We want to give full control to the pathologists, based on straightforward access to all the information required, to be able to make a diagnosis in an environment where they can understand the full complexity of the tumor in question.

Interview with Jean François Pomerol

CEO, Tribun Health, Paris, France

BIOSKETCH: After graduating from HEC, Paris, Jean-François began his career in auditing and corporate finance, notably at Société Générale in Frankfurt. He joined TRIBVN, a pioneer in digital images, in 1999 to contribute to its development. Convinced by the potential of digital pathology, he created Tribun Health in 2016, where he remains as CEO. His in-depth knowledge of the sector and its actors allows him to play an important role in the industry and to guarantee the success of the company’s strategy in the digital pathology market, both in France and internationally.

Interview by Jonathon Tunstall – 21 Dec 2021

Published – 02 Feb 2022

JT – Jean François Pomerol, you are CEO of Tribun Health. Can you tell me something about your field of activity and how long Tribun has been specifically active in the digital pathology market?

JFP – Tribun is a European company based in Paris with 40 people. We sell our products in France, across the whole of Europe, Canada, and the United States.

We are a company that is dedicated to digital transformation in the diagnosis of cancer, and we pride ourselves on being able to accompany our customers on the digitization journey as they switch from microscope based to computer-based workflows. Of course, that is the very visible part of what we do, and I also believe strongly that we are changing the way cancer diagnosis is done through introducing a digital ecosystem and providing access to new sources of data as well as image analysis and AI solutions.

As a company, we started back in 1996 and for a long time we provided solutions for teaching and for educational purposes. By 2016 it had become clear that primary diagnosis in pathology would become commonplace and we felt that this was an area where we could make a difference. So, we created Tribun Health as a dedicated company to specifically address digital pathology and digital diagnosis. We developed our products and managed to get some regulatory clearances to be able to sell our solutions. From that point on, we have been focused on the digital transformation of the clinical pathology lab.

JT – Is it fair to say that as a company you have a lot of experience beyond pathology and that you have been able to bring a lot of previous expertise into the pathology market?

JFP – Yes, we have been involved in the lab business for many years and have operated in several domains of medicine, but specifically, we have gained huge experience in the complex processes of tissue preparation, lab workflows, report generation, etc. We also have very close connections with key opinion leaders and users which helps us to monitor trends and to design products for a specific market need.

JT – Clinical Adoption of digital pathology has been slower than many people expected. Where do you think we are in that process now, and how do you expect adoption of digital pathology systems to proceed over the next few years?

JFP – Adoption has been slow for many reasons. I travel a lot in Europe and the US, and I see that everywhere now, adoption is accelerating. I think that it is in great part due to the new challenges in pathology that cannot be solved by traditional microscope-based workflows. There is much more pressure on pathologists nowadays: higher workloads, more exams, increased complexity of diagnosis due to new predictive factors etc. We are also seeing changes toward predictive insights in a world moving towards personalized medicine. We have witnessed this digital transformation happening all over healthcare, in radiology, genomics, the digitization of clinical information. In many ways pathology has been lagging behind and I feel that we are now at a tipping point and very close to seeing rapid and widespread adoption of digital pathology systems.

JT – Do you think pathologists are more accepting of digitization now? In the past we have seen quite a lot of skepticism, particularly among the most experienced pathologists who are very efficient at, and very used to, microscopic analysis.

JFP – It seems that this type of skepticism is becoming a thing of the past now. I can tell you that all the pathologists we are meeting are no longer saying ‘should we adopt’, or, ‘maybe we will adopt,’ or. ‘I will retire before I care about this.’ The questions now are about how to find the budget, the return on investment, how to develop the business case to present to the lab director. Particularly during Covid we have seen a huge uptick in the use of our solutions.

JT – So Covid has had a direct impact on the business?

JFP – Yes, definitely. For example, we have had many installations where customers used our consultation software and our image management solutions but, they only used them on a portion of their cases, and they still used a microscope for much of their primary diagnosis. During Covid we saw a big change towards full usage of our systems due to the need for remote working. Now we are finding that people have become used to the new way of working and many of them don’t want to go back to the microscope.

JT – So you are saying that it is similar to the uptick in online shopping that we have seen during the Covid crisis? That a similar thing has happened in digital pathology, in that it has pushed forward the natural adoption trend perhaps by several years? That Covid has almost forced adoption?

JFP – Yes, and it has helped to overcome the previous reluctance that we saw from IT departments and CIOs. Many of these people were previously reluctant to allow access to patient images and data from home for security reasons. Covid has given us an opportunity to prove to the IT teams that we can provide security and to demonstrate the benefits to the whole organization. We had been working for two years to launch a national second opinion platform for France (SOSlide), so that every pathologist could send cases to any other pathologist for consultation. As it happens, we launched this in April 2020, just as the crisis was unfolding. There was immediate demand. Suddenly people were saying ‘we need this, we need access, people are stuck at home.’ Previously the comments would have been, ‘we are not sure, we need to validate, we need to do some tests etc.’

JT – Let me ask you a more general question then, about what you see as the current benefits of digital pathology, and how the technology impacts lab organization.

JFP – The more we install our systems, the more we work with pathologists and the more we see that the implementation of digital pathology is not an easy transition. It has deep consequences for the laboratory organization. The impact is not just on the pathologist and the analysis phase, but also on the pre analytical pathways. The tissue preparation protocols also must be reorganized. Digitization also brings large scale change to the lab workflow and the presentation and the traceability of the slides. Many laboratories do not have a barcode system, for example. To get the best out of going digital, you have to completely reorganize your lab. You can now have pathologists as remote workers and save a lot of technician time through merging your tissue prep activities and optimizing the access to cutting and staining machines. There will be a huge impact on how you organize your slides and of course pathologists will be able to work via a network. They don’t need to be in their office, and you can create and assign activities according to specialty and subspecialty. There can be huge consequences for lab productivity and there are many opportunities for cost savings. Of course, you also have immediate benefits for the pathologist workload. Access to information, measurement tools, side by side synchronization of IHC with other stains. This part of the digitization process is all about workflow and access to information. But moving on from that you can add image analysis and AI into the mix which provides a second layer of benefits. Then there are further benefits in terms of triage, slide grading, screening and cell counting.

JT – We talked a little about the impact of Covid, that is, the very positive impact of Covid on the adoption of digital pathology. You also say that pathologist skepticism seems to be declining now. Do you see other major barriers to adoption which remain?

JFP – There were some large barriers in the past. The technology hadn’t matured enough and regulation was stricter. I think those things are in the past now and we have seen a positive shift in attitude to digital pathology. Of course, there is always the question from any lab of ‘how can I justify this, it’s a huge investment and we will need storage?’ I would say we have learned a lot from previous experiences of installations, and we can now clearly quantify the benefits and the cost savings. We also have more flexible offerings now such as SaaS solutions so we can really help people with this question. Sometimes the justification is straightforward, but that is not always the case. In an operation that is already very lean, very efficient, the justifications can be trickier, and we understand that. We also often hear now, ‘how can I manage all the data?’ That is a very valid question, and one way is to define the process as scan, use, diagnose, delete. However, most customers want to keep the digital slide and this storage is costly. We’ve thought a lot about this question, and we now have a specific solution which we launched last year, it manages slides over their lifecycle to split them between short term and long-term archiving with different speeds of retrieval. It is a sort of intelligent archiving solution which combines on premise and cloud solutions to give lower cost, but slower retrieval for the longer-term archive (Storage Management).

JT – You say that there is a big new adoption phase coming, and I do agree with you on this point. What is your vision for how Tribun will be part of that process?

JFP – Our vision is to provide a comprehensive platform for the pathologist to be able to take an informed decision based on data. That means being able to handle images, but also providing a full set of AI solutions and the possibility to integrate genomics profiles into the analysis process. We want to give full control to the pathologists, based on straightforward access to all the information required, to be able to make a diagnosis in an environment where they can understand the full complexity of the tumor in question.

That directly impacts the patient outcome through rapid, accurate diagnosis and the correct therapeutic decision. We are aware that we are in an environment which is increasingly information rich, and so our vision is based on constantly integrating new data into the pathologist’s dashboard.

We recently launched a new version of our solution to facilitate this process. The new version of our IMS (CaloPix 5) was released in October 2021, and we will release a new version of our telepathology platform (TeleSlide Patho) in Spring 2022. We have designed a very easy to use interface because we are aware that as adoption increases, we must engage more and more with pathologists and other stakeholders who are not familiar with digital workflows. For us, that is a clear direction and an area where we are prepared to invest. A lot of the investment is going into image analysis and AI because we believe these tools are becoming critical components of a digital platform. Our AI solutions will be a combination of applications developed by ourselves, together with third party image analysis algorithms integrated into a single ecosystem.

JT – Can you tell me more about this new CaloPix solution that was launched in the autumn?

JFP – Well, it has taken 18 months of effort and investment and it’s really a brand-new version, fully web based and very easy to use. We have maintained the spirit of our platform which is an open system, vendor agnostic and with the capability to integrate with any LIS / LIMS system. As I said, we also have the same philosophy with image analysis and AI. Thus, we are able to interface with any third-party algorithm solutions. We have already signed an agreement with DeepBio for Prostate. We want to be clear in telling customers that if you work with us, this is not a ‘locked’ solution, you can integrate the AI you want to use and you can integrate that directly into the pathologist dashboard. That is the same place where you see your slides, the status of the different cases etc. It is also supported by very high levels of security, HIPAA & GDPR compliance, usability, mobility etc.

JT – How would you say then that Tribun differentiates itself in this market? What is unique about Tribun?

JFP – We have a long history in the lab digitization field. We consider ourselves to be experts in pathology, we are very customer centric, and we have close relationships with our customers. I believe that we understand how they work, the complexity of their workflow and just how stressful the decision-making process can be. I think we are in a good position to accompany our customers through the digital transformation of their workflow. We have worked a lot on the development of our products with these needs in mind and I think we can provide an outstanding experience to help pathologists do their job on a day-to-day basis. We have to remember that this is not about selling software, it is about becoming partners with the pathologist and the lab director and agreeing that we are at the beginning of a digital pathology transformation. That means that we will implement new things and provide a lot of training. We will all be learning along the way, and we will have to improve many processes as we learn. We know that ultimately, we are providing a service to the customer. We have invested a lot in the service part of our offering, and we do get exceptionally good ratings on our service. That is the way we operate. We don’t just sell a piece of new technology; it is a process of human related change management. These are the things that I believe make us unique. Tribun combines a comprehensive platform with a high quality of service and that enables us to be a true partner with any lab that wants to go through the digitization process.

JT – Of course, at the end of all this there is a patient. Do you have anything to say about the impact that digital pathology, and specifically Tribun’s role in digital pathology, have on patient care?

JFP – We know that when a patient first undergoes a biopsy, this is an incredibly stressful time. You want to have a fast diagnosis, a quick turnaround time and, in cases of cancer, it is also critical to get access to a detailed diagnosis to be able to start the appropriate treatment. It’s about going fast but being precise. The therapy options are rapidly expanding in cancer and which drug we choose is becoming critical. That choice depends not just on the clinical aspects but on histology too; the pathology and the genomic data are key. Nowadays pathologists have access to all sorts of information at the level of the tumour structure, and cellular organization and these sorts of things will be key for new targeted therapies. All these new technologies will have a huge impact on patient care, and we want to provide an outstanding diagnostic solution that can integrate seamlessly with all these new sources of information.

JT – I was interested in what you said earlier about the rise of AI and we are all guessing at what the future will bring, It is clear however that there has already been substantial adoption of digital pathology platforms and whole slide imaging, and that now we are seeing a second phase of adoption based on image analysis and AI. So, tell me a little more about what Tribun is doing with your investments in AI and how you are specifically entering this part of the market.

JFP – There is a lot of hype around AI at the moment and of course we still have to tell people, ‘If you want to use image analysis and AI, you first have to digitize your lab.’ Personally, I think we are still at that point of becoming digital, there is still a lot of work to do in getting labs to adopt digitization. Tribun and other companies are working on AI, and we see AI as having major benefits for the lab. Whether it is used for slide triage or cell counting, it saves time and increases the productivity of the pathologist. AI can also help with counting and measuring or determining tissue organization or even by providing new novel digital biomarkers. Clearly AI is a key technology for digital pathology and provides a lot of potential benefits. At Tribun we see that, thus we have decided to invest in this domain, and we have created a computer vision team, with data scientists and PhDs here in Paris. The task however is huge, so we think the way forward is to have an open solution platform onto which we can add options from third party (partner) suppliers. No one company will be able to cover all AI solutions and if another company is offering a nice solution, we want to be able to integrate it into our platform. At Tribun, we specifically work on breast, GI, and lung cancers, but even those areas are huge. Breast cancer itself could swallow up a whole lot of investment. We also have to think of course about the validation and regulatory approval for each application.

JT – Regulation is one of the main barriers and clearly, we also have to think about how the role of the pathologist changes, because it will change. Do you have any comments on that, should the pathologist be afraid of AI or view it as a positive development?

JFP – I don’t believe that AI will replace the pathologist. This is a misunderstanding. I think AI will provide assistance to the pathologist. We still hear complaints about long turnaround times and yet there are pathologists who still manually count cells and nuclei. These are tasks which are very simple for AI, and I think AI will also prove very useful for triage, for pre-screening, or for cell counting. In these areas there are huge opportunities for improvements in productivity and workflow. I don’t see AI ever providing a complete diagnosis, so I don’t think pathologists need to worry about their jobs. Clearly the job will evolve as we integrate more and more data, it will become more data driven. We also need to think about regulation around AI and this is a complex area. I believe some of the regulations need to evolve because having separate approvals for each algorithm, on each scanning platform, for each stain, is becoming a barrier preventing access to this new technology. At Tribun, we have European and Canadian clearances for reading a slide on the screen which is pretty much the general case now, but for the AI part, there is a lot of work to do to convince the regulatory bodies to evolve their regulations.

JT – So I guess the future is a synergy between man and computer, human and algorithm. The pathologist’s brain being very good at pattern recognition and having a lifetime of experience and computers being very good at screening and counting etc.

JFP – Exactly, AI provides assistance and saves time, but it is just a small part of the general picture of increasing complexity in the decision-making process. We have to remember that we are in a period where there are several simultaneous new technologies converging on pathology and cancer diagnostics. The path forward is to create new ways of aggregating all that new information in a way that can be easily presented to the pathologist for him/her to continue to make the best possible diagnosis and to recommend the most appropriate course of therapy for the patient

JT – Jean François Pomerol, we’ll leave it there. Thank you for your time today.