To lower costs, one lab takes automation to task
many hospital laboratories, the one at Abington Memorial
Hospital in eastern Pennsylvania was caught in a crunch: demands
from management to lower its costs and competition from a reference
lab down the street.
In 2000, the
Abington laboratory participated in a benchmarking study using HBSI
Action and found, to its dismay, that “we weren’t meeting
our targets [compared with peers] for hours worked per billable
test and costs per billable test,” recalls Kathryn Durr, administrative
director of pathology. Moreover, Abington was adding outside clients,
such as nursing homes, to boost volume and compete with the reference
lab, but its existing instruments couldn’t keep up with the
to look at better instruments and processes to support taking on
additional clients,” she says.
pathology department chair, Herbert Auerbach, DO, speaking in May
at the Dark Report’s Executive War College, described
the lab as having “run into a wall.”
increase our billables per worked hour. We were at the 50th percentile
using HBSI data, and we weren’t making any improvements,”
he told his audience in New Orleans.
At the same
time, hospital administrators at Abington Memorial, a 508-bed comprehensive
medical center, were pushing the laboratory to cut costs. The lab
runs more than 3 million tests a year, mostly chemistry, of which
42 percent are inpatient and 58 percent are outpatient.
we were pretty efficient in running assays,” says Dr. Auerbach,
who also spoke recently with CAP TODAY. He says the HBSI
data were skewed because Abington has a higher procurement cost
for outpatient tests than most of its peers because it provides
extensive phlebotomy services to its clients. But the hospital brass
disagreed. “They were lumping all our costs together and looking
at us versus our peers, and they just wanted to get [those costs]
down,” he says.
Meanwhile, it was the same story everyone in the lab community faces:
Payers were ratcheting down fees. “Nobody wants to pay for
lab tests,” Dr. Auerbach says. “A lot of our clinicians
and patients regard it as a commodity like water. They expect it
to be there when they turn on the faucet, and everybody wants to
to cut costs while building volume led to a multiyear, two-pronged
effort in which Abington Memorial’s laboratory reorganized
its chemistry, hematology, coagulation, and urinalysis sections
into a single core lab and followed that up by automating the majority
of its tests there. With lab automation, Dr. Auerbach says, “we
hoped to do it cheaper, faster, and better.”
In planning for the automation, which was executed in 2001 and 2002,
Dr. Auerbach and Durr visited other automated labs and took with
them some of their lab personnel to help with the evaluation. “We
drew up a list of the vendors we thought had offerings, invited
each to come to our lab, do a workflow analysis, and make a proposal
as to how their equipment would fit,” says Dr. Auerbach.
to bring in task-targeted automation rather than total lab automation.
The idea was to automate one section of the laboratory at a time.
Each section would get its own automated instruments targeted to
its own workflow. That kept the price tag lower than it would have
been for total lab automation and gave Abington the flexibility
to negotiate with several vendors rather than one.
automation offers much better use of technologist labor,”
Dr. Auerbach says. “We didn’t want to automate a bad
process.” The aim was to simplify processes with automation
to reduce errors and turnaround time and expand the test menu.
The core laboratory
represents 88 percent of lab charges, Durr told CAP TODAY.
“We targeted areas for automation where we could get the most
bang for the buck,” she says. “In terms of sheer volume,”
Dr. Auerbach adds, “when you do chemistry and immunoassay,
you’re doing 70 percent of your lab. Add hematology and you’re
at 80 to 90 percent.”
the first to be automated. Abington purchased a Cell-Dyn WorkCell
system from Abbott Diagnostics; it consisted of two Cell-Dyn 4000
automated cell counters, the slidemaker/stainer module or SMS, a
recirculating track that transports the specimens using a rack-based
conveyor, and the Navigator data manager. The incremental cost for
the automation—excluding analyzer equipment Abington would
have purchased anyway (for example, the Cell-Dyn 4000)—was
about $200,000, Dr. Auerbach estimates.
expenditures for automation, Abington estimated that for every $100,000
spent on automation it would have to save about $35,000 in costs
annually to compensate for the capital expenditure amortized over
five years and the estimated cost of a service contract. “To
translate that into how many worked hours we would have to save,
we used a simple formula,” Dr. Auerbach says. There are 8,760
hours in a normal year. A regular work year is 1,960 hours. “Therefore,
for example, if a piece of automated equipment could save one position
across all shifts seven days a week, that would result in a savings
of 8,760 divided by 1,960 or 4.5 full-time equivalents,”
core lab area of chemistry and immunoassay we sought an integrated
solution,” he says. “We wanted an analyzer or system
of analyzers that would consolidate much of the testing onto one
platform.” Abington selected the Bayer Advia WorkCell, which
included two Advia 1650 chemistry analyzers and two Centaur immunoassay
analyzers. “Bayer was the first to offer an automated integrated
chemistry and immunoassay system. Before this, laboratories that
attempted to integrate chemistry and immunoassay testing had to
do it with customized automation,” he says.
This trend of integration is becoming more common. The analyzers
are linked by an oval track that routes the specimens to the proper
analyzer based on the ordered tests. When the tests are completed,
the sample manager can hold the tubes for reflex testing or sort
the tubes for archival or for off-line testing. “By combining
two random-access high-volume immunodiagnostics analyzers with two
high-volume chemistry analyzers, we were able to streamline the
entire testing process,” Dr. Auerbach says. “We could
now eliminate a major preanalytic step of aliquoting and the resultant
labor, waste, potential for error, biohazard exposure, and resultant
increase in turnaround time, and use one system for both our routine
and stat testing.”
cost of the analyzers, which Abington would have had to buy regardless
of whether it automated, the additional cost of the integration,
track, sample manager, and requisite software was about $400,000
to $500,000, he says.
says having data managers as an interface between the automated
analyzers and the laboratory information system has several advantages.
Previously, the LIS would treat results from each of the analyzers
as different methods. “But with a data manager,” he
says, “the data from four different instruments are consolidated,
and therefore reruns, reflex testing, and autovalidation can be
managed more easily before results are passed to the LIS.”
Since Abington finished implementing automation in the first quarter
of 2002, the core lab’s workload has continued to increase—it
now serves 65 nursing homes and about 50 physician offices—while
staffing has gone down. Automation has saved seven full-time equivalents
through attrition, about 20 percent of the technical staff, Dr.
worked hours per billable test declined from about 0.2 in 2000 to
0.15 in late 2002. The target was to be at least at the 35th percentile
on the HBSI benchmarking data for hours per billable test, and by
the third quarter of 2002 Abington had achieved that. Billable tests
per FTE showed about a 20 percent improvement between late 2001
and late 2002. “We’ve climbed to 13,000 annual billable
tests per FTE,” says Dr. Auerbach. “We can be semicompetitive
with Quest,” the nearby reference laboratory.
Salary and supply
costs and worked hours per core lab test have all declined. Multiple
instruments can share one tube of a patient sample, reducing cost
and the volume of biohazardous waste. The total direct cost of the
average lab test, including labor and supplies, has dropped from
$9.13 to $7.96, Durr reports.
The lab has
also been able to consolidate its floor space usage. “We have
most of our testing in a very confined area,” Dr. Auerbach
says, though that required a new look at heat load and air-conditioning
and similar things.
plummeted. For example, on the Advia WorkCell for chemistry analysis,
69 percent of tubes are sampled, archived, and sorted in the sample
manager in less than six minutes. Stat results are available in
22.3 minutes and routine results in 24.1 minutes. (Those are median
times.) Overall, the median stat turnaround dropped from 52 to 43
minutes after automation, while routine turnaround times dropped
from 100 minutes to
which represents three-fourths of the lab’s workload, 95 percent
of test volume can be processed on one system, including 56 serum
assays, 18 urine assays, and seven fluid assays. In hematology,
62 percent of CBC results are autovalidated, so that technologists
spend their time managing only the exceptions.
process can be managed from PCs within the laboratory. “We
use keyboard video mouse technology, known as KVM switches, to control
everything from PCs,” Dr. Auerbach says. Using a matrix type
of KVM switch technology, the lab could integrate any analyzer that
uses a PC or Unix workstation as a front-end controller, and thereby
gain full control of the analyzer from multiple access points in
the lab. And the new systems are robust. “Over 18 months of
use we’ve seen less than 24 hours of downtime,” he says.
One of the biggest problems in implementing automation was getting
the staff accustomed to computer-controlled rather than personally
controlled testing. “The technologists had to quickly ramp
up their computer skills,” Dr. Auerbach says, to understand
how integrated systems are networked, where the potential pitfalls
are in the information flow, and how to restart the systems. Those
systems now consisted of several computers, such as the data manager,
the workflow manager, the LIS, and the actual analyzer computer.
requires a whole new skill set in your medical technologist,”
Dr. Auerbach adds. “They were used to knowing exactly what
they put on each instrument. Now they have to feed the automated
workcells and keep a continuous flow going, and manage the exceptions.
They have to think about integration.”
training in computer information systems has been limited, he notes.
“They probably receive some training in their didactic curriculum,
but in their practical year of training, their informatics experience
will depend on the lab they trained at,” he says. They have
to be prepared for a networked computer environment, and be able
to work in the traditional role of medical laboratory scientist
and to understand the informatics involved in an automation system.
has to be able to recover from a computer lockup or system crash
without having to call the help desk,” he says.
Under the nonautomated
workflow, Durr adds, technologists and technicians would run one
machine and do each test separately. With automation, “there
was a different dynamic,” she says. “Now they had to
share data and interact with other team members. They had to respond
to the person who was running the data manager.”
and Durr acknowledge that although upfront training was provided
to the technologists and technicians, the lab underestimated the
training needs, not just on the new equipment but also with new
processes. Says Dr. Auerbach: “You can’t just buy a
vendor’s solution and think it’s done. You have to work
to get those FTE reductions. You have to figure out how to change
Durr, “You really can’t experience it until you do it.
At some point you have to take the plunge.”
The bottom line
All in all, lab automation at Abington Memorial Hospital has been
a “resounding success,” Dr. Auerbach reports. “We’ve
been able to reduce cost, achieve FTE reduction, and see opportunities
for growth and additional revenue.” The managed care payers
are now “coming to the table and discussing realistic contracts
we can live with.”
to tweak the automated systems. “We’ll be adding plasma
as an option soon,” Dr. Auerbach says. Other projects include
expanding autovalidation, consolidating the menu, refining how reagents
and tubes are managed, stocking the system to make sure there’s
enough of everything throughout the day, and offering computerized
clinical alerts on important results via the hospital information
system. “We want to expedite delivery of test results to physicians,”
Dr. Auerbach recommends that any laboratory considering automation
take the following steps:
Karen Southwick is a writer in San Francisco.
- Map out your
current workflow and process.
- Examine the
entire process from specimen receipt to result.
- Study the
vendor options and their impact on your laboratory.
the analyzers carefully because they are the potential bottlenecks.
overlook the data management/process control system because it
is a major component of the system.
- Start computer
training for your technologists. “It’s never too soon,”