Digital Imaging - a Web Based Exercise for Blood Cell and Bone Marrow Morphology as Part of a National Quality Assesment Scheme.
Authors: Wells Emma , Ardern John , Brereton Michelle , Hickman Lois , Burthem John , Bromilow Rebecca , Seal Len , De La Salle Barbara , McTaggart Paul , Parker-Williams John , Hyde Keith 
Published: October 2019

Abstract
Over the last four years we have undertaken a development program in collaboration with the UK National External Quality Assessment Scheme for Haematology NEQAS(H) to use internet-based teaching and digital photography to improve consensus opinion on haematological cellular morphology. We began with providing participants with a series of individual images of haematological blood cells to most recently, multiple ‘stitched’ images with tutorial based feedback on cell type and diagnosis.
We present the results from a fourth internet-based blood cell morphology exercise. Participants were invited to visit the Central Manchester Laboratory website (www.manlab.co.uk) or the UKNEQAS (H) website to review a series of digital photographic images of blood cells. Volunteers to the exercise were able to call up images from a previously reported haematology case with complex morphology and report on their findings. Digital images were presented in three formats.
The first provided twelve static images with expert morphological comment and participant’s consensus comments from the original national survey. The second part provided four static images with an interactive tutorial clearly identifying specific cell types and morphology of interest. The third component was a composite of nine individual images ‘Stitched’ together that allowed movement across the image and a zoom facility. Of 426 participants 128 (30%) returned results to UK NEQAS (H).
Part 1: Over 90% of responders gave positive opinion regarding image quality, access to the website, presentation of expert opinion and agreed that the single images appropriately represented the morphological features of the case.
Part 2: Over 95% responded positively to the educational value of the tutorial.
Part 3: Of 128 responders, 34 were unable to download the software necessary to view the ‘Stitched’ image due their Trust’s internet policy. Of the remaining 94 responders, 90% found the image quality adequate and representative. A high proportion (71%) thought the ease of navigation and magnification offered by the Stitched image offered advantages over single static images and provided a better overview of morphology.
The positive feedback from this exercise supports our intention to place digital images of the six annual UK NEQAS(H) blood film surveys on the internet. The problems of downloading stitched imaging software are to be addressed and there is ongoing development of stitching 40–100 single images into a virtual slide.
A key role for external quality assessment schemes is to provide an educational service. The digital imaging procedure offers the opportunity to provide tutorial based learning to highlight interesting morphology and build up consensus opinion. The educational aspect of this is creating much interest and will provide a mechanism for continuing professional development of scientific and medical staff.