Cost analysis reveals a total one time added expense for digital pathology to range from $10,000 – $95,000 (range based on low, medium, or high throughput MoticEasyScan models) with an additional $7,000/annual cost for software and data management. In the index example laboratory setting with recurring shipping expense, breakeven on logistics of digitization is achieved in less than 2 years. Other previously published studies report a capital expense breakeven in approximately 7 years. Notably, in this cited example authors also include storage and file retrieval costs and subsequent savings for a tertiary large scale pathology practice. The capital cost per day over 1 year is $154.80/working day or $58.96/working day over 5 years.  In this example, by year 3 the digitization process becomes cost conservative to the current practice starting at $18,550 saved beginning year 3.  This analysis assumes existing local and remote practice has a suitable internet connection and infrastructure and does not require alteration of their histology practice. Examples could include restricted field of view to encompass relevant tissue requiring additional tissue sections or changes required for LIS/electronic health record integration or additional cost for higher speed internet connections at CLIA-certified reviewing sites.

Time-cost analysis demonstrates an added preparation time +0:06:52/slide with an estimated associated cost of +$3.43/slide for digitization. Diagnostic review time digitally, added an average review time of 56 mins (+00:00:25/slide) and mean cost +$1.57/slide. Notably, this study was the first installation and attempt to digitize histologic specimen at this laboratory. As such, added expense could be reduced due to efficiencies in practice. One example includes, significant time added (~02:00:00 hrs) to the quality review and re-review with re-scan given poor slide preparation. In a prior study by Stratman et al, they demonstrate a savings of 13.4% time savings to a pathologists workday with a time and motion study by automating case assembly, queries, requests, retrieval, and delivery. Mills et al, demonstrate a 00:00:05s/case increase relative to surgical pathology specimen, however, this is not well studied in dermatopathology. They did recognize that with prolonged adoption, reviewer times significantly decrease.

In this labs example, an annualized added expense per slide with digital pathology yields an estimated $167,500 total preparation and review cost annually (assuming 134 slides/day for 250 days). Logistics expense savings of $18,550 in year 3 and $16,750 per year thereafter. The estimated added total annual cost of approximately $150,750. Prior studies do not specifically identify time/cost analysis of producing a high-quality digital image for review. Potential cost saving and quality improving measures not directly evaluated in this study, but reported by others include turn-around time savings, reducing microscope expenses, quality improvement and reduced cost from intradepartmental/extradepartmental consultation/re-review and slide retrieval, improved quality of diagnosis by subspecialists and subsequent reduction of error and over/undertreatment, and reduction of potential slide storage cost. Many of the additionally previously cited savings are not relevant to the private dermatopathology laboratory, such as reduction of laboratory and dermatopathologist FTE due to efficiencies in practice and expanded workloads, though workflow throughput may be expandable without FTE addition.  Added future benefits could also include reference technical component work for other providers (digitized H&E, IHC, special stains) and potential for artificial intelligence algorithms with diagnostic and workflow improvement. These algorithms have demonstrated significant promise for the future, however, have not significantly impacted dermatopathology at the time of this publication.

Limitations do exist in this study, notably, the index dermatopathology practice has an approximate annual case volume of 17,500 cases. The MoticEasyScan Pro 6 is a desktop 6-slide scanner which is best suited for relatively low volume scanning and an appropriate assessment of workload would be required for additional histology work. Another theoretical limitation is the cloud-based server solution, as this may not be available in all physical settings (hospital based, community, independent lab, etc) and require extensive discussion and initial work to establish an appropriate IT solution for each application. Motic does allow for a private server-based connection to MoticFlow however each application is customized for the users needs. With respect to the diagnostic concordance and cost assessment, the study is retrospective in nature with limited sample size limiting annual cost estimates.