In this episode, Dr. Aleks Zuraw sits down with Mariano De Socarraz, President of CorePlus and member of the board of directors at the Digital Pathology Association.
CorePlus is an anatomic and clinical pathology lab in Puerto Rico that fully embraces digital pathology and AI.
Mariano shares how CorePlus, as a technology-forward company, decided in 2018 to fully convert to digital pathology. They took 2019 to prepare, validate their processes following CAP guidelines, and get full buy-in from stakeholders. On January 1st, 2020 they were fully digital.
While acknowledging that glass slides have advantages in simplicity, Mariano believes the benefits of digital pathology for patients and pathologists are too great to ignore. His advice for other practices considering the digital transition:
After seeing a press release about UPMC and IBEX using AI to diagnose prostate cancer, CorePlus reached out to partner with them. They became the first site outside the UK to validate and implement IBEX’s algorithm, running it on over 9500 cases as a QC tool.
The algorithm was able to alert pathologists to missed lesions in 73 patients that would have otherwise been false negatives. CorePlus has now moved the algorithm to the front-end to pre-screen and triage all prostate cases.
They are also partnering with other AI companies like AlpenGlow, Artera and TechCyte to bring these benefits to breast, GI, cytology and other subspecialties. Mariano sees AI generating predictive and prognostic insights right from slides.
Mariano believes medical education must quickly incorporate digital pathology and AI training to prepare the next generation of pathologists. The Digital Pathology Association is key in fostering collaboration to expand access, especially in underserved communities.
While going digital requires some reinvention, Mariano is excited to pioneer this space. He and CorePlus aim to be “missionaries” doing what’s best for patients and the field of pathology.
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The Essence of Patient Care in Modern Medicine
Mariano: [00:00:00] And I know that we live in a world where the patient has been lost. You know, nowadays we call them clients or we call them members or subscribers. But you know, I grew up with Marcus Welby and you know, the idea of a patient is still very ingrained in me and our organization. So we’re here to provide the best possible result for a patient.
It’s incumbent upon us to do that. That’s our commitment as human beings. And we must do whatever we can to provide the best result. results and I think when you look at the Hippocratic Oath it says “DO NO HARM”. So if we can provide a better diagnosis if we can do something for our patients we’re going do it and part of this journey is because we wanted to be able to give them the best from us.
And I think as human beings we need to do that.
Introduction to Core Plus and Mariano De Socarraz
Aleks: Welcome to my Digital Pathology Trailblazers! Today. My guest is Mariano De Socarraz and Mariano is on the board of directors of the Digital Pathology Association. [00:01:00] He’s also the president of Core Plus. Coreplus and of course, he’s going to give us more information on himself. But, I want to let you know that CorePlus is an anatomic and clinical pathology lab in Puerto Rico, founded in 1996.
So already running for quite some time. And they not only embrace digital pathology for primary diagnosis before the pandemic. So this is unheard of in the digital pathology space. But they are also pioneering the use of AI in precision pathology. And Mariano, you are partnering with companies such as IBEX, AlpenGlow, Artera, and TechCyte. You guys are all pioneers. You’re using AI for primary diagnosis. And right now, like for every patient almost, right? So I’m super excited to have you on the podcast. How are you today?
Mariano: Great. It’s great to be here with you, Alex, and I appreciate you reaching out to us to tell a little bit about our story and [00:02:00] where we are, where we’ve been, and where we’re going.
So it’s, it’s exciting to to spend some time with you. I congratulate you also for the work you’re doing because it is also pioneering work, getting, getting the word out to the community that, you know, digital pathology and A.I. is real.
Aleks: Thank you so much. And when I heard your story, I was amazed. So let’s start with you.
The Journey of Core Plus: Pioneering Digital Pathology
Tell the listeners about your background and the beginnings of Core Plus. What kind of practice is Core Plus and who are your clients? Who are your patients? Who are you serving?
Mariano: Well, you know, primary early. We’re an outpatient practice, so we mainly concentrate on offices, surgery centers, etc. We just recently started with a hospital, so we’re really focused on the outpatient market and those are our clients in on the specialists, like obviously urology, [00:03:00] breast surgeons, OBGYNs, podiatry, dermatologist. That’s a broad spectrum of clinicians that we serve and work with.
Aleks: How did you start the practice? Tell me about the day where you thought, Yes, we’re gonna open Core Plus.
Mariano: Yeah, let me give you a little background. I started as a X-ray technologist at Jackson Memorial Hospital in Miami. You know, I don’t even want to tell you how many years ago and during, during that time, I, I rotated through diagnostic ultrasound. In those days, there was just little dots on the monitor. Nothing like in this today. And really got hooked on technology and a medical technology. And from there I was recruited by a company and started doing what was called an insurer, still is application specialist and went around the country. Training radiologists and stenographers.
At that time there, I think there was maybe one or two [00:04:00] schools in the nation. So most of it was kind of a on the job training and we we did that for a long time. And so I have an imaging background. So fast forward to 1996. I had a distribution company, diagnostic ultrasound was one of my primary products.
Obviously, with my background and running into a urologist office promoting the ultrasound, I heard of this. Well, we were going to do prostate biopsy. Well, you can imagine they’re many, many years back. Those procedures weren’t done, let alone thinking of trans rectal. I think in those days it would have been impossible. So we learned about that. And as an entrepreneur, I kept on looking and and really dug in to what was all the biopsy business about and really got interested in it [00:05:00] and thought that we could provide a service through to the urologist.
And that’s how I started the company in this way. It’s called CORE from core biopsy and then Plus as an added service. So that’s how we started back in 96, concentrating on neuropathology, which has always been a focus of our business since day one.
The Evolution of Core Plus into Digital Pathology
Then in about 2000. And so, you know, keep that imaging background there and there in around 2007 2008. And I always thought that, you know, when is pathology going to convert to imaging, which is natural? And I got involved with a company in the, in the Bay Area called Bioimaging. Mohammad Attawar was one of the founders, and the imaging team came in and we were their first customer. And I mean, it was kind of, if you think about it, today was kind of crude [00:06:00] and we were really doing it for ER, PR or to and it was just county, I mean it wasn’t anything like what it is today obviously, but that really showed in what I thought would be the coupling the pathologists from the glass.
And so we started to work with that. But unfortunately I think, you know, things didn’t really work out yet and maybe wasn’t really time, prime time. I wasn’t ready for prime time, too, to really convert your practice to primary rigs. So we had that initial contact back in in 2008. Fast forward to 2018, and since we’re very involved in neuropathology, we saw a press release from UPMC and IBEX and intrigued me because they were talking about using AI to diagnose prostate cancer.
And immediately that opened up the curiosity for [00:07:00] us to to really see, how real is that? So we made contact with IBEX and with Yossi, the CEO came to Puerto Rico to validate that we really existed and, and we started our relationship. And then in 2019 we decided as an organization that by January 1st of 2020, we would be converted to a whole slate imaging for primary rigs.
So we took 2019 to visit and participate in different seminars. Dr. Juan Carlos Santa our Chief Medical Officer, and myself. So we took that year to do that. So that’s the beginning. The other thing is, so we do have a technology company, and I’ve always been interested in technology and I think it’s important. So we build on it.
Aleks: So this is in parallel to your practice with Core Plus?
Mariano: Right, Right. [00:08:00]
Aleks: This is another company that supports you with your…
Mariano: Right
Aleks: …with the cutting-edge stuff.
Mariano: Right. And we want you to know, I don’t like the word LIS and everybody knows it. I like to use the word pathology workflow because I think it’s different than a laboratory information system, even though we do things that our PCR base and others would be considered under the laboratory.
However, the workflow in pathology is different than the workflow in and in the laboratory. Clinical laboratory kind of environment. So we’ve always focused on workflow and, and that’s how I like to talk about it. So pathology workflow platform right now what we’re looking at is a digital AI-enabled ecosystem as we roll that out in the future.
So in 2019, we made a decision to either buy something off the shelf or because we had the technology company to just do it in Alston And we really wanted to control [00:09:00] our destiny. We don’t want to be in somebody else’s ecosystem. They think that the technology that was available was really state of the art from our perspective. And so we decided and embarked on creating our own ecosystem.
So by January 1st of 2020, we used the CAP guidelines for validation and we went through and validated our histology, immunohistochemistry and special stains.
Aleks: So you did everything…
Mariano: Everything…
Aleks: Basically for a digital read. So there is no like, you do the H&E’s, but I&C still comes on glassware.
Mariano: No, everything.
Aleks: I love it. Like you’re okay. We decided in 2018 we’re going to learn about it. Then in 2019, we decided to work on the implementation and by January 1st, 2020, we were up and running. This is so cool. I mean, it’s fantastic, but it’s also unheard of. Like institution. Even a [00:10:00] company following a plan like that to a T is impressive. And so it’s also funny that I said to come and check if you really existed in Puerto Rico.
And that brings me to the question how was the digital pathology journey introducing it in Puerto Rico? Did it even matter the location? I mean, I assume you were pioneers there, but in general, you’re pioneers in the U.S. and there is only a certain percentage of digitally enabled pathology practices. So how was it? what sparked your interest in doing this? They’re actually…
Mariano: You know…
Aleks: How did you end up with Puerto Rico?
Mariano: Yeah, you know, a couple of things. Our number one is, you know, just as an organization, our interest in technology. So, I mean, we embrace technology. You know, I would like to think that we’re a technology company that does pathology [00:11:00] versus a pathology company that uses technology.
I mean, we really embrace technology, number one, and we like to be at the cutting edge. We can guide our own destiny. So, you know, the buck stops here. And, you know, the most important part is that we have full buy in from all the stakeholders. I mean, nobody ever said a peep about lets not do this. So the whole team was excited about doing this. And I think that, that that was really it to me, the catalyst to get this done in the timeframe that we did.
Aleks: So did you encounter any challenges? What were the challenges you’re with?
Mariano: You know, there weren’t any challenges and then everybody else will be doing this. Yeah, but I think the biggest challenge that a lot of people face is number one in terms and I think we were able to achieve that one was it wasn’t a problem. [00:12:00]
Aleks: Is that because of the company mindset that you started the company with like, like you say, your technology company does pathology? Before you were a technology company that was enabling radiology. So, like, because the technology is at the core, it wasn’t the problem to leverage it for another discipline.
Mariano: Right? Yeah. I mean, I think a lot of that is is, you know, also you know, having that background from imaging also helps because it’s really the same thing. You know, years back we used to carry, you know, the X-ray film and you know, you needed a cart to carry that and you know, and the same thing with digital, you know, with slides. So, so you know, imaging was able to decouple the radiologist from the film. And you know, the same thing in my mind that happened with with pathology.
And once we [00:13:00] digitized, as you well know, there’s a whole new universe that opens up in opportunities that as we’re seeing today. Right. So participating in that, it’s, this is really transformative in my mind to the practice of pathology. I mean this is you know, this is this is breaking, you know, what we had before. And it’s a whole new world out there.
Aleks: It’s it gives a like this ideal picture, which for you is reality, where, okay, if there was no internal resistance. So this is how we did it. This was the first that this was a matter of deadline. And then we did it and we just did it because everybody said yes. A question like, did the physicians that you work with, did they even care that it was done digitally?
Do they have any concerns like that? They audit you or it doesn’t matter?
Mariano: It’s funny. [00:14:00] I don’t think it matters. I think that some like it, some understand because it really places you in the forefront. And so from that perspective, they’re interested that they know that you’re really at the cutting edge and you’re providing the best care for their patients.
So I think it is important to do that. And they see the opportunities and the things that we’ve been doing. So obviously the bigger impact has been AI as an additional tool to to help make sure we give the best diagnosis possible.
Embracing AI in Pathology for Enhanced Patient Care
Aleks: Yeah, let’s talk about that. You saw a press release with IBEX that was that had this prostate solution and what did you just like call them and say, hey, we want to implement that as well?
Mariano: Sort of. Yeah. That’s kind of how I kind of I do it a little bit now. I did one of those Web [00:15:00] web websites, you know, fill in and they actually show they were real true on the other side. So they answer. But for us, you know, we’ve been up to date with Gleason scoring. And, you know, just so this was just something very, very curious to us because we wanted to be there.
We wanted to be part of this transformation and we wanted to, you know, kind of believe it. We wanted to try it. We wanted to see if this was really real.
Aleks: So how did you go about the validation and what is the added value for your patients and for your clinicians from this particular application, the prostate, one that you do with IBEX, But then also tell me what other things you have already implemented in the pipeline, because this is not the only AI algorithm that you guys are using on a daily basis.
The Impact of Digital Pathology and AI on Efficiency and Diagnosis
Mariano: Right. Well, you know that you know, number one is why we do this. We do [00:16:00] this for the patients. And I know that we live in a world where the patient has been lost. You know, nowadays we call them clients or we call them members or subscribers. But, you know, I grew up with Marcus Welby and, you know, the idea of a patient is still very ingrained in me and in our organization.
So we’re here to provide the best possible result for a patient. It’s incumbent upon us to do that. That’s our commitment as human beings, and we must do whatever we can to provide the best results. And I think when you look at the Hippocratic Oath, it says, “Do no harm’. So if we can provide a better diagnosis, if we can do something for our patients, we’re going to do it.
And part of this journey is because we want to be able to give them the best of the best from us. And I think as human beings, we need to do that. So that aside, you know, we felt we felt that, right? You know, how could these [00:17:00] tools help us? And, you know, just a curiosity factor. Number one was, you know, can an AI tool detect cancer better or equal to a pathologist?
So that was an important fact. But before that, I think that I don’t want to lose sight of just converting your practice or trends to change the transformation to digital, because I think that alone brings tremendous value to the field. Now we have the ability of remote reading. I mean, it’s funny.
Aleks: Yes.
Mariano: I have a background still that I use where where doctors send doctors and how they’re pictured.
There’s kind of become a famous picture around and there and they have their masks on and insulation as well you got to update us and no and I, [00:18:00] I leave it there because it tells you how long we’ve been doing. But, but let’s think about it. You know, the ability of remote reading. Let’s think about the ability to now, if you want to change the gamma of that slide, you can I mean, you can’t do that with a physical slide.
Professional satisfaction. You know, I think it’s an area that we don’t even think about, you know.
Aleks: Yeah, it’s I think it’s very under-communicated. When you look generally in the physician world, you will see headlines, “Physician Burnout”, “Physician…” like “Bad Mental health issues” with people who are supposed to take care of us. I don’t think in the pathology world we like kind of translated, but pathologists are part of this physician group, right?
So definitely something super…
Mariano: They have the same [00:19:00] pressures, I think, as anybody else, you know. And also now once we have digitized this image, we can share it. I mean, there’s I mean, all the all the opportunities are there from just from that site alone. And we’ve done some analysis internally and we feel that just going digital increases the efficiency by about 30%.
Aleks: How many pathologists do you have?
Mariano: We have six and top specialties.
Aleks: And…They work remotely or hybrid or…
Mariano: Hybrid, hybrid. Some. Some are almost 100% remote, but but it’s hybrid. And so that gives them a nice, balanced quality of life. So some that have children need to be around or that balance I think is important in today’s world.
We have to do that. And again, you know, if you need to read at 5 a.m. or a at 12 midnight, you can do it. I mean, nobody [00:20:00] nobody could stop. You know that that’s that’s up to you. So I think it gives you that nice work-life balance. And I think another factor is ergonometrics.
I mean, our pathologist is going for a 49-inch monitor? I mean, so when you look at their instance a core biopsy, I mean, it’s like right there, boom, it’s there.
Aleks: Yeah, they have like the full thing.
Mariano: So so I mean, those are other aspects, you know, how do we quantify that? I mean, you know, one of the questions I always get asked is what’s what’s your ROI?
And I, I kind of talking with some clients, friends of mine. So I want to another, acronym, that acronym, I want to make it sound something different, I said. And so we came up with a return on innovation and how do we really come up with that formula? So how do we look at, you know, as, you know, professional satisfaction ergonometrics?
You know, I mean, obviously, efficiency was there, but all these other areas that are important, [00:21:00] How do we quantify that? You know, for instance, second opinions, you don’t have to serve FedEx any more.
Aleks: Yeah, sure.
Mariano: So there’s a lot of things. So we can look at it, but we got to just take that step on.
Aleks: Going back to AI. So you guys have the prostate algorithm. What else is out there in what introducing…
Mariano: Right. You asked me a question that I think I didn’t answer. Yes. And then and…
Aleks: The validation.
Mariano: Correct. So once we validated it. Our our whole slide imaging process, then we were working with IBEX, and we did we were their first site outside of Makabe, to use the AI algorithm for prostate.
So this is nuts. This is something they don’t do anymore because it’s not necessary. But we did a calibration. We ran some of our own cases through there, and they did take a few of our [00:22:00] cases to include in the algorithm. And then we went through the validation, as a matter of fact. All right, now we’re we’re putting out for publication our three years of data.
We’ve done over 9500 prostate biopsies using in this case, the second read system, which is what we started with. So we did the validation and once we did the validation, we put into operation on June 1st of 2020 and we don’t discriminate every prostate biopsy as…
Aleks: Goes through the algorithm
Mariano: Goes to the algorithm, though in the initial phase, obviously, which was a second read or what we would consider a 100% QC process that would give everybody, the comfort to see how the algorithm performed.
So it’s really more of cancer, no cancer, a binary look which can, you know, we can also add [00:23:00] gleason. But I think from our perspective will it detect it equally to better than the pathologist? And if you look at the literature right now, you a pathologist might have a false negative of about 3%, general pathologists could go into the teens.
So it’s it is significant. And so what we were able to do once we operationalized the algorithm, we were able to see, that, and so we were able to see the QC that we wanted to measure that impact on our practice. And we came up with a term called VIA impact, and that was the ability of the algorithm to provide an alert where the pathologist missed it, wasn’t there.
And this was obviously done pre-closing of the case. So in our and in the time we used it as a while in the control tool, we had 73 [00:24:00] men that we identified a lesion that wasn’t picked up by the pathology. So you know, we were publishing that which talked about that. I mean we don’t have a problem.
I mean, this is this is reality. I mean, we’re not…
Aleks: Yeah, this is basically human visual assessment. You are a human. So. Yeah…
Mariano: So, so now we were able to look at that. And so we we were also able to see interoperator variability between pathologist and obviously their expertise. And so I think what we came up with this AI impact.
We have some that have a low score, some have a higher score. But in the end what happens is that the practice benefits because now there is kind of everybody is equal, right? And you don’t miss in the patient benefits. Right. We have we’ve pretty much eliminated the calls negative. Never say 100% obviously and nobody will ever believe 100% but we’re pretty [00:25:00] close to that.
And then on the other side, when the cases are positive, you know, they’re positive. And so I think we’re going to end up working in the middle area, right? We’re going to and now we’ve moved that to the front end. And so now, because we believe in the algorithm, we tested it. I mean, that algorithm individually has been run on 300,000 slides.
I mean, it’s a huge amount of cases and data. So we’re very confident that the algorithm works. I mean, remember that the pathologist is still dry, right? So it’s not like the algorithm was working on its own, but it’s another tool and it’ll make you more efficient and will help you maintain consistency. And so we’re very much convinced that AI is here to stay in all of these other aspects that we’re building.
Exploring the Future of Pathology with AI Integration
We also started with breast at the end of the year.
We’re looking now at bringing in GI, and this is with [00:26:00] IBEX, but we’re also, like you said, working with other companies.
Aleks: So this is also for cancer detection?
Mariano: Right? Well, cancer is also a human microorganism.
Aleks: For digital…
Mariano: For GI. The other thing that you know that this helps you with, is really looking at all the different features then you that sometimes you’re looking for in breast microcalcifications or in prostates. Nerves, I mean things like that. The AI can help you and speed you up and get there faster and don’t miss.
Aleks: So do you then identify these things because I assume depending on the company, on your partner, there is like a certain algorithm that they already developed, and then, okay, do they have a use for this? Do you also work partner with them in terms of, Hey, we would like to have like you mentioned microcalsifications.
Can you build an algorithm for that? Because we think it’s relevant.
Mariano: Yeah, No, right now we’re not. I mean, right now we’re, we’re really [00:27:00] ingesting what the companies have. I think we have a very nice relationship with some of our partners. We’re working. We’re providing them with some feedback, user interface, feedback, and ideas. But we’re not we’re not in the algorithm-building business right now.
But we are collaborating. You know, one of the things also that in today’s world of diversity, you know, we have a large Hispanic population, so it enriches the algorithm, you know, So we’re working with multiple organizations to do that. So provide them with a richer…
Aleks: Specific demographic that…
Mariano: Demographics…
Aleks: Didn’t have. Yeah, because…
Mariano: This is about 20% of the U.S. population. So, you know, when you look at it, that’s also a very important aspect in that contribution to having diversity in the algorithm.
Aleks: Very much. I think this is one of the biggest like [00:28:00] pushbacks that the advancements in when the algorithms are built-in and non-diverse population, which often are big academic centers, big centers that have a lot of cases but do not have the diversity.
And I think there has been a lot of pushback and there is a good response from the pathology community like your practice. And I have heard that from others also. Hey, we treat these demographics. How about you use our data as well to enrich the algorithm, to make it more robust?
Mariano: Yeah. And that’s that’s critical. That’s critical. And you know, and, you know, we have the data. And so we’re we’re excited to work with multiple companies longer.
Aleks: And you also described or gave an answer to a question question that I didn’t ask but I hear a lot is like, how do you know that this algorithm [00:29:00] is good enough? Well, you just used it for three years and basically looked at everything with and without an algorithm.
And at some point, you know, okay, it’s good enough, but it takes time and it takes specialists that work with this tool for it’s not, you know, okay, we did so in so many cases because this, and this organization prescribes that it’s a process where those pathologists, whose a specialists in this area, feels confident okay I can use this tool this is my partner I don’t have to please the algorithm all the time.
Mariano: I mean that’s why you do validations and again, I mean, this is a tool for the pathologist. It’s this isn’t a replacement for the pathology. You know, and it’s it’s, you know, it’s hard for people to to maybe embrace that. I think with all of the negative publicity about A.I. and it’s taking over the world that, you know, we’re all going to lose our jobs and so on and so [00:30:00] forth.
The Evolution of Technology and Employment
I think we’ve heard that the Industrial Revolution, we heard that with the combustion engine, we heard that…
Aleks: Cars were invented…
Mariano: You know, with the personal computers and what did it do? It just brought more employment, new industries, and new opportunities. Now, maybe you have to reinvent yourself and maybe that’s where people have a problem.
But, you know, look, it’s here. You know, you either learn about it, or you incorporate it because it ain’t going away. I mean, the genie’s out of the bottle.
Embracing Change: The Impact of AI in Healthcare
It’s here. It works. It’s still the benefit of our patients and the benefit of the professionals. So, you know, there are ways for you to validate those ways for you, you know, and again, I think that everybody wants things to be 100% and nothing in the slide.
Aleks: Nothing in the…exactly nothing in this. I mean, the car can break down. We kind of trust our cars by now. Right.
Mariano: You know what [00:31:00] one other aspect that that that I think about and we’ve talked about our internal incidents.
Optimizing Workflow with AI: A Pathologist’s Perspective
Its what I call cognitive fuel. You know, we all wake up in the morning with the turn of our tank. Hopefully, if we had a good night’s sleep, our tank whole, and, you know, if you look at it at our practice, 50% of the cases that we see are negative. Now, when you’re in a glass-based environment and non-AI environment, you know, you’re looking at each individual like and I’ve seen it numerous times where it’s that last slide that has cancer.
Now, on the other side, you see all of the slides and it’s negative. Now, if I were able to already triage the cases for you and let you spend that cognitive fuel better, and now I [00:32:00] give you more time to do higher level thought and work. What is the return on investment there?
Aleks: It’s better patient care, right?
Mariano: Maybe you get out and see you’re referring clinicians. Maybe you, you know, when you get out and train your stock better, maybe you write me. I mean, but things that are maybe of higher value to the organization than maybe sitting behind the microscope and trying to measure and, you know, typing and let that let the systems do that.
So I think it’s a lot easier. It’s a redistribution of your mental capacity on a daily basis…
Aleks: So, do you have the algorithms and triage or like prioritize cases so that the pathologists can basically like look okay, here the algorithm said there’s going to be cancer, let me take care of this first thing in the morning [00:33:00] before I run out of my cognitive fuel.
Mariano: Right. Well, you know, right now we’ve moved that to the front. So now it’s a triage tool. Now they have that that they have already in the cases, you know, here are your negatives. You’re the quote-unquote, let’s say, borderlines, you know, kind of green, yellow, and red near your positives. And, you know, we are an outpatient facility, so we don’t have this issue of a stat case or we just want to turn around everything as soon as possible because you know, not just the ones that, quote-unquote, have cancer, but the patient doesn’t know what the result is.
So you want to know either negative or positive. You want to know…
Aleks: Exactly…
Mariano: You know, if I get the the the positives. that’s great. How about the other ones who are waiting to find out, hey, my positive or negative? So you just want to get everything moved out as quickly as possible for the benefit of the patient’s rights.
Nobody wants to sit around and wait for a diagnosis. And I think that’s what’s important.
Challenges and Solutions in Digital Pathology
Aleks: [00:34:00] So post going digital did you have like one worst hurdle that you had to overcome? If there was something that you would have to name one, the worst thing that you have had to deal with after going digital? What was that?
Mariano: Well, you know, I think that I, maybe, I, the lesson I was, first of all, I mean, we’re on an island, number one.
Aleks: Yes.
Mariano: So, you know, you know it you know, the only way people can get here is by plane or boat that normally by plane. So. So you know, making this commitment to whole slide imaging primary read what we think we find you said our biggest hurdle or things that we have to take care of is redundancy. Because you know our pathologists are remote, let’s say, and you know, if our systems go [00:35:00] down, you know, we have a problem.
So I think that if there’s anything that I should think about right now in this time it is redundancy. And how do we make well, we make that decision to move, then we have to make sure that our uptime is, you know, 99.9% because there’s no there’s no going back. There’s no going back.
Aleks: Did you have a situation, Oh I don’t know, a hurricane, I mean…
Mariano: Oh yeah, yeah…
Aleks: You guys have hurricane season, right?
Mariano: So I’m saying there’s you know, you those situations happen and you’re like, no. So yeah, that’s…
Aleks: So you can, can you tell me about the day when that went down or.
Mariano: Yeah. So it was a day that everything was down and so it was like, o-oh, pull out the microscopes from the closet. Right. You know, and, but what I’m saying as something to think about if you make that and I think at another site it’s you know, you don’t want that [00:36:00] potential of somebody that maybe used to a 100% convinced to go back, you know, talking with some other people.
You know, I think there’s still something to be said for glass slides. Right. It’s kind of easy. You know, you put it on the microscope and you see it. So, I mean, there’s something to be said for that. And so for some people, you know, it’s an easy pushback to say, look, I can just look at it…
Aleks: Through the same glass. Why should I invest in everything that comes downstream?
Mariano: Right? Right. And one and so so you know, I think that that that that’s important. I know our our team goes crazy if they have to pick up a microscope. So, you know, that’s just not something that they want to do. But I say that’s one thing. I think the other area that maybe you asked me is, you know, we initially, because we didn’t know much about this when we [00:37:00] started, you know, we kind of focused on scanners as kind of like the primary area.
And I think that’s probably the last thing you should think about. And I really think you have to look at your workflow because you really have to re-engineer your workflow. You have to do a lot of retraining of your staff. So all of those things are on Cornell. So I think that thinking about this redundancy issue, I think you have to think about what is your case next, you know what, what’s your volume?
And so on. So that if you’re making the commitment to go truly primary reads that, that you know, you have everything in place.
Aleks: I think it’s very important, I think because this is also a kind of an easy pushback like okay, what if your Internet is down or what if your computer is down? And I don’t know. I don’t see institutions addressing that in a [00:38:00] or I haven’t seen too many people talk about this in a like a risk management way or like, okay, it is a risk.
We acknowledge it is a risk we have this in this plan to manage it, or if it goes beyond so many hours, then we start distributing glass or whatever, like it is a legitimate concern, legitimate and thing that can go wrong. If your digital and your digital infrastructures go down, then you basically cannot provide diagnosis anymore. So I think this is a very valuable point. What do you think…
Mariano: You know, you know, you just you just made a point. And just again, going back to my imaging, I said imaging has been digital. There’s no way you won’t create a film anymore. If they’re down, they’re down, Right? That’s it. I mean, to a certain extent.
Aleks: Figure out how to get them up as soon as possible.
Mariano: I’m saying to a certain extent, we have glass spray.
Aleks: Yeah, exactly. We have at least a backup…
Mariano: So if you can think about it, we have a [00:39:00] backup plan where we’re personally. Yeah, right. Whereas our imaging folks don’t. So I think, you know, hey, look, nothing is perfect. Look at the recent issue with UnitedHealthcare and change health care and the cyber attacks. I mean it’s it’s a disaster. Look, that’s the world we live in and we have to, you know, do the things we need to do to maximize that.
But I think another thing that I have also been thinking something that kind of friction and I think that is part of the lack of adaption. So there’s still a lot of friction for the pathologist you know all of these connectivity issues with the hospital information system with I.T. You know so trying to put all of this together.
Aleks: You also said where it comes from. You mentioned I thought [00:40:00] it’s about the scanner. We need to start with the scanner. If you start with the scanner then you’re going to have to back fix all the workflow issues. If you start with the workflow, then you present that pathologist with something that’s already optimized for their work, and then you eliminate this friction element. But I think there’s still and I don’t know how to call it like education that needs to be done or like pointing out to people who already did it so that those who want to embark on this journey don’t have to reinvent the wheel.
Mariano: And again, this is an early stage. I mean, if you look at an adaption curve, right, we’re we’re really I mean, we’re into this for years, you know, and and and it’s still in early in the game and in that expertise and that’s why, you know, use the word friction because I’ve seen it now how do we and it’s and that’s why I call it a [00:41:00] workflow I mean and you know digital pathology, A.I. enabled workflow because I think if we look at it as a workflow, then we started looking at where that frictions is and we started to use tools that will help us.
You know, it’s not just tools from a diagnostic perspective, but it’s also the tools to help us in the whole workflow aspect. And I think that in my mind the future is going to be totally different than we see today. But we have to work through some of those issues right now.
The Future of AI and Digital Innovations in Pathology
Aleks: What do you think the future’s going to bring in terms of AI and digital innovations?
Mariano: Well, you know…
Aleks: Do you see some trends?
Mariano: I mean…
Aleks: I hope for adaption, but are there any specific trends that you see that are going to be picking up or something that, you know, you are going to be implementing because it’s the next cutting-edge thing that you want to provide your patients with?
Mariano: Well, you know, number one is we’re working as you said, with TechCyte and we want to transition [00:42:00] all of our psychology to 100% QC. Right now in our studies, we’ve done you know currently as part of mandated by CLIA, you have to have a 10% negative review of all your cytology cases. So what we’ve, what we’re doing is converting so that our supervisor, instead of reviewing 10% of the cases from our site, the technologists, the screening cases, we’re going to review 100% using the tech site algorithm.
And we can do that faster than manual. So now, instead of only reviewing 10%, we’re going to review 100%. Okay. So that’s step one in the transformation or cytology. Cytology, you know, has its own technical challenges. So we have to. But it’s also, you know, the same thing happens with the pathologists is [00:43:00] how do we get the cytotechnologists to trust the AI algorithm.
Right. And so that’s, you know, and once we do that, we’re pretty much at over 95% of our cases now being on site. So that’s that’s one I think that’s very exciting from a workflow.
Aleks: What’s this scanner that you guys are using for cytology specimens?
Mariano: Right now we’re using Epredia, 3D Histotech from the P1000, interesting is that they have now a water immersion general capability.
So it helps us, with the cytology. So that’s and we’re trying to look at you know kind of multipurpose scanners, you know, versus trying to, you know, have a specific scanner for a specific application. I mean…
Aleks: How many scanners do you have?
Mariano: We have two right now, the P1000. So there are high capacity scanners, lean more, for redundancy.
Aleks: Good, good. This is good. I [00:44:00] mean.
Mariano: But looking, looking, looking at the future, you know, one of the things that and I was talking to a friend, Mahula Mina, a very well-regarded neuropathologist you might look at him. He said, he came, he gave me the term Histomix. And I think that that is a, you know, something that we’re already seeing.
And, you know, if you look at like you said, our Tera that we’re working with, you know, we’re looking at predictive and prognostic information, whereas before we were looking maybe at a genomic and test and this is right from the glass slide. I mean so you know the the things that are there being developed, it’s going to really change what we do.
I mean, it’s going to be different. And that’s what I think is so exciting and transformative because now they may not only be able to diagnose cancer, going to give them right from the slide a predictive or prognostic [00:45:00] result right there. So I think…
Aleks: That was so great…
Mariano: Those are the new opportunities that we see besides, you know, I think we’re going to have multiple AI algorithms that are being developed now. I mean, we’re working with some of those companies.
Advice for Pathology Practices Considering Digital Transition
Aleks: So other than this advice that you already gave to be workflow-centric, any other advice for other pathology practices that consider digital transition and any like tips?
Mariano: Well, I mean, number one…
Aleks: tricks or something like, remember this, because it’s not going to be…
Mariano: Well, number one… If you have to have buy-in from everybody has to be on board, right?
Everybody has to be on. And I think we can all get lost in the return on investment model because in I know that’s important. And mostly in today’s budgetary constraint hospitals and it’s important to look at that but but sometimes it’s hard to just quantify that 100%. But if you’re going [00:46:00] embark on it, I think it’s important to look at your workflow.
You just can’t say, I’m going to just implement digital pathology, you know, I mean, really have to look at and I think you have to look at it in stages, right? And you got to build successes along the way so that you feel good about what you’re doing instead of trying to do, you know, being a mile wide and an inch deep, you know, be focused and get, you know, and get something done that that is, that is meaningful to your organization and again, to your patients.
You know, one other technology that I’m in and I want to do a plug here, but one other technology that I really like Alpenglow and I think that technology looking at the whole 3D of a core or a tissue, I think that’s going to also impact what we’re doing in pathology. And that’s very, [00:47:00] very early and we’re collaborating with them on a joint grant that we have looking at prostate cancer and Puerto Rican men.
And it’s exciting technology. And again, that’s another potential game changer in total.
Exploring the Potential of Digital Pathology in Puerto Rico
Aleks: So you were in Miami before and then you moved into Puerto Rico. What’s that? Why did you go to Puerto Rico?
Mariano: Well, I had I had a, you know, Puerto Rico here. I had a business in Miami. I had some partners and we dissolved it. And then I just decided to stay in Puerto Rico.
Aleks: Okay.
Mariano: And so I’ve been engineering this… Yeah. Yeah. It’s very, very, very nice. Great environment. I think there’s a lot of opportunity here, too. You there’s a lot of push by, by by government to attract technology companies. There’s incentives here [00:48:00] for technology companies, also for export of services from Puerto Rico. You’ve had companies like Optum open a call centers in Puerto Rico and others because there are some some some very significant potential tax savings in R&D credits.
So it’s a it’s a it’s a beginning of an ecosystem for for the Caribbean. And again, you know, we’re sitting in the middle of between North America and Latin America and…
Aleks: I know, you’re right in the center…
Mariano: …of the market, you know, you could be serving, you know, we’re a bilingual.
Aleks: Exactly. That was also the…
Mariano: Consequently that we can, you know…
Aleks: Merge, merge the South and the Nort.
Mariano: And the North, correct? Correct.
Aleks: Question: You are on the board of directors of the Digital Pathology Association.
Mariano: Right.
Aleks: What’s your role there? Or like [00:49:00] what’s your let me put it differently, what are the questions and that you get most often and what are the contributions how do you contribute in that role?
Mariano: Well well, you know, I think it’s a it’s a very diverse group because, as you know, it’s a mix of industry and and clinical side.
I think that that’s very important because I think there’s this kind of two way communication of the needs from the clinical side to industry and the needs from industry to the clinical side. So I think that that’s a very, a very important way of sharing information and and helping and collaborating. You know, I think they and the whole payment issue and reimbursement issue is an area that everybody’s collaborating on because it affects the whole ecosystem where we’re I think we need to we need to we come together on that. [00:50:00]
And then the other thing is this is, you know, how do we expand the membership of the DPA and bring in others? You know, I’m very interested in in, you know, again, voicing this into the Americans. And I think digital pathology in underserved communities is very important. I think it’s a way of kind of leveling the playing field with pathology and pathologists.
So I think there’s a lot of opportunity at the DPA to I mean, the runway is long to do a lot of positive things for our field.
Aleks: So Digital Pathology Association, obviously, they have the educational arm, but do you think there needs to be a specific…
The Role of Education in Digital Pathology Adoption
…Training or for digital pathology as a discipline, or do you think it’s enough that people could [00:51:00] like learn it on the job when they join the organization that is already digital? How do you see that?
Mariano: I mean, I think I think the DPA does have, you know, multiple webinars and seminars. But I think you you hit something that that is really beyond just the DPA. I think that if we embrace pathology digitally in AI and embrace A.I. as, as a tool for healthcare. I think we’re late in the education game medical schools residency programs need to quickly adopt these and provide the trainees with the knowledge and skillsets to live in this new world.
You know, I don’t see a pathologist reading every single slide in the future. They might be reviewing, but it’s not going to be the same. He’s going to need to know or she’s going to need to [00:52:00] know what an algorithm is, how is it build? How do I and how do I know, you know, how do I get under the hood and be able to measure the efficiency or effectiveness or of this algorithm?
You know, it’s a whole new world and education is important. And so right now, you know, all of the programs and I think the DPA does what it can as an organization. But I think it’s a much bigger challenge to to drive, you know, this into into all aspects of of education, both in medical school and and in residency programs.
So, you know, how are the residents are coming out today. Are they trained in digital pathology? Do they understand algorithms? I mean, now I know that there’s, you know, fellowships in informatics and things like that, [00:53:00]. But, you know, how many programs are they reading, sitting down and diagnosing in digital and maybe not even using the AI, but just digital pathology?
We we collaborate here with the University of Puerto Rico, their residency program. So we have residents that come through. So we’re very focused on education and we do that. But it’s trying to for them to see the other things, make sure they have the case mix, you know, so we do a lot of prostate, so they come here to learn about prostate because as you know, many much of the some of these cases now are in the outpatient environment are really no longer enforced and in the academic institution.
So I think that education is paramount. And, you know, bringing in educating our new our new residents coming here.
Aleks: You know what I see? I see like an over [00:54:00] emphasis on using the tool on teaching people, like using the tools and being afraid that, we cannot do this yet because people cannot use the tool versus teaching principles, teaching the principles of image digitization, of imaging, of light microscopy, like what is a scanner?
It’s actually a microscope. You don’t have to be afraid of it. It has the same components, right? And then the other component AI, like, don’t demonize it, it’s here. Learn to use it. Learn the principles that are guiding it so that you can and decide, okay, is this a good tool for me or not? How you do improve I think and and this should come like a lot earlier than the actual application and using the tools so that people come when like using a tool, it’s like, okay, how long did it take you to use Microsoft Word? [00:55:00]
You opened it, you read the labels and you were able to use it. And like most modern software programs, this is the case. You can hover over things, read the user manual, and you’re ready to use it. But okay, what’s under the hood? How much of this is relevant for us and how much is more like the technical components?
I think that still needs to be and maybe later it’s going to be less and less like I’m thinking about the car. Do I have any idea what’s inside the car? No, I have no idea. I just cared that it drives. But it has been tested so many times that I don’t have the need to it. But I know that my cousins, who are like 20 years older than me, they can they can like, dismantle and assemble a car again and fix the stuff that’s in there.
Right. They knew it, you know, maybe particular, but they had a particular interest. But 20 years ago or 30 years ago in Poland, you [00:56:00] actually needed that skill to fix it. And I think we’re in the transition period. Well, okay, for several years, we will need the knowledge to know what needs to be fixed and go to the creators and ask them to fix it.
And at some point, we will not need that anymore, maybe for the new tools. And so, yeah, principles rather than the like, which buttons to click, how to use the tools.
Mariano: Yeah, well, you know, Dr. Santos says, you know, “When do we drop the word digital and just say pathology?”
Aleks: Right. Radiology doesn’t say digital radiology. They’re just radiology.
Mariano: Right? Right. So what is it just become normal that in you’re right it’s going to take time or time to to do that? I mean, you know, pathologists, you know, I have this I think, you know, everybody, you know, in these transition times. Right. Identify [00:57:00] with something. And I think I mean, if you look at every logo is a microscope on it, right, of some..
Aleks: Right…
Mariano: …shape or some solution there’s that identity, you know, kind of that’s your that’s your identity.
It’s the microscope. I mean, years ago, you’re right. It used to be the beeper or you had a beeper, you are a doctor, right? I mean, it’s the beep or, you know, people walked around a stethoscope already.
Aleks: Yeah.
Mariano: So. Okay, so these are things that identify you, right? And sometimes it’s hard to get rid of those things because they’re, they’re become personal, you know, form, you know how to maximize it.
And again, it’s learning something new. It’s retooling yourself and saying, well you know but you have to give yourself that chance to do that. You know, it’s like electronic medical records, Right? You know, people fight and I understand. But hopefully, like with AI, it will make it better. It’ll help [00:58:00] and we can spend more time with our patients and provide more care, more hands-on time with people that need that.
And maybe that’s the you know in the future also for pathologists to become more and more a part of the care team so they have that time because you know a lot of these things are becoming very complex like genomics, omics in general and all best and the pathologists and to lead that that area to make sure that we’re doing the right test at the right time.
The right interpretation and then supporting as part of the care team. So maybe these tools are there to to change the way you practice so that you can take in maybe that cognitive extra cognitive feel you have to then be able to to be that expert in in, in this space [00:59:00] that is fast changing, you know, with NGS and all of these other things that that maybe some of our other colleagues need support from.
Aleks: So looking back at your journey with digital pathology, is there something that you’re specifically most proud of or it’s like I would have done it anyway, So it’s the way I operate. That’s the way how we how we work. It was inevitable. Or what are your thoughts on that when you look back at what you did?
Mariano: Yeah, I mean, you know, Newton you kind of, you know, you kind of say, you know, you could you could kind of do that and be a little cocky about it.
You know, we definitely embraced technology, but it really isn’t possible without a team that that was focused on it, that, you know, we breathe and live technology. We like it still. So it’s in our DNA. We look for all the opportunities to to [01:00:00] enhance our practice, to provide better patient care. So when this was the opportunity and we saw that, you know, we wanted to be there, we wanted to be pioneers, I mean, that’s definitely one that we enjoyed, you know, And I think that you know, being part of the transformation of pathology is exciting and in a sense, you know, we can prove that that that it can be done and and and it works. And we’ve learned a lot there’s a lot of experience here now elected meals of four years there has to work and we go from here. I think the future and the runway is long and exciting for for people that want to want to be part of it.
Aleks: I think you’ve definitely proved that it can be done and you are an example for others. I mean, I’m impressed. [01:01:00] I’m impressed by the, like speed and consistency of how your practice embraces things and that this is at the forefront. This is okay if there is something new that can improve our patient’s diagnosis, and our patient care, we want to know about it. It’s not like, okay, we already did digital digitization. We already have remote pathologists for good know you’re like, okay, what’s next?
So thank you so much for doing this, for running…
Mariano: Thank you.
Aleks: …for running CorePlus that way. I know this is like a philosophy that you guys have at CorePlus, and yeah, thank you for joining me today. I’ve learned a lot and I enjoyed this conversation a lot.
Concluding Thoughts and Invitation to Puerto Rico
Mariano: Well, number one is you have an open invitation to Puerto Rico. So anytime you want to come…
Aleks: Oh my goodness, I need to, I need to arrive something?
Mariano: And anyone listening to the podcast, we’re always available to support. [01:02:00] We want to let you know we’re missionaries in this and we want to do what’s best for our patients and and for the industry and for digital pathology or pathology in general.
So thank you so much for inviting me, for giving us the space, for letting us talk a little bit about our philosophy and our story, and look forward to other opportunities to conversely, really…
Aleks: Thank you so much. You have a wonderful day.
Mariano: You too, take care. Bye bye.
Aleks: Thank you so much for listening to the end. As I already said in this episode, I truly believe we are over-emphasizing that teaching of how to use the digital pathology tools versus the principles of digital pathology.
So I decided I needed to do something about it. And I wrote the book Digital Pathology 101. So if you want to learn the principles guiding digital pathology, the components, and basically start your digital pathology journey, this book is for you. [01:03:00] It is free in PDF format I’m going to share the link to it below.
You can download the PDF for free or you can buy it on Amazon as well and start your digital pathology journey right now. And if you already have some digital pathology knowledge, it’s going to help you structure it. It’s going to help you teach it to others because the more people understand digital pathology, the quicker the adaption is going to be.
So go ahead, grab the PDF for free from the link below and I’ll talk to you in the next episode.
