Photo courtesy of Dr Mustafa Yousif, Michigan Medicine
Article • Enterprise imaging
From slides to PACS: A blueprint for digital pathology integration
Michigan Medicine became the first US healthcare system to launch a DICOM-based digital pathology PACS integrated with its radiology PACS and enterprise imaging network. At SIIM 2026, the annual meeting of the Society for Imaging Informatics in Medicine held in Pittsburgh in June, Mustafa Yousif, MD, and Benjamin Mervak, MD, shared their experience and outlined the key success factors for planning such a conversion.
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Just as radiology departments discovered after converting from film-based to digital operations, the conversion of pathology labs from being slide-based to digital will be equally beneficial, said Dr Mervak. He explained that pathology departments can now leapfrog directly to advanced PACS and network technologies: DICOM standards are mature, optimised digital workflows are well-defined, and scalable tiered storage, vendor neutral archives (VNA), and faster, more robust networks are less costly.
The case for enterprise integration
Options for workflow integration of pathology images with radiology are available from reputable vendors. Most importantly, the argument for seamless integration into an enterprise imaging network – rather than an isolated pathology department-specific PACS – is solid. Dr Mervak emphasised that enterprise imaging not only integrates pathology with radiology, but also with cardiology, obstetrics/gynaecology, ophthalmology, dermatology, wound care, plastic surgery, gastroenterology and endoscopy, and patients' electronic health records (EHRs).
The big inhibitor is budgetary: a freestanding digital pathology PACS with siloed image storage is significantly less costly for the first five years of operation than a fully integrated one. However, if a digital pathology PACS will be added at a hospital with an established enterprise imaging network, the infrastructure cost of adding pathology may be lower than the total cost of building a dedicated pathology platform from inception. Adoption in either scenario will most likely be based on clinical necessity, the expert pointed out.
What is triggering clinical necessity?
Dr Yousif identified three forces simultaneously converging on pathology:
- Whole slide imaging is scaling, with adoption accelerating across academic and community settings. The pathology department is digitising, whether hospital infrastructure is ready or not.
- DICOM standards for whole slide imaging (WSI) exist, enabling interoperability.
- Artificial intelligence (AI) presumes integrated data. Multimodal models need radiology and pathology data together.
Additional pressures on pathology departments include a national shortage of pathologists, an increase in the quantity of diagnoses and treatments requiring pathology analysis, and an overall volume of work caused by a growing ageing population. Both digital pathology workflow and intelligent harnessing of AI represent inevitable solutions to manage the workload.
Benefits of enterprise integration
The workflow of a digital pathology department already fits inside the framework of enterprise imaging: images are captured, stored, viewed, exchanged within and between hospitals, and analysed. The benefits of investing in an enterprise imaging network that integrates with other imaging systems – especially radiology – are many:
- Growing digital slide data storage demands can be accommodated with a scalable storage architecture, ideally a VNA.
- Pathology slides are easily accessible within a patient's EHR.
- Infrastructure costs are lower than building a dedicated pathology platform from scratch.
- There will be no future data migration costs, which can be as costly as the original purchase of a siloed system.
Planning for success
If pathology isn't participating when the platform is designed, pathology will be served by a platform designed for someone else
Mustafa Yousif
If a hospital is considering migrating from siloed systems to an enterprise imaging structure, it is imperative that pathology and radiology work in tandem and have representation on every planning committee. Subcommittees typically include planning for clinical workflows, standards and interoperability, operations and support, faculty enablement, research and AI, and patient access protocols.
'If pathology isn't participating when the platform is designed, pathology will be served by a platform designed for someone else,' warned Dr Yousif.
Participants in the planning process must include pathology and radiology clinical leads, health system IT/security and imaging informatics professionals, a laboratory information system lead, an EHR/integration lead, and an operations specialist. 'Don't forget to solicit input from pathology operations staff and lab managers, trainee and education leads, research and data science representatives, privacy and compliance officers, and referring clinicians,' Dr Yousif added.
Access control and research advantages
Access control for pathology data should be determined based on the role of the user, clinical specialty, and – in multi-facility health systems – location where access is requested. Questions to be asked include: Who is the user? What level of access should he or she have? Researchers, for example, should only have access to de-identified images; an administrator, none at all. In a multi-hospital network, cross-site access may be limited to tumour boards, but with emergency override paths in place.
Research is much easier in an enterprise imaging network, as clinical data is research-grade. An enterprise archive can be queried by DICOM tags, ICD codes, or laboratory information system (LIS) metadata. Anonymisation is easy, with DICOM confidentiality profiles applied. Standards-compliant DICOM images are easily exported because no proprietary conversion is needed, and auditing is easily performed and reproducible.
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Streamlined clinical collaboration
The advantage of enterprise image access facilitates tumour board preparations and other consultations. Slides are visible the moment they are scanned, and tumour board prep takes only minutes. With multidisciplinary authorised consultations, users simply open a patient's EHR and can see everything – all images for the patient are displayed on one viewer.
'The single viewer is not a feature, but rather is a key point in collaboration,' stressed Dr Yousif.
Lessons learned
'The best of planning doesn't mean perfect planning,' Dr Yousif noted wryly. He offered tips on what he and his Michigan Medicine colleagues learned from their experience: 'None of these are about technology. All of them determine whether the technology works as planned.'
- Create a clear description of the current and desired workflow, agreeing on what changes and what doesn't need to change before having any conversation with a vendor.
- Identify excellent project managers.
- Have a mature IT group and partners in place before beginning anything.
- Active, visible, and sustained sponsorship from executive hospital leadership is essential throughout the project – not just at inception.
- Identify a physician champion willing to dedicate significant time to the project. This person should be experienced working with vendors, fluent in IT, trusted by clinicians, and be an excellent communicator.
Preparing for the digital future
'Digital pathology is real,' Dr Yousif concluded. 'The unknown is when conversion can be financially justified and undertaken.' However, pathologists should start preparing now, he urged – and offered several recommendations:
- Understand IT in the context of the desired system. Vendor selection and IT decisions will be in play for a decade; involving IT leadership early ensures alignment with institutional strategy.
- Prioritise DICOM adoption. It is the foundation for interoperability, research, AI integration, and seamless data exchange.
- Build workflows around the platform. A PACS-driven workflow is a key success factor – retrofitting a new platform to legacy processes undermines its potential.
- Establish cross-departmental partnerships. Pathology representation must be positioned as essential to enterprise imaging adoption, with strong ties to radiology and IT.
- Inventory all image sources. Department archives, USB drives, and cloud buckets should all be catalogued. The size and complexity of this inventory will inform the scope of the transition.
Profiles:
Mustafa Yousif, MD, is an Assistant Professor of Pathology and Director of Digital Pathology at Michigan Medicine, University of Michigan, Ann Arbor, United States. His work bridges diagnostic pathology, enterprise clinical informatics, and AI. Since 2021, he has led the digital transformation of Michigan Medicine’s Department of Pathology, one of the largest such implementations at a US academic medical centre.
Benjamin Mervak, MD, is a Clinical Associate Professor of Radiology and Associate Chair of Rad-Information Technology in the Department of Radiology at Michigan Medicine, University of Michigan, Ann Arbor. His clinical interests include gastrointestinal and genitourinary imaging, rectal cancer, contrast media, and imaging informatics.
11.09.2026
