Note: This is a postgraduate topic. I have included it here simply because I think it is best to introduce this topic early to medical students who have a keen interest in computers. They may think that they may have to forego their interest in computers when they take up medicine. They don't have to. Computers are widely used in Medicine today. This post is an introductory article about the use of computers in the clinical laboratory. There is a good review article in 2014 in the external links below that gives a clear overview of what is to come in the future. There is an article that highlights precautions when interpreting diagnostic tests and when using algorithms.
The computer revolution is among the fastest we have to date, competing with other revolutions in the car industry, electronics industry, weapons industry, space industry, drug discovery industry, food industry and fashion industry. There are countless industries going on and evolving, some which we fail to update ourselves with.
Let's look at computers. Where are we today with computers?
Malaysia is an ancient land mass, but a young developing nation. It is considered old enough, but young enough to still absorb new technologies. Malaysia has evolved and is still evolving. One of the fastest evolving industries in Malaysia today is the use of computers in its clinical laboratories (clinical labs).
The hospital and its associated labs
Some hospitals are big and some are small. Big established hospitals have at least 8 associated clinical labs and 8 specialist clinics in addition to the emergency rooms, day wards, hospital wards, recovery rooms and operation theatres. Let's not forget the mortuary.
Clinical labs
We will focus on the clinical biochemistry lab (USA), also called chemical pathology lab (UK). This may be lumped together with other disciplines and called pathology lab. We will focus on clinical biochemistry lab services.
Lab technologists
The people who perform the laboratory tests in clinical labs are referred to as medical laboratory technologists (MLTs), med techs, lab technologists or just technologists. They have undergone 4 years laboratory training in at least 8 clinical lab disciplines at a local university. They are diploma graduates. Their experiences working in the labs are most precious, but hardly tapped and discussed.
Number of tests
Each lab technologist performs many tests a day, on many instruments and chemistry analyzers in the lab. The technologists then enter the lab results (lab data) into the computers in the lab, or the computers capture lab results automatically.
The number of tests have increased as a result of 2 things - more tests are available now (bigger test selection) and more patients have come to hospital (better hospital awareness).
Big hospitals have well established clinical biochemistry labs which perform a minimum of 20,000 tests per month. As the number of tests have increased, so have the pressure to perform these tests on time and return the test results to the doctor on time.
Turnaround time (TAT)
Is there such a thing as 'right on time' or 'just in time'? That is a subjective notion. In the computerised clinical labs, every step of the workflow and work process is TIMED. Yes, everything is timed.
How is everything timed in the clinical lab? The patient is marked the minute he/she registers at the hospital counter. A set of barcodes is printed that tells his hospital details. It is his hospital ID and digital hospital bookmark. The barcode travels everywhere the patient goes in the hospital.
When his blood specimens are taken and sent to the lab for analysis, the blood sampling time and test requisition times are entered into the computer.
When the specimens reach the clinical lab, another time is stamped (arrival time). The the specimens are processed to obtain the samples needed for analyses. Sometimes the original tubes (primary tubes) are used on the analyzers, without a need for processing and tube transfer.
When the test results are ready, a time is recorded. The test results are conveyed to the computer system in the lab, and travels to the doctor who requested the test. However, the doctor may be away after hours or gone for 3 months's holiday. In this case, the computer system stores the test results till he returns to have a look at them. Or another doctor who is replacing him can take a look at the patient and the patient's data. This is fine.
The average turnaround time (TAT) for a clinical lab data is 1 hour. This means the doctor and the patient has to wait a minimum of 1 hour before the test results are ready. Why is it 1 hour and not less? How can it be less? It can't be less because it takes time to bring the specimen from the ward or clinic to the clinical lab. It takes time for the technologists to centrifuge and separate serum or plasma from blood, unless blood can be used for tests. It is takes time to perform a test. Once the results are ready, they have to be verified by a doctor in the clinical lab, before the same results are flash on the computer screen in the doctor's office.
Clinical chemical pathologists
Who are these people? The clinical chemical pathologists are doctors who have specialised in Chemical Pathology for their postgraduate master's degree. This postgraduate degree is called Master of Medicine in Chemical Pathology (MPath Chemical Pathology), or MPath Chem Path. It is highly sought as it enables the qualified doctor to work in the clinical chemical pathology lab.
Previously, scientists with PhD were running the lab as they have sufficient lab training and 10 years labwork or labbench experience. However, the Health Ministry (Kementerian Kesihatan Malaysia, KKM) had passed a memo that only doctors can run the clinical chemistry lab. So the MPath Chem Path doctors rule the lab. They verify the test results before the result are released to the doctors in the clinics and wards.
I think this is a waste of resources and untapped expertise as PhD are better trained at labwork and the Chemical Pathologists are better at interpreting the test results. They should be working side by side. Unfortunately, this is not the case. So this is a sad thing in reality.
Computers in the labs
Why are there computers in the lab? They are useless unless put to work effectively. The computers have to run on a suitable computer program (software). The computer program be designed and made in-house or bought off the shelf from a computer vendor. It all boils down to how much money the hospital is willing to invest in a computer system.
Cost
A complete computer system is expensive. Costs run from a minimum of RM1 million. Before the purchase is made, an intensive plan of action and numerous meetings and resolutions have been made. Once the decision made is to purchase, then everything must work according to plan (roll-out) until it is time to give the password and magic to the hospital administrator (actually the chief IT person).
Incurring expenses
Nothing runs well and the same for years. Things will breakdown. The computer cables may get chewed up by rodents in the roof and underground. Floods may soak and damage the computer cables. Fire may damage the cables. Too many cables criss-crossing all over the hospital can get mixed up and confused. Maintenance checks need to be in place. A backup system needs to be in place. The mess knows no end. Managing and maintaining a computer system for the hospital can be fun or otherwise. There are challenges.
Mark of excellence
The computer system is an expert system. It is a wonderful machine as it can do wonders. An in-house system that is flexible and expandable is better than a bought system that is restrictive but yet expandable with added cost. A hospital with a good IT team that can design, make, implement, run, manage, expand, rebuild, refine, rerun, ... its computer system is the best for any hospital to have. This IT team of the hospital can become the IT company and serve the wider community. It is bad if a vendor has to come in to offer a complete computer system for a public hospital. That is how I see things.
External links:
1. Test ordering (test requisition) / investigation protocols
(i) Inappropriate tests ordering by doctors vs what the lab thinks is appropriate
Antonin Jabor and Vladimir Palicka
Rational use of clinical chemistry investigations: form diagnoses to processes.
Ann Clin Biochem 1998 35: 351-353
Personal View
http://journals.sagepub.com/doi/pdf/10.1177/000456329803500302
(ii) Static vs dynamic rules for investigative protocol for patients undergoing liver transplant
PG Nightingale, M Peters, D Mutimer, JM Neuberger
Effects of a computerised protocol management system on ordering of clinical tests.
Quality in Health Care 1999;3:23-28
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1055178/pdf/qualhc00010-0027.pdf
2. Precautions in diagnostic data interpretation and when using algorithms
Mauro Panteghini
The Future of Laboratory Medicine: Understanding the New Pressures.
Clin Biochem Rev 2004 Nov 25(4): 207-215
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1934959/
3. Pathology & informatics
Richard G Jones, Owen A Johnson, Gifford Batstone
Informatics and the Clinical Laboratory.
Clin Biochem Rev 35 (3) 2014: 177-193
Review Article
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4204239/pdf/cbr-35-177.pdf
Hagenbichler E, Klinger D, Neuner L, Pfeiffer K-P
Automated computer-assisted evaluation of diagnosis-and-procedure-reports in Austrian hospitals.
Jorgerstr, 3/35, A-1170 Wien: AKH Linz, A-4020 Linz:
Inst. f. Biostatistik, Univ.-Klinik Innsbruck, A-6020 Innsbruck, Austria.
In: Medical Informatics Europe '99, edited by Peter Kokol, Biaz Zupan, Janez Stare
G. Stephens et al. Computerised resources.
In: Medical Informatics Europe '99, edited by Peter Kokol, Biaz Zupan, Janez Stare
- OpenLabs (by St Jame's Hospital, Dublin)
- Scoringprogramm Version 1.2 for 1997
- Scoringprogramm Version 3.1 for 1999 http://www.bmags.gv.at
- Intensivscoringprogramm Version 2.1 for 1999 for ICU
Marjan Premik, Vladimir Mayer, Marina Kuzman, Miroslav Mayer
Bed Utilization Performances of Slovenian and Croatian Acute Hospital Systems.
University of Ljubljana, Faculty of Medicine, Institute of Social Medicine & Croatian National Institute of Public Health. In: Yates J. ed. Hospital Beds: A Problem for Diagnosis and Management? Heinemann Medical Books Ltd, London 1982, IV.
- Calculating 4 hospital bed performance indicators:
- length of stay: 365 * bed occupancy/discharges + deaths
- throughput: discharges + deaths/available beds
- turnover interval: (available beds - occupied beds) * 365/discharges + deaths
- % bed emptiness: (available beds - occupied beds)/available beds * 100
- The Barber-Johnson's method of pictorial representation of hospital bed use.
M.N. Sarkies, K.-A. Bowles, E.H. Skinner, D. Mitchell, R. Haas, M. Ho, K. Salter, K. May, D. Markham, L. O’Brien, S. Plumb, and T.P. Haines.
Data Collection Methods in Health Services Research.
Hospital Length of Stay and Discharge Destination.
Appl Clin Inform. 2015; 6(1): 96–109.
(Research article)
Paul Wolotsky
Clinical Laboratory Computer Systems
Proc Annu Symp Comput Appl Med Care 1979 Oct 17 : 550-551
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231988/pdf/procascamc00013-0562.pdf
Paul Wolotsky
Computerisation of Clinical Laboratories.
Proc Annu Symp Comput Appl Med Care 1979 Oct 17 : 552-557
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231915/pdf/procascamc00013-0564.pdf
C Block
Benefits and limitations of computerised laboratory data.
J Clin Pathol. 1997 Jun 50(6): 448-449
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC499959/pdf/jclinpath00255-0002.pdf
5. Consumer Protection
Austrian Federal Ministry of Labor, Social Affairs and Consumer Protection.
https://www.sozialministerium.at/site/
