College of American Pathologists
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  Merged lab on track with efficient design


CAP Today


March 2008
Feature Story

Anne Paxton

Some people might wonder how a clinical laboratory could share similarities with FedEx, the Dallas Airport's SkyTrain, and the Boeing plant in Everett, Wash. But Indianapolis-based Clarian Pathology Laboratory has shades of all three. Housed in a new $65 million building in the city's Central Canal area, the highly automated, 150,000-square-foot facility is considered a model of laboratory consolidation and a harbinger of the future of clinical laboratory design. It was intended to optimize production in diagnostic testing while maintaining a collaborative work environment, says chief pathologist John Eble, MD, MBA. And by all accounts, it is succeeding.

With 16 hospitals and health centers across Indiana, Clarian is the largest health system in the state. "It started out in 1997 with Methodist Hospital of Indiana, and two hospitals owned and operated by Indiana University-Indiana University Hospital and the James Whitcomb Riley Hospital for Children. Those hospitals were pooled in a new not-for-profit organization, Clarian Health," explains Dr. Eble, who also chairs the university's Department of Pathology and Laboratory Medicine.

Since its formation, Clarian has con­structed two hospitals in the western and northern suburbs of Indianapolis about 10 miles out; soon it will open a hospital in Lafayette (about 50 miles away), and it is embarking on construction of another northeast of Indianapolis. "So within two and a half years, we'll be up to seven hospitals," he says.

Between them, University Hospital and Riley initially had two highly complex clinical labs about 100 yards apart and connected by a tunnel, and when Clarian was formed it inherited the two quaternary care laboratories. "One of our tasks from the beginning was to see what we could do to reduce redundancy, thereby reducing costs and rationalizing the system."

Neither laboratory had a comp­lete set of services and there was little overlap between them. For example, there was no bacteriology at Child­ren's, nor any serology or virology at University. The problem was that the laboratories at all three hospitals were hemmed in by other programs. "We really hadn't been able to do significant renovations in many of these labs for a long time because of the lack of 'swing space' to operate while renovations were going on. So Clarian was interested in seeing what could be done to move some or all of the laboratory functions outside the hospitals."

There wasn't much doubt about how much space Clarian wanted from the laboratories. "They needed all we could give. Basically they came to us and said, What can you do in aid of this goal?"

At about this time, Clarian was building its "people mover" transit system, a dual monorail similar to the SkyTrain at Dallas/Fort Worth International Airport. The electric-powered, three-car train, which connects the three hospitals along a 1.5-mile route, is rare among hospital systems, though not unique. Many hospitals that try to build such a system are stymied by resistance from the neighbors, Dr. Eble says. Clarian was able to construct it in part because the distance was not great, it could run a track under an interstate overpass, and the track crossed a commercial/warehouse type area and undeveloped vacant lots.

For the consolidated laboratory, which opened its doors in spring 2006, the train offered a golden opportunity. Instead of using primarily a courier system to transport samples, Clarian installed its pneumatic tube system, the largest one of its kind in the U.S., right under the people mover tracks. With its six high-speed lines between the new laboratory and each hospital, stations along the way, and 50,000 feet of steel six-inch tubing, the pneumatic tube system allows efficient, continuous specimen tracking, FedEx-style.

It also creates fairly simple transport logistics for the laboratory, Dr. Eble says. Only objects too large for a pneumatic tube capsule or from places not connected to the system (such as from the suburban hospitals) have to go by courier. "It really is like the phone system. We use it all the time, but we don't do the maintenance on it. So there's not much we in the laboratory have to do with wrenches and screwdrivers."

Because the city insisted that parking be provided on site for the 500 employees, Dr. Eble says, three floors of the building are devoted to cars and another three to work space. "That includes offices for the 40 pathologists, educational space for medical technologists and cytotechnologists, programs for residents and fellows, and about 10 percent shell space."

Clarian is a not-for-profit corporation, but it's run on sound financial principles, Dr. Eble says, and it conceived of the consolidated laboratory as being more or less self-supporting. "Basically the capacity of the laboratories at Methodist, IU, and Riley was constrained by lack of space. It was difficult to bring in new kinds of testing. So the business plan for the building was based on growth in the amount of testing and consequently the billings that could be done."

"We really didn't begin actively seeking outreach testing until last year," Dr. Eble says, noting that Clarian hesitated due to worries about being overextended. "At the beginning we had two LISs and three front doors. So it just didn't seem to us we were going to be able to give the level of service and performance that would be required." Once they were in the new building for a few months, they began to reach out to doctors' offices, particularly large physicians' groups that had an affiliation with Clarian.

As it turned out, outreach growth was one area where Clarian's planners were off the mark: Their projections were too low. "We projected for 2007 to have about $5 million in increased outreach charges, and I think we ended up with somewhere around $17 million. So it's been growing much faster than we projected. That's almost entirely the result of having sought out these large groups, which have brought business in big chunks. When those groups are pretty much done with and we market to smaller groups and other hospitals, the growth will, I think, slow down somewhat."

The laboratory decided to consolidate onto a Cerner Millennium LIS, which is an element of an institutionwide electronic medical record that Clarian is phasing in. "Obviously, the LIS is a kind of EMR limited to laboratory records, and the digital radiology system is an EMR limited to radiology, and the main missing piece-the progress notes or nursing notes of a medical record system-is being implemented. But it can't be done instantly; it has to be rolled out in a measured way." Most of the relatively minor bottlenecks in the system, Dr. Eble says, have been caused by people rather than engineering or electronics.

"It's fair to say we are highly satisfied. But anything as complicated as this takes a good bit of tuning and tweaking to get it running as smoothly as possible." For example, most of the samples come into the laboratory through the pneumatic tube system and people have to remove them from the capsules. "They have to do certain things before they can be put on line. One of the challenges is having the bar-coded labels put on correctly at the site of blood drawing. And another challenge is to get the time of collection into the system. It means training literally thousands of people who draw blood to label the tubes properly."

If there is a problem within the tube system, humans are usually the culprits as well. "Somebody doesn't close the capsule properly, the little door springs open, and the capsule gets wedged somewhere in the tube system, or someone keys in the wrong address and the capsule goes somewhere it was not intended to go." But given the volume of traffic on the tube system, he says, problems have been fairly minimal.

The old university hospital laboratory that Dr. Eble's staff used to occupy was designed in the 1960s, under the architectural concept that there should be a different room for every kind of function. "You'd have a bacteriology room, an anaerobic bacteriology room, a mycobacteriology room, a mycology and parasitology room. And they would all have hard drywall between them."

"That really hindered flexibility. Today our concept is much more to have large laboratory rooms that are divided functionally by casework, and sometimes by partitions that are relatively easy to take down and move when you need to." Like an airplane manufacturing plant, Clarian Pathology Laboratory used an extra large open space to maximize its automation level. "We really wanted a robotic line arrangement with as much of chemistry and hematology automated as possible to produce the lowest labor costs and turnaround times for those tests," and the building's architecture provided the flexibility to accomplish this.

The elongated shape of the building, more than a football field long, made installing the 100-foot-long auto­mated track system a breeze-and it took the time pressure off Clarian when making the purchase. Because the building didn't have to be designed around it, the laboratory waited until the last minute to select a state-of-the-art system.

Consolidation has succeeded not only by meeting the initial goals Clarian set but also by bringing dramatic growth in laboratory testing, Dr. Eble says. "I don't know that in 1999 we had enough prescience to be able to predict it. We thought there would be growth, and we believed Clarian was going to be successful in tracking patients and taking good care of them." But in the end, "we were able to give back probably 75 percent of the space we had in the hospitals, and we're doing an average of 19 billable tests a minute 24/7, 365 days a year. We've increased our testing volume from 6 million to 10 million per year. So it's worked out very nicely."

Anne Paxton is a writer in Seattle.