Image-based approach enables self-verification and confidence in results
Able to correlate Moichor results with what his team was seeing on the smear
More chemistry data helps inform diagnostic decisions and at a low price point
Despite the chronic backlog of over 100 emails that plague his email inbox, Dr. Speer said he always keeps a sharp eye out for potentially exciting projects that flutter in, seemingly out of the blue.
So in 2019, when Moichor CEO Shevy Karbasi sent one such email, it was inevitable that Dr. Speer would reply. “What drove me to respond to Shevy was that I’ve always known that there has been a need for something to change our current understanding of hematology quality control. And I knew that our approaches would have to be an entirely different methodology than everything that we have tried historically,” Dr. Speer said.
“I’m always looking out on the horizon, and so when Shevy wrote me I was ready to see what he had to say,” Dr. Speer said. “The conversation we had was exciting, to say the least,” he said.
Shortly after their email exchange, Shevy drove to Oakley, California with a prototype of the Moichor microscope to demo for the Medical Center for Birds.
The two kept in touch as Moichor built its dataset with the Gabriel Foundation and launched its commercial product the following year. Soon, questions, observations, and thoughts made their way back to Dr. Speer from colleagues about their experiences and successes with Moichor.
It was at this point that Dr. Speer decided to run an in-house hematology data side-by-side for comparison.
Dr. Speer points out that all estimated WBC data is subject to variability. In his words: “That variability could be reason enough to support a need to improve what my practice has been doing — it’s the right thing to do.”
For Dr. Speer, hematology has always been an arena that is imperfect. “When you are boots on the ground, you understand the reality of the many soft data points that we use. And often, we talk about this data as if they're as solid as a rock.”
“But, a lot of the tests that we do are not as perfect as they could be — or as we think and want them to be. Sometimes those differences can massively influence what we do clinically.”
Dr. Speer had an inkling he was getting variability between the tech’s manual reads but didn’t have an effective way to measure it or to apply a process to standardize their reads.
“If you’re going to take a scientific approach,” Dr. Speer said, “you want to refute your hypothesis. Well, my hypothesis was that I don’t think we are as accurate as we want to be. And we failed to refute that hypothesis,” he said.
For Chemistry, Dr. Speer currently uses an Abaxis but doesn’t have access to all the data points he’d like. There are several competing factors that drove him to the Abaxis including the costs of maintaining his previous in-hospital Cobas Mira Chemistry Analyzer, concerns over reference labs making changes in the reagents they used without communicating those changes, and then of course cost.
“Doing the limited number of chemistries that Abaxis had to offer was probably not a perfect-world scenario, as far as all the data points we'd like, but it was economical and largely could be used to influence the lion’s share of clinical decisions required,” he said.
Over the years, Dr. Speer has applied estimate counts, manual differentials, Natt & Herrick's, suspensions, the Unopette system and experimented with other modalities. He tried a number of reference laboratories as well, but he has always returned to estimated white cell count, which he has had the best experience with, and which largely seemed to provide enough to get by with.
As he recalls: “The first time I met Shevy, I said, ‘I know that what we have and do here is not good enough, but we don’t have any other options that are consistent and meet our needs better.’”
“What drove me to try Moichor was an understanding that this is an imperfect science, and if we can improve the science, then maybe we can move forward. You guys are offering the opportunity to bring about a change.”
For Dr. Speer, that change has multiple layers of opportunity. On the one hand, there’s the automation and sophistication of data that will allow for future opportunities, with regard to reworking some of their reference ranges.
But he also recognizes immediate possibilities as well. “The opportunity to standardize our in-house hematology reads is of great value to us right now,” he said. “When we’re dealing with sick animals, we want to be able to immediately get this information, and we want to always be learning how to do better and how to be more accurate in order to make clinical judgments that must be made immediately sometimes. As such, we’ll always want to be able to do hematology in-house too; but this paired approach allows us to really raise our game.”
“When there’s not a level of urgency, we want to send those to Moichor and by using the images associated with the slides, we can standardize our in-house interpretations of those same smears.”
“When we did our side-by-side comparison it was a little bit humbling to realize how substantial some of the discrepancies were. And I could see the weak spots that we have. For example, we were able to identify differences in cell identification between the two individual technicians who are reading in-house hematology. As a result, we're already changing the way we do our blood smears to try to get a more uniform smear.”
Additionally, for Dr. Speer, Moichor’s bundled CBC and Chemistry enables a much more sustainable profit margin for his practice with access to desired data points he was not able to capture using his Abaxis.
“When I look at the economics of hematology, paired with the low chemistry costs, those are substantially less than any corporate lab has been able to quote us, and can make it possible for a meaningful profit margin. Also, I can increase the number of blood chemistries that I have over what the Abaxis system is capable of. And the chemistry you’re offering is more specific to what I need.”
Moichor onboarded Dr. Speer’s team with basic training for submitting samples and a demonstration of how to use the web-based portal. As the side-by-side progressed, the Moichor team provided ongoing feedback and answered questions about how Moichor interpreted the sample data coming in from the Medical Center for Birds.
Moichor CEO Shevy Karbasi said the goal was to make Moichor’s methodology as transparent as possible so that clinicians could feel confident in Moichor’s results and access the images and data themselves. “We want this to be the opposite of a black box,” Shevy said.
For The Medical Center for Birds, this is an ongoing process. Dr. Speer plans to continue to duplicate, review, compare, and improve his processes over time. In Dr. Speer’s words:
“In the end, there really is no way we all can’t improve with this approach!”
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See side-by-side study
“I think our immediate value will be to learn how to correlate what we’re seeing in the results provided by Moichor with what our team is seeing on the smear,” Dr. Speer said.
“I’m chipping into the definition criteria for how we are calling monocytes, and that we are probably counting thrombocytes as if they are lymphocytes. So those images specifically will help us raise our in-house quality control.”
“In addition, we have always wanted to get more data out of our chemistry profiles, and we are excited by the opportunity to do this and not damage that profit margin for our bottom line.”
The Medical Center for Birds continues to use Moichor, and also continues to run CBCs in- house. For Dr. Speer, he likes having the option of both methods. This allows him to run his high-priority CBCs in-house and send the rest to Moichor, and to continue to learn and improve.
“I think we are truly chipping at the opportunity for some real innovative science to open up doors that we’ve known have been there all along — we just haven’t been able to see through them just yet. But soon, with this data, we'll be able to open those doors and look on the other side and see some interesting things that I think are really going to be quite powerful,” Dr. Speer said.
When asked why other avian and reptile vets should try out Moichor’s automated CBC and do their own side-by-side, Dr. Speers said: “They should do it because it will open their eyes like it did for me. Look at what we found out about what we've been getting by with.”
“I know that we all can do better. We already know that there can be significant variability in hematology data that we generate in a number of methods, and this technology may offer us an ability to move a bit more cohesively forward.” (Beaufrère and Ammersbach, Advances in Clinical Pathology and Diagnostic Medicine in Current Therapy in Avian Medicine and Surgery, 2016)
I think we are truly chipping at the opportunity for some real innovative science to open up doors that we’ve known have been there all along — we just haven’t been able to see it yet. But soon, with this data, we'll be able to open those doors and look on the other side and see some interesting things that I think are really going to be quite powerful.