日韓台の視点から考える臨床検査技師の未来

菊地 良介; 原 祐樹; 安江 智美; 石井 脩平; 濤川 唯; 竹浦 久司

doi:10.14932/jamt.19-73

Abstract

Advancements in science and technology and the considerable development of transportation and communication technologies have ushered an age in which people, along with information, frequently travel across countries, thereby advancing globalization. As a result, medical institutions that do not actively participate in medical tourism have increasing numbers of foreign patients. Therefore, it has become necessary to train individuals so that they will possess international knowledge, language skills, response skills, and research ability, on the premise of possessing specialized knowledge and skills as biomedical laboratory scientists (BLSs). To do so, it is very important to enrich the international exchange activities carried out by organizations, particularly those of the Japanese Association of Medical Technologists (JAMT). With this background, in 2018, the JAMT launched a working group for the internationalization of young BLSs (Young WG) and the improvement of their response skills. The first mission of Young WG was to hold the International Young BLS Forum during the 68th JAMT Congress in May 2019. The aim of this forum was to discuss the future images of BLSs with young BLSs of Japan, Korea and Taiwan. As a discussion theme during this forum, we focused on the use of artificial intelligence (AI) in the medical field for quality control, genomic medicine and telemedicine. Here, we outline our journey from the launching of Young WG to the hosting of the 1st International Young BLS Forum during the 68th JAMT Congress and put together discussions on the use of AI in the medical field for quality control, genomic medicine and telemedicine.

Translated Abstract

技術革新に伴う医療技術の進歩は，グローバル化がますます加速している。街中や病院内において，外国人とのコミュニケーションが必要となる機会は日常的に増えている。その結果，臨床検査技師を取り巻く環境は大きく変化してきている。臨床検査技師の国際化を進める上で大切なことは，語学力と併せて，国際感覚を醸成することが重要である。すなわち，臨床検査技師としての専門的な知識及び技術を有することを前提とした上で，宗教・文化・習慣・教育・感性が国によって異なる中で共存できる能力を有する人材の育成が必要となってきている。このような背景の中で，国際化に対応するためには何が必要かを考えられる若手技師の育成を目的とし，若手技師国際化対応力向上ワーキンググループ（若手WG）が2018年に発足した。若手WGの初めての挑戦は，2019年5月に開催された第68回日本医学検査学会での国際フォーラムを開催することであった。このフォーラムでは，日本，韓国，台湾の若手臨床検査技師が将来の臨床検査技師像について，今後医療分野に普及する人工知能に焦点を当て，精度管理，ゲノム医療，そして遠隔医療を議論テーマとした。そこで今回我々は，若手WGの立ち上げからその取り組みとしてのThe 1st International Young BLS Forumと精度管理，ゲノム医療，遠隔医療についての議論成果について報告する。

I Establishment of the working group for the internationalization of young BLS¹⁾

With the implementation of internationalization in various fields including economics, industry, and culture, coexisting with people and international cooperation are becoming more and more important every day. In fact, there are many opportunities to communicate with foreigners in towns and hospitals, which indicates improvement in that domestic globalization. There is no doubt that practical skills in languages that are spoken globally, including English, is one of the strengths and tools necessary to survive such an environment, that is, a globalized society. It is also important to foster international sensibility. International sensibility is the ability of a person to coexist with other people with different religion, culture, customs, education, and level of sensitivity. In addition to these qualities and abilities, it is necessary to foster an environment that encourages active communication, to properly understand other party’s intentions and thoughts, to provide logical explanations, and to be able to counter or persuade an argument. Possessing international response skills is having the ability to state one’s own opinion properly and be able to respect others in a dramatically competitive and changing society such as a global society. Against this backdrop, in order for young biomedical laboratory scientist (BLS) to accumulate experience to know the world and train them to think what needs to be done to respond in an internationally accepted manner, we launched a working group (Young WG) for the internationalization of young BLS and improvement of their response skills in 2018¹⁾. The founding members of the Young WG consisted of BLS currently undertaking clinical laboratory work, who have had 1) a short-term study in the US, in a program that is co-run by the American Society for Clinical Pathology (ASCP), an organization that is in friendly relations with Japanese Association of Medical Technologists (JAMT), and have had 2) experience studying abroad. The Young WG had nine general members: one in Hokkaido, one in Saitama, one in Tokyo, one in Kanagawa, two in Aichi, one in Osaka, one in Hiroshima, and one in Fukuoka, making a total of nine people in the group.

II Objective(s) of the working group for the internationalization of young BLS

The Young WG has three pillars of objectives. The first pillar: To gather BLS belonging to JAMT who are aged 40 years old or younger and provide them with a venue (forum) to hold discussion, beyond borders, with an eye on improving their international response skills and also looking into the future image of clinical laboratory testing. This forum will provide the opportunity to exchange opinions with foreign countries (such as South Korea and Taiwan) about the issues, improvements, and future image of clinical laboratory testing.

The second pillar: To enable young BLS who participate in the forum to share the experience and knowledge they gained in the forum with other BLS via national conferences and branch conferences, which can help widen the area of activity of this project and aid the internationalization and improvement of response skills of BLS. The third pillar: To present the results of continuous forum activities conducted in South Korea and Taiwan to the Asia Association of Medical Laboratory Scientist (AAMLS). Through these three pillars, we aimed to present the results of activities at the conferences held by the International Federation of Biomedical Laboratory Scientist (IFBLS) and apply these findings in the laboratory.

III Efforts made by the working group for the internationalization of young BLS

The 68th JAMT Congress was held on May 18 and 19, 2019 in Shimonoseki. This congress was an academic meeting to commemorate the 40 years of interaction between the JAMT and the Korean Association of Medical Technologists (KAMT). As a special event in this congress, a forum for improvement of international response skills was hosted by young BLS. Therefore, a forum entitled International Young Biomedical Laboratory Scientist Forum (International Young BLS Forum) was held at this conference as the first stage of the Young WG project. This forum was held jointly by the JAMT, KAMT, and Taiwanese Association of Medical Technologists (TAMT). It involves a 3-hour discussion among BLS (aged < 40 years old) who deal with the current issues and future development of clinical laboratory tests in these three countries. The forum was intended for those to exchange opinions and common issues and differences.

IV The 1st International Young BLS Forum

The following themes were discussed in this forum, which is the first of its kind: 1. Can an artificial intelligence be used for quality control in a clinical laboratory? (Group A); 2. The evolving genomic medicine—the future image of the genomic medicine (Group B); and 3. The future vision of telemedicine for biomedical laboratory scientists (Group C), based on the three viewpoints (precision management, genomic medicine, and telemedicine) regarding artificial intelligence (AI), which is used in medical practice.

A total of 30 participants attended this forum, including 21 individuals recommended by JAMT, KAMT, and TAMT and 9 members of the Young WG (Table 1). The participants were divided into three groups; each group consisted of Young WG members, and each group made preparations and carried out their discussions for the day. At the end of the forum, each group presented the results of their discussion.

Table 1 Participants of the 1st International Young BLS Forum

Group A	JAMT WG Committee Members	Ryosuke Kikuchi
		Naoki Inoue
		Yuki Hara
	JAMT Participants	Mayuko Hirotsu
		Ayako Fujii
		Fumiya Takagi
	KAMT Participants	Kim Sun-Hee
		Nam Hyun-Su
	TAMT Participants	Li Po-Yu
		Chen Wei-An
Group B	JAMT WG Committee Members	Shuhei Ishii
		Go Kobayashi
		Rie Kimura
	JAMT Participants	Shiho Azami
		Miho Yoshida
		Yuka Izuo
	KAMT Participants	Koh Na-Kyung
		Yun Jeong-Hee
	TAMT Participants	Yang Chia-Ju
		Lai Hung-Ming
Group C	JAMT WG Committee Members	Yui Namikawa
		Tomomi Yasue
		Masafumi Yamamoto
	JAMT Participants	Eisuke Ito
		Yuya Onozawa
		Daisuke Ito
	KAMT Participants	Park Dong-Chul
		Moon Hye-Min
	TAMT Participants	Wen Chiao-Ni
		Huang Yen-Lin

Here, we will report on how we, the young WG, made preparations and held the forum, as well as the results we obtained from the three countries within 6 months. With this being the focus of the report, we will state the results from each of the three groups, including the struggles of hosting a forum as well as future challenges and prospects.

V Can AI be used for quality control in a clinical laboratory?²⁾

The quality control team asked the KAMT and TAMT participants the following questions to gain an understanding of the current status of quality control in each country. The questions were related to 1) external quality control, 2) international certification of the clinical laboratory, 3) internal quality control, 4) quality control of the microscope test, and 5) patient’s data. Details about the current status of these five factors in Japan, South Korea, and Taiwan were shared in the forum. Furthermore, the JAMT, KAMT, and TAMT participants created slides to present the current status of quality control in their countries on the day of the forum. The mailing list created by the team and Social Network System were used in the discussion and to contact other countries.

1. Quality control teams’ day at the forum

1) Slide presentation to understand the situation in each country

Each country made 15-minute presentations using the slides that were mentioned previously.

2） Discussion about the uses of AI in quality control

Each country’s problems related to quality control were identified based on the slide presentation. Each country’s problems were raised during the course of the discussion, as shown in Table 2. In addition to problems like “The number of facilities that do not participate in external quality control is not few” and “Variations due to differences between BLS” that are common between countries, there were also problems like “Quality control of physiological tests has not been standardized” and “Physiological examinations are often performed by nurses, and BLS are not sufficiently involved in the quality control of physiological examinations” that are unique to each country. These results also indicated that each country has relatively similar problems related to quality control as in other countries. On the contrary, as the issues that are unique to each country depended on the status of medical care in each country, it would be difficult to address these issues. Next, we classified the problems that were raised into three categories, namely, “Will be resolved,” “Can be resolved,” and “Will not be resolved,” which addresses the question on whether they can be resolved through the use of AI. The classification is presented in Table 3. These results suggested that rather than using AI in performing all tasks, it is necessary for the BLS to continue proposing and acting in ways by which they can coexist with AI. Thereafter, while advancing our discussions, we also created slides for the final presentation.

Table 2 Each country’s problems of quality control

JAPAN
There are still many laboratories that are not participating the EQA programs
The method of EQA for physiology is unclear
EQA samples couldn’t be treated same as patient
It is difficult to make ISO accreditation mandatory
Unclear definition of shifts and trends
Internal Quality depends on control limits
Methods of physiology assurance aren’t standardized
Biases due to interpersonal differences in education and experience
Appropriate systems using patient’s date depend on the budgets and the number of beds in hospital
There is a risk of increasing re-examination and cost (Q5)
Required the introduction cost for the systems using patient’s date
KOREA
In EQA, some of the test items will be further subdivided
In some hospitals, nurse often do physiology examination
Many laboratories are not participate in ISO
Unclear definition of shifts and trends
There are some biases because of personal’s experience
There are not enough time to train or practice
“Check the moving average” is just checking while observing in hematology. Sometimes users are miss to check because the are busy
TAIWAN
There are still many laboratories that are not participating the EQA programs. We should encourage more and more laboratories to get that.
The slight shift of IQC is easy to be ignored
The frequency of interpersonal consistency test is not enough
New employees are not familiar with photo survey, so the senior staffs should pay more attention to new employees and make sure the results are correct
It needs programming skill to design the moving average system, setting data groups, criteria for including (excluding) assay results, calculation algorithm used to calculate average values, control limits that determine out-of-control alarming.

Table 3 There are things AI can do and things AI can’t.

Definitely
AI can solve the IQC problems like slight shift
Maybe (if some problems about AI were resolved)
1. Introduce AI into small hospital
2. Using AI for morphological education
3. Improve EQA in small laboratories
Not solved
Physiology examinations

3) Final presentation

Quality control team’s final presentation was carried out by three individuals, each being a representative nominated from the JAMT, KAMT, and TAMT participants. Japan presented the introduction and the part about each country’s problems related to quality control, which was followed by Taiwan’s explanation about whether AI can help overcome these issues. Finally, South Korea stated the conclusions drawn from the discussions about “How we will operate after AI is introduced to clinical laboratories.” We concluded that introduction of AI to clinical laboratories would help resolve many issues related to quality control, while risk detection, analysis, and evaluation will be handled by AI and that our job would be to establish an environment that allows the use of AI and to respond to the risks identified by AI.

VI Evolving genomic medicine: The future image of genomic medicine³⁾

It is said that the pre-analysis stage is more important than the analysis stage in the process of genomic diagnosis of cancer. For this reason, in order to conduct highly accurate genomic diagnosis, it is necessary for the BLS to be thorough with quality management of samples used for genomic medicine. Furthermore, while it is considered certain that in future AI technology would be introduced to the field of genomic medicine, it remains unclear as to how BLS should respond to this situation. Therefore, in order to understand the current status of sample processing in each country and their thoughts on the use of AI, five questions were listed (Table 4). Moreover, we created slides for the day’s presentation, which included each country’s response to those questions. Prior communication between each country was deepened through the use of the mailing list created within the group as well as the group LINE chat. A day before the forum, the members who could participate gathered to run a simulation of the discussion using the plan-do-check-act (PDCA) cycle.

Table 4 Questions for understand the current status of genomic sample processing in each country

What percentage of formalin solution do you use?

How long is the fixation time?

Are you immediately putting the pathological tissue samples into the fixative?

Who performs the formalin fixation of postoperative specimens?

How do you do quality control in immunohistochemistry?

How do you deal with AI? (Ideal)

1. Genomic medicine teams’ day at the forum

1) Slide presentation to understand the situation in each country

The KAMT, TAMT, and JAMT participants presented for 15 minutes. There were four presenters, two from KAMT and another from TAMT. One participant presented for JAMT. Questions were designed to gain an understanding of the situation in each country; they each had guidelines in place and had been using the recommended 10% neutral buffered formalin to fix tissues. The countries also shared a common understanding about the method of handling genomic samples, such as the fixing time and quality control for immunohistochemistry. As such, we believed that each country performed a thorough quality management in order to provide an accurate genomic diagnosis.

2) Discussion on the use of AI in genomic medicine

Two members from the WG acted as facilitators to advance the discussions. The discussions were held based on the slide presentations from each country, and slides for final presentation were created at the same time. Each country’s plans regarding the use of AI are summarized in Table 5. The active use of deep learning and accumulation of accurate data were raised as similarities between the countries. After consolidating each country’s ideas, we exchanged ideas about the role of BLS. Specific examples that were raised included training the AI, accumulation of accurate genomic data, management of big data, as well as compliance with laws and management of personal information. It is also expected that coexistence of BLS with AI would allow the unification of various tests. We concluded that this would ultimately lead to improvement in the diagnostic accuracy and testing efficiency in genomic medicine and provide patients with a significant merit. Furthermore, JAMT participants suggested that “the treatment time may become shorter if unnecessary tests will be omitted through the use of AI”, while KAMT and TAMT participants mentioned that “the use of AI may help identify not only the diagnosis, but also provide an accurate prognosis”. These would be significant to patients in any case, and all countries recognized jointly that the patient always comes first. However, these discussions also revealed issues such as training of the BLS, used of big data archiving methods, standardization of learning models between facilities, and solving ethical problems.

Table 5 Each country’s plans regarding the use of AI

JAPAN
Using deep learning.
Need to accumulate big data.
Lots of cancers are predictable and preventable from blood samples or smear samples.
Management of the fixation time and immunohistochemistry.
AI detects gene mutation from HE morphology only and leads to treatment immediately.
AI can avoid non-necessary examinations.
KOREA
Using deep learning.
Need to accumulate big data.
AI integrates clinical date and pathological data.
Integrate surgical data, pathological data, Immunohistochemistry data, molecular data and digital pathological data.
Improve the accuracy diagnostic rate in genomic medicine by using AI.
TAIWAN
Monitoring the examination process.
Organizational tissue bank management.
Construction of personal diagnostic data.
Alignment of big health data with appropriate and timely decision.
AI Integrates all genomic medicine studying, pharmacogenetics, racial, life style and medical history, and leads to predictable disease and personalized treatment.

3) Final presentation

In the genomic medicine team, the two JAMT-recommended participants who did not present during the forum attended by participants from three countries gave the final presentation. The audience asked, “what are the problems that arise from introduction of AI?” to which the presenters responded, “problems related to standardization and ethics come to mind.”

VII Future vision of telemedicine for biomedical laboratory scientists⁴⁾

Each member was asked to answer a questionnaire, which consists of items related to the situation of medical care in each country, the involvement of telemedicine in the facilities they work in, as well as the current situation of AI technology. The questionnaire was intended for gaining knowledge about the status and social situation of telemedicine in Japan, South Korea, and Taiwan. In particular, the participants’ opinions regarding the four items (current status of telemedicine and AI, challenges and problems, AI technology, and future vision) were summarized by country and slides were created (hereinafter referred to as “preview slides”).

1. Telemedicine teams’ day at the forum

1) Slide presentation to understand the situation in each country

A single recommended participant from each country presented the preview slides for 15 minutes.

2) Discussion about telemedicine and AI

Taking into consideration what was presented by the preview slides, concerns regarding the similarities and differences in the relationship between telemedicine and AI in each country were raised and discussions about it were held. We also discussed in teams about what technology would be necessary in future and what we should do in these situations, before including them in the slides for the final presentation. The discussions and the preparation of slides took 90 minutes. After presenting the situations in the three countries from the preview slides, the following five points related to telemedicine and AI were raised: ① technology that is already being implemented, ② technology that can be used in the near future, ③ social background, ④ problems, and ⑤ the future vision of telemedicine using AI and the future of our BLS, taking into consideration points ① to ④. Below, we present the discussions on points ① to ⑤.

In the field of AI, the technology used to automatically measure some of the echocardiographic parameters and to analyze blood cells has already been employed. In the field of telemedicine, we have an available “tele-consultation” platform that allows physicians to consult specialists in each field, a telemedicine system for emergency medicine, a system for remote monitoring of patients with chronic heart disease and COPD, and built-in cardiac devices used for remote monitoring. However, all of these tasks require human involvement. With this current situation in mind, sharing of information in the field of emergency medicine using a mobile phone, surgical training using a virtual reality simulator, use of automatic judgment system for severity classification in telepathology, automatic analysis of results of measurements obtained from patient-derived samples, and automatic analysis of algorithm of problems related to quality management, as examples of technology that can be realized in the near future, were raised during the discussion. While some of these issues have already been investigated, others were discussed by the participants of this forum and were all interesting content, regardless of whether they can be realized. We all agreed that such examples would bring significant merit to medicine. However, the progress in such technology is thought to relate closely to the social problems that each country has. As a social background of AI and telemedicine shared by countries, low-birth/aging society and super-aging society, lack of physicians, uneven distribution of medical staff, the excessive use of medical resources, and ineffective management of hospitals were tackled during the discussion. We expect that the use of AI and telemedicine will effectively improve and resolve these problems. Automation of various tasks through use of AI will allow people to focus on tasks that require human involvement and high level of expertise. This means that a small number of staff can be used effectively, which helps resolve the issue on understaffing. This can also help us focus on areas with less medical staffed, which could lead to business expansion. The use of AI will not only benefit BLS, but also all healthcare professionals in general. We agreed that this would help solve the problem related to lack of physicians and uneven distribution of medical staff in the field of telemedicine, leading also to the correction of differences in medical care between different regions. If AI is applied in telemedicine, it will help improve the use of medical resources and hospital management. However, in practice, there remain various problems. Examples of the problems include the need to build a strict security system to protect personal information, the lack of a legal framework that is necessary to use this sort of technology in multiple countries that differ in attitude, and the great likelihood that the devices and facilities that can be used will be limited. Furthermore, the fact that patients prefer to receive medical care through direct face-to-face interaction with physicians might also be one reason why telemedicine using AI and IoT is difficult to implement worldwide. In addition, concerns on whether one can accurately identify who is responsible for a misdiagnosis or medical error in medical care or for performing a non-face-to-face medical treatment using AI remains a big problem that needs to be resolved. Taking these into consideration, we then discussed the future of telemedicine using AI and how we, the BLS, should be involved with it (Table 6). For example, in home-based medical care, it is mainstream for the physicians and nurses to conduct the tests, and BLS are less involved. However, the use of AI and tele-consultation tools in a context requiring expert judgment will probably increase the involvement of BLS. These various technologies would be involved not only in the context of medical care, but also in the process of training medical professionals. As such, it would be ideal for the training courses to provide time for the trainees to learn about medical informatics and AI. By receiving such specialized education, it will also be possible for BLS to participate in projects to implement the latest technology, construct plans, and execute them with various experts. It would also be useful to establish qualifications related to AI and information security to produce human resources that excel in medical informatics analysis even after obtaining their BLS license. In future, it would be important for BLS to gain expert knowledge not only in medicine but also in information security and AI, collaborate with experts in engineering and systems, and be part of the team involved in developing healthcare applications and various software. Through these discussions, we ultimately selected two keywords to determine the relationship between the development of telemedicine using AI and BLS. The first keyword is the “Fusion of BLS with AI” and the second is “Teamwork.” It is not only important for BLS to use AI in testing work, but to also gain expert knowledge on information security and system development, so as to fuse and coexist with AI. In addition, we believe that possibilities for BLS will expand through actions that exceed the traditional framework of actions for BLS and joining forces with staff and teams from various fields of expertise. We created slides by summarizing the above contents and carried out the final presentations.

Table 6 How will BLS work as a professional?

BLS accompanies nurses and doctors on the field of home medical care and conducts the examination (Try to assemble or join a multidisciplinary team)

Professional judgment will be supported by AI and telemedicine

Continued learning of medical laboratory informaticsand the latest progress of AI

Join and plan a roadmap to modernize the newest technical capabilities (automation, digitalization, etc.) to set the stage for new technologies implementation

To acquire license to analyze medical information for BLS

To develop healthcare app or software operation

3) Final presentation

One representative from JAMT, KAMT, and TAMT, conducted the final presentation. They began by introducing the telemedicine and AI technologies that are currently being used as well as the technology that can be used in the near future. They then mentioned the social situation in each country (low-birth/aging society, lack of physicians, etc.) that had to be taken into consideration, before stating the problems that we counter as we seek to use AI in the field of telemedicine. The presenters stated the future outlook on “how BLS should be involved,” while also listening to the opinion of forum participants.

VIII Conclusion

Here, we outlined that our journey from the launch of Young WG to the hosting of the 1st international young BLS Forum at the 68th JAMT Congress, and that use of AI in the medical field for the discussions in quality control, genomic medicine and telemedicine. The international young BLS Forum was held jointly by JAMT, KAMT, and TAMT at the 68th JAMT Congress. As this was our first attempt to host such a forum, we were unsure on how to develop the proceedings. However, the participants maintained a proactive attitude as young people and engaged in active discussions throughout the forum. Although few, there were some situations where we felt frustrated from not being able to express our opinions clearly or understand what the other party was saying. Despite this, the participants showed tenacious attitude to try and convey their opinions to one another. We think that this opportunity to discuss the future role of BLS with other country’s BLS while remaining respect to each other and without being restricted by borders was a great asset to the young BLS from collaborate with the three countries. We are convinced that this forum has been a good opportunity for young BLS to engage in internationalization activities in the future.

We found that there are many common social elements in our three countries through discussion. Moreover, we considered the use of AI in the quality control, genomic medicine and telemedicine field as an indispensable resource for solving our current problems. However, many issues remain to be solved, such as the development of security and legal systems, and the definition of responsibility for medical errors caused by AI. Therefore, we agreed that it is desirable to acquire the knowledge necessary for information security and AI in the educational curriculum of BLSs. In near future, we believe that coexistence with AI and teaming up with experts outside the medical field will produce benefits for patients and medical staff, and further expand the possibility of BLSs.

Conflict of Interest

There is no potential conflict of interest to disclose.

Acknowledgments

We would like to special thank Naoki Inoue, Go Kobayashi, Rie Kimura, and Masafumi Yamamoto for their activities in the young WG and their contributions to this forum. We also would like to thank Makiko Utsumi, Tomoyuki Kato and Sunghyun Lee for their management and contributions to this forum. Moreover, we would like to express our appreciation to all the participants for taking time out of your busy duties to attend the forum, and to all of your organizations, including JAMT, KAMT and TAMT for sending excellent participants to this forum.

References

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