Community Hospital Laboratory Information System

Jeffrey Busko

Jerry Kennedy

Patti Vignone

March 2, 1998

TABLE OF CONTENT

I. BACKGROUND

ORGANIZATION
LABORATORY INFORMATION SYSTEM
SCOPE OF PROJECT

II. EVALUATION OF EXISTING LIS

PERCEPTIONS, ATTITUDES, AND PROBLEM IDENTIFICATION
DETAILED ANALYSIS OF TECHNICAL PROBLEMS
EVALUATION CRITERIA

III. LABORATORY INFORMATION SYSTEM VENDOR REVIEW

MARKET OVERVIEW
FOCUSED VENDOR ANALYSIS
ADVANTAGES AND DISADVANTAGES OF THREE VENDORS
COMPARATIVE ANALYSIS OF THREE LIS VENDORS
COST/BENEFIT ANALYSIS

IV. RECOMMENDATIONS

V. APPENDICES

REFERENCES
FOOTNOTES

I. BACKGROUND

1. Organization:

Community Hospital, a health care organization committed to quality care, began operating over fifty years ago. It has evolved into a 300-bed facility employing approximately 1500 full and part-time employees.

Community Hospital offers a wide range of services including emergency medicine, surgery, oncology, OB/Gyn, laboratory, physical therapy, pharmacy, radiology, and skilled nursing. A facility-wide PC based Hospital Information System (HIS) from ABO & Company (ABOC) was initiated in 1997. Wide Area Network (WAN) was used to upgrade the connectivity feature. The installation of fiber and wires were placed throughout the hospital to support the connectivity requirement. The hospital purchased 346 PC's from Dell Computer Company and downloaded software to make it Windows 95 compatible. About 40 laser printers and 20 bar-coded label printers were placed intermediately through out the hospital.

2. Laboratory Information System

The laboratory at Community Hospital performs over a million tests per year and employs approximately 50 full and part-time employees. Shared Medical System (SMS), the laboratory's first Laboratory Information System (LIS), was instituted in 1992. SMS used a central computer for processing as well as dummy terminals and printers. The system was fully interfaced with the laboratory instruments and was capable of generating patient and workload reports for clinicians and management.

To accommodate the hospital-wide information system, SMS was replaced in April 1997 with Best Laboratory Group (BLG), the LIS component of the ABOC system. Although concerns existed regarding the relative newness of the BLG system to ABOC, the vendor representative and account manager assured the hospital that problems would be minimal. ABOC bought the Multiple Evaluation Technologist Workstation (METS) software package from a competitor with the intention of using it as an interface engine. However, the METS system that it did not work well and, in order to maintain integrity, a workaround was developed which consisted of an extra PC at each workstation within the department.

Many LIS problems were encountered with BLG and are discussed in greater detail later in this document. Numerous telephone and onsite service calls resulted in workaround solutions that were often labor intensive and did not solve the problem. In December of 1997, a decision was made to replace the BLG system.

3. Scope of Project

The scope of this project is to evaluate Community Hospital's LIS problems and explore potential vendor solutions. This analysis will incorporate the following evaluation components from an administrative, technical, and customer perspective:

Analysis of the present problems
Development of appropriate evaluation criteria
Identification of major LIS vendors who have potential solutions
Focused comparative analysis of three vendors
Recommendations based upon resolution criteria

II. EVALUATION OF EXISTING LABORATORY INFORMATION SYSTEM PROBLEMS

1. PERCEPTION, ATTITUDES AND PROBLEM IDENTIFICATION

A survey was developed to identify perceptions, attitudes and problems associated with the BLG LIS. This survey was broken down into three user groups; administration, technical and customers. One-on-one interviews were conducted to clarify survey answers. The following is a sample of statements that were used to identify perceptions and attitudes. The results of the survey were used to identify potential LIS solutions.

Results of Current LIS System -- Administration Survey

Sample of Survey Statements	AVERAGE MEASUREMENTS
Sample of Survey Statements	MEAN	MEDIAN	MODE
1. The system supports future business and strategic plans.	3(5's), 2(4's), 1(3) = 4.3	3(5's), 2(4's), 1(3) = 4 or	3(5's), 2(4's), 1(3) = 5
2. The LIS provides administrative decision-support.	3(5's), 2(4's), 1(3) = 4.3	3(5's), 2(4's), 1(3) = 4 or 5	3(5's), 2(4's), 1(3) = 5
3. The costs justify the benefits.	4(5's), 1(4's), 1(3) = 4.5	4(5's), 1(4's), 1(3) = 5	4(5's), 1(4's), 1(3) = 5
4. We are receiving the level of support we expected.	3(5's), 2(4's), 1(3) = 4.3	3(5's), 2(4's), 1(3) = 4 or 5	3(5's), 2(4's), 1(3) = 5
5. BLG has integrated well with the HIS.	3(2's), 2(3's), 1(4) = 2.7	3(2's), 2(3's), 1(4) = 2 or 3	3(2's), 2(3's), 1(4) = 2

Total number of surveys distributed to administration:	6
Total number of surveys completed:	6
Survey response rate:	100%

Results of Current LIS System -- Technical Staff Survey

Sample of Survey Statements	AVERAGE MEASUREMENTS
Sample of Survey Statements	MEAN	MEDIAN	MODE
1. Laboratory equipment interfaces well with the current system.	4(4's), 4(3's), 2(2) = 3.2	4(4's), 4(3's), 2(2) = 3	4(4's), 4(3's), 2(2) = 3 or 4
2. The system has effective data confidentiality/security measures.	5(2's), 4(3's), 1(2) = 2.4	5(2's), 4(3's), 1(2) = 2 or 3	5(2's), 4(3's), 1(2) = 2
3. There are very few data quality issues (data is accurate and error-free).	4(5's), 5(4's), 1(3) = 4.3	4(5's), 5(4's), 1(3) = 4	4(5's), 5(4's), 1(3) = 4
4. The system provides efficient operation of daily business activities.	4(5's), 5(4's), 1(3) = 4.3	4(5's), 5(4's), 1(3) = 4	4(5's), 5(4's), 1(3) = 4
5. The system is flexible.	5(2's), 4(3's), 1(2) = 2.4	5(2's), 4(3's), 1(2) = 2 or 3	5(2's), 4(3's), 1(2) = 2

Total number of surveys distributed to administration:	11
Total number of surveys completed:	10
Survey response rate:	91%

Results of Current LIS System -- Customer Survey

Sample of Survey Statements	AVERAGE MEASUREMENTS
Sample of Survey Statements	MEAN	MEDIAN	MODE
1. BLG has had a positive impact on patient care.	30(4's), 20(3's), 15(2) = 3.2	30(4's), 20(3's), 15(2) = 3	30(4's), 20(3's), 15(2) = 4
2. The system is end-user friendly	20(4's), 20(3's), 25(2) = 2.9	20(4's), 20(3's), 25(2) = 3	20(4's), 20(3's), 25(2) = 2
3. The LIS provides information when and where you need it.	35(5's), 20(4's), 10(3) = 4.4	35(5's), 20(4's), 10(3) = 5	35(5's), 20(4's), 10(3) = 5
4. The system provides value to the customer's requirements.	30(4's), 20(3's), 15(2) = 3.2	30(4's), 20(3's), 15(2) = 3	30(4's), 20(3's), 15(2) = 4
5. Patient information retrieval is easy for both standard and customized reports	35(5's), 20(4's), 10(3) = 4.4	35(5's), 20(4's), 10(3) = 5	35(5's), 20(4's), 10(3) = 5

Total number of surveys distributed to administration:	80
Total number of surveys completed:	65
Survey response rate:	81%

RATING SCALE:

1= Strongly Agree

2= Agree

3=Neither Agree

4=Disagree nor Disagre

5=Strongly Disagree

DEFINITIONS:

MEAN - This is the average resulting from adding together all of the values and then dividing that sum by the number of values.

MEDIAN - This average is the halfway point of the observations if they are listed in order from the largest to the smallest value.

MODE - This average is the most commonly held value of all of the observations.

2. Detailed Analysis of TECHNICAL Problems

Upon completion of the survey, the gravity of the technical problems stood out. These problems, which are listed below, have adversely effected the quality of patient care, the turn-around-time of results, and the inpatient length of stay.

Lack of valid formatting of results - Inappropriate combinations of integers and characters may be contained in a result field. For example, a glucose result of 100 could be reported out as 1,000. The clinical significance between the two results, the first considered normal and the second considered a panic value, can be a matter of life or death.
Data integrity is compromised - Duplicate tests on a single patient sample may cause the generation of two patient reports, each with different test results. For example, a glucose may be resulted out as 100 on one report and as 92 on a second report without warning. Although not clinically relevant, these inconsistencies lead to questions regarding the integrity of the data.
Data quality issues (information is not accurate and error free) - Patient accession numbers, which identify the patient sample throughout the pre-analytic, analytic and post-analytic process, randomly change in the system. Inconsistencies begin at the time the bar-coded label is printed and continue to the time the results are reported. Patient reports cannot be released until these inconsistencies are fixed. This usually involves canceling, crediting, charging and duplication corrections.
Patient demographic and result information is lost during LIS downtime - The BLG system requires daily maintenance with necessitates bringing the system down. In doing so, the HIS interface is interrupted and patient demographic and result information is lost. Virtually any changes or additions to the files, printers, etc., requires the system to be brought down and up again to recognize the changes. This sometimes requires re-activation, de-activation, and re-activation of both the LIS and HIS to reinitiate the interface connection.
System not fully understood by users - Learning curve greater than usual because off-site BLG training was not with the version of software that was installed. Further on-site training was necessary, however it was not at the level of detail required to enable efficient daily operations.
BLG technical support lacking - Numerous telephone and on-site service calls resulted in workaround solutions that often were labor intensive and did not solve the problem. In addition, BLG does not provide night phone support coverage and, being on the West Coast, many problems are not addressed until 11:00 a.m. the following morning.

3. EVALUATION CRITERIA

Based upon the problems identified with the BLG system, the following criteria was developed to evaluate a new LIS vendor:

Required Functions

General function: Validation of patient information, input and measurement results; Storage of reference values; Link to external databases; Interactive inquiry; Interfacing to ABOC, Interfacing to laboratory analyzers
Management/financial functions: Provide facilities for performance of financial tasks and management reports. Some or all of these functions may be performed by third party software running on a computer separate from but linked to the main laboratory system.

Required Capacity

Hardware capacity: 50 terminals and 30 workstations; Number/speed of printers; Disk storage; Off-line storage
User interface: Appropriate character sets; Number of different tests handled; Field lengths

Required Flexibility

Modifiable to meet the user's needs including tailoring the screen and report formats
Open for add-on software modules either in the main LIS or on a connected workstation
Allow for alteration to meet future changes in data protection legislation
Room for workstation expansion

Required Performance

Eliminate bottlenecks: Ensure input of sample information and output of test reports will not be slower than in the existing manual system.

Requirements Reliability and Security

System integrity; Safety
Designed to comply with data protection legislation
Vendor statement or certificate of software quality

Requirements relating to compliance with standards

Compliance with standards which include:

general IT and telecommunications standards
standards which are specific for Medical Information

High-level language based on an official or de facto standard
Recognized operating system but not one specifically designed for LIS's

III. LABORATORY INFORMATION SYSTEM VENDOR REVIEW

1. Market Overview

Fifty-seven LIS vendors market over 66 systems in the United States [1]. These systems can be categorized according to hospital and non-hospital markets. Hospital vendors can then be subdivided into six different categories based upon the number of hospital beds and the number of daily patient requisitions processed.[2]

Nine vendors were initially identified as meeting Community Hospital's requirement of flexibility and functionality. After eliminating those vendors who were either too new to the market place to provide stability or whose system was too small to support the needs of Community Hospital, three were selected:

CompuLab

SMS

Sunquest

2. FOCUSED VENDOR ANALYSIS

The following are the features and benefits of each LIS as contained in the vendor's literature:

CompuLab [3]

CompuLab it is the most comprehensive integrated clinical system in the market for hospitals under 250 beds. The CompuLab LIS provides extensive flexibility to address the special needs of each individual laboratory. By allowing each laboratory to define the applications of the system, the requirements are more easily met, personnel are more easily trained and the system is more effective. Equally important, as the needs of laboratory change, the system is easily adapted.

CompuLab is designed to provide useful, effective information for supporting those responsible for an effective, cost-efficient operation. The reports are well thought out as to format and degree of detail in an effort to provide a useful tool.

CompuLab is designed to manage the workflow of an entire laboratory. Each step, from the test request to the distribution of the patient reports, is monitored, organized and streamlined. The CompuLab system provides a well-organized, easy-to-use, flexible patient record. A patient's demographics, orders, results, and charges are easily viewed. The system is designed for clear, simple, patient record updating to facilitate maintaining current, accurate complete information, whether the system is utilized stand-alone or interfaced with a hospital information system.

SMS [4]

Shared Medical Systems Corporation, founded in 1969, provides computer-based information systems to integrated health networks, health corporations, community health information networks, acute-care hospitals, physician groups, manage services organizations, and other health providers. This system includes a full range of clinical, financial, patient management, managed care, imaging, management decision, and electronic data interchange services that use diverse computing and networking technologies, ranging from remote processing to distributed processing systems, to onsite systems.

Sunquest Information Systems, Inc.[5]

Sunquest was developed by a laboratorian in Johnstown, PA in 1979 and has developed into one of the largest and most trusted names in the LIS business. The FlexiLab system is a comprehensive, high-speed LIS that automates the management of laboratory functions from requisition entry to final reporting. The newest version has enhanced Windows functionality and features a new database schema. It supports episode tracking to help efficiently manage concurrent inpatient and outpatient care processes.

FlexiLab products are multi-module systems that automate every aspect of a lab department. It is designed so lab can define all critical parameters and formats. By creating it's own custom system out of standard parts, Community Hospital will have an LIS to meet virtually all of the specific requirements.

3. ADVANTAGES AND DISADVANTAGES OF THREE VENDORS

When compared to the evaluation criteria set forth above, the advantages and disadvantages of the three vendors can be summarized as follows:

	Feature	Evaluation Criteria Standard	CompuLab	SMS	Sunquest
a)	Required Functions	Yes	Yes	Yes	Yes
b)	Required Capacity	Yes	Yes	Yes	Yes
c)	Required Flexibility	Yes	Yes	Yes	Yes
d)	Required Performance	Yes	Yes	Yes	Yes
e)	Requirements Relating To Reliability and Security	Yes	Yes	Yes	Yes
f)	Requirements Relating To Compliance With Standard	Yes	Yes	Yes	Yes

4. Comparative Analysis of Three LIS Vendors[6]

	COMPULAB CompuLab LIS	Rating	SMS SMS OPENLab	Rating	SUNQUEST FlexiLab	Rating
EVALUATION CRITERIA

ADMINISTRATIVE
Number of contracts operational	84	1	111	2	538	3
Hospital bed size (100+)	67	1	111	2	516	3
First system installation	1983	3	1983	3	1980	3
Most recent installation	Ongoing	3	Ongoing	3	Ongoing	3
LIS Staff to develop/ install/support/other	13/11/14/18	1	38/36/48/15	1	161/62/200/130	3
SUBTOTAL		9		11		15

HARDWARE
IBM compatible	Yes	3	Yes	3	Yes	3
Fault-tolerant processors	Yes	3	Yes	3	Optional	2
Optical disk archives supported/standard	Yes	3	Yes	3	Yes	3
Terminals/workstations	3-200+	3	15-212	3	32-500+	3
SUBTOTAL		12		12		11

SOFTWARE
Programming language	DBL	1	C,C++	1	ANSI standard M, C, C++	3
Operating system	DBOS	1	UNIX, AIX, OS/2, NT/VMS	2	ANSI standard, C, C++, IBM AIX, DECO OSF-1, OPEN VMS, MS windows	3
Ethernet environment	Yes	3	Yes	3	Yes	3
Database system	RDBMS	3	Sybase SQL server	3	InterSystems M	3
Full transaction logging	Yes	3	Yes	3	Yes	3
SUBTOTAL		11		12		15

FEATURES (Installed/contracted)
Chemistry/hematology	84/7	1	111/36	2	516/42	3
Bar-coded collection labels	73/7	1	111/36	2	516/42	3
Microbiology	84/7	1	111/36	2	516/42	3
Surgical pathology	24/2	1	24/7	2	335/62	3
Cytology	22/2	1	21/6	2	335/62	3
A/D/T	81/7	1	111/36	2	516/42	3
Order entry	61/3	1	111/36	2	516/42	3
Result reporting	61/3	1	111/36	2	516/42	3
% Stand-alone LIS installation	-	1	15%	1	98%	3
Number of laboratory instruments interfaced with LIS	200+	2	280+	3	200+	2
Source code	Escrow	2	Yes	2	Yes	2
User programming in separate partition	Yes	3	-	1	Yes	3
User group	Yes	3	Yes	3	Yes	3
SUBTOTAL		19		26		37

HIS interface
ABOC interface	No	1	No	1	Yes	3
ASTM/HL7 interface	Yes	3	Yes	3	Yes	3
SUBTOTAL		4		4		6

REPORT CAPABILITY (Installed/contracted)
Ad-hoc reporting	80/7	1	111/46	2	275/35	3
Utilization management	84/7	1	111/46	3	125/20	3
Remote faxing/printing	81/7	1	15/26	2	516/42	3
SUBTOTAL		3		7		9

LOINC
Index field for test definition	-	1	Yes	3	-	1
Dictionary for each new installation	Yes	3	Yes	3	-	1
SUBTOTAL		4		6		2

COST (Largest)
Hardware	$500K	3	$2.1M	1	$500K	3
Software	$100K	3	$2M	2	$1M+	1
Monthly maintenance	-	1	$24K	2	1.25% of software price	3
SUBTOTAL		7		5		7

GRAND TOTAL		69		83		102

Rating Key: 1 = Minimal Value; 2 = Moderate Value; 3 = High Value

5. COST/BENEFIT ANALYSIS

Based upon the results of the comparative analysis, financial information was requested from Sunquest to examine the financial viability of upgrading. The initial Sunquest system one year financing is approximately $800,000. Under the BLG system, one year financing is approximately $1,080,000. The actual breakdown of expenditures is listed below:

Item	BLG	Sunquest
Hardware	$ 350,000	$ 250,000
Software	$ 400,000	$ 300,000
Implementation and Education	$ 180,000	$ 100,000
Support and Maintenance	$ 150,000	$ 150,000
Total	$1,080,000	$ 800,000

Note that Community Hospital has put out a lot of money for the system but it has also recovered some funds due to the failure of other ABOC software packages within the hospital.

IV. RECOMMENDATIONS

Based upon the analysis above, our choice for a new LIS vendor for Community Hospital is Sunquest. Our recommendation is based upon three factors:

Sunquest met the evaluation criteria of functionality, capacity, flexibility, performance, reliability, security, and compliance with standards;
Of the three vendors, Sunquest attained the highest number of points (102) on the comparative analysis evaluation;
A Sunquest upgrade is financially feasible.

V. APPENDICES

1. REFERENCES

Web Sites:

Shared Medical System: http://www.smed.com
Sunquest: http://www.sunquest.com
CompuLab Laboratory Information System: http://www.compulab.com
Healthcare Information Systems: http://vwco.com/hcis.html

Winsten, Dennis: The Seven F's to Easier LIS Selection. Advance for Laboratory Managers, January 1997, pages 40, 54, 56.
ABOC Manual and ABOC Representative
Sunquest Representative
CompuLab Representative
SMS Representative

2. FOOTNOTES

[1] Aller, M.D. Raymond, Weilert, M.D. Michael, Carey Kimberly: Some LIS capabilities worth search

for. CAP Today, November 1995, pages 40-41.

[2] Information Systems Buyers' Guide. Advance for Laboratory Managers, June 1996, pages 40-68.

[3] CompuLab Laboratory Information System: http://www.compulab.com

[4] Shared Medical System: http://www.smed.com

[5] Sunquest: http://www.sunquest.com

[6] Aller, M.D. Raymond, Weilert, M.D. Michael, Carey Kimberly: Some LIS capabilities worth search for. CAP Today, November 1995, pages 40-56.

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Rema Padman, rpadman@andrew.cmu.edu