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, theclinical laboratory must transmit information quickly and accurately tothe clinician.

That has always been a challenge, and it is becomingmore difficult with the new emphasis on cost-effectiveness. We believe that containing costs without sacrificing quality ofpatient care makes computerization mandatory. One year ago, weinstalled a comprehensive laboratory information system (PathNet, CernerCorp., Kansas City, Mo.) at our 550-bed hospital.

Today ourmicrobiology department is virtually paperless. PathNet cah be used as a stand-alone microbiology system or, in theway we have chosen, as a total laboratory information system. Itsflexibility permits a user to predefine criteria according to thelaboratory’s needs, policies, and procedures.

The microbiology part of the system tracks specimen status fromorder entry through result reporting, constructs on-line worksheets,captures workload units, and issues standardized and validated resultreports. Here in detail is what it provides: * Organized, readable charts. Two types of reports for the patientchart are generated at user-specified times. The cumulative reportchronologically lists all validated results for each patient sinceadmission to the hospital (Figure I). We print cumulative reports at 3a.m. every day. Data verified after the cumulative report is issued appear oninterim reports, which ae printed three times daily.

One of thesereports, reflecting updated cultures and about 80 per cent of our dailymicrobiology activities, is printed at 2:30 p.m., in time for afternoonrounds. Another interim report, printed at 8 a.m.

, contains the bulk of theresults from hematology and chemistry. Both labs begin their day at 5a.m. and by 7:30 a.m. have completed most of the routine work. Thethird report, printed at 7 p.

m., contains data on patients scheduled forsurgery the next morning. Cumulative and interim reports are printed in chronological orderby culture date and time within the microbiology section of the chart.This means if culture results are sent to the floor on day one, forexample, and additional results are sent five days later, all the datapertaining to that culture are listed together. Before we computerized, handwritten reports from each laboratorysection were glued, in the order received by the floor, in shingleformat on the patient chart. The clinician had to search through theentire chart to find all results of a particular culture. There wasalways the possibility that reports would be misplaced or fall off thechart and disappear.

Moreover, many of the manual entries were illegible. Now no oneneeds to interpret handwriting, since the charts are computer-printed. The chronological order and legibility of the charts have markedlyreduced phone calls from the floors to our microbiology department.Before, it was much easier for the clinician to call for results than tolook for the scattered reports and decipher the handwriting. Previous cumulative and interim reports are discarded once newcumulative reports are issued.

The reports are in two different colors,allowing the clinician to readily select either the total history of thepatient 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 werereceived, and the time cultures were started. Since multiple tests may be performed on one specimen, eachspecimen is given an accession number. The accession number is acombination of the date and a number between 1 and 9,999. A fungusculture, a bacterial culture, and an AFB culture on one specimen, forinstance, all have the same accession number. The chart clearlydocuments that three cultures were set up from one specimen, instead ofappearing to show that three different specimens were received for threedifferent tests on the same day. * Specimen and media labels.

System-generated labels for eachspecimen and for the inoculated media bear the accession number, thepatient’s name, the patient’s medical number, the culture typethat has been ordered, when it was collected and started, and thespecimen source. * On-line worksheets. Work performed by the technologist,including notes, daily observations, and biochemical testing results, isrecorded directly on the terminal. This on-line worksheet (Figure II)has several advantages. When more than one technologist works on aculture, there’s no stumbling over someone else’shandwriting–everything is typed. The worksheet also organizes testingin any desired manner.

That is, some labs work on specimens accordingto source, others according to the time of receipt. Cultures to be read are grouped alphabetically by thepatient’s last name. The worksheets are automatically presented bythe computer alphabetically, one right behind the other.

When thetechnologist completes one culture, the computer instantly brings up thenext culture; reports cannot be misalphabetized or misfiled. Atechnologist can work from start to finish without having to search forinformation. * Workload recording. Since all work performed is recorded on theworksheet, the system automatically captures the microbiologydepartment’s workload. Both raw counts and workload units arepresented 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.

Thethird shift receives credit for preparing and performing Gram stains oncultures; the day shift receives credit for identification andsusceptibility testing. Workload units can reflect laboratory-defined standards or, as wedo it, College of American Pathologists guidelines. In addition, thesystem permits the laboratory to accumulate workload data for differentperiods, such as weekly, biweekly, or monthly. A year-to-date workloadreport is also printed. We used to spend at least eight hours per month manually compilingmicrobiology workload data.

Now the reports are an automatic byproduct of daily computerized record keeping. * Consistent reporting. Most lab sections use numbers to reportresults, but microbiology uses words and phrases.

We standardizedreporting by creating mnemonic codes that technologists utilize whenentering data. As a result, organisms are always reported in the sameway on the chart. Our method for coding organisms uses the first letter of the genusand as many letters as will fit of the species name.

For example,Staphylococcus aureus is coded as S AUREUS. The system also recognizesdesignated synonyms. If the technologist enters SA or S AUR, it willstill appear on the chart as Staphylococcus aureus. Terms in our medicalmnemonic and test directory are easilyt added or changed in a matter ofseconds 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 toprepare more customized reports with free-text comments. We use freetext to document phone call results, including the date and time of thecall and the name of the person who took the call. * Easy-to-review results. The microbiology staff can readilyrecall results–listed in chronological order, in the same format as thechart–through an on-line microbiology report inquiry. Results can berecalled to the terminal screen by culture date, culture type, oraccession number. * Tracking and identification of requested tests. Tests cannot beforgotten or lost.

A report on pending work, issued each morning,tracks all requested procedures that have not been reported within theexpected turnaround time. A routine urine culture should take only twodays to be reported, but a routine culture of cerebrospinal fluid isexpected to take five days, and a fungus cultue, six weeks. Every day the system generates a log of tests ordered inalphabetical order by patient name. All cultures ordered each day foreach patient are itemized in one place. * Validated results. All results are validated as accurate, basedon culture type and source.

When an unusual or particularly virulent organism is reported, or when an organism has a susceptibility patternthat is abnormal, the entire result report is printed on a microbiologyexception report. These results also are flagged on the terminalscreen. The exception report is printed in our laboratory in the earlymorning hours and reviewed at the beginning of each work day. Allresult reports containing free-text comments are reproduced on theexception report because they are not standard and cannot be validated. * Freedom of movement. With just a few keystrokes, technologistscan branch from one program to another or from one patient to another orfrom one patient to another patient. Technologists can choose to takeinformation, such as the patient’s demographics or a specificculture, with them to another program and may return, if they wish, totheir original place.

When technologists, receive phone calls, for example, they canbranch out of the function on which they are working at the time, lookup information for the person calling, and then return to their work.The first computer transaction does not have to be aborted or initiatedagain. Our microbiology information system will grow with addedcapabilities. Plans call for an infection control module, which assistsin identification of patients with nosocomial infections, to beincorporated into the information system.

The microbiology system will also be interfaced with automatedinstruments and linked to other departments in the hospital. A terminalhas just been installed in the emergency room, and we plan to provideterminals in the intensive care units and eventually at all nursingstations. One entry will make data available in several placessimultaneously, further expediting results. By managing every event in microbiology and the entire laboratory,the system gives us a total picture of our activity and ofpatients–without using reams of paper. Technologists spend less time performing clerical tasks now thanthey did under the manual system. It also takes them far less time tofind patient results in response to telephone calls. With the manualsystem, a technoligst had to put the phone down, go to the various filesin order to retrieve the results, nd then return to the caller with theinformation.

The same information can be gathered and conveyed in a fewseconds with the computer. In addition, we have increased the amount of information that makesit to the chart while decreasing the amount of time it takes to providethe data. For example, a preliminary report on each active culture goeson the patient’s chart each day that the cultue is active until thefinal results are reported. Technologists can now be much more sparing in the workup ofindividual isolates and susceptibility testing because it is now easy tosee what previous and simultaneous cultures contain. If severalcultures from different sources contain the same organism, only one hasto be exhaustively worked up and tested for susceptibilities.

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

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