Laboratory services are a crucial part of medical care and contribute to physicians’ treatment-related decision-making. However, paper-based information exchanges between physicians’ offices and laboratories waste physicians’ time and prevent them from using outpatient test results in a timely and effective manner. To solve this problem, improve the safety and quality of patient care, and save patients’ time and energy, the present study developed a web-based system for electronic information exchange between laboratories and offices in Microsoft Visual Studio with the ASP.net technology and the Microsoft SQL Server database.
The developed web-based software enables electronic communication between offices and laboratories (two important healthcare bases), establishes information exchange (sending requests and receiving laboratory results) between these two bases, and also notifies the patients. The software gained the overall satisfaction of the users, and this highlights the need for electronic communications in the healthcare domain.
Keywords: information systems, interoperability, physicians’ offices, laboratories, health information exchanges
Laboratory services play a pivotal role in directing treatment-related activities in physicians’ offices. In these offices, laboratory services can continue care by the continuation of laboratory tests on patients with chronic diseases and by notifying healthcare providers (HCPs) about increased risk conditions and potential gaps in healthcare.1
The laboratory service cycle or process consists of different phases (pre-preanalytical, pre-analytical, analytical, post-analytical, and post-postanalytical),2 and any error or inefficiency in each phase can disrupt the entire process and lead to ineffective patient management.3,4 The majority of “laboratory errors” occur outside the laboratories, not in the analytical stage but in pre- and post-analytical stages.5-8
Information exchange between laboratories and offices, particularly in developing countries, is still paper-based, which can lead to errors in the laboratory service cycle, especially in the pre- and post-analytical phases. In developing countries, most primary healthcare centers do not have electronic medical records, and outpatient healthcare centers are rarely connected electronically to their reference laboratories.9-13 Even developed countries, which are pioneers in this domain, have not fully addressed the challenges related to interoperability.14-17 Paper-based communications, where patients themselves occasionally carry laboratory information, waste a great deal of time and energy commuting between outpatient centers and laboratories outside these centers.18,19 This imposes heavy delay and backlog on the transfer of test results, and physicians cannot always have timely access to these results. HCPs at offices should receive laboratory results on time so that they can make better treatment-related decisions. If HCPs fail to follow-up test results, patients are exposed to a heightened risk of misdiagnosis or delayed treatment, and this leads to unfavorable treatment outcomes and threatens the quality of care and patient safety and satisfaction. Therefore, it is essential to receive and follow-up laboratory results in order to improve patient safety and the quality of care.20,21 In some cases, information exchange between physicians and the laboratory (both requests for tests and retrieval of results) is performed via email, fax, special landlines, and printers; in addition to suffering from the mentioned problems, these methods are not documented or reliable.22-24
Laboratory service process errors are more important in offices because these healthcare centers are most frequently visited by patients25 and, as such, a large number of tests are requested and the process of test is more complicated in offices.26 Accordingly, the present study aimed to overcome the problems associated with paper-based information exchange between laboratories and offices, improve outpatient safety and the quality of care, and help save time and energy by developing an electronic information exchange system27 for laboratories and offices,28 especially in the COVID-19 pandemic when electronic information exchange could be effective.29,30
In this applied study, the processes related to information transfer between diagnostic laboratories and offices were examined, and a list of physicians’ and laboratories’ needs was drawn up based on a review of sources (books and articles) and surveying physicians (n=5) and laboratories (n=5). Next, conceptual models of the software connecting offices and laboratories were identified based on the processes discovered in the previous phase, and the software was developed via object-oriented programming and unified modeling language (UML)31 in Enterprise Architect (Sparx System).32
Based on the resulting models, a web-based software was developed with the ASP.net technology33 and C# programming language in Microsoft Visual Studio.net34 with the Microsoft SQL Server database.35
Finally, the software was run for one month in May 2020 to connect four urban laboratories and eight urban offices. The users (physicians and laboratory personnel) were trained on how to use the software on its first day of running. After exchanging 60 requests and test results between laboratories and offices, the software was evaluated by assessing the satisfaction of the final users (physicians, laboratory personnel, and patients) via checklists. The checklists were developed upon a review of sources and based on the opinion of experts (three medical informatics faculty members and two computer specialists) with three dimensions of user interface, performance, and system functionality. The validity of the checklists was examined based on expert consensus, and their reliability was investigated by Cronbach’s alpha. Every question on the checklists was answered with “yes,” “no,” or “to some extent” (scored 2, 0, and 1, respectively). The acceptable range for user satisfaction was ≥ 85 percent.
Results of Software Preparation and Development
The web-based software was developed based on UML modeling (Figure 1). The developed software is responsive and can thus be run on any hardware, including laptops, tablets, cellphones, and desktop computers. Its user interface has been designed based on the general principles in order to facilitate its use, and all the menus and information items related to specific topics can be accessed when needed. Some important forms of the software can be observed in Figure 2 and Figure 3.
The software developed for the office can record patient information, request/send tests, view test results, set the next appointment, and manage the users. Physicians or their secretaries can register patients’ identification information when they enter the office, and then register test requests in the electronic system and send the requests to the laboratory. Also, using this system, physicians can view and examine patient test results recorded by the laboratory. The software can also set the next appointment for the patient.
Following the logical workflow of the laboratory, the laboratory software can set a sampling appointment for the referred patients, record and send test results, manage users, and define tests. The definition of tests lets the laboratory update its list of tests and send it to physicians via the electronic system.
In the patient system, patients can log in their profile, view the list of requests and test results, and be notified of the sampling time and physician’s appointments set for them.
Results of Software Evaluation
The software was run at eight offices and four independent laboratories outside these offices in Tehran for 60 test requests and results during a month. The software was then evaluated by assessing the satisfaction of final uses (physicians, laboratory personnel, and patients) while focusing on user interface, system performance, and operational functionality via checklists.
Results of Software Evaluation at the Office
The checklist for assessing physicians’ satisfaction with the software was designed based on a review of sources and the opinions of experts, and its validity was confirmed upon expert consensus. Its reliability was also approved by Cronbach’s alpha (α=0.89). This checklist comprised five questions on user interface, six questions on operational functionality, and three questions on software performance. A score of 2 was assigned to “yes” and 0 to “no.” Since there were eight participants, the score of each question could range from 0 to 16. Table 1 presents the results of assessing physicians’ satisfaction.
Based on Table 1, physician’s satisfaction was 93.75 percent with the user interface, 98.9 percent with the operational functionality, and 97.9 percent with the software performance, all of which are > 85 percent and, thus, acceptable.
Results of Software Evaluation at the Laboratory
The checklist for assessing the laboratory personnel’s satisfaction with the software was designed based on a review of sources and the opinions of experts, and its validity was confirmed by expert consensus. Its reliability was also approved by Cronbach’s alpha (α=0.91). This checklist comprised five questions on user interface, four questions on operational functionality, and four questions on software performance (13 questions in total). As there were four participants, the score of each question could range from 0 to 8. The valid range of 85-100 was set, and if the level of satisfaction was > 85 percent for each dimension, the software would be deemed acceptable. Table 2 presents the results.
Based on Table 2, the laboratory personnel deemed the software acceptable in all the dimensions.
Results of Software Evaluation According to Patients
The validity of the checklist developed to assess patient satisfaction was confirmed by expert consensus. Its reliability was also approved by Cronbach’s alpha (α=0.9). This checklist comprised two questions on user interface, four questions on operational functionality, and two questions on software performance (eight questions in total). As there were 60 participants, the score of each question could range from 0 to 120. The confidence level of 85-100 was set, and if the level of satisfaction was > 85 percent for each dimension, the software would be deemed acceptable. Table 3 lists the results.
As part of the healthcare system meeting most of the needs of outpatients, offices are an important medical body in any society. Physicians who work at offices often need laboratory test results for making treatment-related decisions. Therefore, there is a need to exchange laboratory test requests and results between offices and laboratories. The present study established electronic exchanges to overcome the errors associated with paper-based exchanges. The web-based software connecting the offices and laboratories developed in this study can cover different phases of the laboratory service process.
Discussion and Examination of the Status of the Software in the Laboratory Service Cycle
The software is compatible with the laboratory service cycle and covers all its five phases, thereby improving the precision and speed of different phases. The software provides electronic access to previous laboratory results of a patient to the physician in the pre-preanalytical phase, and this can aid physicians in decision-making. Also, with an electronic request, the software reduces the physicians’ workload in the pre-analytical phase. During the analytical phase, it improves the tracking of current requests and prevents the loss or delay of results. Similar to the analytical phase, it allows the physicians to track the results in the post-analytical phase. The main effect of this software in this phase is accelerating the turnaround time, such that the results are often sent to the physician as soon as they are received at the laboratory, and this allows for more rapid interventions by the physician. This phase is greatly affected by cognitive factors that may influence the interpretation of results and the choice of appropriate measures. As a result, by notifying the patient and quickly sending the test results to the physician, this software leads to a rapid response and quicker follow-up by the physicians.
User satisfaction with the software was also evaluated, and the results are reported in detail below.
Results of Examining User Satisfaction with the Software
Laboratory personnel’s satisfaction with the software in all three dimensions was also acceptable (>94 percent). Studies have rarely evaluated the software connecting the office and laboratory from the viewpoint of laboratory personnel, and this merits more attention in future studies. The only study to do so was36 conducted by Félix Gascón et al. In their study, an integrated laboratory test request module was designed for communicating with the laboratory information system (LIS). All the examined laboratories showed that running the laboratory module in the EHR improved the analysis process, enhanced safety in patient identification, reduced errors of sampling containers, and shortened the response time. In the present study, enhanced communications between the office and laboratory, improved workflow, saving time and paper resources, and resolving the illegibility of physicians’ handwriting have been mentioned, which indicate quality-related, organizational, and financial advantages.
Discussion and Examination of Similar Interventions in Previous Studies
This was one of the few studies that emphasized mutual exchanges, while most studies focus on unilateral transfer from the laboratory to the outpatient center, or vice versa, and others emphasize the exchange of alarms and suggestions.37 Another advantage of the developed software is notifying the patient; this feature was not found in previous studies in the domain of outpatient care.
In practice, to convince outpatient centers, offices, and laboratories to adopt information technology for electronic transfer, the merits of such exchanges should be explained to them. Based on the evaluation, the physicians, laboratory personnel, and patients were satisfied with the outcomes of electronic exchanges. This result can motivate the use of this technology by outpatient centers and laboratories, and encourage the authorities to invest in this technology.
A challenge facing this project was convincing laboratories and, often, office physicians early in the work to use the software. Our team had to devote sufficient time to justify and persuade them. We also faced limitations, including the small sample size, since the use of technology in developing countries still requires culture-building.
Laboratory services are a major part of healthcare and contribute to the treatment-related decision-making of physicians, including those working in outpatient centers. Therefore, information exchange between outpatient centers and laboratories is essential. Still, there are inevitable errors in the paper-based exchange of such information, and these errors can be partly resolved by establishing appropriate computer-based interfaces. The web-based software developed in this study enables electronic communication between the office and laboratory (two important healthcare bases). It establishes information exchange (sending test requests and receiving the results) between these two bases, while also notifying the patients.
The most important feature of the present study was its focus on outpatient healthcare centers in which the majority of healthcare services are offered and where there is a great need for information exchange with external institutes, including laboratories. Outpatient centers are often run by non-affiliated organizations or persons, and convincing these parties to accept and use information technology needs a further understanding of the effects and advantages of this technology.
Another point is that, in this study, the electronic viewing of results, electronic sending of requests, and, in general, the benefits were independent of electronic health record (EHR) acceptance. In fact, this study showed that better performance can be achieved without an EHR and only through sending the requests and receiving the results electronically.
Overall, the developed software enhances the quality of patient care, saves costs, and promotes patient safety. By ensuring the satisfaction of users, it demonstrates the need for establishing electronic communication in this domain for developing countries and countries without electronic systems.
With regard to the value added offered by electronic exchanges in the healthcare domain, it is suggested that developing countries and developed countries that have paper-based exchanges among healthcare centers use electronic information exchange software programs to reduce medical errors, improve patient care quality, and save the costs and time of patients and HCPs. To this end, standards and models should be developed, and the infrastructure for implementation of electronic exchange should be fortified. Moreover, measures should be taken with regard to electronic insurance to facilitate electronic exchanges in the healthcare domain.
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