Hospitals worldwide are increasingly looking to implement laboratory automation systems to ensure good practice. Pharma Focus Asia editor Kerstin Zumstein speaks to Professor Sunil Sethi, National University, Singapore, about the wider implications.
The laboratory automation system (LAS) is a combination of analytical instruments linked by sophisticated sample management modules, robotic devices and tracking systems. It harnesses the strengths of robotic technology to transport and process sample tubes when they arrive at the laboratory. Automation solutions are put in place in centres with high-test volumes.
The LAS has been around since the 1990s, but started taking off at the turn of the century. One of the reasons for the rapid increase in LAS over the last five years, according to Sunil Sethi, Professor of Medicine at the National University of Singapore, is that it has become more user-friendly: 'There are many other factors that have prompted more labs to move onto significant lab automations. The biggest push, however, is that it has become significantly more affordable.'
The benefits of greater productivity, improved patient and staff safety, and re-focusing of staff duties on value-added activities have to be balanced against the economics of such a system. 'The vendors who sell these automation devices to most hospitals have become more flexible with their pricing', explains Sethi, 'not so much in terms of the cost, but more regarding the way the finances can be structured. There are a lot of lease and high-purchase financing options, which have made the LAS more reasonably priced.'
In recent years, the practice of laboratory medicine has changed due to advances in science and technology concerning both the instruments used and the methods employed. The LAS is emerging as the leading laboratory solution and has proven capable of handling large volumes of specimens in markets such as Canada, the USA, Japan and Western Europe.
According to Sethi: 'The USA and the UK also have significant lab automation in place - and have done for a long time - but the actual forerunners in LAS are the Japanese and the Koreans.' However, the situation for the rest of Asia is a different matter. In Singapore there are no fully automated labs; the fully automated lab at the National University Hospital will be the first in Singapore.
Training plays an important role in the successful implementation of the LAS. 'It requires an entirely different skill set,' explains Sethi. 'The old lab model involved a lot of manual processing in the form of handling tube samples, loading and unloading analysisers, generating documents and so forth.' With a complete automation system, all functions are replaced by automatic analytical modules, such as robotic arms or tracking systems. Consequently, staff now have a different job profile.
'The advantage is that the new duties are much more meaningful to staff, because they can pay attention to the value of the experiments rather than carrying the samples around and doing mundane tasks' Sethi says. With the LAS, the lab staff gain an insight into how these results are obtained and their quality when they are sent on to the doctors.
These changes do not necessarily mean that staff will have to be made redundant. Instead, the LAS will require re-training and re-engineering. 'What we need now are qualified technologists who are able to solve all the system-specific issues', says Sethi explains. 'Junior technologists, for instance, can upgrade their job profiles.'
The issue of staff competencies also merits consideration when working out the financial feasibility of LAS implementation. Analysis of the ROI cannot be exclusively computer-based. The capability of the staff in dealing with the automation system is a key factor in the success and ROI of each programme.
'A lot of the complications that we had with the backers were based on the training issue.' Sethi explains. 'The actual numbers regarding the ROI for such a heavily computer-based project are established by the head counts (required for automation), the skill level of staff and the productivity of the lab.'
Regulatory pressures are increasing, and governments worldwide are driving change in a number of areas, including:
The LAS can help with implementing these points because it fits into most directives and governmental schemes. The automation of the lab workflow makes it a safer environment. For instance, eliminating most of the manual processes defuses the danger of handling tube samples. Injuries and other risks are minimised with automated processes because human error is eliminated, or at least significantly reduced. Consequently, patients get more precious and reliable results.
Another aspect of productivity derives from the improved turnaround time. In most LAS solutions, the target test platforms are in four areas coinciding with traditional laboratory divisions: chemistry, immunochemistry, routine haematology and coagulation investigations. The traditional turnaround time can be significantly reduced in all four areas. 'We used to run our samples in 45 minutes to three hours,' Sethi remembers. 'Now, we are looking at running all samples in 60 minutes. This is a remarkable improvement.'
Patients are becoming increasingly interested and involved in their treatment. They expect better information and greater cost-efficiency, better access to information, more convenient healthcare services, greater control over their lives, and more options for self-diagnosis.
'Treatment is much more successful for the clinical staff when there is a partnership with a patient who is checking their own health,' says Sethi. 'We want to encourage home monitoring, self monitoring, keeping a condition under control.' Due to the internet and general access to detailed information, patients are more informed about their health, especially with regard to high cholesterol and metabolic conditions.
On the one hand, patient education on certain conditions and new treatments has improved. On the other, today's technology can perform home monitoring of various chronic disorders. This point-of-care treatment is on the increase. 'Self-monitoring is actually becoming a standard practice with a lot of our patients,' comments Sethi. 'They demand more, more access to their own results. This may mean better access and control for these patients.'
The financing aspect of home monitoring is a funding issue. There are various models that are possible, from state-funded schemes like the NHS in the UK to insurance-based models like Medicare in the USA. 'In Singapore,' explains Sethi, 'we have a co-payment scheme, which involves a patient partially funding their own treatment and the government covering the rest.'
With the increasing sophistication of healthcare, the costs are going up. 'But you cannot and should not put a price on health,' cautions Sethi. 'People should steer away from the question of who pays for it and concentrate on good practice and what is good for the patients.'
Technology-based systems may eliminate human errors, but not errors as such. Extra consulting may be needed regarding the traction. A new kind of preventive maintenance is also required. 'You have to monitor the system, maintain it, make sure it's running correctly,' explains Sethi. 'So, daily maintenance by looking at the track, checking the robotic arms, looking at the monitor and so on is going to influence our daily workflow.'
The daily, weekly and monthly maintenance routine has to be extended according to the automated devices. 'But I don't see it being a problem, because staff are used to having to check,' adds Sethi. 'Also, these new devices are built to last. The tracks are meant to be running on a 24/7 basis. Nevertheless, we have scheduled downtime where we stop the tracks, maintain the system and then fire it up again.'
There is a lot of integration of the LAS with the laboratory information system (LIS). This automation-information integration is essential to efficient test requisition, sample testing and result reporting. Automated laboratory systems support hospital-wide upstream initiatives such as computerised clinician order entry as well as downstream processes of soft-copy results on an electronic medical record.
There are various drivers of change in the healthcare environment, but it is technological advances that are making the implementation of the LAS possible. After all, healthcare IT is a big growth area and continuing advances in molecular science are leading to new information.
'IT tools are vitally important,' Sethi says. 'If the IT support is robust and sufficient, then results can be sent around the world in no time. Thus, the IT support is the basis of the systems efficiency.
'At the moment, everyone is looking at the automation-information continuum. This means we've got to link the software which runs the automation system with the software run by the laboratory, which is the LIS. There must be a pipeline of information going from the automation system onto the LIS, and then onto our doctors or the patients to review the results.' The successful introduction of the hardware is just one aspect of LAS implementation; the integration of the LAS with the LIS is vital to the system's success.
In the USA, the medical technologist's career path is not that attractive, which means there is a significant shortage of medical technologists. This is one of the key issues for automation, because automated process can achieve the equivalent cycle with fewer staff, which makes it especially attractive to the USA. In Singapore, however, this is not an issue.
Lab automation will take a while, but it will definitely continue to spread across the globe. All stakeholders are moving in the same direction, which makes implementation that much easier. But who are the stakeholders in laboratory automation and how will they all benefit?
There are many factors currently driving laboratory automation, whether it is a question of performance metrics, process quality metrics and safety. The escalation of clinical workloads and the reduction in operating budgets also play their part.
But ultimately, the many benefits were what persuaded Sethi to implement lab automation at the National University in Singapore. 'Its picking up tremendously,' he says. 'One day, hopefully, lab automation will be the norm.'
Sunil Sethi, National University, Singapore
