July 2018—“Robbie,” the autonomous service robot that transfers specimens for Florida Hospital’s central laboratory, may not quite be ready for his gold watch. But after five years of faithful service delivering samples between the different esoteric testing units, he’s nearing the end of his natural lifespan with signs of wear. “He hits the walls every once in a while,” says Julie Hess, executive director of Florida Hospital’s Central Florida Division of Laboratory Services, Orlando. The lab’s use of robots like Robbie may double soon; two robots are on the laboratory’s draft new equipment plan.
That’s just one example of how Florida Hospital’s laboratory, which already performs more than 10 million billable tests per year for its 10 laboratory locations in central Florida, is planning to accommodate its steady increase in test volume, about three to five percent year over year, with newer models of equipment and instrumentation. Central Florida is experiencing a population boom, Hess notes. The laboratory managers at Florida Hospital report that both growth and technological advances are driving the kinds of instrument purchases they are contemplating and the timeline for those purchases.
That trend is not universal, however. At Minnesota-based Allina Health Laboratory, interviewed by CAP TODAY a year ago about its instrument purchasing plans, some add-ons and instrument refreshes are planned. But other acquisitions are on hold as the laboratory analyzes how vendor offerings fit with Allina Health System’s changing needs.
Florida Hospital’s major acquisitions this year include replacing all of the system’s aging chemistry equipment with newer models from the same vendor (Roche)—that instrument update is halfway completed—and the laboratory expects to do the same with hematology systems from Sysmex. Florida Hospital is unusual in that its centralized laboratory supporting outpatient testing is within the hospital. “We want to capitalize on test utilization,” Hess says, “making sure we’re not doing unnecessary testing, especially for our inpatient population. But we also continue to grow well in our outreach area. That pattern ensures a viable balance of tests through utilization and continued outreach growth.”
In the future, Hess sees instrument purchases as having to also adapt to Florida Hospital’s pattern of building micro-hospitals or freestanding emergency departments, which currently total two. “We’ve had to purchase new equipment to outfit those laboratories. There’s been an interesting change in the hospital model—what I like to think of as a ‘tiny-house’ movement of hospitals. They want a full-service laboratory in a very small space. It’s been challenging to make sure we can have a full breadth of test menu for an ER setting that may potentially have overnight patients. In addition, we would like those instruments to be consistent with what we already have in our larger lab facilities.”
Molecular diagnostics has been on the increase, particularly in oncology and infectious disease testing, and Hess expects continued expansion. The laboratory has Verigene (Luminex) analyzers that perform blood culture bacterial identification by molecular testing, and recently added the Enteric Pathogens panel. A respiratory panel is performed on the BioFire FilmArray. “The technology and test panels supporting oncology are changing rapidly, so requests will be made to upgrade existing equipment,” Hess says. Looking ahead, the laboratory is considering new sequencing platforms for its HLA typing, instruments to support pharmacogenetics, and, probably a few years down the road, instruments to sequence organisms for microbiology.The budget for new instruments is adequate in some ways, inadequate in others, Hess finds. “As new locations are being built, we are given a capital budget to buy the equipment, so with hospital expansion we can get laboratory equipment. It’s in our established hospitals, when we need to update and refresh both the equipment and the facility, that it’s been a challenge to get capital dollars approved. We have to focus our capital requests on improved patient outcomes. As long as we can connect a request to improving the length of stay or driving overall cost of care or more excellent patient care, possibly through increased sensitivity with new test methodology, that helps move those purchases forward.”
Hess cites one molecular microbiology test that was brought in-house, allowing the laboratory to provide antibiotic resistance or susceptibility results within an hour. “We calculated about $350,000 in savings per year for the pharmacy by our spending about $40,000 in lab to add CRE testing on the Cepheid Infinity.” And that impressive return on investment convinced hospital administrators to sign on to the purchase.
Sepsis continues to be a “pain point” for her laboratory. “We are looking closely at how we’re managing infectious disease and considering automating microbiology with the BD Kiestra. The potential to reduce the turnaround time of cultures could translate into a different model of care for our patients and our management of antibiotic usage. But that would be a multimillion dollar spend for us.”
The overarching issue for the laboratory is a shortage of space. “Every change we need to make, we continue to have to consider our space constraints. Especially as we are in a legacy institution here. The walls around us really can hold us back.” Just to be able to get the replacement chemistry and hematology instruments in, “we had to go through a major construction remodel. And not just at our main laboratory, but all of our satellite hospitals as well.” In looking at microbiology automation, for example, “We’ve been working with architects to see how we can gut what we have and remodel it completely so that we can fit equipment in and improve the workflow. All of this is happening with limited or no interruption to lab services.”
Hess is not worried about the impact of the reorganization of the diagnostics industry signaled by, for example, Danaher’s acquisition of Cepheid.
“Overall, I would say, regarding those mergers, we’re looking at what the particular product offers us and our patients. If it meets our needs with one owner, then it would probably meet our needs with another owner, unless we hear rumors of their discontinuing an instrument line because it duplicates something they already offer.” Florida Hospital has some of the Nanosphere platforms, so there were questions when Luminex acquired Nanosphere. “But we were reassured they weren’t touching the platform we had or changing their timeline on development.”
Improving data analytics, now performed on a homegrown system, is another priority for this year. “We are requesting capital for a lab analytics system that will overlay with our LIS.” Hess doesn’t expect a change in the Sunquest LIS anytime soon, “but getting access to our own data so we can tell a strong story of need or improvement may help us acquire needed equipment capital in the future.”
Information technology is another pain point, Hess says. “Connecting lab and IT to get IT-related projects approved has been a significant challenge the last few years.” The laboratory and IT must work together to ensure data security before moving forward with any acquisition. “We want to avoid data breaches and the risk of ransomware that could cripple normal operations. So now selecting the best equipment is only the first step, but ensuring data security may be one of the most important steps.” In one case, equipment the hospital had acquired already could not be interfaced for more than a year because the vendor did not meet security standards.
Competition from the other large hospital system in her region does sometimes influence the hospital’s business model. “They keep us sharp and on our toes,” Hess says. But instrument acquisition is more likely to be affected by Adventist Health System, Florida Hospital’s parent organization. “If there is significant buying leverage that we can utilize, then we want to go with something that’s better for the overall organization.”