Chapter 6: Viewers, workstations, and performance

This chapter focuses on what happens after slides are scanned: how you actually look at them, what kind of workstation you need, and how network and display choices affect diagnostic work.

6.1 Why viewers and workstations matter as much as scanners

What you need to know

Even the best scanner cannot fix a poor viewer or workstation; the pathologist’s experience is dominated by:
- Viewer responsiveness (how fast panning and zooming feel).
- Display quality (resolution, brightness, color).
- Input devices and ergonomics (mouse, tablet, shortcuts).
Viewers are not just “picture viewers”; they are clinical tools that must support:
- Consistent navigation across multiple slides and stains.
- Side‑by‑side comparison of current and prior cases.
- Annotations, measurements, and sometimes image analysis overlays.
A slow or clumsy viewer increases fatigue, lengthens turnaround time, and may discourage adoption of digital reporting even if the underlying WSI quality is good.
Digital pathology implementations that focus heavily on scanners but neglect viewer and workstation design often struggle with user satisfaction and long‑term uptake.
Thinking in terms of “end‑to‑end diagnostic experience” (scanner > storage > viewer > workstation) is more useful than optimizing any single component in isolation.

Reference
Jahn SW, Plass M, Moinfar F. Digital pathology: Advantages, limitations and emerging perspectives. J Clin Med. 2020;9(11):3697. doi:10.3390/jcm9113697. Available at: https://doi.org/10.3390/jcm9113697

6.2 Viewer features and how pathologists actually use them

What you need to know

Mature WSI viewers share a common feature set, which you should expect as a baseline:
- Fast zooming and panning with keyboard and mouse shortcuts.
- Thumbnail overview with current viewport indicator.
- Slide trays for multi‑slide cases, with easy switching between H&E, special stains, and immunostains.
- Measurement tools (distances, areas, counts) with sensible units and easy export.
- Annotation tools (points, regions, labels) that can be saved and shared.
More advanced features that are increasingly important:
- Support for z‑stacks and multi‑channel images (e.g., fluorescence, multiplex IHC).
- Side‑by‑side or overlaid views for comparing stains or timepoints.
- Integration with AI tools, including overlay heatmaps and probability scores.
Open‑source tools such as QuPath can be used as concrete examples of modern viewer behavior and functionality, even if your clinical system is different.
When evaluating viewers, test them with real cases, not demo slides:
- Large resection cases with many slides.
- Challenging biopsies where subtle detail matters.
- Workflows that involve review of previous cases or external consultations.

Reference
Bankhead P, Loughrey MB, Fernández JA, et al. QuPath: Open source software for digital pathology image analysis. Sci Rep. 2017;7(1):16878. doi:10.1038/s41598-017-17204-5. Available at: https://doi.org/10.1038/s41598-017-17204-5

6.3 Monitors and display characteristics: your new “microscope”

What you need to know

In a digital pathology workflow, the display is effectively your microscope. Its properties directly affect what you see and how comfortable you feel during long reporting sessions.
Important display characteristics include:
- Resolution and size: enough pixels and physical size to show a decent field of view without constant zooming; many labs use 27–32 inch screens with several megapixels.
- Luminance (brightness) and contrast: bright enough for comfortable viewing with good dynamic range.
- Color reproduction: consistent and appropriate for histological stains; wide color gamut can help but must be well controlled.
- Uniformity: minimal variation in brightness and color across the screen.
There is ongoing debate about whether all pathologists need medical‑grade displays or whether high‑quality professional or consumer displays are sufficient for many tasks; current guidelines stress the importance of:
- Defining minimum performance requirements.
- Periodic checks and calibration.
- Matching displays to the intended clinical use.
Buying displays only on price, without considering these properties, can undermine an otherwise good digital implementation.

Reference
Abel JT, Ouillette P, Williams CL, et al. Display characteristics and their impact on digital pathology: A current review of pathologists’ future “microscope”. J Pathol Inform. 2020;11:23. doi:10.4103/jpi.jpi_38_20. Available at: https://doi.org/10.4103/jpi.jpi_38_20

6.4 Workstation ergonomics and occupational health

What you need to know

Moving from microscopes to screens changes the physical demands on pathologists:
- More time looking at bright displays.
- Different neck, back, and wrist positions.
- Different pattern of breaks and micro‑movements.
Common issues include eye strain, headaches, neck and back pain, and “mouse shoulder” if workstations are not set up well.
Practical layout points:
- Screen height so that your gaze is slightly downward, not craned up.
- Chair, desk, and input devices adjusted to keep wrists neutral and shoulders relaxed.
- Thoughtful placement of multiple monitors so that most of your time is spent looking straight ahead, not constantly twisting.
Occupational health guidance for digital pathology emphasizes:
- Regular breaks and variation of tasks (screen work versus grossing, meetings, microscopy where still in use).
- Attention to ambient lighting and glare.
- Training users in basic workstation setup, just as you would train them to use a microscope correctly.
A little planning here goes a long way; poor ergonomics can make even the best viewer and scanner feel unpleasant to use.

6.5 Network performance, remote reporting, and practical troubleshooting

What you need to know

Viewer performance depends critically on network bandwidth and latency between the workstation and the image server:
- Bandwidth limits how much data you can pull per second.
- Latency affects how “instant” each new tile feels when you move or zoom.
For routine surgical pathology, you want viewer performance that feels comparable to moving a microscope stage:
- Minimal delay when you pan.
- Predictable performance even at busy times of day.
Remote reporting introduces extra challenges:
- Variable home internet bandwidth and latency.
- Encryption and VPN overhead.
- Shared use of home networks by other household devices.
Good practice for remote digital pathology includes:
- Defining minimum network requirements for home use.
- Providing clear troubleshooting checklists (check local network, VPN, viewer logs, server status).
- Having backup options (for example, fall back to glass slides or different network paths if performance is unacceptable).
Guidance documents from professional bodies can help structure your thinking about what is “acceptable” for remote primary diagnosis and when to fall back to on‑site reporting.

Reference
Aslam M, Barrett P, Bryson G, et al. Guidance for remote reporting of digital pathology slides during periods of exceptional service pressure. The Royal College of Pathologists; 2020. Available at: https://www.rcpath.org/static/626ead77-d7dd-42e1-9499-88e43dc84c97/RCPath-guidance-for-remote-digital-pathology.pdf

--- title: "Chapter 6: Viewers, workstations, and performance" format: html: toc: true toc-depth: 3 code-fold: false df-print: paged smooth-scroll: true execute: echo: true warning: false message: false --- # Chapter 6: Viewers, workstations, and performance This chapter focuses on what happens after slides are scanned: how you actually look at them, what kind of workstation you need, and how network and display choices affect diagnostic work. --- ## 6.1 Why viewers and workstations matter as much as scanners **What you need to know** - Even the best scanner cannot fix a poor viewer or workstation; the pathologist’s experience is dominated by: - Viewer responsiveness (how fast panning and zooming feel). - Display quality (resolution, brightness, color). - Input devices and ergonomics (mouse, tablet, shortcuts). - Viewers are not just “picture viewers”; they are clinical tools that must support: - Consistent navigation across multiple slides and stains. - Side‑by‑side comparison of current and prior cases. - Annotations, measurements, and sometimes image analysis overlays. - A slow or clumsy viewer increases fatigue, lengthens turnaround time, and may discourage adoption of digital reporting even if the underlying WSI quality is good. - Digital pathology implementations that focus heavily on scanners but neglect viewer and workstation design often struggle with user satisfaction and long‑term uptake. - Thinking in terms of “end‑to‑end diagnostic experience” (scanner > storage > viewer > workstation) is more useful than optimizing any single component in isolation. **Reference** Jahn SW, Plass M, Moinfar F. Digital pathology: Advantages, limitations and emerging perspectives. J Clin Med. 2020;9(11):3697. doi:10.3390/jcm9113697. Available at: https://doi.org/10.3390/jcm9113697 --- ## 6.2 Viewer features and how pathologists actually use them **What you need to know** - Mature WSI viewers share a common feature set, which you should expect as a baseline: - Fast zooming and panning with keyboard and mouse shortcuts. - Thumbnail overview with current viewport indicator. - Slide trays for multi‑slide cases, with easy switching between H&E, special stains, and immunostains. - Measurement tools (distances, areas, counts) with sensible units and easy export. - Annotation tools (points, regions, labels) that can be saved and shared. - More advanced features that are increasingly important: - Support for z‑stacks and multi‑channel images (e.g., fluorescence, multiplex IHC). - Side‑by‑side or overlaid views for comparing stains or timepoints. - Integration with AI tools, including overlay heatmaps and probability scores. - Open‑source tools such as QuPath can be used as concrete examples of modern viewer behavior and functionality, even if your clinical system is different. - When evaluating viewers, test them with real cases, not demo slides: - Large resection cases with many slides. - Challenging biopsies where subtle detail matters. - Workflows that involve review of previous cases or external consultations. **Reference** Bankhead P, Loughrey MB, Fernández JA, et al. QuPath: Open source software for digital pathology image analysis. Sci Rep. 2017;7(1):16878. doi:10.1038/s41598-017-17204-5. Available at: https://doi.org/10.1038/s41598-017-17204-5 --- ## 6.3 Monitors and display characteristics: your new “microscope” **What you need to know** - In a digital pathology workflow, the display is effectively your microscope. Its properties directly affect what you see and how comfortable you feel during long reporting sessions. - Important display characteristics include: - **Resolution and size**: enough pixels and physical size to show a decent field of view without constant zooming; many labs use 27–32 inch screens with several megapixels. - **Luminance (brightness)** and **contrast**: bright enough for comfortable viewing with good dynamic range. - **Color reproduction**: consistent and appropriate for histological stains; wide color gamut can help but must be well controlled. - **Uniformity**: minimal variation in brightness and color across the screen. - There is ongoing debate about whether all pathologists need medical‑grade displays or whether high‑quality professional or consumer displays are sufficient for many tasks; current guidelines stress the importance of: - Defining minimum performance requirements. - Periodic checks and calibration. - Matching displays to the intended clinical use. - Buying displays only on price, without considering these properties, can undermine an otherwise good digital implementation. **Reference** Abel JT, Ouillette P, Williams CL, et al. Display characteristics and their impact on digital pathology: A current review of pathologists’ future “microscope”. J Pathol Inform. 2020;11:23. doi:10.4103/jpi.jpi_38_20. Available at: https://doi.org/10.4103/jpi.jpi_38_20 --- ## 6.4 Workstation ergonomics and occupational health **What you need to know** - Moving from microscopes to screens changes the physical demands on pathologists: - More time looking at bright displays. - Different neck, back, and wrist positions. - Different pattern of breaks and micro‑movements. - Common issues include eye strain, headaches, neck and back pain, and “mouse shoulder” if workstations are not set up well. - Practical layout points: - Screen height so that your gaze is slightly downward, not craned up. - Chair, desk, and input devices adjusted to keep wrists neutral and shoulders relaxed. - Thoughtful placement of multiple monitors so that most of your time is spent looking straight ahead, not constantly twisting. - Occupational health guidance for digital pathology emphasizes: - Regular breaks and variation of tasks (screen work versus grossing, meetings, microscopy where still in use). - Attention to ambient lighting and glare. - Training users in basic workstation setup, just as you would train them to use a microscope correctly. - A little planning here goes a long way; poor ergonomics can make even the best viewer and scanner feel unpleasant to use. **Reference** Jahn SW, Plass M, Moinfar F. Digital pathology: Advantages, limitations and emerging perspectives. J Clin Med. 2020;9(11):3697. doi:10.3390/jcm9113697. Available at: https://doi.org/10.3390/jcm9113697 --- ## 6.5 Network performance, remote reporting, and practical troubleshooting **What you need to know** - Viewer performance depends critically on network bandwidth and latency between the workstation and the image server: - Bandwidth limits how much data you can pull per second. - Latency affects how “instant” each new tile feels when you move or zoom. - For routine surgical pathology, you want viewer performance that feels comparable to moving a microscope stage: - Minimal delay when you pan. - Predictable performance even at busy times of day. - Remote reporting introduces extra challenges: - Variable home internet bandwidth and latency. - Encryption and VPN overhead. - Shared use of home networks by other household devices. - Good practice for remote digital pathology includes: - Defining minimum network requirements for home use. - Providing clear troubleshooting checklists (check local network, VPN, viewer logs, server status). - Having backup options (for example, fall back to glass slides or different network paths if performance is unacceptable). - Guidance documents from professional bodies can help structure your thinking about what is “acceptable” for remote primary diagnosis and when to fall back to on‑site reporting. **Reference** Aslam M, Barrett P, Bryson G, et al. Guidance for remote reporting of digital pathology slides during periods of exceptional service pressure. The Royal College of Pathologists; 2020. Available at: https://www.rcpath.org/static/626ead77-d7dd-42e1-9499-88e43dc84c97/RCPath-guidance-for-remote-digital-pathology.pdf