all have to speak the same language, but nobody’s aspiring to get anybody else’s expertise because that’s not the point. The point is to come together, speak the same language, have a great product that is serving everybody’s needs. So yeah.
Kate:
Exactly. It comes into product creation, which I’ve also learned a ton about. Again, areas that I never, as a veterinarian, learned about, as a pathologist, never learned about, but I’ve had a lot of fun learning about because what I know is that every bit that I learn, again, I have to limit myself because I don’t want to go… I want to let those teams do their expertise, but every bit that I learn, I know that I can get closer to providing an experience for the customer, being the veterinarian, to enjoy using this service, to get the most out of it, to feel like they’re actually doing something good for themselves and their patients. So that’s what I want. And so talking with these teams has been really inspiring because they have all this tech experience and they say, “Okay, what is it that you envision?” And I tell them and then they do that. So it’s really neat. Now, it’s not always smooth because they might come back with something-
Aleksandra:
Do you have some features or some visions that they said, “No way, that’s not happening”?
Kate:
No, not… No, because anything’s possible. So I don’t know, I’m actually in the process of… I’ve got a bigger vision happening right now that I actually am meeting with them. I told you after we talked just to discuss and I thought, “Oh, maybe this isn’t possible” then I thought anything is possible. It’s just a matter of, there’s a lot of factors that go into that, right? And that you have to figure into your old business plan but no, not that. There were some hiccups in the beginning and it wasn’t on anybody’s fault in particular, but aligning those visions of things like what you aesthetically want it to look like.
And that can be challenging because what one person finds to be aesthetically pleasing might not be what another person finds to be. So we had a little bit of a thing in the beginning where I was like, “Oh, I don’t know.” And it’s just about communication. The app wasn’t live yet, this was all just part of the design process. They were saying, “What do you think about this?” And I think we need to reassess those design elements because this is not what I had in mind for design, color response, what icons, stuff like that. Yeah.
Aleksandra:
There’s one part, the other part that at some point, when I was in the digital pathology company took part of was the user interface, like where all the buttons come? What’s most intuitive? Where do they look first? So that was also an interesting thing. I guess you had to develop this from scratch.
Kate:
Yeah, but I didn’t. They did. We worked together, so that’s the thing. At first, I thought “I don’t know anything about that stuff” and what I realized is that I don’t have to if I hire a team that does. That’s the whole point of hiring a team that has done these things before and can stand something up and say, “What do you think about this?” And then if you have any particular feelings about something, they can make adjustments, but I don’t have to spend my time thinking where’s the button going to be because as long as they understand my end goal, they can create something that at least is a good place to start, that can be adjusted.
Aleksandra:
I love that you basically did it before with the existing technology. You did it how you wanted to do with WhatsApp using the phone and then was basically translating what’s already out there, streamlining it and putting it into one tool. And you say you had a couple of tools for reporting whatever, so that is cool.
Kate:
All in one place. Yeah.
Aleksandra:
I think it’s so… It’s great because it’s basically doing digital pathology without any additional anything.
Kate:
Yeah. And I mean, that’s the goal, just to be able to make things easier for people. Ease of use, that’s a big thing. And cost effectiveness. And that’s what I’ve found that is valuable about this services that it achieves both of those things and so some people may say, “Well, you don’t have the whole slide to review.” So is that an issue? Especially from the pathology standpoint, other pathologists may they say “I don’t feel comfortable.” I remember distinctly, like I said, I didn’t create telecytology app, Static Telecytology. There actually are a couple of veterinary universities that offer that as a surface. So you send them photos, but they do it through email, it’s not through an app. And I remember, when I first heard of that, I remember thinking, “I don’t think I’d be comfortable evaluating a slide through just photos of certain areas.”
And it’s funny because here I am now, because I do realize the utility of it that you can diagnose and you can at least get a lot of clues from well-taken photos, having multiple objectives, multiple areas, and then we have the expertise as pathologists to know the limitations. If I get one photo of just a spindle cell and that’s it, I know how to communicate to the veterinarian what that could be, that I’m really limited with that information. It’s really no different than the limitations you get with a full slide review. Maybe you didn’t hit the certain area that had the pathology in it, so it’s just different.
Aleksandra:
Yeah. Totally. And if you also have a certain level of expertise at the point of care, that’s splitting your job into two because if it was a full slide, you still have to find those areas and then you have to find the answer. Here, they find the areas, you provide the answer. Faster-
Kate:
Exactly. And that helps keep the cost low. Yeah.
Aleksandra:
Exactly. Cost is lower, the whole thing is faster. The veterinarians are learning from every case because they provided the images, then they get the answer. The next time, maybe if it’s visible, they don’t have to submit the case. So phone is what we need. Microscope, obviously. The app. I want to know if you had any hurdles or technical difficulties when you were developing the app. What technical problems? Specifically, tell me. What were the hurdles?
Kate:
So, well, we’ve intentionally grown slowly because what I did not want to happen was have this big, like me shouting from the rooftops about the app, putting time and energy into marketing it so that people know about it and then get a big run on cases right when we opened the doors and then having a technical issue. Because I don’t have that technical expertise, that made me nervous and I want that experience to be good and not the app crashed. So we did that intentionally and that was really good because we’ve had this user base that’s started with us and have been almost like a second beta test where we’ve watched them go through the app and tried to pick up on any kind of issues that might arise.
And there haven’t been a ton, but there have been some technical things, just like any other technology. And I had to get used to that because I was like, “Is this because I don’t have… Is there something happening on our end that this is not good?” And then I realized this is just the growing pains of having a tech, being in the tech space, it’s going to happen. So a couple things-
Aleksandra:
It’s [inaudible [00:26:00], it’s going to break and it’s going to have bugs. I had to learn that as well. I was the same impression. And the beginning was like, “Why do you provide me a software that’s not perfect, that something crashes, something doesn’t work?” And then slowly, I understood, “Okay, it’s so complex that it’s not possible to foresee every kind of thing. That’s why you’re testing. And then when you release it, people are doing additional testing so there’s going to be something that’s going to crash anyway.” So just live with it and make it better than expected.
Kate:
Yeah, exactly. I think being communicative with the people using it, letting them know this is… First of all, please tell us if something happens because we can’t know unless we know, unless you tell us. Two, sincere apologies. We recognize that your time’s valuable. You may have put in your case in, so this didn’t happen much, but a couple times, somebody would’ve put their case information in and then the app closed or it stalled or something. And that, they are owed a sincere apology because they took the time at their busy day to put that in and now, they have to go back and do it again. That’s a small thing, but it’s not. It’s somebody’s time. So acknowledging that that was a problem for them, apologizing and then fixing it. I mean, that’s all you can do. There are going to be things that are going to happen, but you want to make sure that people understand that you care and that you’re going to fix it.
And so what’s hard for me is I don’t have a technical background, so I can’t personally go in there and fix it. I have to communicate with my team and let them fix it. And luckily, they’ve been super quick. I mean, the biggest thing is they’re quick on fixing bugs and investigating things that have come up. But you asked for specific, so that was one specific. Let’s see. Oh, one of the bigger ones that we had was we updated. So again, I’ve learned all this stuff. I didn’t even know what updating an app meant six months ago, but we made some backend adjustments to nothing that the vet or the user is going to see, but there was some backend adjustments to some flow of things.
And so the app team submitted an update to the App Store, everything was fine, but then it actually caused an issue. Well, so we knew this was going to happen. The user had to reset their password after this app update. So it popped up and said “Because of a system upgrade, you have to reset your password.” The problem is that the problem came up when they were putting their password or they were resetting their password or they clicked the link to reset password. We’re all used to that, right? It goes to your email and then you reset the password.
Aleksandra:
Yeah, you’ll get an email.
Kate:
We were hitting some firewalls with the email servers, so some people were getting that email and some people weren’t. And it wasn’t a matter of it going to their spam folder, it was just that it was not a [inaudible [00:28:44] in because of a firewall. So I had to get with my team and say “This is a big problem because now, they can’t get into the app. This isn’t just like a little annoyance, they can’t get in.” So we really had to buckle down and figure out how to fix that pretty quickly and it didn’t happen quickly. There was a lot of, I mean, and I shouldn’t say quickly, I mean, we fixed it within the week, but that doesn’t feel very fast when you know people who need your service.
Aleksandra:
Yeah, when you have a case that’s [inaudible [00:29:10]
Kate:
Yeah. And so there was a lot of back and forth with a couple clinics. They were very understanding and we eventually got them in and fixed the problem but yeah, that was probably the one where I was really struggling the most where I was like, “Oh, technology”, but it’s growing pains.
Aleksandra:
Yeah. So obviously, you upload images. Did you have any problems with too many images, too big images or anything with the images? I’m super interested in the image side of this.
Kate:
Yeah.
Aleksandra:
Then we’re going to dive in. What kind of images are you even accepting? How do you teach that? But let’s start with the technical.
Kate:
Sure. Yeah. So I wouldn’t say problems with it. We had considerations when we were developing. How many images are people going to be able to upload? Because all of this takes space, cloud space. The good thing about these images is they’re small, way smaller comparably to our digital scanner images. So that’s another cost savings area there that this is a JPEG and not a digital file that takes up a huge amount of space, but if they’re submitting, we allow up to 20 photos to be submitted. But just because most people aren’t going to submit more than that, if they need to, then at this point, they can email me. So it’s a little clunky there. That’s another place where I want to tweak things so that it doesn’t feel like, “Okay, now, I have to email outside of this app” but most people are not submitting more than 20 photos, so it works out for most people. But that was just to limit the amount of space that is taken up by each case. But again, it’s usually more than sufficient to have 20.
Aleksandra:
And where do they send it? To the server? How is that set up? I’m super interested in that as well.
Kate:
We might have to get my app team on here with me next time. That, I don’t know. I don’t know where they are. They are in a secure place. I should probably know more specifics about that, but my app team, that’s their area of expertise. So what I care about is that they’re secure, that there’s no-
Aleksandra:
Could you access them through the app as well?
Kate:
Yep. Yeah. So my screen, very similar to what the user sees, but it’s just a case list. And so I will click the case so it has a pending list and then if you submit a case, it immediately shows on my pending list and when I click it, what comes up for me is exactly what you just entered in that form. The case information, the patient information, and then there’s a box that has all the photos and I can click them and they open, they can open full screen, I can zoom in on them as if they were a photo. So they’re not dynamically zoomable.
So there’s no smartness as far as filling in pixelation and all of that. That’s a goal for the future. But right now, it’s literally just images. And then my screen, I can click a button that says enter and then I get a form in the app, this is all in the app. And I enter my report and then I review it and then I click report finalized. Then what you see on your end, you get an alert on your phone that your report has been finalized. You go into the app, you can view the report directly in the app or you can download it as a PDF and it has all the information populated into that PDF, so that can easily go into the record.
Aleksandra:
This is so cool. I love it. That’s fantastic.
Kate:
Yeah. And so-
Aleksandra:
Yeah, okay then. If we ever get together with your app team, I want to know also how long do you keep those images and all this digital pathology nerdy stuff that people are asking when they set up digital pathology?
Kate:
Yeah, and those are still some details that we’re working out on the back end because like I said, it’s a learning curve for me. So those conversations are always ongoing. And one thing you asked me that I didn’t answer was how did we train each other? Because we’re both-
Aleksandra:
Yes. Tell me about that.
Kate:
Yeah. I have learned as much as I possibly can to understand what we’re talking about when we have our meetings. They’re very good at communicating what they mean without… They’re programmers, but they have… Their business is set up to be able to communicate what they’re doing to the lay person. On the flip side of things, me explaining what I do takes some challenges as you understand to people who don’t live in this world, but they didn’t really need to know a lot of details there. I think with our test images and stuff that were coming through there, this is different-
Aleksandra:
What’s on the image? Different [inaudible [00:33:34].
Kate:
Yeah, whatever, right? Yeah. But I mean, it’s a pretty intuitive process. I think they understand what it is and definitely now, after a couple conversations. So it wasn’t this big hurdle to really get past.
Aleksandra:
Yeah. I think for the development team, the information that they’re interested in is your workflow and the type of files, the type of things you work with and what you do with them. Where I see this pathology to computer version translation is more image analysis side of things. So if you ever wanted to incorporate some kind of blood, automated blood differential or whatever where you have to plug in image analysis, that’s where you have to explain actually what’s on those images and how to identify those different cells.
Kate:
Yeah, that’s a totally different process and that’s something that I am starting to realize that I will, without giving away too much, I will need to have those conversations and be a bit of a liaison between the programmers that don’t have experience in the medical space. And it’s hard because I’m trying to ask these questions, “This is what I want to happen. Can you make that happen even though it’s specialized for medicine?” It feels… What I’m doing now is a very simple process from a programming standpoint, but you know what I have visions for to make it even better might take some more. I think honestly, getting a project manager, so if you’re in the world of business, you’ve heard of project managers before, they can really help facilitate those conversations and get everybody on the same page as far as speaking the same language, so that’s something I’ve been looking into.
Aleksandra:
Did you have one for this project?
Kate:
Not for this, not yet, but I’m looking into it. Yeah, I’ve actually contacted a couple to see if they can help, but even that’s a little hard because-
Aleksandra:
Oh, very much. The more complex it gets, the more you need to.
Kate:
Yeah. People, and really just tapping into people’s expertise is something that’s been really helpful.
Aleksandra:
So let’s talk about the requirements for the images. So okay, we take them with the phone but they have to be diagnostic and they have to be a certain quality. What’s needed and how do you convey this to the veterinarians or the people who are providing the images?
Kate:
Yeah. So at this time, the way that we really give feedback about image quality is via the chat. So there’s not at this point, and this is being developed, so that’s why I say it. At this point, there’s not much in the way of training to get images, though. Because of the success of the service so far, and I realize that people are going to continue to use it, I really want to make that accessible to people because they want to know, they want to know those tips to help them get good images. So I do have a sheet that’s downloadable from the app. It’s a one-sheet tips and tricks showing diagnostic areas of a slide, showing overstained versus understained areas, giving tips on how to get good images, explaining that we really like to have 10X, 40X and 100X use, not just all 100X because these are things that veterinarians oftentimes just don’t know. And it’s not because they’re dumb, it’s not anything that has to do with them, it’s just they haven’t been trained before.
So yeah. So it’s important to give them that information. I do provide some training in the sense of they have a downloadable sheet, but my plan is to make it even better, really make something a little bit more user-friendly, something that I know that they’re going to review because even though they may not feel comfortable with taking photos, again, I’m able to help them in the chat. So if I get a really blurry photo and that’s all I have, I don’t have other diagnostic photos, I can chat and say “Hey, this one’s pretty blurry. Can you go in and take a couple more?” Or “I need at least five more or whatever and I can give back guidance.” That just creates a lot of… That’s manual. So anything that can make things faster on both of our ends would be really helpful in training them from the beginning.
And it doesn’t take a lot of training, but just a little guidance on what do we need? What do we like to see? What can help create really diagnostic photos that’s good information for them to have? So I really like to have at least five photos, really more the better with this type of service, but sometimes, vets think, “Oh I don’t want to give her too many because I don’t want her to have to look at too many.” So communication, yes, I want to see a lot because you increase the likelihood that we’re going to have a diagnostic case or at least some helpful information, if not straight up diagnostic if we had a lot of photos. And there’s actually a paper that was written in the past, I think five years, published in Veterinary Clinical Pathology that looked at that and looked at the utility of static telecytology and they found that submission of at least five or more photos increased the accuracy of diagnosis. So there’s data to support that and I would agree with that. Usually, five or more is a good amount of photos to [inaudible [00:38:19].
Aleksandra:
We can link to this paper in the description as well. So feel free to send it to me and I’m going to put it in the description for those who need some scientific proof that this is a legitimate technology. We’re not inventing this.
Kate:
Yeah. And the human medicine too, they call it Rapid On-site Evaluation, ROSE. So that’s something they’ve been doing for years in the human medical world. And there have been papers written and in this area as well, a lot of looking at providing cytology services to third world countries or countries that don’t have those resources available to them. And so there’s been some research there and I think there are parts that really extrapolate to veterinary medicine because of the financial limitations that we have to deal with because we don’t have that, I don’t want to say benefit of insurance because at least in the US, it’s not the most fun thing to deal with and it’s not always super beneficial, but it takes… It’s just a different process, as we were talking about earlier.
Aleksandra:
I think that static images are not so showcased because now, with the hype of scanners of super high resolution, whole slide images, and also the artificial intelligence and image analysis on top of those slides, the fact that you can actually just do it with your phone and have a consultation with the tools that you have is not really advertised so much, which I think is a pity because basically, this is that entrance for digital pathology to everyone who would benefit from this. Be it a MD pathologist, veterinary pathologist, veterinary non-pathologist, veterinarians, people from remote areas, everybody has a smartphone. If you have a microscope and you’re using it for something, take images and consult. But I think it’s downplayed in that era of personalized medicine and AI giving you insights that you were not able to see in the slide, which is a fantastic technology, but there’s a lot before that. This is the very advanced thing, but you can start small right now with your microscope at home.
Kate:
Yeah, and that’s absolutely right. And the things that yes, this is not the sexy technology. The digital scanners are, AI is, and there is a place for that and it is a, I mean, we got to keep moving technology forward. And like I said, I work with these companies to read the whole slide images. I believe in the power of those advanced diagnostics. It doesn’t change the fact that it’s not-
Aleksandra:
No, it doesn’t change the gap that’s before it, right?
Kate:
The gap, yes.
Aleksandra:
The advance technology addresses something else than what we’re doing here.
Kate:
Right. Yeah, and I feel very strongly about that because they’re forgotten. The people that live have a one or two-doctor practice that work in a rural area, they are not going to have the ability to have a scanner in their clinic from the start.
Aleksandra:
Never ever will they-
Kate:
I mean, there’s-
Aleksandra:
Yeah, [inaudible [00:41:25] have a need for that. No.
Kate:
And the business, unless these scanners are free, which they’re not ever going to be, even if they were, I mean honestly, money aside, if you just don’t do a ton of cytology but you still have the need for a pathologist’s opinion because you want to provide top quality medicine and you want that help, you don’t want to feel uncomfortable when you’re looking through your microscope and having no idea what you’re looking at, you are going to be in a position where you having a scanner in your practice is not only the cost-prohibitive, but you may not feel comfortable with it because even though a lot of them are pretty intuitive, there are troubleshooting issues. And I talk to a lot of veterinarians and I hear them and they say, “I don’t want to mess around with slide chase. I don’t want to mess around with having to troubleshoot and spend 30 minutes of my day trying to figure out why my slide isn’t scanning in well.” That’s not a knock on the digital companies.
Aleksandra:
Same story at larger institutions, even high throughput scanners, you have more hardware to deal with and here’s your phone. The only thing that you need to know-
Kate:
Everybody knows how to use their phone.
Aleksandra:
How to take good pictures, which I actually have a little guide for how to take good pictures, not really on the diagnostic side, but more for educational and posters and conferences, so I’m going to link to that [inaudible [00:42:41]
Kate:
Yeah. Do it. Yeah.
Aleksandra:
I’d love to see it in the description as well. And whenever you have your guide, let me know and we can put it there as well.
Kate:
Great. I will.
Aleksandra:
So if you were starting this project again right now, what would you do differently?
Kate:
It’s a great question. It really makes you evaluate what you’ve done.
Aleksandra:
Or is there something that you would not do at all because it was a waste of time, didn’t need to do it, had to scrap it, something that lesson learned that if somebody wants to do that or if you were doing it again or for your next level project, what would that be?
Kate:
Yeah. To be honest with you, I’ve been really happy with the way things have progressed. So there’s nothing really huge, so I think that definitely was it. That doesn’t mean that things haven’t happened. I think partly, I’m pretty much an eternal optimist, so anytime something happens, I just deal with it and then move on, so it’s hard for me to remember painful times. But I think that, well, one thing that I was… Yeah, this is not necessarily a bad thing, but I was very cautious in the beginning because I do have a large Facebook group, I have a lot of people that I have a direct megaphone essentially too, because they follow me on social media and I then provide those educational things for them. I was reluctant to talk-
Aleksandra:
We’re going to link to that as well.
Kate:
Of course.
Aleksandra:
Yes.
Kate:
I was reluctant to talk too much about this service initially because I worried, this sounds cocky and it’s not at all, I was worried about too much business just because of my own life, my own… I wanted to make sure that as the sole pathologist, I didn’t get overrun with cases until I was ready and until I knew that I would have other pathologists that could help and either be contractors or even employees at some point. So I was pretty hesitant to really talk about it on social media and so that slowed growth. And it’s not all about growth, honestly, it’s about letting people know that this exists so they have this resource. From the business standpoint, of course, you want things to grow.
You’re spending, I mean, this is my full-time job. I support myself with this business, so I, of course, want it to be successful and I want people, and it’s heartwarming for me to know that something that I’m so passionate about and that can support me as my job is also just so helpful for veterinarians. I mean, that’s just the win, but I was hesitant to talk much about it because I didn’t want to get overrun with cases and so it was slower to grow because it did. If you’re not talking about it, people don’t know about it.
The cool thing has been is that the people that do know about it, there’s been a nice word of mouth. Vet Med is very tight-knit and there are little sub communities like the mobile veterinarians, they talk about the service in their Facebook groups.
Aleksandra:
That’s like proof for them.
Kate:
Yeah, it really is. So I guess if I had to do it again, I would maybe be a little less reluctant to talk about it in the beginning, but we’re still at the beginning. I mean, we’ve only had this available through the app for a couple of months, so I think it’s-
Aleksandra:
Don’t worry. Once you’re ready, I’m like, “I think it’s fantastic. I’m going to be spreading the words. So you’re just give me green light. This is going to go out to the internet” but no, I just, it’s-
Kate:
I’m ready. I’m ready for it. I mean, people, I want them to submit their cases.
Aleksandra:
Very good.
Kate:
I have a plan now to, if I do get overwhelmed personally, then I have a plan for how to-
Aleksandra:
You have a plan?
Kate:
Yeah, and it’s not just grab any pathologist. The pathologists that would work with me, they would need to understand the mission behind this and have the same communication kind. We have company pillars, we have company things that are important to us, and kind and effective and just communication is really important. And opening that channel of communication between the practitioner and the… Or the practitioner and the pathologist is a big part of this too. So yeah.
Aleksandra:
Yeah, which is like a non-existent thing. You get the report from a reference lab and here you go, do whatever you want with it or not.
Kate:
Yeah. And there’s value in that. It’s just not… It’s just there can be breakdown in communication. I mean, you know how it is. The practitioner may not understand what the report means and then they have to call and their call may not go through or you deserve, as a pathologist, time off. So you may not be in the… And then maybe you get back to them on Monday and that’s totally acceptable, but there’s just a breakdown in that continuity of communication that technology can help us with.
Aleksandra:
I love your app because it lets people start with digital pathology with what they have. Digital pathology, sometimes, this word is intimidating. It means that, oh, you have to have ton of expensive gear and ton of experience, otherwise, you cannot get into digital pathology. You can right now, with this phone or another one with your microscope. And in the podcast, we talked that, okay, you don’t even have to do diagnostics, you can do education, you can do sharing what you see under the microscope. This is all digital pathology. So I’m all about digital pathology for everyone, so thanks for coming up with this idea. Thanks for seeing the need. Thanks for stepping up. Even though this is outside of our education, it’s something we think is valuable and want to take it to the next level and bring it to more people. Thanks so much, Kate.
Kate:
Yes. Well, I appreciate your support. I mean, especially having other pathologists support and just seeing that yes, it serves its purpose for the need that it’s meant for. Yeah, just having support is everything. So I appreciate your ongoing friendship and support and having me back, I mean, I always love talking about this stuff.
Aleksandra:
Also yeah, I’m going to have you back once you come up with this image analysis thing. Oh, then maybe we invite the team as well because I’m going to be asking many technical questions.
Kate:
Yeah, I have some good ideas. So hopefully, we’re going to keep moving things forward because I don’t want to stop with just a good service. This is a very good service, but always thinking how can we make it better and staying within the… And when I say make it better, it’s staying within the low cost realm. We don’t want to strive for bigger and better if it’s going to cause things to get excessively expensive. That’s not what we’re trying to create. So we’re trying to be very creative and yeah, more to come.
Aleksandra:
Great. And I’m going to link to everything below, everything that Kate has to offer. She has plenty of stuff for cytology education in that realm and to our previous episodes. So have a look and talk to you next time.
Kate:
Okay. Thanks everybody and thank you for having me, Alex.
