Integrated laboratory information system a large...

Journal of Automatic Chemistry, Vol. 14, No. 6 (November-December 1992), pp. 223-229

Integrated laboratory information system ina large hospital laboratory in Singapore

Edward Jacob, It-Koon Tan, Kim-Seng Chua andSee-Heng LimClinical Biockemistry Laboratories, Department ofPathology, Singapore GeneralHospital, Outram Road, Singapore 0316, Singapore

This paper describes an integrated approach to the computerizationof all major disciplines of laboratory medicine and pathology.Installed in the Department of Pathology, Singapore GeneralHospital (SGH), the computer system discussed comprises aRISC-based Data General Aviion 6200 computer and MeditechMAGIC software. The system has been interfaced with thehospital host IBM computer and supports patient informationtransfer, result reporting, phlebotomy management, and compila-tion of laboratory and financial management reports. The main

functions of the system include: on-line and off-line acquisition ofpatient information and test data; preparation ofsinglecumulative reports; transmission of reports within and betweenlaboratories; instantaneous provision of data in response totelephone enquiries; calculations of quality controlproductivity statistics and indices; and generation of billing lists.The computer enables reports to be provided on patient tests resultsin individual wards, at various specialist out-patient clinics, and inthe Accident and Emergency Department of the SGH through theIBM mainframe, as well as to remote printers installed at severalother major hospitals.

The use of the MAGIC integrated laboratory informationsystem has resulted in a significant increase in laboratory efficiencyand productivity.

minicomputer running on Medical Information tech-nology (Meditech) Software written in Meditech Inter-pretive Information System (MIIS). Two identical on-line systems were purchased, one in 1983 to serve thehaematology laboratories and the 24-hour emergency/routine biochemistry laboratories sited on the same floorwithin SGH, and another in 1984, to serve the mainbiochemistry laboratories ofthe Department ofPathologywhich is housed in a separate building some distanceaway. The other laboratories at SGH were not ready forcomputerization.

The annual number of tests in the biochemistry andhaematology departments was 820000 and 700000,respectively, when the two computer systems werepurchased. The systems were linked through modemsand telephone lines and have performed well 18].

With a background of many years of laboratory comput-ing experience in the field of biochemistry and haema-tology, it was decided in early 1990 to computerize all thedivisions in the Department of Pathology. It was decidedthat a single large computer system could cater for all ofthe divisions. This was considered to be a better approachthan using small individual systems for each separatediscipline--for example the various divisions of theDepartment would be able to share the same patientdatabase (see table 1).

Introduction Configuration of the newly-acquired MAGIC system

The Department of Pathology of the Singapore GeneralHospital (SGH) provides both routine and specializedlaboratory services to hospitals and clinics, and togovernment ministries. The Department acts as thereference and training centre for laboratory medicine inSingapore and the region.

An off-line minicomputer system was installed in theBiochemistry Division of the Department of Pathology in1974; the workload was then 426000 tests per annum.The off-line system, which comprised a NOVA 1220computer with 48KB memory, paper tape reader, severalteletypes and printers, served the laboratories well forabout 10 years [1-5].

With a doubling of the workload to about 820 000 testsper annum in 1980, and the aging of the minicomputer,it was felt that a new computer was needed. Anexhaustive study of laboratory computers on the market,and the experiences of other hospital laboratorycomputer users [6-17], led to the final choice of aninteractive multi-user database management operationsystem. The computer was a Data General Eclipse S/140

The group had many years’ experience with staffwith theMeditech software and it was felt that this outweighedany small advantages that any other system could offerand decided on an upgraded design from Meditech, Inc.called the MAGIC System.

The system consists of a Data General RISC basedAVIION 6200 Series Computer with 16 MB memory,

Table 1. Number ofspecimens processed in 1990.

Division No. of specimens

BiochemistryHaematologyDiagnostic BacteriologyMicrobiologySerology/ImmunologyVirologyHistopatho!ogyCytology

443 132275 158224 783100 351213 2957484550 74359 100

Total 441 407

0142-0453/92 $10.00 () 1992 Taylor & Francis Ltd.223

E. Jacob et al. Integrated laboratory information system

AUTOMATEDINSTRUMENTS

DA A GENERALAVIION 600

Termino.L WPrinter

BIOCHEMISTRYDEPT OF PATHOLOGY

AUTOMATED AUTOMATEDINSTRUMENTS INSTRUMENTS

Terminat

Prlnter

TerminG[

Printer

HISTOPATHOL00YDEPT OF PATHOLOGY

BIOCHEMISTRYBLOCK 6

TermnGt TermlnG

Prin terPrinter ,!

HICROBIOL00YDEPT OF PATHOLOGY AUTOMATED

INSTRUMENTS

HAEMATOL00YBLOCK 6

Figure 1. Layout of the integrated laboratory computer system in the Department of Pathology, Singapore General Hospital (SGH).

3 GB disc storage, 2"3 GB helical tape drive, Ethernetinterface, 24 units ofcommunication servers providing 10serial ports each connected to the Ethernet Local AreaNetwork. The 3 GB disc storage is made up of three unitsof GB disc drive. It is organized with one unit as themaster, one unit as the shadow and one for archiving. Thesystem layout is shown in figure 1.

The CPU, the console VDU, the live and archival discdrives and the helical tape drive are housed in theComputer room of the Department. Cables on anEthernet network link terminals from the various labora-tories to the CPU.

Networking

As the laboratories of the various disciplines are distri-buted over a wide area within the department, it wasnecessary to connect all the peripheral devices in eachlaboratory to the central CPU through a cable network. Acable system to link all the peripherals within the hospitalwas adopted as it allowed higher speed ofcommunication(19-2 baud rate) and minimal incremental cost foradditional links in the future (see figure 2). To serve thehospital’s future needs a fibre-optic cable was laid in theunderground tunnel of the hospital (see figure 3).

The specifications of the fibre-optic cable are: four core,multimode and 62"5/125. It is, however, running at

Ethernet bandwidth of 10 MBit/s; it will be upgraded to aFibre Distributed Data Interface (FDDI), with a speed of100 MBit/s, in the future.

Software

The operating system is the MAGIC Operating System,designed by Meditech. The computer language is theMAGIC language and the application programmemodules which are in use are as follows:

(1) Laboratory--for biochemistry, haematology andnuclear medicine.

(2) Microbiology--for diagnostic and enteric bacteri-ology, serology, immunology and virology.

(3) Anatomical pathology--for histopathology andcytopathology.

(4) Accounts receivable--for finance and billing.

The software is an integrated package running on acommon database.

Features of the MAGIC computer operations

Each section of the Department uses the computerindependently and is responsible for its own patient datainput, request input, workload production, result entry,

224


Block 6 Level 5Avilon Server

Block 3LevelOPD

Comm server

Finance/Client Service(Room 2-22)

Server

-+l.,+.===r \\

Block 6 Level 5

ICL

Comm server

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(No Repeater)

Comm server

Histopatho[ogyData Typlng Area

(Room 2-18)

Comm server

Block 7 Level

Fan Out Box

Block 99-2 A3 Admln

ColmServer

’[[I Mul tl-connect

""i’ Repeater

Serology(Room 02-01)

MicroblotogyComputer Processing Area

(Room 1-13)

Fibre-Optic Line(through dry riser

and into undergroundtunnel)

Block 5 Level 2

Multi-connect .i.ji[i? t Room

Repeater

Block BFault Reporting Centre

(No Repeater)

Comm server

BiochemistryComputer Room

(Room 3-4)

Figure 2. Cable system linking all the computer peripherals in the various buildings of the hospital.

report printing, record purging and archiving, statisticalanalyses and workload production. The various labora-tory disciplines have been alloted their own independentdisc space in the live and archival disc. Access to eachgroup’s disc space is by separate passwords.

The integrated package provides a common database fordemographic data. This has resulted in a considerablesaving in manpower in terms ofdata entry: once patient isadmitted into the system, this information can beaccessed by any of the laboratory users.

Some customization had to be done to suit localrequirements: such additional fields as requisitionnumbers, race, financial class and service codes havebeen added. New programs were written for workloadstatistics for accumulating the number of tests done ineach laboratory.

Transfer of demographic data

Patients admitted to SGH have their demographic datakeyed into the Hospital’s host IBM computer PatientCare System (PCS). This information is downloaded on areal-time basis to a personal computer (PC) sited in thelaboratory. The data are processed and then uploaded tothe Meditech’s patient database. Ward transfers, bed

changes, discharges are entered at the nursing stationsinto the host IBM computer. These transactions are

automatically passed to the laboratory PC, which thenupdates the Meditech’s patient database (see figure 4).This is an excellent feature because all laboratories havereal-time updated patient demographic data; wardenquiries and results reporting are now faster and moreefficient.

Meditech to IBM result reporting

The laboratory system.is linked to the Hospital IBM 3090System for demographic transfer--the link is through aPC. All test results from the laboratory system, afterverification, are transmitted via a microcomputerthrough a protocol converter to the IBM host.

The results are initially downloaded to the PC and a hardcopy is printed for verification. Unsatisfactory results canbe suppressed at this stage and the rest transmitted to thehost computer. The IBM computer then transmits allresults to IBM printers located in the wards (seefigure 5). This has improved the turnaround time forresult reporting. Reports are generated throughout theday, and ward staff have been given the facility ofinitiating a printout of reports through the wardterminals.

225


CabLe Tunnel

Fibre OpticCabLe

ServiceTunnel

Pabx Room TetetiFt ComputerIn Tunnel Room Room

(No Repeater) Level 2 Level 5

Multl-connect MuLti-connectRepeater Repeater

Figure 3. Fibre-optic cable network laid in the underground tunnel of the hospital.

Fault ReportingRoom(No Repeater)

Locatlon

FibreOPticCabLe

UndergroundTunnel

BLock 9

MuLtl-connectRepeater

ard TransFers

Hospta[

*--I Bed SwapsHost Computer

D,scharges

downLoads

Nedltech

Personal

Computer

Laboratory

Patient

Data

Base

LaboratoryModule

NicrobiotogyModuLe

PathoLogyNodute

Figure 4. Automatic transfer ofpatient demographic informationfrom the hospital mainframe computer to the laboratory infor-mation system through a personal computer.

I SGH.MeLllCh .I prints

Computer reports -I reports Computer reports

printsunapproved

Ustlng

Lis;ingPrlnrs

Figure 5. Transmission of laboratory test results from thelaboratory information to the hospital mainframe computerfor theprinting of reports within the wards and out-patient departments.

ReportformatsThe MAGIC software allows for composite reportsfeaturing results for a patient from all laboratorydisciplines. The present arrangement, however, is foreach discipline to generate their own separate reports.

There are a number ofoptions for the format of reportingby the system for the various laboratory disciplines.Figures 6-9 are examples of single reports generated bythe system for some of the laboratories. The histopath-ology division was one ofthe last to be computerized butit has made considerable gains. A large part of histologyreporting is in text form and requires word processing;this is done efficiently through the MAGIC software. Thesystem uses a laser printer and reports are neat and wellpresented. A major bonus is automatic SNOMED codingof diagnosis. Each division of the Department selects itsreports based on prefixes created. Biochemistry andhaematology reports carry age-specific reference intervalsand delta checks and panic values are used to highlight,or flag, abnormal results. Free text is allowed in thecomment field to describe, for example, haemolysis,turbidity Or to alert the clinician that the specimen wasinappropriate and a repeat specimen was desirable.

Result reporting to outside clients

Laboratory reports are transmitted via telephone linesthrough modems to be printed at remote printers locatedon site in other hospitals and the premises of clients whoare important users of the Department’s services (see

226


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Oepartmenl Pathology: K

Singapore General Hospital PAGERUN ON 16109/91-1500 BIOCHEMISTRY REPORT RUN FOR 16109191A,B SGII HARD 48 NRIC U1234567MALE AGE: 59 CLASS: RM/BED: ID C162

1609:BC0001S REQUEST BC543276 RECV: 16/09191UNK COLLN: IGI09/91UNKORDERED: UE,CRE.GLU, (CALCIUM,P04), LFT/ALT/AST, LDH, CIIO,TG,IIDL,LDL,

PROSTATE SP AG, ICD, CEA, (T3UoT4,FTI). ALPIIAFOETO PROT

[UE,CRE,GLU]UREA 5.6 MMOL/L (2.8-7.7)SODIUM 1420 MMOL/L (135-145)POTASSIUM 4.90 MMOLIL (3.3-4.9)CIILORIDE 106fl MHOL/L (96-108)GLUCOSE 9.00 MMOL/L (3.1-10.0)

FASTING (3.1-6.6)CREATININE 9111 UHOL/L (44-141)[(CALCIUM,P04))CALCIUM.TOTAL 2.27 HMOL/L (2.10-2.60)PHOSPHATE,INORG 1.03 MMOL/L (0.77-1.38)[LFT/ALT/AST]

PROTEIN,TOTAL 650 G/L (62-82)ALBUMIN 380 G/L (37-51)BILIRUBIN,TOTAL 180 UMOL/L (3-24)ALKALINE PIIOSPH 310 U/L (32-103)ALT(GPT) 29 U/L (7-36)AST(GOT) 29 U/L (15-33)LDH 290 U/L (180-380)[CHO,TG,HDL,LDL]

CHOLESTEROL 7.18 MMOL/L (4.78-7.50)DESIRABLE LEVEL <5.17MHOL/L (0.72-1.68)BMOL/L (0.56-2.09)MMOL/L -5.17)

DESIRABLE LEVEL <3.33UG/L (0-4.0)U/L (2-9)UG/L (0.5-3.5)

HDL CIIOLESTEROL I. 290TRIGLYCERIDE I. 14LDL CHOLESTEROL 5.37

PROSTATE SP AG I.OICD 7.7CEA 2.50[(T3U,T4,FTI)]

T3 RESIN UPTAKE 106TIIYROXlgE (T4) 75FTI 7.9ALPHAFOETO PROT 3.2

(77-129)NHOLIL (59-155)

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Singapore HospitalSinsalx)re

A Tradition of Caring, & Excellence

Figure 6. Example of a biochemistry report.

figure 10). This has improved the turn-around-time forresult reporting and reduced the frequent telephoneenquiries for the tracing of results.

Shadowing (or mirroring)As the computer is shared by all laboratory disciplines itis absolutely necessary that downtime is kept to theminimum. The system provides this through a hardwarefacility called the system fault tolerance. The system isconfigured with one disc drive and a second disc drive, ashadow drive, attached to the first. The second driveautomatically and continuously keeps a real-time mirrorimage copy ofthe database ofthe live disc. Should the livedisc malfunction, this second disc drive automaticallytakes over and services the laboratory network at normalthroughput. The system runs 24 hours and a completebackup is done every day from the shadow disc. With thisfeature, operators can continue to use the system duringbackup. It takes approximately 45 min to transfer Gb ofdata to the helical tape drive.

ArchivingFor histopathology, as results are of lifetime significance,it is always kept on-line. However, after 90 days, thedescriptive part of the text in the report is removed from

Singapore General Hospital

Oeparlmenl hllelo|),=

PAGERUN ON I0109191-1455 IIAEHATOLOGY REPORT RUN FOR 241001’31

TAN.IIWA SGII WARD 47 NRIC SD1335HALE AGE: 33 CLASS: Ol IIHIOEO: lllZ ID I01’31075600F

Z4OO:IIAOGZZII REQUEST IIA699102 RECV: Z,i100191 L35G COLLN: 24100191 UNKORDERED: FOC JR

[FUC JR)(IIEHOGItAH JR]

WOC 13.4 XIO(O)/L (4.0-10.0) RBClib 13.3 G/Ok (14.0-lO.O) IICTflCV 94.1 FL (75-96) HCIIHCIIC 32.6 G/DL (32.-36) ROWI’LT 233 XIO(9)/L (140-440) HPV[IIIFF C’i

LYHPII 15.0 (15-41) HOHO’GIIAH 73.’3 (40-75)[BLOOD FILIi

RBC COHHENT R[ICS ARE CRENATED

4.33 XIO(IZ)/L (4.5-G.3)40.7 (30-52)30.7 PG (27-32)1Z.3 (10.9-15.7)’3.4 (6.3-I0. I)

It. (2-10)

SinAapore 14ospilal Tradition of CarinB Excellence

Figure 7. Example of haematology report.

the system. For biochemistry, haematology and micro-biology, if a patient’s file has not been active for 90 days,the results are archived onto another disc. These resultscan be recalled when required.

Colour graphics

The MAGIC System offers colour graphics on the screendisplay. In addition to the regular tabular types of datapresentation,’ data can be presented in graphical form, forexample line graphs, point graphs and bar graphs.

It is believed that graphs will help improve the qualityand efficiency of care delivered to the patient, because itcan provide a visualization of patterns and relationshipsfor diagnosis and treatment. Progression, regression andsubtle changes in values are more easily perceivedgraphically than from a table of values.

Windowing

The use of winows or pop-up screens is another usefulfeature of the MAGIC system. Windows allow theoperator to focus attention to options he or she is unsureabout, and helpful instructions are displayed so thatinput can be continued without having to leave thescreen. The facility saves the operator valuable hours incomputing time.

227



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MICROBIOLOGY REPORT

NAME: CIIUA,AH LOCATION: TTSII IARO 52 NRIC: SB0751

SEX/AGC/RACE: GO CLASS: A/C#: I0291020142HDATE REC’D: 03/07/91 RM/BED:

SI’EC 11: 91:DUOOO559R SOURC’E: URINE REQ FORM: UZ5435

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E,COLI KLEB SP

ST STAHPICILLIN

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Figure 8. Example of a microbiology report.

Quality-control monitoring routine

In addition to the usual quality-control (QC) routines ofdaily QC logs, summaries of Qc specimen values overselected time frames, Levy-Jenning plots, there is also aQC routine called the ’Multi-Rule Quality ControlRoutine’. With this routine, QC specimens are given userdefined pre-set limits (for instance mean + 2 S.D.).Each time such a QC specimen is run with a batch ofpatients’ specimens, the QC test value can be viewedeither on-line through the automated instrument on-lineviewing mode or through worksheet entering proceduresto verify the validity of the batch results. This featureallows real-time on-line quality control.

Automated instrument downloading

The automated instrument routine allows capture ofresults on-line as they emerge from the automatedinstruments. Both haematology and biochemistry haveall their fully automated instruments linked on-line to thecomputer. These instruments handle approximately 80%of the workload of these laboratories. The speed ofacquisition and processing of data has been greatlyincreased, and errors caused by manual transcription oflarge volumes of laboratory data have been eliminatedwith the direct link of the MAGIC System to the hostIBM. More than 80% of the reports for haematology andbiochemistry are printed directly in the wards within 8 h,the majority within 4 h of test requests.

228


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HISTOPATHOLOGY

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SUBMITTING

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30/08/91

TISSUESUTERUS CERVIX, OVARY

DESCRIPTIONUterus, cervix left ovary. Cervix measuring appearsunremarkable, the partially bisected measuring

Endometrium is thin. The post uterine diffusewhorled white about Left fallopianovary measuring (Cervix-2,endometrium-l,whorled whitearea-2,tube-l,ovary-2). (DR. CHEW).

MICROSCOPIC DESCRIPTIONshowCervix chronic cervicitis with squamous metaplasia.

Endometrium

Myometrium

DIAGNOSISTHLSO Specimen

basal endometrium with focal’pseudodecidualised

Shows islands o endometrial glands andinterspersed amongst hypertrophic smooth musclefibre bundles. Islands of endometrial glands and

also in the ragged thesurface posterior uterine wall.

left fallopian tube is unremarkable.The left ovary shows corpora albicantes, fewwhich have central cystic

definite endometrial cysts

Adenomyosis.

Pathologist,:

(D.)T82900:M76510 <ANI>

o/o9/91PAGE (END)

Tradition CarinB Exceflence

Figure 9. Example of a histopathology report.

I00 baud

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Med’+/-ech _Mde

Prin+/-ers

,TTSH

LegendAH Alexandra HospitalTPH Toa Payoh Hosplta[TTSN Tan Took Sen9 Hospi+/-atKKH Kandan9 Kerbau Hospi+/-L

Figure 10. Transmission of laboratory reports to four other majorhospitals using modems, telephone lines and on-site printingterminals.

A special feature called the instrument download routineallows the operator to send specimen and test requestsdirectly to an instrument which has a two-way communi-cation with the computer. The user may download dataeither for individual specimens or for an entire batch.This feature allows automatching of results to the correctspecimen for immediate transmission.


Discussion

Several important factors have contributed to the suc-cessful implementation of the on-line laboratorycomputer. Prior experience of the staff of biochemistryand haematology was an advantage as they had becomefamiliar with the concept and use of a system for dataprocessing: this experience reduced the time needed forlearning to live with the new system.

A familiarization progamme was offered to staff of thesections that were being introduced to the laboratorycomputer for the first time. Since staffinterest, motivationand co-operation is essential for any new system imple-mentation, great care was taken to ensure that allmembers ofstaffwere kept fully briefed as the implemen-tation programme developed. Staffco-operation, in termsof suggestions and criticism, was actively encouraged andthis approach generated a great deal of enthusiasm andresulted in ready acceptance.

The ease of hardware operation, the user-friendliness ofthe various application programs and the good perfor-mance of the system were important in the gaining ofconfidence and acceptance of the laboratory staff.

All programs produced information and instructions insimple English on screen; in addition, requests fordirection are displayed whenever more than one optionoccurs during a run.

The MAGIC System described has significantlyimproved laboratory mangement and quality ofwork andhas resulted in enhanced efficiency and productivity.

References

1. TAN, I. K., TAY, B. S., LIM, S. H., TAW, C. K. and No,M.C., Electronic-data-processing in the clinical bio-chemistry laboratories in Singapore. In Proceedings of the9th Malaysia-Singapore Congress of Medicine (1974).

2. TAN, I. K., TAr, B. S., LIM, S. H., TAW, C. K. and No,M. C., Singapore Medical Journal, 16 1975), 166.

3. TAN, I. K., Israel Journal of Medical Science, 13 (1977), 20.4. TAN, I. K. and JACOB, E., Annals of the Academy of Medicine

Singapore, 11 (1982), 424.5. TAN, I. K., JACOB, E. and LM, S. H., Rubin, M. (Ed.)

Computerization and Automation in Health Facilities (CRC Press,Florida, 1984), 111.

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10. JOMAXN, P. A. and OwwN, J. A., Annals of Clinical Bio-chemistry, 15 (1978), 276.

11. MORGAN, L. M., McCONNELL, G., CHANDLER, E. andWFLSI-IAN, S. G., Annals of Clinical Biochemistry, 17 (1980),47.

12. RAPPOPORT, A. E., In Proceedings of the XI InternationalCongress of Clinical Chemistry (Vienna, 1982), 1357.

13. ROESLF.I-ENGIHARDV, A., In Proceedings of the XI Inter-national Congress of Clinical Chemistry (Vienna, 1982),1363.

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15. HOHENWALLNER, W., WIMMER, E. and SOMMER, R., InProceedings of the XI International Congress of ClinicalChemistry (Vienna, 1982), 1437.

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