Designing and Validating Autoverification Rules for Hematology Analysis in Sysmex XN-9000 Hematology System

BACKGROUND

Hematology analysis is a common test among patients in hospital. However, manual verification of hematology analysis is time consuming and tedious, with variation between inter-individual laboratory workers. This study was to establish and validate a set of autoverification rules for hematology analysis in the department of laboratory medicine, Zhongshan Hospital of Sun Yatsen University.

METHODS

Hematology analysis was measured by a Sysmex XN-9000 hematology system in the Department of Laboratory Medicine, Zhongshan Hospital of Sun Yatsen University. SYSMEX Laboman EasyAccess 6.0 and the laboratory information system were used to construct the algorithm and design the autoverification rules of hematology analysis according to Clinical and Laboratory Standards Institute document Auto 10A and 41 rules of Hematology Review Criteria. The laboratory turnaround time (TAT), autoverification pass rates, false positive, false negative, and the average error rate were verified after implementing autoverification rules.

RESULTS

Approximate 1,300 specimens were collected daily and transferred to our laboratory for hematology analysis; that is necessary to build a database and to design autoverification rules. The average autoverification passing rate was 81%; the false positive rate was 13.6%; the false negative rate and the average error rate was nearly zero, indicating that incorrect reports were almost eliminated. Moreover, since implementing autoverification, the TAT was reduced by 27.0% in in-patient reports, by 21.9% in out-patient reports, and by 39.0% in emergency reports, which enhanced the productivity in our laboratory.

CONCLUSIONS

Our laboratory accelerated verification and decreased TAT and the odds of human review errors in the released results since implementing the autoverification. Thus, we can save more time and concentrate on verifying the abnormal results and processing emergency tests.

Routine Health Information System (RHIS) improvements for strengthened health system management

BACKGROUND

A well-functioning routine health information system (RHIS) can provide the information needed for health system management, for governance, accountability, planning, policy making, surveillance and quality improvement, but poor information support has been identified as a major obstacle for improving health system management.

OBJECTIVES

To assess the effects of interventions to improve routine health information systems in terms of RHIS performance, and also, in terms of improved health system management performance, and improved patient and population health outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE Ovid and Embase Ovid in May 2019. We searched Global Health, Ovid and PsycInfo in April 2016. In January 2020 we searched for grey literature in the Grey Literature Report and in OpenGrey, and for ongoing trials using the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. In October 2019 we also did a cited reference search using Web of Science, and a 'similar articles' search in PubMed.

SELECTION CRITERIA

Randomised and non-randomised trials, controlled before-after studies and time-series studies comparing routine health information system interventions, with controls, in primary, hospital or community health care settings. Participants included clinical staff and management, district management and community health workers using routine information systems.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed records to identify studies for inclusion, extracted data from the included studies and assessed the risk of bias. Interventions and outcomes were too varied across studies to allow for pooled risk analysis. We present a 'Summary of findings' table for each intervention comparisons broadly categorised into Technical and Organisational (or a combination), and report outcomes on data quality and service quality. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included six studies: four cluster randomised trials and two controlled before-after studies, from Africa and South America. Three studies evaluated technical interventions, one study evaluated an organisational intervention, and two studies evaluated a combination of technical and organisational interventions. Four studies reported on data quality and six studies reported on service quality. In terms of data quality, a web-based electronic TB laboratory information system probably reduces the length of time to reporting of TB test results, and probably reduces the overall rate of recording errors of TB test results, compared to a paper-based system (moderate certainty evidence). We are uncertain about the effect of the electronic laboratory information system on the recording rate of serious (misidentification) errors for TB test results compared to a paper-based system (very low certainty evidence). Misidentification errors are inaccuracies in transferring test results between an electronic register and patients' clinical charts. We are also uncertain about the effect of the intervention on service quality (timeliness of starting or changing a patient's TB treatment) (very low certainty evidence). A hand-held electronic device probably improves the length of time to report TB test results, and probably reduces the total frequency of recording errors in TB test results between the laboratory notebook and the electronic information record system, compared to a paper-based system (moderate-certainty evidence). We are, however, uncertain about the effect of the intervention on the frequency of serious (misidentification) errors in recording between the laboratory notebook and the electronic information record, compared to a paper-based system (very low certainty evidence). We are uncertain about the effect of a hospital electronic health information system on service quality (length of time outpatients spend at hospital, length of hospital stay, and hospital revenue collection), compared to a paper-based system (very low certainty evidence). High-intensity brief text messaging (SMS) may make little or no difference to data quality (in terms of completeness of documentation of pregnancy outcomes), compared to low-intensity brief text messaging (low-certainty evidence). We are uncertain about the effect of electronic drug stock notification (with either data management support or product transfer support) on service quality (in terms of transporting stock and stock levels), compared to paper-based stock notification (very low certainty evidence). We are uncertain about the effect of health information strengthening (where it is part of comprehensive service quality improvement intervention) on service quality (health worker motivation, receipt of training by health workers, health information index scores, quality of clinical observation of children and adults) (very low certainty evidence).

AUTHORS' CONCLUSIONS

The review indicates mixed effects of mainly technical interventions to improve data quality, with gaps in evidence on interventions aimed at enhancing data-informed health system management. There is a gap in interventions studying information support beyond clinical management, such as for human resources, finances, drug supply and governance. We need to have a better understanding of the causal mechanisms by which information support may affect change in management decision-making, to inform robust intervention design and evaluation methods.

Communication of Critical Laboratory Values: Optimization of the Process through Secure Messaging

BACKGROUND

Timely communication of critical laboratory results is important yet cumbersome.

OBJECTIVE

To assess the impact of a new technology on the process of reporting critical laboratory results at our 480-bed, adult/children, tertiary-care, medical school-affiliated health center in the southeastern region of the United States.

METHODS

We changed the process of reporting critical values by telephone only to reporting via telephone and a secure messaging app. Physician order entry, an online on-call roster for availability, and support from the C-suite (executive branch of the organization) were instrumental in implementation.

RESULTS

Consistently, before our process changes, more than 95% of the critical laboratory results were reported in less than 30 minutes. Use of the app reduced the time taken for reporting results. The need to involve pathology residents and attending physicians in reporting has been eliminated by this process.

DISCUSSION

Secure messaging has facilitated the reporting of critical laboratory values, making it more efficient and providing a reliable record of the process. This process meets or exceeds the standards of the accrediting agencies. The method is suitable for activating rapid-response teams in case of hypercritical values.

Establishing and Evaluating Autoverification Rules with Intelligent Guidelines for Arterial Blood Gas Analysis in a Clinical Laboratory

Arterial blood gas (ABG) analysis is important for acutely ill patients and should be performed by qualified laboratorians. The existing manual verifications are tedious, time-consuming, and prone to send wrong reports. Autoverification uses computer-based rules to verify clinical laboratory test results without manual review. To date, no data are available on the use of autoverification for ABG analysis. All autoverification rules were established according to AUTO10-A. Additionally, the rules were established using retrospective patient data, and then validated by actual clinical samples in a "live" environment before go-live. The average autoverification passing rate was 75.5%. The turnaround time (TAT) was reduced by 33.3% (27 min vs 18 min). Moreover, the error rate fell to 0.05% after implementation. Statistical analysis resulted in a kappa statistic of 0.92 ( p < 0.01), indicating close agreement between autoverification and senior technician verification, and the chi-square value was 22.4 ( p < 0.01), indicating that the autoverification error rate was lower than the manual verification error rate. Results showed that implementing autoverification rules with intelligent guidelines for ABG analysis of patients with critical illnesses could decrease the number of samples requiring manual verification, reduce TAT, and eliminate errors, allowing laboratorians to concentrate more time on abnormal samples, patient care, and collaboration with physicians.

Patient identification: hybrids and doppelgängers

Safe laboratory practice requires accurate patient identification. Adverse events may occur when a patient has identifiers similar or identical to those of another patient (a ' doppelgänger'), is doubly registered (a 'duplicate registration'), or when registration details are derived from two or more separate sources (a 'hybrid registration'). Distinguishing doppelgängers from duplicate registrations is not always easy. A search of the Harefield Hospital Patient Administration System (PAS) database revealed 39 registrations that shared a forename, surname and date of birth with at least one other registration. Thirty-seven of these cases involved a duplicate registration, one involved a hybrid registration, and one involved a doppelgänger. The National Strategic Tracing Service can help with resolution of difficult cases. Many serious patient identification errors involve what the Serious Hazards of Transfusion (SHOT) Report refers to as 'extraordinary' coincidences of patients with similar names. Such coincidences are, in fact, not extraordinary, but ordinary. A major challenge will be to establish how adverse events involving coincidence can be described in a way that does not create the impression of extraordinary bad luck.

[Good Practice of Clinical Physiology Examination for Patient Safety with a Team-Based Approach: Quality Practice in Ultrasonographic Examination]

For the safety of patient care, a team-based approach has been advocated as an effective measure. In clinical physiology examination, we have been making efforts to promote good practice for patient safety based on such an approach in Tokai University Hospital, as represented by quality practice in ultrasonographic examination. The entire process of ultrasonographic examination can be divided into three parts: pre-examination, examination, and post-examination processes. In each process of the examination, specific quality issues must be considered, eventually ensuring the quality and safety of patient care. A laboratory physician is responsible for not only quality assurance of examination, diagnosis, and reporting, but also patient safety. A laboratory physician can play a key role in all aspects of patient safety related to each process of the examination by taking a leadership role in the team-based approach.

[Development and Current Status of Quality Management Systems for Specimen Examination]

ISO 15189:2003 was published as an International Standard in 2003 by Technical Committee ISO/TC212 of the International Organization for Standardization (ISO). This international standard based on ISO 9001 specifies requirements for competence and quality that are specific to medical laboratories. With the publication of this standard, we will have to markedly change our concept. We have to adopt methods to manage the causes of errors in measurement processes rather than methods to manage only the results of measurements. The new concept of the Quality Management System (QMS) which manages the result of measurements is summarized. With the publication of ISO 15189, the definition of the quality assurance of examination results became clearer and stricter. This report describes the contents of ISO 15189 and the method of enforcing it.

[The JLAC Coding System for Clinical Laboratory Tests]

Clinical laboratory data are essential for the diagnosis of and therapy for patients in hospital. In addition to such direct clinical use in hospitals, the collected personal clinical laboratory data have been recognized as very important for the life-long health care of individual patients. Furthermore, the data derived from a large number of patients are utilized for epidemiological studies and safety evaluation of new drugs. For the above-mentioned secondary use, laboratory data which are obtained at different times and in different facilities must be comparable. Recently, a huge amount of medical information has been accumulated and utilized as "big data" for the development of national healthcare and life science industries. Under these circumstances, the JLAC, a coding system of laboratory tests developed and maintained by JSLM, is attracting increasing attention for the spatial and temporal comparison of laboratory test data.

Quality indicators from laboratory and radiology information systems

Consequences of the computerization of laboratory and radiology information system (LIS and RIS) are not well documented. The aim of this study was to evaluate the impact of computerization of LIS and RIS of four hospitals on performance and quality of care. The study was divided into three phases. First, the subprocesses and information flows of LIS and RIS were described. Then, a literature review was performed in order to identify the indicators used to assess the impact of computerization. Finally, comparisons were made between 2 hospitals. Using the initial framework, each partner described its process mapping concerning LIS and RIS. The review identified a wide panel of indicators. Only 41 were useful to assess the impact of information systems. For each two by two comparison, lists of relevant indicators have been selected from the identified indicators and according to the process mapping comparison. Two by two comparisons have to be completed. Eventually, these indicators may be integrated in the quality process of hospital information systems.

Improving integrated care in chronic kidney failure patients with a standard-based interoperability framework

This paper introduces the evaluation report after fostering a Standard-based Interoperability Framework (SIF) between the Virgen del Rocío University Hospital (VRUH) Haemodialysis (HD) Unit and 5 outsourced HD centres in order to improve integrated care by automatically sharing patients' Electronic Health Record (EHR) and lab test reports. A pre-post study was conducted during fourteen months. The number of lab test reports of both emergency and routine nature regarding to 379 outpatients was computed before and after the integration of the SIF. Before fostering SIF, 19.38 lab tests per patient were shared between VRUH and HD centres, 5.52 of them were of emergency nature while 13.85 were routine. After integrating SIF, 17.98 lab tests per patient were shared, 3.82 of them were of emergency nature while 14.16 were routine. The inclusion of a SIF in the HD Integrated Care Process has led to an average reduction of 1.39 (p=0.775) lab test requests per patient, including a reduction of 1.70 (p=0.084) in those of emergency nature, whereas an increase of 0.31 (p=0.062) was observed in routine lab tests. Fostering this strategy has led to the reduction in emergency lab test requests, which implies a potential improvement of the integrated care.

Electronic health information quality challenges and interventions to improve public health surveillance data and practice

OBJECTIVE

We examined completeness, an attribute of data quality, in the context of electronic laboratory reporting (ELR) of notifiable disease information to public health agencies.

METHODS

We extracted more than seven million ELR messages from multiple clinical information systems in two states. We calculated and compared the completeness of various data fields within the messages that were identified to be important to public health reporting processes. We compared unaltered, original messages from source systems with similar messages from another state as well as messages enriched by a health information exchange (HIE). Our analysis focused on calculating completeness (i.e., the number of nonmissing values) for fields deemed important for inclusion in notifiable disease case reports.

RESULTS

The completeness of data fields for laboratory transactions varied across clinical information systems and jurisdictions. Fields identifying the patient and test results were usually complete (97%-100%). Fields containing patient demographics, patient contact information, and provider contact information were suboptimal (6%-89%). Transactions enhanced by the HIE were found to be more complete (increases ranged from 2% to 25%) than the original messages.

CONCLUSION

ELR data from clinical information systems can be of suboptimal quality. Public health monitoring of data sources and augmentation of ELR message content using HIE services can improve data quality.

Measuring the impact of a health information exchange intervention on provider-based notifiable disease reporting using mixed methods: a study protocol

BACKGROUND

Health information exchange (HIE) is the electronic sharing of data and information between clinical care and public health entities. Previous research has shown that using HIE to electronically report laboratory results to public health can improve surveillance practice, yet there has been little utilization of HIE for improving provider-based disease reporting. This article describes a study protocol that uses mixed methods to evaluate an intervention to electronically pre-populate provider-based notifiable disease case reporting forms with clinical, laboratory and patient data available through an operational HIE. The evaluation seeks to: (1) identify barriers and facilitators to implementation, adoption and utilization of the intervention; (2) measure impacts on workflow, provider awareness, and end-user satisfaction; and (3) describe the contextual factors that impact the effectiveness of the intervention within heterogeneous clinical settings and the HIE.

METHODS/DESIGN

The intervention will be implemented over a staggered schedule in one of the largest and oldest HIE infrastructures in the U.S., the Indiana Network for Patient Care. Evaluation will be conducted utilizing a concurrent design mixed methods framework in which qualitative methods are embedded within the quantitative methods. Quantitative data will include reporting rates, timeliness and burden and report completeness and accuracy, analyzed using interrupted time-series and other pre-post comparisons. Qualitative data regarding pre-post provider perceptions of report completeness, accuracy, and timeliness, reporting burden, data quality, benefits, utility, adoption, utilization and impact on reporting workflow will be collected using semi-structured interviews and open-ended survey items. Data will be triangulated to find convergence or agreement by cross-validating results to produce a contextualized portrayal of the facilitators and barriers to implementation and use of the intervention.

DISCUSSION

By applying mixed research methods and measuring context, facilitators and barriers, and individual, organizational and data quality factors that may impact adoption and utilization of the intervention, we will document whether and how the intervention streamlines provider-based manual reporting workflows, lowers barriers to reporting, increases data completeness, improves reporting timeliness and captures a greater portion of communicable disease burden in the community.

[The external evaluation of study quality: the role in maintaining the reliability of laboratory information]

The external evaluation of quality of clinical laboratory examinations was gradually introduced in USSR medical laboratories since 1970s. In Russia, in the middle of 1990 a unified all-national system of external evaluation quality was organized known as the Federal center of external evaluation of quality at the basis of laboratory of the state research center of preventive medicine. The main positions of policy in this area were neatly formulated in the guidance documents of ministry of Health. Nowadays, the center of external evaluation of quality proposes 100 and more types of control studies and permanently extends their specter starting from interests of different disciplines of clinical medicine. The consistent participation of laboratories in the cycles of external evaluation of quality intrinsically promotes improvement of indicators of properness and precision of analysis results and increases reliability of laboratory information. However, a significant percentage of laboratories does not participate at all in external evaluation of quality or takes part in control process irregularly and in limited number of tests. The managers of a number of medical organizations disregard the application of the proposed possibilities to increase reliability of laboratory information and limit financing of studies in the field of quality control. The article proposes to adopt the national standard on the basis of ISO 17043 "Evaluation of compliance. The common requirements of professional competence testing".

Building a personalized medicine infrastructure at a major cancer center

Our understanding of cancer biology is rapidly increasing, as is the availability and affordability of high throughput technologies for comprehensive molecular characterization of tumors and the individual's own genetic makeup. Thus, the time is right to implement personalized molecular medicine for all patients with cancer. Personalized approaches span the full cancer care spectrum from risk stratification to prevention, screening, therapy, and survivorship programs. Several molecular therapeutics have entered clinical trials creating a huge opportunity to couple genomic markers with this emerging drug tool kit. The number of patients managed in major cancer centers creates a challenge to the implementation of genomic technologies required to successfully deliver on the promise of personalized cancer care. This requires a major investment in infrastructure to facilitate rapid deployment of multiplex, cost-effective, and tissue-sparing assays relevant across multiple tumor lineages in the Clinical Laboratory Improvement Amendments (CLIA) environment. Efforts must be made to ensure that assays are accessible to patients most likely to be enrolled onto molecular-marker-driven trials and that the tests are billable and payable, which will make them accessible to a wide range of patients. As the number of patients and aberrations increase, it will become critical to provide decision support for genomic medicine. Institutional commitment is needed to optimize accessibility and quality of research biopsies and to facilitate novel personalized cancer therapy trials. This article will focus on the challenges and opportunities that accompany the building of infrastructure for personalized cancer therapy.

Quality assurance of LOINC mapping for laboratory tests - a local experience with people, process and technology

In Hong Kong Hospital Authority (HA), the Electronic Patient Record (ePR) module of Clinical Management System, implemented since 2003, bring together all the information from various clinical module and hospitals into a single corporate wide, longitudinal, integrated record. Nowadays there are billions of laboratory test results stored in the web-based ePR where laboratory results being shared with the HA clinicians for patient care. In order to produce interoperable laboratory data in the ePR, the HA adopts LOINC (Logical Observation Identifiers Names and Codes) as the reference standard for laboratory tests. Every local test codes have been mapped with LOINC code where possible. Thus, the accuracy of LOINC mapping for laboratory tests in the HA is imperative. This paper describes a quality assurance program of LOINC mapping for laboratory tests conducted in 2011/12. With the use of right people, right process and right technology, we reviewed over 28,000 local test codes and there are around 2,400 distinct LOINC concepts mapped and defined in the system.

Impact of selective mapping strategies on automated laboratory result notification to public health authorities

Automated electronic laboratory reporting (ELR) for public health has many potential advantages, but requires mapping local laboratory test codes to a standard vocabulary such as LOINC. Mapping only the most frequently reported tests provides one way to prioritize the effort and mitigate the resource burden. We evaluated the implications of selective mapping on ELR for public health by comparing reportable conditions from an operational ELR system with the codes in the LOINC Top 2000. Laboratory result codes in the LOINC Top 2000 accounted for 65.3% of the reportable condition volume. However, by also including the 129 most frequent LOINC codes that identified reportable conditions in our system but were not present in the LOINC Top 2000, this set would cover 98% of the reportable condition volume. Our study highlights the ways that our approach to implementing vocabulary standards impacts secondary data uses such as public health reporting.

Assessing inpatient glycemic control: what are the next steps?

Despite the emergence of glucometrics (i.e., systematic analysis of data on blood glucose levels of inpatients) as a subject of high interest, there remains a lack of standardization on how glucose parameters are measured and reported. This dilemma must be resolved before a national benchmarking process can be developed that will allow institutions to track and compare inpatient glucose control performance against established guidelines and that can also be supported by quality care organizations. In this article, we review some of the questions that need to be resolved through consensus and review of the evidence, and discuss some of the limitations in analyzing and reporting inpatient glucose data that must be addressed (or at least accepted as limitations) before hospitals can commit resources to gathering, compiling, and presenting inpatient glucose statistics as a health care quality measure. Standards must include consensus on which measures to report, the unit of analysis, definitions of targets for hyperglycemia treatment, a definition of hypoglycemia, determination of how data should be gathered (from chart review or from laboratory information systems), and which type of sample (blood or point of care) should be used for analysis of glycemic control. Hospitals and/or their representatives should be included in the discussion. For inpatient glucose control to remain a focus of interest, further dialogue and consensus on the topic are needed.

Laboratory information management systems for DNA barcoding

In the field of molecular biology, laboratory information management systems (LIMSs) have been created to track workflows through a process pipeline. For the purposes of DNA barcoding, this workflow involves tracking tissues through extraction, PCR, cycle sequencing, and consensus assembly. Importantly, a LIMS that serves the DNA barcoding community must link required elements for public submissions (e.g., primers, trace files) that are generated in the molecular lab with specimen metadata. Here, we demonstrate an example workflow of a specimen's entry into the LIMS database to the publishing of the specimen's genetic data to a public database using Geneious bioinformatics software. Throughout the process, the connections between steps in the workflow are maintained to facilitate post-processing annotation, structured reporting, and fully transparent edits to reduce subjectivity and increase repeatability.

The role of 2D bar code and electronic cross-matching in the reduction of misidentification errors in a pathology laboratory. A safety system assisted by the use of information technology

INTRODUCTION

Mismatching of patients and specimens can lead to incorrect histopathological diagnoses. Most misidentification errors in laboratories occur during the manual pre-laboratory and laboratory phases. In the past few years, we have examined this vital and challenging issue in our unit and introduced appropriate procedures. Recently, we have paid special attention to the problem of specimen mix-ups in the gross examination phase and the mismatching of blocks and slides in the cutting phase.

OBJECTIVE

We have focused on the reduction of the potential sources of mismatching of specimen containers, tissue blocks and slides, focusing in particular on the most critical steps which are gross cutting and preparation of microtome sections.

DESIGN

A 2D bar code directly printed on the labels of specimen containers, and directly printed onto cassettes and slides, is now being used; in addition, the system performs an electronic cross-check of tissue blocks and slides, which is managed by the laboratory information system.

RESULTS

The present system permits full sample traceability from the moment samples reach the laboratory to the issuing of the final report. Indeed, the LIS records samples, blocks and slides in real time throughout the entire procedure, as well as the operator's name, and the date and time each individual procedure is done. This facilitates later monitoring of the entire workflow.

CONCLUSIONS

The introduction of 2D bar code and electronic cross-checking represents a crucial step in significantly increasing the safe management of cases and improving the quality of the entire work process.

Implementation of a platform dedicated to the biomedical analysis terminologies management

BACKGROUND AND OBJECTIVES

Assistance Publique - Hôpitaux de Paris (AP-HP) is implementing a new laboratory management system (LMS) common to the 12 hospital groups. First step to this process was to acquire a biological analysis dictionary. This dictionary is interfaced with the international nomenclature LOINC, and has been developed in collaboration with experts from all biological disciplines. In this paper we describe in three steps (modeling, data migration and integration/verification) the implementation of a platform for publishing and maintaining the AP-HP laboratory data dictionary (AnaBio).

MATERIAL AND METHODS

Due to data complexity and volume, setting up a platform dedicated to the terminology management was a key requirement. This is an enhancement tackling identified weaknesses of previous spreadsheet tool. Our core model allows interoperability regarding data exchange standards and dictionary evolution.

RESULTS

We completed our goals within one year. In addition, structuring data representation has lead to a significant data quality improvement (impacting more than 10% of data). The platform is active in the 21 hospitals of the institution spread into 165 laboratories.

Electronic laboratory data quality and the value of a health information exchange to support public health reporting processes

There is increasing interest in leveraging electronic health data across disparate sources for a variety of uses. A fallacy often held by data consumers is that clinical data quality is homogeneous across sources. We examined one attribute of data quality, completeness, in the context of electronic laboratory reporting of notifiable disease information. We evaluated 7.5 million laboratory reports from clinical information systems for their completeness with respect to data needed for public health reporting processes. We also examined the impact of health information exchange (HIE) enhancement methods that attempt to improve completeness. The laboratory data were heterogeneous in their completeness. Fields identifying the patient and test results were usually complete. Fields containing patient demographics, patient contact information, and provider contact information were suboptimal. Data processed by the HIE were often more complete, suggesting that HIEs can support improvements to existing public health reporting processes.

Reducing missed laboratory results: defining temporal responsibility, generating user interfaces for test process tracking, and retrospective analyses to identify problems

Researchers have conducted numerous case studies reporting the details on how laboratory test results of patients were missed by the ordering medical providers. Given the importance of timely test results in an outpatient setting, there is limited discussion of electronic versions of test result management tools to help clinicians and medical staff with this complex process. This paper presents three ideas to reduce missed results with a system that facilitates tracking laboratory tests from order to completion as well as during follow-up: (1) define a workflow management model that clarifies responsible agents and associated time frame, (2) generate a user interface for tracking that could eventually be integrated into current electronic health record (EHR) systems, (3) help identify common problems in past orders through retrospective analyses.

Investigating the semantic interoperability of laboratory data exchanged using LOINC codes in three large institutions

LOINC codes are seeing increased use in many organizations. In this study, we examined the barriers to semantic interoperability that still exist in electronic data exchange of laboratory results even when LOINC codes are being used as the observation identifiers. We analyzed semantic interoperability of laboratory data exchanged using LOINC codes in three large institutions. To simplify the analytic process, we divided the laboratory data into quantitative and non-quantitative tests. The analysis revealed many inconsistencies even when LOINC codes are used to exchange laboratory data. For quantitative tests, the most frequent problems were inconsistencies in the use of units of measure: variations in the strings used to represent units (unrecognized synonyms), use of units that result in different magnitudes of the numeric quantity, and missing units of measure. For non-quantitative tests, the most frequent problems were acronyms/synonyms, different classes of elements in enumerated lists, and the use of free text. Our findings highlight the limitations of interoperability in current laboratory reporting.

LIMS USER ACCEPTANCE TESTING

Laboratory Information Management Systems (LIMS) play a key role in the pharmaceutical industry. Thorough and accurate validation of such systems is critical and is a regulatory requirement. LIMS user acceptance testing is one aspect of this testing and enables the user to make a decision to accept or reject implementation of the system. This paper discusses key elements in facilitating the development and execution of a LIMS User Acceptance Test Plan (UATP).

Electronic interchange of lab test orders and results between laboratories reduces errors and gives full traceability

Introduction of electronic lab test ordering and reporting corresponding results between laboratories when exchanging special tests for analysis in service labs, instead of manual paper based workflow, have reduced the fault rate by a factor 10 and reduced reporting time by 2 days compared to the manual workflow. Retyping orders and results into different IT systems is not longer needed as all 9 different labsystems in more than 60 laboratories are using the same standards and procedures resulting in full interoperability. The solution, challenges, implementation process and outcome is described in the paper.

Terminology modeling for an enterprise laboratory orders catalog

Laboratory test orders are used in a variety of clinical information systems at Partners HealthCare. At present, each site at Partners manages its own set of laboratory orders with locally defined codes. Our current plan is to implement an enterprise catalog, where laboratory test orders are mapped to reference terminologies and codes from different sites are mapped to each other. This paper describes the terminology modeling effort that preceded the implementation of the enterprise laboratory orders catalog. In particular, we present our experience in adapting HL7's "Common Terminology Services 2 - Upper Level Class Model" as a terminology metamodel for guiding the development of fully specified laboratory orders and related services.

[Laboratory alert value reporting by the clinical laboratory at an academic medical network]

BACKGROUND

An alert value is a result suggesting that the patient is at imminent danger unless appropriate remedial actions begin promptly. Report of alert values (AV) by the clinical laboratories has taken special relevance in recent years due to its contribution to patient's care.

AIM

To report results of AV informed during 2007 within the Health Network of the Pontificia Universidad Católica de Chile.

MATERIAL AND METHODS

Analysis of AV recorded in a centralized database of the laboratories of the health network, between January and December, 2007.

RESULTS

Total number of AV was 5.366, which represented 0.3% of total examinations and corresponded mainly to the clinical chemistry area. Potassium levels generated the higher number of AV detected, followed by positive blood cultures. Eighty two percent of AV corresponded to hospitalized patients. The greater number of AV was reported to intermediate and intensive care services. Thirty two percent of AV was informed to the physician or professional in charge of the patient within 5 minutes of obtaining the results and 79% within 30 minutes.

CONCLUSIONS

To obtain a real impact on patient management, it is fundamental to shorten the lapse between the obtainment of tests results and the warning, supported on appropriate computerized systems, and to spread the procedure to all personnel involved in patient's care.

The reference change value: a proposal to interpret laboratory reports in serial testing based on biological variation

BACKGROUND

A proposal to calculate and use the reference change value (RCV) as an objective guide for interpreting the numerical results obtained in clinical laboratory serial testing is introduced in this study.

METHODS

A database showing the results of a compilation of 191 publications on biological variation and including information on a number of analytes provided the standardized criterion based on biology for calculating the RCVs.

RESULTS

For each of the 261 analytes included in the study, the RCV was determined using Harris's formula, replacing analytical imprecision with the desirable specification of analytical quality based on half the within-subject biological variation at 95% probability levels. The result is a guide for a common criterion to identify clinically significant changes in serial results.

CONCLUSIONS

The RCV concept is an approach that can be offered by laboratories to assess changes in serial results. The RCV data in this study are presented as a point of departure for a widely applicable objective guide to interpret changes in serial results.

[Compliance with laboratory requirements regarding the secondary use of clinical specimens and laboratory data]

Clinical specimens as well as associated laboratory data (values and images) have been utilized to assure the overall quality of laboratory testing systems, including the evaluation of assay performance, individual analysis for the diagnosis and safety of patients, and education of medical laboratory technologists. Such secondary uses of clinical specimens and laboratory data require compliance with regulations and guidelines concerning ethical and social issues. We formulated an internal rule regarding the secondary use of specimens and laboratory data in our clinical laboratory, according to the view of the Japan Society of Laboratory Medicine (2002), and implemented it. Because a profound consideration of personal information and any conflict of interest has been recently emphasized in Japan, we have revised our internal rule. It is important to continue discussions on these ethical and social issues and observe the regulations and guidelines for the laboratory-based uses of post-assay specimens and data.

The development of a highly constrained health level 7 implementation guide to facilitate electronic laboratory reporting to ambulatory electronic health record systems

Electronic laboratory interfaces can significantly increase the value of ambulatory electronic health record (EHR) systems by providing laboratory result data automatically and in a computable form. However, many ambulatory EHRs cannot implement electronic laboratory interfaces despite the existence of messaging standards, such as Health Level 7, version 2 (HL7). Among several barriers to implementing laboratory interfaces is the extensive optionality within the HL7 message standard. This paper describes the rationale for and development of an HL7 implementation guide that seeks to eliminate most of the optionality inherent in HL7, but retain the information content required for reporting outpatient laboratory results. A work group of heterogeneous stakeholders developed the implementation guide based on a set of design principles that emphasized parsimony, practical requirements, and near-term adoption. The resulting implementation guide contains 93% fewer optional data elements than HL7. This guide was successfully implemented by 15 organizations during an initial testing phase and has been approved by the HL7 standards body as an implementation guide for outpatient laboratory reporting. Further testing is required to determine whether widespread adoption of the implementation guide by laboratories and EHR systems can facilitate the implementation of electronic laboratory interfaces.

Using the e-Chasqui, web-based information system, to determine laboratory guidelines and data available to clinical staff

13% of all drug susceptibility tests (DSTs) performed at a public laboratory in Peru were duplicate. To determine reasons for duplicate requests an online survey was implemented in the e-Chasqui laboratory information system. Results showed that 59.6% of tests were ordered because clinical staff was unaware of ordering guidelines or of a previous result. This shows a benefit of using a web-based system and the lack of laboratory information available to clinical staff in Peru.

LIS--connecting the pieces. When it comes to laboratory information systems, the debate is between interoperability and best of breed

Lab directors usually choose best of breed. CIOs usually choose enterprise solutions. An integrated LIS may really be just interfaced. KLAS LIS Perception Report is planned for November.

Standardization of terminology in laboratory medicine II

Standardization of medical terminology is essential in data transmission between health care institutes and in maximizing the benefits of information technology. The purpose of this study was to standardize medical terms for laboratory observations. During the second year of the study, a standard database of concept names for laboratory terms that covered those used in tertiary health care institutes and reference laboratories was developed. The laboratory terms in the Logical Observation Identifier Names and Codes (LOINC) database were adopted and matched with the electronic data interchange (EDI) codes in Korea. A public hearing and a workshop for clinical pathologists were held to collect the opinions of experts. The Korean standard laboratory terminology database containing six axial concept names, components, property, time aspect, system (specimen), scale type, and method type, was established for 29,340 test observations. Short names and mapping tables for EDI codes and UMLS were added. Synonym tables were prepared to help match concept names to common terms used in the fields. We herein described the Korean standard laboratory terminology database for test names, result description terms, and result units encompassing most of the laboratory tests in Korea.

Integration of scanned document management with the anatomic pathology laboratory information system: analysis of benefits

Electronic document management systems (EDMSs) have the potential to improve the efficiency of anatomic pathology laboratories. We implemented a novel but simple EDMS for scanned documents as part of our laboratory information system (AP-LIS) and collected cost-benefit data with the intention of discerning the value of such a system in general and whether integration with the AP-LIS is advantageous. We found that the direct financial benefits are modest but the indirect and intangible benefits are large. Benefits of time savings and access to data particularly accrued to pathologists and residents (3.8 h/d saved for 26 pathologists and residents). Integrating the scanned document management system (SDMS) into the AP-LIS has major advantages in terms of workflow and overall simplicity. This simple, integrated SDMS is an excellent value in a practice like ours, and many of the benefits likely apply in other practice settings.

[The expectations for the third generation clinical laboratories in Japan]

The author expressed his hopes and expectations for third generation clinical laboratory schemes or systems in Japan. The history of development of the clinical laboratory in Japan can be classified three generations after the Second World War, the first generation (1945-1975), the second generation (1970-2005) and the third generation (2001-). The third generation clinical laboratory can be called "the clinical laboratory for the 21st century". The author advised some suggestions for the clinical laboratory for the 21st century. The main advice of the author is as follows: 1) The necessity of professional physicians of clinical laboratory medicine in hospitals. 2) The necessity of standardization and holding nationwide common reference values of main clinical laboratory tests. 3) The realization of a network of high-grade laboratory tests between all clinical laboratory divisions of the national university hospitals.

Managing transferability of laboratory data

Considerable attention has been focused on definition and enhancement of the analytical quality in laboratory testing over the past decades. Advances in laboratory technology and computer informatics have allowed a major sense of confidence with the analytical phase and more efforts should now be focused on extra-analytical areas of improvement, that should further strengthen the link between cost effectiveness and clinical outcome. Deduction and implementation of common reference intervals, to be possibly shared by a regional network of clinical laboratories, appear so far a crucial step to increase efficiency and harmonization. With the experience gained from External Quality Control exercises and with the consensus of several contributory laboratories, this process is underway in Italy. Quality performances resulting from widespread implementation of common reference intervals and longitudinal comparison of patient's data, will allow clinical laboratories to accomplish with a major transferability, amplifying health benefits and meeting increasing health systems demand.

Clinical Governance and Laboratory Medicine: is the Electronic Medical Record our best friend or sworn enemy?

This review attempts to address the question: is the Electronic Medical Record (EMR) our best friend or sworn enemy in the context of Clinical Governance and Laboratory Medicine? It provides a brief overview of the history and development of Clinical Governance before going on to define an EMR. It considers how EMRs could assist in delivering quality care in laboratory medicine. A number of outstanding issues regarding EMRs and electronic health records (EHRs) are identified and discussed briefly before the author provides a brief outlook on the future of clinical governance and EMRs in laboratory medicine.

The California Clinical Data Project: a case study in the adoption of clinical data standards for quality improvement

The California Clinical Data Project is a statewide initiative to remove barriers to the widespread and effective use of information technology to improve chronic disease care. The project is a case study in the development and widespread adoption of clinical data standards by varied and often competing stakeholders. As an initial step, the project defined precise data standards for the batch reporting of pharmacy claims data and laboratory results data. These uniform standards facilitate the flow of existing electronic clinical information into disease registries and electronic health record systems. Pharmacy and lab results data now are being exchanged electronically with this standard among the largest health plans, medical groups, and clinical laboratories participating in California's pay-for-performance programs. Lessons from this project may apply to the development and adoption of data standards for other states and locales and for the emerging national health information infrastructure.

Automated reporting of GFR--coming soon to a laboratory near you!

BACKGROUND

Serum creatinine concentration is an unreliable and insensitive marker of chronic kidney disease (CKD). To improve CKD detection, Australasian guidelines have recently recommended that laboratories calculate and report an estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) formula with every request for serum creatinine concentration.

OBJECTIVE

This articles aims to provide timely information to health professionals about how to appropriately interpret and act upon eGFR reports. It also discusses the treatments shown to reduce renal and cardiovascular risk in CKD patients, and the indications for nephrologist referral.

DISCUSSION

The accuracy and precision of eGFRs are reasonable in most adults in whom calculated values are ENTITY lt 60 mL/min/1.73 m2. However, eGFRs should be interpreted with caution in some settings (particularly patients with eGFRs ENTITY gt 60 mL/min/1.73 m2 and children). Automatic laboratory reporting of eGFR will enhance early detection of CKD, allow the timely institution of appropriate reno- and cardio-protective therapies, and better inform decisions regarding the prescription of renally excreted medications.

Electronic laboratory reporting for the infectious diseases physician and clinical microbiologist

BACKGROUND

One important benefit of electronic health information is the improved interface between infectious diseases practice and public health. Electronic communicable disease reporting (CDR), given its legal mandate and clear public health importance, is a significant early step in the sifting and pooling of health data for purposes beyond patient care and billing. Over the next 5-10 years, almost all CDR will move to the internet.

METHODS

This paper reviews the components of electronic laboratory reporting (ELR), including sifting through data in a laboratory information management system for reportable results, controlled "vocabularies" (e.g., LOINC, Logical Observation Identifiers Names and Codes [Regenstrief Institute], and SNOMED, Systematized Nomenclature of Medicine [College of American Pathologists]), the "syntax" of an electronic message (e.g., health level 7 [HL7]), the implications of the Health Insurance Portability and Accountability Act for ELR, and the obstacles to and potential benefits of ELR.

RESULTS

There are several ways that infectious diseases physicians, infection control professionals, and microbiology laboratorians will participate in electronic CDR, including web-based case reporting and ELR, the direct, automated messaging of communicable disease reports from clinical lab information management systems to the appropriate public health jurisdiction's information system.

CONCLUSIONS

ELR has the potential to make a large impact on the timeliness and the completeness of communicable disease reporting, but it does not replace the clinician's responsibility to submit a case report with important demographic and epidemiologic information.

[Can a laboratory investigation be called anything? "The NPU system" sorts out the concepts and gives systematic stringency]

When communicating results from laboratory investigations from the laboratory to the requesters and further between different information systems, it is important that the value as well as the unique identity and name of the laboratory investigation are correctly cited. A committee under the International Federation for Clinical Chemistry and Laboratory Medicine (IFCC) and International Union for Pure and Applied Chemistry (IUPAC) has developed a systematic nomenclature for the correct classification of laboratory investigations. Each generic laboratory investigation is provided with a unique NPU code. The system is in use among approximately 30 different clinical laboratories in Sweden, and has capacity to be the common denominator of all laboratory investigations, and to be used as the identifier in various information systems. The NPU system for the Swedish laboratories is currently administered by EQUALIS and partly financed by the participating laboratories. Other ways of funding, of benefit for the whole health care sector, will be investigated.