Journal:Laboratory information system – Where are we today?

Full article title	Laboratory information system – Where are we today?
Journal	Journal of Medical Biochemistry
Author(s)	Lukić, Vera
Author affiliation(s)	Railway Healthcare Institute (Belgrade, Serbia)
Primary contact	Email: veralukic dot lab at gmail com
Year published	2017
Volume and issue	36 (3)
Page(s)	220–224
DOI	10.1515/jomb-2017-0021
ISSN	1452-8266
Distribution license	Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported
Website	https://www.degruyter.com/view/j/jomb.2017.36.issue-3/jomb-2017-0021/jomb-2017-0021.xml
Download	https://www.degruyter.com/downloadpdf/j/jomb.2017.36.issue-3/jomb-2017-0021/jomb-2017-0021.xml (PDF)

Wider implementation of laboratory information systems (LIS) in clinical laboratories in Serbia has been initiated ten years ago. The first LIS in the Railway Health Care Institute has been implemented nine years ago. Before the LIS was initiated, manual admission procedures limited daily output of patients. Moreover, manual entering of patients data and ordering tests on analyzers was problematic and time consuming. After completing tests, laboratory personnel had to write results in patient register (with potential errors) and provide invoices for health insurance organisation. First LIS brought forward some advantages with regards to these obstacles, but it also showed various weaknesses. These can be summarised in rigidity of system and inability to fulfil user expectation. After 4 years of use, we replaced this system with another LIS. Hence, the main aim of this paper is to evaluate advantages of using LIS in laboratory of the Railway Health Care Institute and also to discuss further possibilities for its application. After implementing LIS, admission procedure has proven to be much faster. LIS enabled electronic requests, barcoded specimens prevent identification errors, bidirectional interface replaces redundant data entry steps, QC data are transferred automatically, results are electronically validated and automatically archived in data base, billing information is transferred electronically, and more. We also use some advanced options, like delta check, HIL feature, quality indicators and various types of reports. All steps in total testing process are drastically improved after the implementation of LIS, which had a positive impact on the quality of issued laboratory results. However, we expect development of some new features in the future, for example auto-verification and inventory management. On the example of the laboratory of the Railway Health Care Institute, we show that it is crucial that laboratory specialists have the main role in defining desirable characteristics of LIS which institution aims to buy. This paper suggests that the main feature of LIS should be the flexibility of system and capability of adjustment to user needs and requests.

Keywords: laboratory information system, flexibility, advanced options

Background

Laboratory information system is a software which receives, processes and stores information generated by the laboratory workflow. It automates the workflow of all information related to total testing process. Wider implementation of LIS in Serbia has gained momentum in last ten years. It is expected that LIS facilitates communication between laboratory and clinicians and enables faster delivery of patient reports. The main aim of this paper is to evaluate advantages which the laboratory of the Railway Health Care Institute experienced with the implementation of LIS, as well as to point out at some advanced options and possible further use of its features.

Workflow before LIS

In last few decades medical laboratories have experienced dramatic transformation, due to automation and development of information technology. This transformation can be presented on the example of the laboratory department in the Railway Health Care Institute. In the early 2000s, the Institute purchased high capacity automated analyzers for hematology, clinical chemistry and immunochemistry. This represented a huge breakthrough at the time. However, from today’s point of view, there were significant imperfections and slowdowns in the working process. Here we point out at some tasks which wasted most of our time. In spite of high quality laboratory equipment, there were still too many manual procedures. Registration of patients was slow due to admission desk procedures which required hand writing of all patient data, as well as writing receipts for paid analyses. Admission desk represented a ‘bottleneck’ which limited daily number of patients, in spite of huge throughput capabilities of analyzers. Following that, all ordered tests were locally entered on analyzers. Thus, after obtaining results, patient reports were printed from each analyzer on individual slips of paper where different papers were attached in order to produce a final report for patient. This form of report was visually unacceptable and rather difficult to read due to different fonts and formats. After that, all results were rewritten by hand in paper protocols for permanent storage. At the afternoon shift, staff again went through all data and made invoices for health insurance organization. Tubes were manually marked with IDs, as well as sample cups, and samples were aliquoted from tubes to cups. These actions represented a weak point for identification error, caused by personnel fatigue or lack of concentration. The results were then reviewed by clinical chemistry specialist in printed form, without access to previous results. Progressively, we have recognized an emerging need for implementation of laboratory information system in our everyday practice.

Implementation of LIS

First LIS was installed in our laboratory in 2008. It brought some advantages in terms of accelerations of admission procedures, but it did not fulfil our expectations. In the meantime, the laboratory purchased the last generation of analyzers, which caused additional inadequacy with LIS: it did not follow analyzers’ possibilities and did not allow them to achieve their maximal performance. Moreover, LIS did not have capability to adjust to user needs. Its rigidity did not allow for further improvements, and it began to impede the efficiency of the laboratory. That made us aware that we had to acquire new LIS.

Replacing existing LIS with new one

Although literature data implies that laboratories change their LIS only every 10 to 20 years because it is an enormous undertaking, the laboratory of the Railway Health Care Institute had to do that only 4 years after the first installation. We defined clear list of requirements for the new LIS in order to avoid previously experienced obstacles. Our requirements were specific about each desired feature and function for each step of total testing process, from preanalytical to postanalytical phase. The following was crucial when choosing the appropriate LIS: laboratory specialists had to be deeply involved in the selection process, and particularly in direct discussion of each and single feature of LIS with vendor, or, even better, with software developer. In summer 2012, simultaneously with integration of clinical chemistry and immunochemistry module, the installation of new LIS was completed. Here we present some of the benefits of using the new LIS.

Firstly, the interface with hospital information system (HIS) enables use of electronic test request and eliminates paper request form, which drastically accelerated admission desk procedures. Electronic request enabled the quality of communication between laboratory and clinicians. Moreover, LIS performs automated printing of receipts and bills for analyses which patients pay at admission desk. Printing of patient’s informed consent for venipuncture is also automated. By entering patient’s information and test orders in LIS, system generates electronic invoice for health insurance organization, without any further need for additional actions of admission personnel. Complete electronic register of patients is printed at the end of the day, so that personnel is not required to manually write paper register in order to be in accordance with legislative.

All samples are signed with barcode labels, so we use primary tubes for test analyses. Additionally we ended the time consuming and error prone sample aliquoting to sample cups. Operators on laboratory analyzers are now fully concentrated on analytical phase, because local test ordering on analyzers is replaced by automated order transfer from LIS. Moreover, LIS has bidirectional interface with all analyzers, so there is no need for entering orders into analyzers manually, nor retyping results from analyzer into LIS. After tests completion, results are transmitted to LIS and available to biochemist for review and verification. For few analyses which have to be manually performed (urine sediment, FOBT), manual test result entry is facilitated by configured drop-down lists with offered values for each parameter. This makes a result input much faster and also prevents typing errors which were very frequent in previous LIS, and a reason for recall of reports during review.

Verification screen offers plenty of data. On the top of the screen there are demographic data about patient and his/her diagnosis. Then there is current report with highlighted results which fall outside of the reference range. When cursor is positioned on any measured parameter, three previous results for that parameter are displayed at the bottom of the screen. With simple button press, we can see all results for that parameter from all previous reports for that patient, which can be displayed numerically but also graphically. User can define delta check rules and there will be a pop-up window warning if the rules are violated. Also, we have configured critical values for some tests. If critical value is obtained for some patient, there will be red color alarm in LIS, which is visible to all logged users regardless of the part of the program they are currently using. System enables entering time of communication of critical value to the doctor, monitors turnaround time (TAT) and stores reports about all communicated critical values. In printed form, critical value is also specially marked. During verification, clinical chemistry specialist can also see results of quality control for each parameter.

Just as in patient results, all values of quality control are automatically transmitted to LIS, as QC files. Transfer of control values does not need any additional operator action, for example ordering in LIS or manual input of obtained values. LIS calculates running mean and standard deviation, and generates Levey-Jennings graph which can be seen from verification screen. Also, on verification screen we can see all values of repeated measurements, and we can choose which of them will be reported. On this screen we can also make comments for doctor or patient. These comments may be configured as typical, which occur frequently, but they can be also typed in a free form text. Moreover, we can make some technical comments which are visible just for laboratory personnel. After the validation is completed, reports are ready for printing or e-mailing. Also, validated results are automatically sent to electronic health record and are immediately available for the doctor.

Notes

This presentation is faithful to the original, with only a few minor changes to presentation, including the addition of PMCID and DOI when they were missing from the original reference. No other modifications were made in accordance with the "no derivatives" portion of the distribution license.