AN EVALUATION OF THE EFFECTIVENESS OF THE LABORATORY INFORMATION SYSTEM WITH SPECIAL REFERENCE TO THE MICROBIOLOGY LABORATORY

Abstract :-

The use of Laboratory information systems (LIS) for data management is increasing rapidly. The present study examines the efficacy and cost effectiveness of LIS with reference to the Microbiology laboratory in Bhopal Memorial Hospital and Research Center, Bhopal. Questionnaires, walk through surveys and outcome assessments were used. Indicators of laboratory performance prior to installation of LIS were compared with those assessed after installation of the system. It was found that LIS streamlined the workflow of the laboratory, increased productivity, reduced the incidence of errors, reduced the hospital stay of patients and the overall costs. We concluded that LIS contributed to improvement in the efficiency of the Microbiology laboratory and consequently in quality of patient care.

Key words:-

Laboratory Information System, LIS, Microbiology

INTRODUCTION:

In developed countries, LIS has revolutionized the way in which laboratories manage their data (1). However, in India, LIS is still in its infancy.

Computing in Medical Microbiology is less advanced than that in the related laboratory specialities of Pathology and Haematology. This is largely because of the more complex nature of analytical work in Microbiology, little of which is either numerical or performed on analyzers that can easily be interfaced to computer systems. Also, Microbiology reports are essentially descriptive, text based, with many specimens having multiple tests performed (2). This study was therefore carried out to assess the utility of LIS in a microbiology laboratory in our country.

MATERIAL AND METHODS:

Study setting : This study was undertaken in the Department of Microbiology, Bhopal Memorial Hospital And Research Center (BMHRC), Bhopal. BMHRC caters primarily to the victims of the Bhopal gas disaster and their dependents. It is a 350 bed super speciality hospital with state of the art facilities.

Study period : a) Pre intervention period (before implementation of LIS i. e. from January 2002 to December 2002) and (b) Post intervention period (after implementation of LIS i. e. from January 2003 to December 2003).

Estimation of the extent of fulfillment user requirements : The software and hardware requirements as well as functional specifications of the end users were compiled through questionnaires and interviews. The extent of fulfillment of these requirements were then examined.

A walk through survey of the laboratory : The present laboratory workflow was studied and present performance was compared with past performance (when LIS was not in use).

Interviews of laboratory and hospital staff using predesigned proformas : The questionnaires evaluated the comfort level of users and the extent of awareness of services available on LIS.

Study of laboratory records : The following laboratory records were studied - sample receiving register, result entry register, report dispatch register, records of laboratory stocks, equipment maintenance records, staff overtime records and records of cash payment receipts.

Workload and productivity of the laboratory was determined using time study formats (3, 4, 5) by examining average investigations per technical staff per month, average turn around time of each test and checking for errors in the workflow.

Examination of billing and financial outlay analysis : Transparency, ease, accuracy and speed of billing practices were examined by cross checking laboratory records and payment receipts. Recurring costs in terms of consumables, maintenance of equipment and staff salaries were examined both prior and after installation of LIS.

Statistical analysis : P values were computed using a two-tailed t-test with unequal variances over two 12 month periods comparing indicators in the pre intervention period and post intervention period(6).

RESULTS :

LIS software from Siemens India software LTD was installed in the Department of Microbiology, BMHRC, in January 2003.

Extent of fulfilment of user requirements : The system was found to have user friendly templates for patient data, MRD details, order processing, sample processing, result processing, laboratory cumulative result processing, trend analysis. There were 4 computer terminals in the microbiology laboratory with two printers shared between them. Computer terminals with printers were available at all end user sites. User friendly templates for ordering of tests, accessibility of reports, tracking of billing and data analysis were available. The extent of fulfilment of user requirements was an average of 7.02 on scale of 1 to 10.

Results of the walk through survey of the laboratory :

Registration of test requests and sample labelling : In the pre intervention period, request forms and sample labels were filled manually. An approximate estimate of the expected expenditure was given to the patient. Post intervention, tests are ordered on the computer which already contains patient data, but manual labelling of samples persists. The updated price of each test appears on the screen each time the test is ordered. An accurate estimate of expenditure is therefore given to the patient.

Sample collection and receipt : In the pre intervention period, patient data and tests ordered were entered manually in laboratory records. Time of receipt of sample was rarely recorded. Post intervention, patient data and tests ordered appear on the system by default. The time of receipt of every sample is recorded automatically.

Sample number : In the pre intervention period, sample numbers were added manually to each sample. Post intervention, an unique ID is generated automatically for every sample.

Quality of sample : In the pre intervention period, with repeated changes of staff, awareness about the guidelines for appropriate collection of samples was only 23.4%. Post intervention, the criteria for appropriateness of sample appears on the template each time the sample is ordered. The user is therefore reminded of the guidelines every time.

Processing of samples : In the pre intervention period, there were 12 + 3 telephonic queries per day as to the status of the result. Post intervention, the fact that the sample is under process is entered on the template, so there are only 2 + 1 telephonic queries per day.

Initial result and Final Result : In the pre intervention period, a separate preliminary report was issued prior to the final report. Critical values had to be highlighted manually. Post intervention, fresh results and any changes can be entered at any point of time till final certification. Critical values automatically get highlighted in the system.

Laboratory statistics and Trend analysis : In the pre intervention period manual calculation was needed to collect data for laboratory statistics and infection surveillance in the hospital. Post intervention, the system instantly calculates and provides the required data pertaining to any time period.

Results of questionnaires : The mean satisfaction level about LIS among users was 5.08 on a scale of 1 to 7.The level of awareness about LIS was 100% among laboratory staff and 87% among hospital staff.

Study of laboratory records : In the pre intervention period, all records were maintained manually. 3.2% of reports had transcription errors. Reports were batched for dispatch, resulting in a 6-8 hours delay in the receipt of reports by end users.

Certification of receipt of reports added to the delay. Post intervention, records are automatically saved on the system and are dispatched as and when they are ready. Transcription errors are minimal. There is no manual certification of receipt of reports.

Workload and productivity : The observations are detailed in tables 1, 2 and 3.

Examination of billing and financial outlay analysis : In the pre intervention period, with manual billing, errors in details of laboratory services, transcription and calculation of dues were noted. Tracking and auditing of services was cumbersome. Dues were computed over a period of 6-12 hours. Post intervention, errors have been reduced by a factor of 4 and dues are computed within minutes. Recurring costs in the laboratory have been reduced by a factor of 2 per test.

DISCUSSION :

Evaluation of LIS in the Microbiology laboratory is complicated because of the predominantly manual nature of activities, diversities of staff, variation in intensity of care of services and the intangible outcomes of medical care therapy forcing qualitative judgements of evaluations. Therefore we measured only certain components and characteristics from which inferences were drawn and corrective actions were taken. The user requirements have been partially fulfilled. The comfort and satisfaction levels are acceptable, though there is room for improvement. Awareness about LIS services among hospital staff needs to be improved for optimal utilization of the system. There was a significant reduction in turn around times for all tests (P<0.001) since the reports are sent as and when they are ready. There is no dependence on a porter to transport reports to end users. This further reduced the turn around time. Despite reduction in staff and increased requests for investigations, productivity was significantly higher in the post intervention period (P<0.001). This was probably because LIS led to a restructuring of workflow. After installation of LIS, laboratory personnel prioritize their time better, leading to more streamlined work. In addition, two old technical staff have been replaced by two new technical staff. Despite their initial lack of familiarity with the system, productivity continued to rise and errors were minimal. Quality assurance checks showed improvement in the quality of reports. With use of LIS, recurring cost in terms of consumables, and salaries were found to be lesser; billing of services became transparent and faster.

LIS has contributed to a major improvement in the quality of microbiology laboratory services. However, there is still scope for further improvement. Regular awareness programmes about LIS, interfacing of automated equipment with the system and barcoding facilities for sample identification would go a long way in making the system more effective.

ACKNOWLEDGEMENT :

The authors gratefully acknowledge the clerical help extended by Mr. Tej Singh Sanodiya.

Pre intervention period

Post intervention period

Bacteriological tests/ Technical staff / month

900

1600

Technical staff/ month

staff/ month

Number of technical staff

7

5

Turn around times before and after installation of LIS

Test type

Pre intervention period

Post intervention period

Microscopy

2-3 hours

(P< 0.001)

By routine method

(P< 0.001)

By BacT/ Alert method

48 hours

(P< 0.001)

Routine Serological tests

12-30 hours

(P< 0.001)

Immunological tests

12 hours

(P< 0.001)

Microscopy

(P< 0.001)

Fungal culture

30 days

(P< 0.001)

batches.

20 days

batches. (P< 0.001)

By MB/BacT method

42.7days

Errors before and after installation of LIS

Types of errors

% of error in pre intervention period

% of error in post intervention period

Errors in labeling of specimens

3.60%

0.50%

Transcription errors

3.20%

0.60%

Errors in patient identification

2.00%

0.30%

Missed orders

4.10%

1.00%

Delay in receipt of final result

41.40%

2.40%

REFERENCES :

Department of Microbiology, Bhopal Memorial Hospital and Research Center, Bhopal

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