Development of a computerized provider order entry system for laboratory

LIST OF TABLES

Table 3.1: List of laboratory tests for malaria, tuberculosis and HIV based on WHO IDSR and CDC.(CDC, 2015a, 2015b)(CDC, 2014a, 2014b)(WHO & CDC, 2010)(CDC, 2012)(Caminero, 2005) 2

Table 3.2: Recommended minimum data element of patient identification based on WHO RSS. (WHO, 1999) 28

Table 3.3: List of attributes of the first ER diagram 48

Table 3.4: List of attributes of the final ER diagram 52

LIST OF ABBREVIATIONS

AFB	:	Acid-Fast Bacilli
API		Application Programming Interface
ARV	:	anti-retroviral
CDC	:	Centers for Disease Control and Prevention
CPR	:	computerized patient record
CPOE	:	Computerized Provider Order Entry
DBDL	:	Data Base Definition Language
DST	:	Drug susceptibility testing
EHR	:	Electronic Health Record
eLAB	:	electronic Lab order Entry Management
ELR	:	electronic laboratory reporting
e-mail	:	electronic mail
EMR	:	Electronic Medical Record
ER	:	Entity relationship
ELISA	:	Enzyme-linked Immunosorbent Assay
GHS	:	Ghana Health Service
HIS	:	health information system
HL7	:	Health Level 7
HIV	:	human immunodeficiency virus
ICT	:	Information and Communication technologies
IS	:	information system
IDSR	:	Integrated Disease Surveillance and Response
IHE	:	Integrating Healthcare Enterprise
IIBA	:	International Institute of Business Analysis
LOINC	:	Logical Observation Identifiers Names and Codes
MOH	:	Ministry of Health
MDR	:	Multi drug resistance
NAA	:	Nucleic acid amplification
OpenMRS	:	Open Medical Record System
PC	:	personal computer
PIN	:	Personal Identification Number
PCR	:	Polymerase Chain Reaction
RDT	:	Rapid diagnostic test
RSS	:	Recommended Surveillance Standard
RDBMS	:	Relational Database Management System
SMS	:	Short Message Service
SQL	:	Structured Query Language
SNOMED-CT	:	Systematized Nomenclature of Medicine-Clinical Terms
SDLC	:	systems development life cycle
HUG	:	the University Hospitals of Geneva
TB	:	Tuberculosis treatment
UML	:	Unified Modeling Language `
USA	:	United States of America
USB	:	Universal Serial Bus
WB	:	Western blot tests
WHO	:	World Health Organization

CHAPTER 1

2. INTRODUCTION

2.1. Background

The laboratory services play important role in health care provision and an estimation of 70% of all medical decisions made by clinicians are based on the results of laboratory test. The laboratory provides clinicians and other health care professionals information that will help them to detect disease or predisposition to a certain disease, to confirm or reject as diagnostics, to establish prognostic and to monitor efficacy of therapy followed by a patient.(McPherson & Matthew R. Pincus, 2011)

Managing the follow up of radiological test as well as diagnostics test is a complex process since it requires information exchange between patients, doctors, nurses and laboratory technician using a combination of information systems, including paper-based, telephone and electronic systems. This environment with multiple steps, players and information systems increases the risk of errorswhich could lead to suboptimal clinical outcomes. It is also shown that the rate of missed results test is highin hospitals which used entirely paper-based systems and in those which used amixture of paper and electronic systemsdue to the error in the communication workflow between actors within the health care setting. (Callen et al., 2011)

In a qualitative study conducted in United States of America (USA) in 2010 by Nancy C. Elder and al, practicingfamily physicians confirm that the implementation of an Electronic Medical Record (EMR) was the most important achievementdone to decrease testing process errors. Custom results management information systems have been reported to improve both physician and patient satisfaction then a standard EMR.(Elder, Mcewen, Flach, Gallimore, & Pallerla, 2010).

Computerized providerorder entry (CPOE)allows medical staff to enter electronically orders for medications, diagnostic tests, and regiments as well as procedures before a surgery, with the objective to improve the clarity and specificity of physician orders, to facilitate the rapid communication of orders, and to providesignificantly enhanced decision support capabilities compared to traditional handwritten orders.(Maslove, Rizk, & Lowe, 2011)

Continuous quality audit requirementssuch as electronic system that providescapacity for clinicians to acknowledge that they have viewed test results and document their follow-up actions in the systemhasbeen advocated to improve the communication workflow in the management of test result. But many facility still continue to use the traditional practice in the laboratory result management andone of the most used is to telephone results for urgent or critical tests to clinician. It has proved to be time-consuming with potential for errors and the one of using mobile phone calls has also been proved to be expensive.(Callen et al., 2011)

The computerized system for managing the laboratory test result do not solve the communication process problem between actor involved in patient care even if some improvement has been recognized. A systematic review conducted in 2011 on the implication of missed test result for hospitalized patient, reveals that by replacing the telephone call notification of urgent laboratory result with a computer system,28.8%(529/1836) of the urgent biochemistry lab results during a six-month period were never accessed. The radiology follow-up assessment using an email alert system for important radiology investigation reported that 20.0% (10 598/52 883) of email were not viewed by the referring physician.(Callen et al., 2011)

The communicationbetween health care providers and patients isalso an essential component of the patient care. Traditionally, face-to-face and telephone communication have been the primary means for the patients to interact with their health providers. However, with advances in technology, internet applications for communications, particularly electronic mail (e-mail) or mobile technology like Short Message Service (SMS) can be also used as viable media for patient communication. While benefits of e-mails in enhancing communication were recognized by both patients and providers, concerns about confidentiality and security were also expressed.(Ye, Rust, Fry-Johnson, & Strothers, 2009)

In rural and resource-limited settings area of Africa, where internet still present some logistic problems, the widespread availability of mobile communication, along with its ease of use and relatively low cost make it a promising medium to improve health related communications.(Siedner, Haberer, Bwana, Ware, & Bangsberg, 2012)Recently severalinitiatives has been conducted to Internet connectivity to a growing number of remote locations within the rural area but the internet traffic demands was not able to deliver basic quality services needed for simple web application due to the poor infrastructure, lack of economic interest from telecommunication providers and lack of the governmental support result in a relatively disconnection in large part of rural area.(Johnson, Pejovic, & Belding, 2011)

Cell phone text message (SMS) is been demonstrate to be an important tool to improve communication with patient and to solve challenges related to transportations and access to clinicians in rural area. In a study conducted in southwestern Uganda in 2012 to assess the acceptability of using SMS for communication with human immunodeficiency virus (HIV)-infected patients, all participants expressed interest to receive information about laboratory results by cell phone text message, stating benefits of increased awareness of their health statusand decreased transportation costs due to the reduction of movement between the house and the health facility.(Siedner et al., 2012)

Even though issues related to privacy and confidentiality of information has been raised, some measures like the use of the Personal Identification Number (PIN) code and deletion of the message after receiving the notification have been retained as measures to protect confidentiality.(Siedner et al., 2012)

Despite of EHR benefits, in most African country, public and private hospitals are still running paper based system for laboratory order or semi-automated system combining stand alone or web application and use of email to share result between clinicians and laboratories technician. Only a few established ones has implemented an Electronic Medical Record (EMR) or a Computerized Provider Order Entry system for radiology, pharmacy and laboratory department.(Jiagge, 2007)

In Ghana thereare four main categories of health care delivery systems:«the public, private-not-for-profit, private-for-profit, and traditional systems» centered on the Ministry of Health (MOH). The MOH is the policy maker body and all the health sector actors are responsible to it. MOH uses the Ghana health service for the implementation of the policies. Established by the Ghana Health Service and Teaching Hospitals Act 525, 1996, the Ghana Health Service (GHS) is responsible for the administration and management of the hospitals owned by the government and excluding teaching hospitals and quasi-state institutions such as the universities and security services (Military and police hospital).(MOH Ghana, 2009)

The health services are organizedon a three-tier system of care; from primary through secondary to tertiary services. They are run at five levels from bottom to top: community, sub district, district, regional and national. The community and sub-district levels health facility provide primary care. Thedistrict and regional hospitals provide secondary health care. The teaching hospitals are the top inproviding tertiary services and they are responsible for the most specialized clinical and maternity care. (MOH Ghana, 2009)

Clinical care at the district level are assured by the district hospital and they are supposed to serve an average population of 100,000-200,000 people in a clearly defined geographical area. District hospital contains between 50 and 60beds and should provide the following services: «Curative care, preventive care, and promotion of heath of the people in the district. Quality clinical care by a more skilled and competent staff than those of the health centers and polyclinics.Treatment techniques, such as surgery, laboratory and other diagnostic techniques appropriate to the medical, surgical, outpatient and in-patient services». (Ghana Health Service, 2015)

The aim of this project is to use information system approach to improve the management of the laboratory orderwithin the district hospital by taking into account the data workflow between clinical services and improve patient communication experience using notification alert based on SMS and email capabilities provide by mobile technology and internet.