Digital pathology is no longer a proof of concept. Across Europe and beyond, pathology departments are moving from pilot projects to routine clinical practice. At Sahlgrenska University Hospital in Gothenburg, the pathology department is undergoing a large-scale digital transformation. While the transition has improved workflows, collaboration, and access to expertise, it has also exposed the operational and technical challenges that accompany digital pathology at scale.
Here, we share the learnings and impacts of this technology upgrade from a number of viewpoints.
A shift in the workflow
For years, the office of Florian Puls, a member of the soft tissue pathology team at Sahlgrenska University Hospital, was crammed with trays of glass slides awaiting assessment, additional staining, or discussion ahead of multidisciplinary conferences.
Today, much of the same diagnostic work is organized through digital case lists. Scanned slides are available at the click of a button, allowing cases to be reviewed, shared, and discussed within seconds. The shift in Florian’s daily workflow reflects a broader transformation taking place throughout the department.
At Sahlgrenska University Hospital, digital pathology is no longer an experimental project. Several subspecialized pathology teams now work entirely digitally, while others continue their transition from conventional microscopy. The result is a department-wide transformation that is changing how pathologists diagnose disease, collaborate, teach, and prepare for the future.
Sahlgrenska University Hospital is Sweden’s largest hospital, and one of Europe's largest university hospitals, providing care to more than 1.1 million patients each year. With 17,400 employees, including 2,900 physicians and 5,250 nurses, it provides a broad range of specialized clinical services while also serving as a major center for medical research and education. Its expertise in organ transplantation includes the world’s first live birth following a uterus transplant, achieved by a team at Sahlgrenska in 2014, a milestone that attracted worldwide attention.
It is also renowned for its contribution to clinical research, with approximately 3,300 scientific publications produced by its researchers each year. In 2026, the Swedish Research Council ranked Sahlgrenska University Hospital as Sweden’s leading university hospital for clinical research.
A better way of working
For Jan Siarov, dermatopathologist and section manager at Sahlgrenska University Hospital, digital pathology has fundamentally changed the way he works.
"Digital pathology has not only changed how I review cases, but also how I interact with colleagues and trainees," says Siarov. "We can share cases instantly, discuss findings together regardless of where we are, and create learning opportunities that simply weren’t as easy to achieve in a purely microscope-based workflow.
Removing geographical restrictions from the workflow has also made a difference. "We have colleagues supporting us from different sites and locations, and digital pathology has made those collaborations much easier," says Siarov. "Instead of moving glass slides between laboratories or between individual pathologists’ workstations, we can share cases instantly and involve specialists regardless of where they are located."
Siarov has found similiar benefits to both education and supervision. He now has the option to sit down with residents to review cases either in person or online. "This creates new opportunities for teaching and supervision that are both efficient and interactive," he says. "Access to digitized archives also gives trainees opportunities to learn from a much broader range of cases."
Beyond collaboration and teaching, the concept of arbetsmiljö, or workplace environment, has also been an important driver behind the department’s digital strategy. Years spent at a microscope can place considerable strain on the neck, shoulders, and back. Digital workstations provide greater flexibility and allow pathologists to work in more ergonomic positions throughout the day.
When digital meets diagnostic reality
The transition has not been without challenges.
Sahlgrenska’s pathology department comprises numerous subspecialized teams, each with distinct workflows, diagnostic requirements, and traditions. While some groups embraced digital pathology early, others were more cautious.
Even among teams now fully committed to digital workflows, certain diagnostic situations continue to highlight the limitations of current technology.
The transition has also forced pathologists to rethink longstanding concepts. For decades, pathologists have reported findings such as the number of mitoses per high-power field. But once the microscope is gone, what exactly is a "high-power field"? Most criteria have now been standardized to measurements in mm², but some are still based on definitions developed for conventional microscopy.
Image quality can present another challenge. A digital slide is only as good as the scan itself. Tissue folds, staining artefacts, incomplete scans, or areas that are out of focus can make assessment difficult. Paradoxically, however, a very high-quality scan can sometimes introduce a different problem. Subtle discoloration of a cell on an immunohistochemical slide, which might not be appreciable during conventional microscopic evaluation, can become readily visible on a digital image and potentially be misinterpreted as positive staining.
As a result, even teams that work almost entirely digitally occasionally return to the original glass slides when diagnostic uncertainty arises.
Scaling change across a large department
Implementing digital pathology in a large, highly subspecialized department requires more than technology alone.
"We chose to introduce digital pathology step by step rather than asking everyone to change overnight," says Mats Wolving, Head of the Gastrointestinal Pathology Team. "That meant starting with a few teams, refining the workflows, solving technical and practical issues, and then gradually bringing more groups into the digital environment."
The strategy has allowed teams to adapt gradually while providing opportunities to identify and address problems before broader deployment.
"With a smaller group, we have a more controlled testing environment because fewer people are affected," says Wolving. "The downside is that the transition takes longer and requires the laboratory to maintain two parallel workflows for a period of time."
Gastrointestinal pathology was among the first subspecialties to transition to digital diagnostics. While the team now works comfortably within the new system, the experience has highlighted the operational complexity of large-scale transformation.
Scanning capacity remains a critical consideration. As more teams enter the digital workflow, slide volumes increase and scanner availability can become a potential bottleneck.
"Additional quality-control steps mean that the early laboratory process takes slightly longer," Wolving explains.
Despite occasional setbacks, however, confidence in the new workflow continues to grow. "Right now, things are running smoothly. I'm a reluctant optimist," he says. "But there's still a lot ahead of us."
Preparing for the AI era
Digital pathology represents only one part of a broader modernization effort. The department is simultaneously preparing for the implementation of a new laboratory information system (LIS), designed to integrate laboratory workflows, digital images, and diagnostic reporting more effectively.
For a pathology department employing more than 250 staff members, such a transition is a major undertaking. It is also occurring at a time when pathology is experiencing significant change globally. Growing case volumes, increasing diagnostic complexity, workforce shortages, and the rapid emergence of AI are reshaping the specialty.
Several AI-related projects are already underway at Sahlgrenska University Hospital. The increasingly digital environment also creates opportunities to combine highly specialized diagnostic work with research and technological development. For specialists interested in both clinical pathology and the development of new diagnostic approaches, this combination is one of the advantages of working in a large university hospital department.
Those involved in our AI development and research are energized by the possibilities it brings to pathology.
The patient at the center
For now, the work of digitalization continues. New teams are being introduced to the digital workflow, existing systems are being refined, and the department is preparing for further changes as the new LIS is introduced.
There will inevitably be further challenges to solve. Large-scale changes involving hundreds of employees, thousands of cases, and several interconnected systems cannot be completed overnight. After months of planning, meetings, and occasional crisis management, there is a sense of fatigue across the department, and many are looking forward to the day when the transition is complete.
The purpose, however, is not to make pathology digital for its own sake.
If digital pathology allows cases to be handled more efficiently, makes specialist expertise available regardless of location, improves collaboration, and provides a platform for new diagnostic tools, the hope is that these improvements will ultimately benefit the patients waiting for a diagnosis.
And that is what makes the transition worth the effort.
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