Journal of Automatic Chemistry, Vol. 14, No. 6 (November-December 1992), pp. 223-229 Integrated laboratory information system in a large hospital laboratory in Singapore

Edward Jacob, It-Koon Tan, Kim-Seng Chua and running on Medical Information tech- See-Heng Lim nology (Meditech) Software written in Meditech Inter- Clinical Biockemistry Laboratories, Department of Pathology, Singapore General pretive Information System (MIIS). Two identical on- Hospital, Outram Road, Singapore 0316, Singapore line systems were purchased, one in 1983 to serve the haematology laboratories and the 24-hour emergency/ This describes an to the computerization paper integrated approach routine biochemistry laboratories sited on the same floor all medicine and of major disciplines of laboratory pathology. within and another in to serve the main Installed the General SGH, 1984, in Department of Pathology, Singapore biochemistry laboratories of the Department of Pathology Hospital the system discussed comprises a (SGH), which is housed in a separate building some distance RISC-based Aviion 6200 computer and Meditech away. The other laboratories at SGH were not ready for MAGIC The has been with the software. system interfaced computerization. hospital host IBM computer and supports patient information result management, and compila- transfer, reporting, phlebotomy The annual number of tests in the biochemistry and tion and The main of laboratory financial management reports. haematology departments was 820000 and 700000, the include: on-line and acquisition functions of system off-line of respectively, when the two computer systems were patient and test data; single information preparation of The systems were linked modems cumulative within and between purchased. through reports; transmission of reports and telephone lines and have performed well 18]. laboratories; instantaneous provision of data in response to telephone enquiries; calculations quality control of With a background of many years of laboratory comput- statistics and indices; and billing lists. productivity generation of ing experience in the field of biochemistry and haema- The computer enables to be on patient tests results reports provided tology, it was decided in early 1990 to computerize all the in individual wards, at various specialist out-patient clinics, and in divisions in the Department of Pathology. It was decided the Accident and the SGH through the Emergency Department of that a single large computer system could cater for all of IBM as well as to remote installed at several mainframe, printers the divisions. This was considered to be a better other approach major hospitals. than using small individual systems for each separate The use the MAGIC integrated of laboratory information discipline--for example the various divisions of the system has resulted in a increase in laboratory efficiency significant Department would be able to share the same patient and productivity. database (see table 1).

Introduction Configuration of the newly-acquired MAGIC system

The Department of Pathology of the Singapore General The group had many years' experience with staff with the Hospital (SGH) provides both routine and specialized Meditech software and it was felt that this outweighed laboratory services to hospitals and clinics, and to any small advantages that any other system could offer government ministries. The Department acts as the and decided on an upgraded design from Meditech, Inc. reference and training centre for laboratory medicine in called the MAGIC System. Singapore and the region. The system consists of a Data General RISC based An off-line minicomputer system was installed in the AVIION 6200 Series Computer with 16 MB memory, Biochemistry Division of the Department of Pathology in 1974; the workload was then 426000 tests per annum. Table 1. Number of specimens processed in 1990. The off-line system, which comprised a NOVA 1220 computer with 48KB memory, paper tape reader, several Division No. of specimens teletypes and printers, served the laboratories well for about 10 years [1-5]. Biochemistry 443 132 Haematology 275 158 With a doubling of the workload to about 820 000 tests Diagnostic Bacteriology 224 783 per annum in 1980, and the aging of the minicomputer, Microbiology 100 351 213 295 it was felt that a new was needed. An Serology/Immunology computer Virology 74845 exhaustive study of laboratory on the market, Histopatho!ogy 50 743 and the experiences of other hospital laboratory Cytology 59 100 computer users [6-17], led to the final choice of an interactive multi-user database management operation Total 441 407 system. The computer was a Data General Eclipse S/140

223 0142-0453/92 $10.00 () 1992 Taylor & Francis Ltd. E. Jacob et al. Integrated laboratory information system

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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, Ethernet Ethernet bandwidth of 10 MBit/s; it will be upgraded to a interface, 24 units of communication servers providing 10 Fibre Distributed Data Interface (FDDI), with a speed of serial ports each connected to the Ethernet Local Area 100 MBit/s, in the future. Network. The 3 GB disc storage is made up of three units of GB disc drive. It is organized with one unit as the master, one unit as the shadow and one for archiving. The Software system layout is shown in figure 1. The is the MAGIC Operating System, The CPU, the console VDU, the live and archival disc designed by Meditech. The computer language is the drives and the helical tape drive are housed in the MAGIC language and the application programme Computer room of the Department. Cables on an modules which are in use are as follows: Ethernet network link terminals from the various labora- and tories to the CPU. (1) Laboratory--for biochemistry, haematology nuclear medicine. (2) Microbiology--for diagnostic and enteric bacteri- Networking ology, serology, immunology and virology. As the laboratories of the various disciplines are distri- (3) Anatomical pathology--for histopathology and buted over a wide area within the department, it was cytopathology. necessary to connect all the peripheral devices in each (4) Accounts receivable--for finance and billing. laboratory to the central CPU through a cable network. A cable system to link all the peripherals within the hospital The software is an integrated package running on a was adopted as it allowed higher speed of communication common database. (19-2 baud rate) and minimal incremental cost for additional links in the future (see figure 2). To serve the hospital's future needs a fibre-optic cable was laid in the Features of the MAGIC computer operations underground tunnel of the hospital (see figure 3). Each section of the Department uses the computer The specifications of the fibre-optic cable are: four core, independently and is responsible for its own patient data multimode and 62"5/125. It is, however, running at input, request input, workload production, result entry,

224 E. Jacob et al. Integrated laboratory information system

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Colm Finance/Client Service Serology Server (Room 02-01) (Room 2-22) Biochemistry Computer Room Histopatho[ogy (Room 3-4) Data Typlng Area Microblotogy (Room 2-18) Computer Processing Area (Room 1-13)

Figure 2. Cable system linking all the computer peripherals in the various buildings of the hospital. report printing, record purging and archiving, statistical changes, discharges are entered at the nursing stations analyses and workload production. The various labora- into the host IBM computer. These transactions are tory disciplines have been alloted their own independent automatically passed to the laboratory PC, which then disc space in the live and archival disc. Access to each updates the Meditech's patient database (see figure 4). group's disc space is by separate passwords. This is an excellent feature because all laboratories have real-time updated patient demographic data; ward The integrated package provides a common database for enquiries and results reporting are now faster and more demographic data. This has resulted in a considerable efficient. saving in manpower in terms ofdata entry: once patient is admitted into the system, this information can be Meditech to IBM result reporting accessed by any of the laboratory users. The laboratory system.is linked to the Hospital IBM 3090 Some customization had to be done to suit local System for demographic transfer--the link is through a requirements: such additional fields as requisition PC. All test results from the laboratory system, after numbers, race, financial class and service codes have verification, are transmitted via a microcomputer been added. New programs were written for workload through a protocol converter to the IBM host. statistics for accumulating the number of tests done in each laboratory. The results are initially downloaded to the PC and a hard copy is printed for verification. Unsatisfactory results can be at this and the rest transmitted to the demographic data suppressed stage Transfer of host computer. The IBM computer then transmits all Patients admitted to SGH have their demographic data results to IBM printers located in the wards (see keyed into the Hospital's host IBM computer Patient figure 5). This has improved the turnaround time for Care System (PCS). This information is downloaded on a result reporting. Reports are generated throughout the real-time basis to a personal computer (PC) sited in the day, and ward staff have been given the facility of laboratory. The data are processed and then uploaded to initiating a printout of reports through the ward the Meditech's patient database. Ward transfers, bed terminals.

225 E. Jacob et al. Integrated laboratory information system

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ard TransFers Report formats Hospta[ MAGIC *--I Bed Swaps The software allows for composite reports Host Computer featuring results for a patient from all laboratory D,scharges disciplines. The present arrangement, however, is for each discipline to generate their own separate reports.

downLoads Laboratory There are a number of options for the format of reporting Module Nedltech by the system for the various laboratory disciplines. Laboratory Personal Nicrobiotogy Figures 6-9 are examples of single reports generated by ModuLe Computer Patient the system for some of the laboratories. The histopath- Data Base ology division was one of the last to be computerized but PathoLogy Nodute it has made considerable gains. A large part of histology reporting is in text form and requires word processing; this is done efficiently through the MAGIC software. The Figure 4. Automatic transfer ofpatient demographic information system uses a laser printer and reports are neat and well from the hospital mainframe computer to the laboratory infor- presented. A major bonus is automatic SNOMED coding mation system through a personal computer. of diagnosis. Each division of the Department selects its reports based on prefixes created. Biochemistry and SGH. haematology carry age-specific reference intervals MeLllCh .I I prints reports Computer reports -I reports Computer reports and delta checks and panic values are used to highlight, or flag, abnormal results. Free text is allowed in the comment field to describe, for haemolysis, prints example, unapproved Ustlng turbidity Or to alert the clinician that the specimen was inappropriate and a repeat specimen was desirable.

Lis;ing Result reporting to outside clients Prlnrs Laboratory reports are transmitted via telephone lines Figure 5. Transmission of laboratory test results from the through modems to be printed at remote printers located laboratory information to the hospital mainframe computerfor the on site in other hospitals and the premises of clients who printing of reports within the wards and out-patient departments. are important users of the Department's services (see 226 E. Jacob et al. Integrated laboratory information system r Singapore General Hospital Singapore General Hospital Oeparlmenl hllelo|),= Oepartmenl Pathology: K PAGE RUN ON I0109191-1455 IIAEHATOLOGY REPORT RUN FOR 241001'31 TAN.IIWA SGII WARD 47 NRIC SD1335 Singapore General Hospital PAGE HALE AGE: 33 CLASS: Ol IIHIOEO: lllZ ID I01'31075600F RUN ON 16109/91-1500 BIOCHEMISTRY REPORT RUN FOR 16109191 Z4OO:IIAOGZZII REQUEST IIA699102 RECV: Z,i100191 L35G COLLN: 24100191 UNK A,B SGII HARD 48 NRIC U1234567 ORDERED: FOC JR MALE AGE: 59 CLASS: RM/BED: ID C162 [FUC JR) (IIEHOGItAH JR] 1609:BC0001S REQUEST BC543276 RECV: 16/09191UNK COLLN: IGI09/91UNK (4.5-G.3) ORDERED: UE,CRE.GLU, WOC 13.4 XIO(O)/L (4.0-10.0) RBC 4.33 XIO(IZ)/L (CALCIUM,P04), LFT/ALT/AST, LDH, CIIO,TG,IIDL,LDL, lib 13.3 G/Ok (14.0-lO.O) IICT 40.7 (30-52) PROSTATE SP AG, ICD, CEA, (T3UoT4,FTI). ALPIIAFOETO PROT flCV 94.1 FL (75-96) HCII 30.7 PG (27-32) HCIIC 32.6 G/DL (32.-36) ROW 1Z.3 (10.9-15.7) [UE,CRE,GLU] I'LT 233 XIO(9)/L (140-440) HPV '3.4 (6.3-I0. I) UREA 5.6 [IIIFF C'i MMOL/L (2.8-7.7) (15-41) HOHO' It. (2-10) SODIUM 1420 MMOL/L (135-145) LYHPII 15.0 POTASSIUM GIIAH 73.'3 (40-75) 4.90 MMOLIL (3.3-4.9) [BLOOD FILIi CIILORIDE 106fl MHOL/L (96-108) RBC COHHENT R[ICS ARE CRENATED GLUCOSE 9.00 MMOL/L (3.1-10.0) FASTING (3.1-6.6) CREATININE 9111 [(CALCIUM,P04)) UHOL/L (44-141) 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 <5.17 HDL CIIOLESTEROL I. 290 MHOL/L (0.72-1.68) TRIGLYCERIDE I. 14 BMOL/L (0.56-2.09) LDL CHOLESTEROL 5.37 MMOL/L -5.17) DESIRABLE LEVEL <3.33 PROSTATE SP AG I.O UG/L (0-4.0) ICD 7.7 U/L (2-9) CEA 2.50 UG/L (0.5-3.5) [(T3U,T4,FTI)] T3 RESIN UPTAKE 106 (77-129) TIIYROXlgE (T4) 75 NHOLIL (59-155) FTI 7.9 (4.6-11.6) ALPHAFOETO PROT 3.2 UGIL (I-I0) SinAapore 14ospilal Tradition of CarinB Excellence

Figure 7. Example of haematology report.

Singapore Hospital A Tradition of Caring, & Excellence Sinsalx)re the system. For biochemistry, haematology and micro- biology, if a patient's file has not been active for 90 days, Figure 6. Example of a biochemistry report. the results are archived onto another disc. These results can be recalled when required. figure 10). This has improved the turn-around-time for result reporting and reduced the frequent telephone enquiries for the tracing of results. Colour graphics Shadowing (or mirroring) The MAGIC System offers colour graphics on the screen display. In addition to the regular tabular types of data is shared all it As the computer by laboratory disciplines presentation,' data can be presented in graphical form, for is absolutely necessary that downtime is kept to the example line graphs, point graphs and bar graphs. minimum. The system provides this through a hardware called the fault tolerance. The is facility system system It is believed that graphs will help improve the quality one disc drive and a second disc a configured with drive, and efficiency of care delivered to the patient, because it shadow attached to the first. The second drive drive, can provide a visualization of patterns and relationships and a real-time mirror automatically continuously keeps for diagnosis and treatment. Progression, regression and the database of the live disc. Should the live image copy of subtle changes in values are more easily perceived disc this second disc drive malfunction, automatically graphically than from a table of values. takes over and services the laboratory network at normal throughput. The system runs 24 hours and a complete backup is done every day from the shadow disc. With this feature, operators can continue to use the system during Windowing backup. It takes approximately 45 min to transfer Gb of The use of winows or pop-up screens is another useful data to the helical tape drive. feature of the MAGIC system. Windows allow the operator to focus attention to options he or she is unsure Archiving about, and helpful instructions are displayed so that For histopathology, as results are of lifetime significance, input can be continued without having to leave the it is always kept on-line. However, after 90 days, the screen. The facility saves the operator valuable hours in descriptive part of the text in the report is removed from computing time.

227 E. Jacob et al. Integrated laboratory information system

Singapore General Hospital Singapore General Hospital

Dcparlmcn! P,alltolul.),: parlmenlofPalholoyTelex:X$200291'^TL^U

HISTOPATHOLOGY DEPARTHERT OF PATIIOLOGY BIOPSY HOSPITAL MICROBIOLOGY REPORT PATIENT TEO,GEOK DEPT NRIC SJ011 CLASS B1 NAME: CIIUA,AH LOCATION: TTSII IARO 52 NRIC: SB0751 RACE/SEX/AGE IF 14 ACCOUNT N: I0191071396A SEX/AGC/RACE: GO CLASS: A/C#: I0291020142H SUBMITTING 30/08/91 DATE REC'D: 03/07/91 RM/BED: SI'EC 11: 91:DUOOO559R SOURC'E: URINE REQ FORM: UZ5435 TISSUES UTERUS CERVIX, OVARY ORDERED: UR DII'SLIDE' DESCRIPTION Uterus, cervix left ovary. Cervix measuring appears unremarkable, the partially bisected measuring URINE CULT DIP-SLIDE Endometrium is thin. The post uterine diffuse DOUBTFUL SIGNIFICANT whorled white about Left fallopian ovary measuring (Cervix-2,endometrium-l,whorled white VIABLE COUNT >i00,000 CFU/ML area-2,tube-l,ovary-2). (DR. CHEW). (I) ESCIIERICIIIA COLt MICROSCOPIC Cervix DESCRIPTIONshow chronic cervicitis with squamous metaplasia. (2) KLEDSIELLA SPECIES Endometrium basal endometrium with focal'pseudodecidualised E,COLI KLEB SP ST ST Myometrium Shows islands o endometrial glands and AHPICILLIN interspersed amongst hypertrophic smooth muscle fibre bundles. Islands of endometrial glands and GENTA also in the ragged the NALI ACID surface posterior uterine wall. COTR IMOX left fallopian tube is unremarkable. ITROFU The left ovary shows corpora albicantes, few which have central cystic definite endometrial cysts DIAGNOSIS THLSO Specimen Adenomyosis.

Pathologist,:

(D.) T82900:M76510 o/o9/91 PAGE (END)

Tradition CarinB Exceflence

Sing,pore Hospila| Tradition of Caring Excellence Figure 9. Example of a histopathology report. Figure 8. Example of a microbiology report.

Quality-control monitoring routine In addition to the usual quality-control (QC) routines of daily QC logs, summaries of Qc specimen values over Prin+/-ers I00 baud selected time frames, Levy-Jenning plots, there is also a ,TTSH QC routine called the 'Multi-Rule Quality Control TAS +/-elephone llne Routine'. With this routine, QC specimens are given user Med'+/-ech defined pre-set limits (for instance mean + 2 S.D.). _Mde Each time such a QC specimen is run with a batch of patients' specimens, the QC test value can be viewed either on-line through the automated instrument on-line viewing mode or through worksheet entering procedures to verify the validity of the batch results. This feature allows real-time on-line quality control. Legend AH Alexandra Hospital TPH Toa Payoh Hosplta[ TTSN Tan Took Sen9 Hospi+/-at KKH Kandan9 Kerbau Hospi+/-L Automated instrument downloading The automated instrument routine allows capture of Figure 10. Transmission of laboratory reports to four other major results on-line as they emerge from the automated hospitals using modems, telephone lines and on-site printing instruments. Both haematology and biochemistry have terminals. all their fully automated instruments linked on-line to the computer. These instruments handle approximately 80% of the workload of these laboratories. The speed of acquisition and processing of data has been greatly A special feature called the instrument download routine increased, and errors caused by manual transcription of allows the operator to send specimen and test requests large volumes of laboratory data have been eliminated directly to an instrument which has a two-way communi- with the direct link of the MAGIC System to the host cation with the computer. The user may download data IBM. More than 80% of the reports for haematology and either for individual specimens or for an entire batch. biochemistry are printed directly in the wards within 8 h, This feature allows automatching of results to the correct the majority within 4 h of test requests. specimen for immediate transmission.

228 E. Jacob et al. Integrated laboratory information system

Discussion 2. TAN, I. K., TAr, B. S., LIM, S. H., TAW, C. K. and No, M. C., Singapore Medical Journal, 16 1975), 166. Several important factors have contributed to the suc- 3. TAN, I. K., Israel Journal of Medical Science, 13 (1977), 20. cessful implementation of the on-line laboratory 4. TAN, I. K. and JACOB, E., Annals of the Academy of Medicine computer. Prior experience of the staff of biochemistry Singapore, 11 (1982), 424. and haematology was an advantage as they had become 5. TAN, I. K., JACOB, E. and LM, S. H., Rubin, M. (Ed.) familiar with the concept and use of a system for data Computerization and Automation in Health Facilities (CRC Press, processing: this experience reduced the time needed for Florida, 1984), 111. learning to live with the new system. 6. ABSON, J., PRALL, A. and WoovvoN, I. D. P., Annals of Clinical Biochemistry, 14 307. A familiarization progamme was offered to staff of the (1977), sections that were being introduced to the laboratory 7. ABSON, J., PRALL, A. and WoovvoN, I. D. P., Annals of computer for the first time. Since staff interest, motivation Clinical Biochemistry, 14 (1977), 315. g. and co-operation is essential for any new system imple- ABSON, J., PRALL, A. and WoovvoN, I. D. P., Annals of Clinical 14 mentation, great care was taken to ensure that all Biochemistry, (1977), 323. members ofstaffwere kept fully briefed as the implemen- 9. UNDIILL, P. E. and GBSON, P., Annals of Clinical Bio- tation programme developed. Staff co-operation, in terms chemistry, 15 (1978), 235. of suggestions and criticism, was actively encouraged and 10. JOMAXN, P. A. and OwwN, J. A., Annals of Clinical Bio- this approach generated a great deal of enthusiasm and chemistry, 15 (1978), 276. resulted in ready acceptance. 11. MORGAN, L. M., McCONNELL, G., CHANDLER, E. and WFLSI-IAN, S. G., Annals of Clinical Biochemistry, 17 (1980), The ease of hardware operation, the user-friendliness of 47. the various application programs and the good perfor- 12. RAPPOPORT, A. E., In Proceedings of the XI International mance of the system were important in the gaining of Congress of Clinical Chemistry (Vienna, 1982), 1357. confidence and acceptance of the laboratory staff. 13. ROESLF.I-ENGIHARDV, A., In Proceedings of the XI Inter- All information and instructions in national Congress of Clinical Chemistry (Vienna, 1982), programs produced 1363. simple English on screen; in addition, requests for 14. In of the XI International direction are displayed whenever more than one option JAROSCH, E., Proceedings Congress of Clinical Chemistry (Vienna, 1982), 1431. occurs during a run. 15. HOHENWALLNER, W., WIMMER, E. and SOMMER, R., In The MAGIC System described has significantly Proceedings of the XI International Congress of Clinical improved laboratory mangement and quality of work and Chemistry (Vienna, 1982), 1437. has resulted in enhanced efficiency and productivity. 16. NIEDERER, R., FLURY, R. and KELLER, H., In Proceedings of the XI International Congress of Clinical Chemistry References (Vienna, 1982), 1443. 17. FLYNN, F. V., In Albert K. G. M. M. (Ed.), Recent Advances 1. TAN, I. K., TAY, B. S., LIM, S. H., TAW, C. K. and No, in Clinical Biochemistry (1978), 255. M.C., Electronic-data-processing in the clinical bio- g. TAN, I. K., In Yu, M. (Ed.), Annual Report of the chemistry laboratories in Singapore. In Proceedings of the Department of Pathology (Ministry of Health Singapore, 9th Malaysia-Singapore Congress of Medicine (1974). 1983), 20.

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