A paperless microbiology laboratory; a comprehensive information system allows this microbiology laboratory to operate without handwritten data entries Essay

To meet its objective of maintaining or improving patient care, the
clinical laboratory must transmit information quickly and accurately to
the clinician. That has always been a challenge, and it is becoming
more difficult with the new emphasis on cost-effectiveness.

We believe that containing costs without sacrificing quality of
patient care makes computerization mandatory. One year ago, we
installed a comprehensive laboratory information system (PathNet, Cerner
Corp., Kansas City, Mo.) at our 550-bed hospital. Today our
microbiology department is virtually paperless.

PathNet cah be used as a stand-alone microbiology system or, in the
way we have chosen, as a total laboratory information system. Its
flexibility permits a user to predefine criteria according to the
laboratory’s needs, policies, and procedures.

The microbiology part of the system tracks specimen status from
order entry through result reporting, constructs on-line worksheets,
captures workload units, and issues standardized and validated result
reports. Here in detail is what it provides:

* Organized, readable charts. Two types of reports for the patient
chart are generated at user-specified times. The cumulative report
chronologically lists all validated results for each patient since
admission to the hospital (Figure I). We print cumulative reports at 3
a.m. every day.

Data verified after the cumulative report is issued appear on
interim reports, which ae printed three times daily. One of these
reports, reflecting updated cultures and about 80 per cent of our daily
microbiology activities, is printed at 2:30 p.m., in time for afternoon

Another interim report, printed at 8 a.m., contains the bulk of the
results from hematology and chemistry. Both labs begin their day at 5
a.m. and by 7:30 a.m. have completed most of the routine work. The
third report, printed at 7 p.m., contains data on patients scheduled for
surgery the next morning.

Cumulative and interim reports are printed in chronological order
by culture date and time within the microbiology section of the chart.
This means if culture results are sent to the floor on day one, for
example, and additional results are sent five days later, all the data
pertaining to that culture are listed together.

Before we computerized, handwritten reports from each laboratory
section were glued, in the order received by the floor, in shingle
format on the patient chart. The clinician had to search through the
entire chart to find all results of a particular culture. There was
always the possibility that reports would be misplaced or fall off the
chart and disappear.

Moreover, many of the manual entries were illegible. Now no one
needs to interpret handwriting, since the charts are computer-printed.

The chronological order and legibility of the charts have markedly
reduced phone calls from the floors to our microbiology department.
Before, it was much easier for the clinician to call for results than to
look for the scattered reports and decipher the handwriting.

Previous cumulative and interim reports are discarded once new
cumulative reports are issued. The reports are in two different colors,
allowing the clinician to readily select either the total history of the
patient or the most recent patient information.

* Specimens identified by number. When specimens are logged in,
the system records the time they were collected, the time they were
received, and the time cultures were started.

Since multiple tests may be performed on one specimen, each
specimen is given an accession number. The accession number is a
combination of the date and a number between 1 and 9,999. A fungus
culture, a bacterial culture, and an AFB culture on one specimen, for
instance, all have the same accession number. The chart clearly
documents that three cultures were set up from one specimen, instead of
appearing to show that three different specimens were received for three
different tests on the same day.

* Specimen and media labels. System-generated labels for each
specimen and for the inoculated media bear the accession number, the
patient’s name, the patient’s medical number, the culture type
that has been ordered, when it was collected and started, and the
specimen source.

* On-line worksheets. Work performed by the technologist,
including notes, daily observations, and biochemical testing results, is
recorded directly on the terminal. This on-line worksheet (Figure II)
has several advantages. When more than one technologist works on a
culture, there’s no stumbling over someone else’s
handwriting–everything is typed. The worksheet also organizes testing
in any desired manner. That is, some labs work on specimens according
to source, others according to the time of receipt.

Cultures to be read are grouped alphabetically by the
patient’s last name. The worksheets are automatically presented by
the computer alphabetically, one right behind the other. When the
technologist completes one culture, the computer instantly brings up the
next culture; reports cannot be misalphabetized or misfiled. A
technologist can work from start to finish without having to search for

* Workload recording. Since all work performed is recorded on the
worksheet, the system automatically captures the microbiology
department’s workload. Both raw counts and workload units are
presented in the workload units are presented in the workload report.

Workload is calculated for various types of patients–e.g.,
outpatients versus inpatients–as well as for different shifts. The
third shift receives credit for preparing and performing Gram stains on
cultures; the day shift receives credit for identification and
susceptibility testing.

Workload units can reflect laboratory-defined standards or, as we
do it, College of American Pathologists guidelines. In addition, the
system permits the laboratory to accumulate workload data for different
periods, such as weekly, biweekly, or monthly. A year-to-date workload
report is also printed.

We used to spend at least eight hours per month manually compiling
microbiology workload data. Now the reports are an automatic byproduct of daily computerized record keeping.

* Consistent reporting. Most lab sections use numbers to report
results, but microbiology uses words and phrases. We standardized
reporting by creating mnemonic codes that technologists utilize when
entering data. As a result, organisms are always reported in the same
way on the chart.

Our method for coding organisms uses the first letter of the genus
and as many letters as will fit of the species name. For example,
Staphylococcus aureus is coded as S AUREUS. The system also recognizes
designated synonyms. If the technologist enters SA or S AUR, it will
still appear on the chart as Staphylococcus aureus. Terms in our medical
mnemonic and test directory are easilyt added or changed in a matter of
seconds without affecting the system’s performance.

While the bulk of reported data are entered using short mnemonics,
there is enough space on the terminal screen for the technologist to
prepare more customized reports with free-text comments. We use free
text to document phone call results, including the date and time of the
call and the name of the person who took the call.

* Easy-to-review results. The microbiology staff can readily
recall results–listed in chronological order, in the same format as the
chart–through an on-line microbiology report inquiry. Results can be
recalled to the terminal screen by culture date, culture type, or
accession number.

* Tracking and identification of requested tests. Tests cannot be
forgotten or lost. A report on pending work, issued each morning,
tracks all requested procedures that have not been reported within the
expected turnaround time. A routine urine culture should take only two
days to be reported, but a routine culture of cerebrospinal fluid is
expected to take five days, and a fungus cultue, six weeks.

Every day the system generates a log of tests ordered in
alphabetical order by patient name. All cultures ordered each day for
each patient are itemized in one place.

* Validated results. All results are validated as accurate, based
on culture type and source. When an unusual or particularly virulent organism is reported, or when an organism has a susceptibility pattern
that is abnormal, the entire result report is printed on a microbiology
exception report. These results also are flagged on the terminal

The exception report is printed in our laboratory in the early
morning hours and reviewed at the beginning of each work day. All
result reports containing free-text comments are reproduced on the
exception report because they are not standard and cannot be validated.

* Freedom of movement. With just a few keystrokes, technologists
can branch from one program to another or from one patient to another or
from one patient to another patient. Technologists can choose to take
information, such as the patient’s demographics or a specific
culture, with them to another program and may return, if they wish, to
their original place.

When technologists, receive phone calls, for example, they can
branch out of the function on which they are working at the time, look
up information for the person calling, and then return to their work.
The first computer transaction does not have to be aborted or initiated

Our microbiology information system will grow with added
capabilities. Plans call for an infection control module, which assists
in identification of patients with nosocomial infections, to be
incorporated into the information system.

The microbiology system will also be interfaced with automated
instruments and linked to other departments in the hospital. A terminal
has just been installed in the emergency room, and we plan to provide
terminals in the intensive care units and eventually at all nursing
stations. One entry will make data available in several places
simultaneously, further expediting results.

By managing every event in microbiology and the entire laboratory,
the system gives us a total picture of our activity and of
patients–without using reams of paper.

Technologists spend less time performing clerical tasks now than
they did under the manual system. It also takes them far less time to
find patient results in response to telephone calls. With the manual
system, a technoligst had to put the phone down, go to the various files
in order to retrieve the results, nd then return to the caller with the
information. The same information can be gathered and conveyed in a few
seconds with the computer.

In addition, we have increased the amount of information that makes
it to the chart while decreasing the amount of time it takes to provide
the data. For example, a preliminary report on each active culture goes
on the patient’s chart each day that the cultue is active until the
final results are reported.

Technologists can now be much more sparing in the workup of
individual isolates and susceptibility testing because it is now easy to
see what previous and simultaneous cultures contain. If several
cultures from different sources contain the same organism, only one has
to be exhaustively worked up and tested for susceptibilities.

We thus feel more qualified to meet our objectives of improving
patient care and containing costs.


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