Clinical laboratory and expert system]

Computer-based expert systems are designed to incorporate the knowledge of a human expert such that the computer program will solve problems in a manner similar to the human expert. The systems can be applied fruitfully to many phases of the laboratory testing, including order entry, specimen collection, analysis, result verification, and reporting. Interpretive reporting by means of expert systems is useful for influencing physician's use of laboratory and they offer potential help for clinical decision making. Although much of the early work in the clinical laboratory involved stand-alone expert systems, approaches that integrate more closely with laboratory information system or hospital information system are being used. A short review on the technology of expert system with an emphasis on the roles played by clinical laboratory is made. A trial system dealing with thyroid diseases, based on interpretation of hormonal levels (TSH, Total and Free T3, T4), is described.     

Economic and organizational impact of a clinical decision support system on laboratory test ordering

Background

We studied the impact of a clinical decision support system (CDSS) implemented in a few wards of two Italian health care organizations on the ordering of redundant laboratory tests under different perspectives: (1) analysis of the volume of tests, (2) cost analysis, (3) end-user satisfaction before and after the installation of the CDSS.

Methods

(1) and (2) were performed by comparing the ordering of laboratory tests between an intervention group of wards where a CDSS was in use and a second (control) group where a CDSS was not in use; data were compared during a 3-month period before (2014) and a 3-month period after (2015) CDSS installation. To measure end-user satisfaction (3), a questionnaire based on POESUS was administered to the medical staff.

Results

After the introduction of the CDSS, the number of laboratory tests requested decreased by 16.44% and costs decreased by 16.53% in the intervention group, versus an increase in the number of tests (+3.75%) and of costs (+1.78%) in the control group. Feedback from practice showed that the medical staff was generally satisfied with the CDSS and perceived its benefits, but they were less satisfied with its technical performance in terms of slow response time.

Conclusions

The implementation of CDSSs can have a positive impact on both the efficiency of care provision and health care costs. The experience of using a CDSS can also result in good practice to be implemented by other health care organizations, considering the positive result from the first attempt to gather the point of view of end-users in Italy.

     

The future of clinical laboratory database management system]

To assess the present status of the clinical laboratory database management system, the difference between the Clinical Laboratory Information System and Clinical Laboratory System was explained in this study. Although three kinds of database management systems (DBMS) were shown including the relational model, tree model and network model, the relational model was found to be the best DBMS for the clinical laboratory database based on our experience and developments of some clinical laboratory expert systems. As a future clinical laboratory database management system, the IC card system connected to an automatic chemical analyzer was proposed for personal health data management and a microscope/video system was proposed for dynamic data management of leukocytes or bacteria.     

Perspective of laboratory examination system for infectious disease]

The primary goal of the clinical microbiology laboratory is to provide accurate diagnostic testing and high-quality, rapidly, anytime service at the lowest cost for its customers. In regard to beginning microbiological test as one of emergency test system, the agreement among laboratory staff and the communication with practical conference among clinical divisions are needed, especially about 1. Place and time for receive, 2. Methods of handling and store, 3. Ordering system and information about patients, 4. Selection of items and method, 5. Reporting system and 6. Decision of laboratory staff. As items of microbiological test on this system, smear test, immunoserological test and auto-blood culture equipment are needed. According to the new law of infectious disease, laboratory system should be established in the cases of outbreak. As for the inexperienced cases of import infection, network system of information should be practically used.     

Introduction and some problems of the rapid time series laboratory reporting system]

We introduced an on-line system of biochemical, hematological, serological, urinary, bacteriological, and emergency examinations and associated office work using a client server system NEC PC-LACS based on a system consisting of concentration of outpatient blood collection, concentration of outpatient reception, and outpatient examination by reservation. Using this on-line system, results of 71 items in chemical serological, hematological, and urinary examinations are rapidly reported within 1 hour. Since the ordering system at our hospital has not been completed yet, we constructed a rapid time series reporting system in which time series data obtained on 5 serial occasions are printed on 2 sheets of A4 paper at the time of the final report. In each consultation room of the medical outpatient clinic, at the neuromedical outpatient clinic, and at the kidney center where examinations are frequently performed, terminal equipment and a printer for inquiry were established for real-time output of time series reports. Results are reported by FAX to the other outpatient clinics and wards, and subsequently, time series reports are output at the clinical laboratory department. This system allowed rapid examination, especially preconsultation examination. This system was also useful for reducing office work and effectively utilize examination data.     

Automation of the immunohematology laboratory]

Automation finds a particularly justified application in the field of immunohematology in which any human failure can have dramatic consequences for the patients. The purposes of automation, indissociable from computerization, were reminded by the French regulatory: to decrease the risks of human error linked to each step of the tests performed; to guarantee a reliable traceability of all the elements having contributed to the test process; to manage all the alarms of dysfunction of the system. The main devices available today permit automation of a part of the pre-analytical phase and of all the steps of the analytical phase by the realization in routine of ABO-RH1 grouping, phenotyping, of irregular antibody screening and of compatibility testing. They use the reaction of agglutination either in micro-plates or in filtration. One distinguishes two types of materials: full automates managing all the steps from the sample positioning on the carrier down to the final result without any handling of the samples (Autovue, Galileo, ID gel station, Qwalys, Tango, Techno) and the semi-automates, which require intervention of an operator for the phases of centrifugation, stirring and incubation (Mitis 2, Hemos, Rosys, Swing) the reading being automated for all. All include the possibility of a connection to the central data processing system .If some devices allow the choice of reagents, others can only work with the reagents supplied by the manufacturer. In all the cases, optimization of the automated systems implies a specific training of the staff and the strict compliance with the standard operating procedures by each individual.     

Altering a computerized laboratory test order form rationalizes ordering of laboratory tests in primary care physicians

BackgroundTo reduce physicians’ inappropriate laboratory requests for their patients, administrators have used methods such as modifying a laboratory request order form with an agreed requesting protocol for the most common diagnoses in primary health care.ObjectiveTo study the effects of removing the erythrocyte sedimentation rate (ESR) and aspartate transaminase (AST) which are considered of limited clinical value for primary care clinical decision-making from a computerized laboratory test order form. These tests were removed to another new view from the electronic laboratory menu where the physicians, instead of just ticking the desired test from the list, had to do 4–8 s extra work by writing down the abbreviation to order the test.MethodsAn observational controlled prospective study based on a before-after design was performed by removing AST and ES from the laboratory test order form of the computerized laboratory system for all primary care in the city of Helsinki, Finland. The numbers of annual and monthly use of AST and ESR and their controls, alanine transaminase (ALT) and C-reactive protein (CRP) ordered by General practitioners (GPs) was recorded over an eight-year period: four years before and a four years after the removal of AST and ES.ResultsRemoving AST and ESR from the computerized laboratory test order form decreased their use by up to 90%, whereas the use of the control tests increased throughout the follow-up period. The variation in use of these removed tests also decreased.ConclusionRemoving a laboratory test from a computerized laboratory test order form may significantly reduce GPs’ use of the laboratory test. Further studies are needed, however, to ensure the safety of this type of intervention.     

Choosing effective laboratory tests for diabetes care, and the reimbursement system]

Diabetes mellitus is a prototype chronic disease. The number of patients with diabetes in Japan is estimated to be about 6.9 million. Expenditure for diabetes care is increasing rapidly and this increase imposes a major economic burden. The Japanese Government has developed health-care payment policies designed to balance the growth of health-care expenditure against other national priorities. Often these policies tend to limit the various services. The Japan Diabetes Society(JDS) published management guidelines for diabetes for general practitioners in 1999. There is increasing concern about the cost of laboratory studies, including self-monitoring blood glucose(SMBG), as well as the cost of general diabetes care. The Japanese Society of Laboratory Medicine(JSLM) has also developed standards to choose effective laboratory tests for general practitioners. Health professionals must have a clear knowledge of the reimbursement system in order to understand the economic factors that control the services available to their patients. Ideally, however, the reimbursement system should meet the financial needs of the services necessary to conform to the professional consensus of the acceptable quality of care for people with diabetes.     

Biosensing techniques for the laboratory medicine]

Biosensing techniques are utilized in micro analysis of the biological constituents with an integrated device. Their applications to laboratory medicine are of great interest. Recently, several types of micro electrodes or ion sensitive field effect transistors (ISOFET) were developed. For fabrication of the biosensor selection of the proper bio-element and transducer to assay our sample, is important. In this article we will indicate some items on the future prospect of biosensing techniques for laboratory medicine.     

Effective clinical information system closely connected with clinical laboratory data for infectious diseases]

Nowadays, information on clinical laboratory tests for infectious disease is almost supported by information on such as clinical, identical and susceptible microbiological tests. However, information support necessary for clinical diagnosis and therapy with clinically valuable data remains unsatisfactory. To offer more useful microbiological information to support clinics from clinical laboratory division, exchange of clinical information between clinical divisions, integrated systems of clinical information in the district and establishment of domestic and international information network et al are required. Establishment of these advanced total information network systems for clinical microbiological tests for infectious diseases may exceedingly contribute to earlier diagnosis, control and prevention of various infectious diseases.     

The introduction of a new clinical laboratory system, so-called the profiles for each diagnosis related group]

We try to establish a new clinical laboratory system, so-called profiles for each diagnosis related group which have features as shown below. 1) The profiles are clinical manuals that are utilized by home doctors and show how to diagnose, follow up, observe complications and judge therapeutic effect. 2) The profiles are constructed on condition that they cover 60% of cases and cases that they cannot handle are supposed to be referred to the major hospitals or the specialized doctors. 3) The profiles are guaranteed to be reformed and maintained according to medical advancement. 4) The target diseases of the profiles are thyroid disease, liver diseases, diabetes mellitus, respiratory disease, infectious disease, renal disease, cardiac disease, hyperlipemia, collagen disease, hematological disease, osteoporosis and gynecological disease. We present the profiles for thyroid disease, hyperlipemia and collagen disease which have been accomplished.     

Electrophysiological tests in clinical laboratory]

We briefly described recently developed methods for testing cardiac electrophysiological phenomena such as 24-hour Ambulatory ECG, high resolution ECG, body surface mapping ECG, heart rate variability, QT and QT dispersion, and T wave alternans. Of these methods ambulatory ECG monitoring is important and useful for detecting malignant arrhythmias and ischemia attacks, especially in cases of vasospastic angina. Using this method, it is possible to quantitatively analyze arrhythmia and elucidate the pathophysiology of vasospastic angina. The monitoring system is useful not only for diagnosis, but also for assessing treatment efficacy. Heart rate variability is currently used for analyzing the autonomic nervous system; however, the exact meaning of each index still remains to be confirmed. The concept of QT dispersion was recently introduced as an index for detecting dispersion of ventricular repolarization and QT dispersion is still controversial. T wave alternans monitoring has been recently introduced as a new method of assessing the microvolt level of T wave alternans, which has been hypothesized to correlate with the occurrence of arrhythmic events in myocardial infarction. The possible roles of these methods and their applications for clinical practice are discussed.