AP labs diving deeper into automation

Anne Paxton

September 2019—Talk to a few anatomic pathology laboratory directors about automation, and you may hear references to early network television, when automation’s downsides were mined for comedy. In one interview with CAP TODAY, a lab director drew parallels between potential backups in the automated AP lab and Lucy and Ethel’s travails keeping pace with a chocolate factory conveyor belt.

There is strong agreement, to state it in 1960s TV terms, that even for core or centralized AP labs with the necessary volume, the traditional automation options have progressed well beyond the modern Stone Age, but reaching Tomorrowland may require a shift in thinking.

For Jeffrey W. Prichard, DO, the image of the Jetsons’ flying car fits the futuristic automation of clinical pathology, which already has fully automated lines that handle specimen ­identification, preparation, testing, storage, and retrieval. In AP, says Dr. Prichard, division director of anatomic pathology operations, informatics, and quality for Geisinger Health System, Danville, Pa., only the most standardized and predictable processes have proved to be amenable to automation.

“But AP automation opportunities are there when you look for them,” he says. AP laboratories should consider not just full automation but partial automation as well, and they should look beyond mechanical robotic automation, where innovation has been slow, and consider data automation and the benefits it brings, Dr. Prichard says.

At his core laboratory, “We have automated our tissue processors and we have automated our slide stainers. We load the slides on and both the slide and reagents come off at a certain time. The stainers took over work that requires a few FTEs to complete, so I consider those fully automated, and I think that is analogous to trusting a fully automated car to drive up and down a six-lane highway like the I-95 to Florida,” Dr. Prichard says. But for the many variable or delicate processes in the AP lab that remain largely manual, automation is a trickier proposition. “I think the technology is not necessarily good for making it into my parking lot space.”

The progress he has witnessed in the past five or 10 years has been in the area of partial automation that still requires human interaction and oversight. He compares the complementary automation features arising in AP to driver’s assist functions in automobiles, such as cruise control, drowsiness and lane detection, and emergency braking.

His laboratory has consolidated six other labs at Geisinger over the past 10 years and runs couriers for the system of nine hospitals in Pennsylvania. One aim has been to reduce FTEs. “But we have not been able to realize that because our system has been growing so rapidly,” he says. In fact, he has not been able to recruit permanent histotechnologists fast enough to keep up with the volume, having to rely instead on temporary help, which is costly.

“We shoot for a turnaround of 80 percent in two days and in the past we have averaged 84 percent to 86 percent, but I have seen it steadily dropping to 80 percent this past year. I am attributing that drop to the slowdown in histology, because it is not that our pathologists haven’t kept up. The bottleneck has been in the manual processes in embedding and sectioning.”

The laboratory’s setup right now has mechanical automation starting with six Sakura Tissue-Tek VIP processors and two Leica Peloris processors. “We have been moving from our bank of reliable VIP processors we’ve had for many years and are acquiring the Peloris processors as we have been replacing the old ones,” Dr. Prichard says. At the embedding and cutting stages, the process becomes manual. But the staining tests are all done through a Roche Symphony HE stainer and, for IHC, Roche BenchMark Ultras and Leica Bonds. “Those I consider fully automated; they just need to be loaded and offloaded. You have to manually move the slides onto the coverslipper for the special stains in IHC, but the HE stainer has the integrated coverslipper.”

Because of the surge in volume at his lab, it hasn’t been difficult to get the budget to acquire new instruments, and he has not written off the technology that’s available for further automation. “I have been demoing these automation technologies at the trade shows. I just haven’t found one that actually saves me time,” even for the limited optimized type of control tissues used in demos. “I do look at the automated sectioners, and I am hoping they get more versatile and more efficient.” But right now, “It takes a long time to watch them cut a single section.”

“There is too much variability. Adapting to all the variant tissue, the density of the tissue, the amount of tissue in the block—that still remains part of the art of the histotechnologists. They can adjust the speed at which they’re sectioning in order not to compress the tissues and get good sections off of it. And that is not something that automation is yet able to achieve.”

Data automation has been the source of most of the labor-saving innovation in his laboratory in recent years, Dr. Prichard says. For example, “About eight years ago we fully automated barcode tracking throughout our Pennsylvania hospitals. There were still tissues being misidentified, and people were trying to read five-figure accession numbers off the blocks.” At one point there was a labeling error for every 5,000 blocks. But since switching to barcoding, “we’ve done 2.2 million tissue blocks without a block misidentification error recorded in the lab.”

Since barcoding is now 2D and contains much additional information, it has also automated workload distribution. “You need to assign cases to pathologists and ensure they have the right specialty training, you need to even the load among the pathologists with that training, and you need to know which space they are located at during the day. This was being done by accessioning staff in the lab. Now it is simplified, and it has kept our doctors happy that we aren’t overloading them compared to their colleagues.” (A sample warning: “Please note that on 09/09/2014 either the GI pod case limit for a pathologist has been reached or the daily case limit for a pathologist working in pod GI has been reached.”) Alerts to residents about specimens assigned to them go out by secure text to their phones. “That has been an efficiency for us and a crowd pleaser for the residents.”

An especially intriguing application is Dr. Prichard’s automating of quality management by creating structured data sets or multiple choice inputs for when quality errors occur. “Our process has multiple steps that are very manual and involve lots of people and lots of handoffs at multiple sites. Every handoff is a risk for the testing process,” he notes. To stem potential errors, he employed a kind of crowdsourcing. He asked all staff involved in the process and quality monitoring to provide input, when something has gone wrong at their station, through a structured data set that allows the system to count and trend the occurrence of quality errors. If an error has occurred, an alert graphic automatically displays on the monitor for that section of the lab. “Because of those, they have named me Dr. Redbar. I guess I am a little bit proud of that,” Dr. Prichard says.

The customized data input system allows the lab to report the 10 most frequent issues an individual has reported and provide feedback about the same errors occurring anywhere in the system. “I do that to try to engage the staff in the quality process, so that if an error happens to them, it shows how often it happens to anyone else and it includes whether management is doing anything to improve quality already.” There has to be a two-way street when crowdsourcing and engaging people in quality management, Dr. Prichard explains. Nine years of this system has produced 127,000 issues input by staff, he says, “which is an awful lot of crowdsourcing information we would not have had otherwise about the quality of our process.”

All of which has not hurt the bottom line. By automating collection of the data, “we have seen half a million dollars in labor savings by decreasing the incidence of these issues and not having to put labor into fixing them over time. Decreasing the amount of delays happening in cases year over year saved 31,000 days in delayed reporting of issues. Eighteen percent of those were inpatient cases. So, if even 10 percent of those delays happened with hospital and surgical patients for one day, that represents a $2.5 million savings in length-of-stay costs for the system.” That figure got Dr. Prichard a lot of attention from the C-suite, he says. “They are considering rolling this out beyond the lab into other areas of the hospital, such as the ICU, for managing their processes as well.”

Automation at AdventHealth Central Florida’s pathology laboratory, which serves nine hospitals in the Greater Orlando area, was installed about five years ago, but the lab started thinking about it several years earlier, says Debbie Dickman, MA, MT(ASCP)SH, senior manager of the pathology laboratory.

“We have always had some sort of automated H&E stainer, but everything else was very manual; we only started doing the special stains in histology and making sure we have good tracking from the computer side five years ago,” Dickman says. Now, the laboratory uses Sunquest CoPathPlus for its main tracking system and employs a variety of instruments: Leica Peloris for tissue processors, SlideMate slide printers from Thermo Fisher, a Sakura H&E stainer with an integrated coverslipper, special stainers from Agilent, and Leica Bond instruments for immunohistochemistry.

It’s true that labs must be a certain size to justify automation, says the laboratory’s histology manager, Jason Molnar, MHSA, HT(ASCP)^CM QIHC. “You have to have the bandwidth, the volume, to be able to justify it because these automated instruments are quite expensive.” For his laboratory, the hopes of achieving economies of scale with centralization have been realized. The 35 technologists at the core lab process about 1,600 cassettes or roughly 350 cases a day. “If you put all the work back in the nine hospitals in our system and had to staff all those places, we would probably be closer to 50 people,” Molnar says. The lab can also handle steady volume increases—about 10 percent per year on average—without adding new staff.

The laboratory’s 2D barcode system allows tracking of specimens from point of collection in the procedure rooms all the way through the pathology process to the time that the specimen container is discarded and until the time the slides are discarded or sent to research 10 years later. “We track all steps in our process. In the laboratory where we process histology, we have 10 cutting stations, four embedding centers, and two distribution computer terminals to scan and track our blocks and slides,” Molnar explains. “So we have about 15 scanning apparatuses in the main laboratory.”

“We use codes that have RFID tags that are picked up by our WiFi system, so we know where the specimen is at all times,” Dickman adds.

But achieving a smooth workflow is challenging, Molnar says. “Realistically speaking, we are a full-service hospital, and it is difficult to get everything out because we handle all the makeups and specimens that other small reference labs or even larger reference labs that deal with biopsies don’t have to deal with.”

The lab considered acquiring a new Roche stainer this year but, for practical reasons, ended up staying with the relatively older stainers that are not interfaced with the LIS. “Once our slides come off the stainer, we triage them. Then we put them back together because as a full-service hospital we get larger specimens and they usually process them at different times and in multiple parts. Then we verify in the system that we have all the parts for that case before we distribute it to our pathologists,” Molnar explains.

They would like to see a continuous workflow, says Dickman, but are working with sites that are one hour away, waiting for specimens to come out of the procedure room. “The majority of our work comes in the afternoons, so we have these big pulses of work we are trying to push out.” The manual steps are many, starting with grossing. “Then the tissues come off the processors at different times.”

“I know there is more automation available out there, but I don’t know how much is practical for a high-volume lab like ours that has a large variety of case mixes,” she says.