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Strategic planning for an integrated bar code system.

Labeling specimens at collection makes patient ID more reliable while saving the authors' lab $22,000 a year in hematology and chemistry alone. Series coordinator: Bernard L. Kasten, M.D.

OPTIMIZING WORKFLOW by integrating a bar code specimen identification system into our hospital information system (HIS) and laboratory information system (LIS) has been a major thrust of our management effort and planning strategy over the past five years at Bethesda Hospitals, a 725-bed, two-site, not-for-profit Cincinnati facility.

We had long recognized that in the increasingly cost-conscious and cost-constrained environment confronting the clinical laboratory we would have to take prudent steps to assure maximum efficiency in workflow. To take full advantage of the bar code capabilities of our automatic chemistry and hematology analyzers, we decided to design a fully integrated system of automated specimen identification.

The system identifies patient specimens from the time of collection through report generation and billing. Bar codes steer specimens directly to the appropriate analyzers. Positive patient ID, including bar code representations of the medical record and specimen identification (accession) numbers, remains consistent throughout all contacts with the HIS and LIS. Test orders entered into the HIS by a physician or nurse travel "downstream" to the LIS. A special printer in the laboratory generates a collection list, which contains data in both alphanumeric and bar code form. Having a barcoded specimen label available at the time of collection has become known as the collection list approach,|1~ which has been adopted by many laboratories.

The collection list contains the patient's name, room number, age, sex, and infection control status. Next to the patient's name on 8.5-inch-wide label stock are printed peel-off bar code labels bearing the specimen identification (accession) number. These labels will be affixed to tubes containing specimens for automated chemistry and hematology tests, peripheral blood smears, and any other ordered test that works with the bar code system.

All label information that can be read by human operators has been reformatted by the direct thermal printer, which produces small but consistently legible characters, to conserve space and allow the inclusion of more data.

* No secondary relabeling. The phlebotomist carries the collection list to the hospital floor, verifies the patient ID, collects the specimen, peels the appropriate bar code label off the list, and affixes it to the tube. That act settles the question of specimen ID once and for all. It also eliminates secondary relabeling, by which a technologist in the lab would have to use a dedicated bar code printer to create labels and affix them to tubes containing specimens slated to be run in automatic analyzers that wouldn't work without them.

The collection list labels display the bar code symbology--that is, style or language--that will best fit the analyzer for which the specimen is bound. For example, of the four major bar code symbologies,|2~ Code 39 works best on the Abbott EPx, whereas Interleaved 2 of 5 (I 2 of 5) is most appropriate for the Coulter STKS. Figure 2 is a model of specimen identification and workflow as handled by the collection list system.

The logic behind the collection list approach is simple. Since specimens must be labeled at the point of collection anyway, phlebotomists virtually follow their usual procedures. The operators of automatic instruments can thus spend their time reviewing test results, operating and maintaining equipment, and performing quality assurance activities. Hematology technologists counting cells for differentials can simply scan bar-coded slide labels for patient ID instead of the more tedious manual steps required without bar codes.

* Early troubleshooting. We devised our bar code system with the assistance of a committee of laboratory managers and supervisors. Technologists' suggestions were elicited as well. Implementation was smooth because we identified technical and managerial issues in the early phases of project development and addressed them immediately.

Workflow was a primary consideration. We wanted to retain the kinds of data provided on our non-bar coded labels while adding order comments, HIS specimen number priority (whether routine or Stat), and other information we had been unable to include before. The reason was that the dot matrix printers we used couldn't print characters small enough to contain that much information while remaining legible.

* Technical solution. An advance in technology just being introduced when we began our five-year plan--the intelligent printer|3~--finally enabled us to begin the coordinated use of bar codes.

We selected the MedPlus 2400F (MedPlus Inc., Cincinnati). This model has an 8.5-inch-wide carriage, which allows collection list and bar code specimen labels to be printed side by side. This unique capability helps keep the collection list to a reasonable length. The printer can produce high-density codes of near-photographic quality: 200 dots per inch (dpi). We obtain an acceptably accurate first-read rate--more than 99% (obtaining a positive read on at least 99 out of 100 scans)--on all the bar code-capable analyzers in our laboratory.

One especially useful feature of the MedPlus is its ability to print more than one bar code symbology on the same line. Although most analyzers accept two or more languages, each tends to perform best with the one it "prefers." The printer we bought, programmable to interface with most major laboratory information systems, was easily adapted to the label-generation output of our LIS.

* Approval. Like most hospital laboratorians who want to make sweeping changes, we had to address the concerns of administration: How much would a bar code system cost? Would it work well and reliably? Would the staff accept it?

Time saving. In support of our proposal we cited a 1990 study done at a large California lab that was saving nearly $260,000 a year by using an integrated bar code system.|4~ Coauthor Kasten also directed an in-house study on the time to be saved by eliminating secondary labeling: eight minutes per 20 chemistry and hematology specimens and 10 seconds per differential slide, or more than three hours of technologist time per day. Such technologists at our institution earn $20 per hour, including overhead and benefits. The annual saving is therefore about $22,000 in the hematology and chemistry sections alone.|5,6~ An additional and substantial amount of time and money would be saved when technologists no longer hand-keyed specimen accession numbers into analyzers that were capable of using bar codes but not yet set up to do so.

Fewer errors. One important but invisible saving was to prevent the costly lawsuits that can arise from patient identification errors. The more precise identification of specimens allowed by bar code labels is a significant, if undocumented, risk management factor.

The right skills. Perhaps the most beneficial saving stemmed from the intangible "human factor." Since senior medical technologists who are skilled automatic analyzer operators are becoming harder to find, their time is best spent on work they consider challenging. For their own part, technologists appreciate being relieved of specimen ID and accessioning work.

* Joining the crowd. When we began to plan our collection list system in 1987, the intelligent printer was new. We were one of the few hospital labs that wanted to make it the centerpiece of a comprehensive program. Our cost-benefit analysis convinced hospital administration of the economic merits of our proposal. When our hospital's exhaustive review and justification process was complete and the system went on line in 1991, we joined more than 150 laboratories that had by then successfully adopted this efficient means of managing specimen identification and workflow.

* Startup. Implementation went smoothly. Coauthors Disney and Schrand provided in-service staff training on paper loading, paper feed alignment, and simple troubleshooting. The printers were reliable from the very beginning. The only technical difficulty we encountered was incorrect installation of cable connectors by the hospital's electrical contractor.

Our plans for the immediate future include obtaining about 10 more bar code printers for nonlaboratory sites where specimens are collected for our lab, such as the hospital emergency rooms and intensive and cardiac care units. Most of the new printers will be the wide-throat model previously described. A few narrow-throat MedPlus 1400 models will be used within the lab to print labels for aliquots and derivative specimens.

One of the most versatile features of the system is the option to specify at the time of test ordering where the labels are to be printed. If it's more convenient than printing them in the lab, they can be printed in the emergency room, pre-admission testing suite, or other site of the point of test order. Thus when collections are done at remote sites, the tubes can be labeled with bar codes on the spot.

* Commitment. Our bar code system is now well established and very popular with the laboratory staff. The concerns voiced during project development have been answered. A case in point: We accomplished in minutes the change of symbology from Code 39 to I 2 of 5 that was required by chemistry analyzers we obtained after the bar code system was in place. The monetary saving projected by our time studies has also been realized. No one would consider going back to the old way.

* Looking back. The principal factors that tend to frustrate the full use of bar code technology in clinical labs generally are managerial and technical, as they were for us at the outset:

Integration. The laboratory has developed no clear plan for blending the use of bar codes into overall workflow.

Cost management. Would-be implementers are daunted by the prospect of planning and budgeting for the capital cost of initiating a bar code system.

Capability. The staff hesitates to use high-resolution intelligent printers, which are still relatively new.

"Early adopter unease." It's difficult to obtain administrative support when management believes, incorrectly, that few laboratories have successfully converted to an integrated system.

Inertia. Laboratory staff and management resist change.

All these factors can be readily addressed. As reports of successful integrated bar coding applications are shared, our experiences and those of other "early adopters" should encourage laboratories to accelerate implementation.

* A new standard. Printing a bar code collection list using an intelligent printer has become the industry standard. The system can be used with many different kinds of LIS; most automatic instruments also tie in. The growing acceptance of the collection list system in independent and hospital laboratories across the country has deepened the support of our administrators while bolstering our own confidence in our choice.

We predict that the bar code revolution will overtake other laboratory systems quickly and painlessly. Once it arrives, delighted laboratorians across the country will wonder why it was so long in coming.


1. Kasten BL. Bar code barriers gone. CAP Today. January 1991; 5(8): 6-8.

2. Kasten BL. What are all those lines and spaces? Understanding bar code technology. MLO. December 1992; 24(12): 25-27.

3. Kasten BL, Schrand P, Disney M. Joining the bar code revolution. MLO. December 1992; 24(12): 22-25.

4. Neeley WE. Heighten efficiency with an integrated bar code system. MLO. March 1990; 22(3): 24-27.

5. Pasternack A. Bar codes ready for labs. CAP Today. June 1992; 6(6): 38-39.

6. Kasten BL. Bar code benefits. CAP Today. May 1991; 5(5): 14, 61.

Dr. Kasten is associate director of pathology and laboratory services, Schrand is laboratory computer system manager, and Disney is laboratory information system analyst, Bethesda Hospitals, Inc., Cincinnati, Ohio.

Lab workflow using an integrated bar code system

1. Test ordered on hospital information system (HIS)

2. Order received on laboratory information system (LIS)

3. For inpatients, bar code labels are printed in the clerical areas of both main labs and affixed at the bedside throughout the hospital. In the eight satellite drawing sites, including the emergency room and critical care areas, labels are printed and affixed on site. For outpatients, bar code labels are printed and affixed:

* In a Stat lab in a free-standing emergency facility

* In an outreach laboratory when specimens are received from physicians' offices

* On site for outpatient tests such as pre-admission and ambulatory treatment

4. Labels are carried to floors and applied at time of collection

5. Labeled specimens arrive in lab; arrival time noted on LIS

6. Test orders downloaded to analyzers

7. Accession numbers read by scanners

8. Ordered tests performed; bar-coded hematology slides wanted at time of differential count

9. Results verified on LIS

10. Results uploaded to HIS; available for viewing and printout at nursing stations and in physicians' offices
COPYRIGHT 1993 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1993 Gale, Cengage Learning. All rights reserved.

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Title Annotation:Bar Codes, part 2
Author:Kasten, Bernard L.; Schrand, Pam; Disney, Mary
Publication:Medical Laboratory Observer
Date:Jan 1, 1993
Previous Article:Helping staff excel: career growth without a ladder.
Next Article:Creating a newsletter for the laboratory.

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