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The VA computer system goes on line.

The VA computer system goes on line

Changes afoot within the medical centers and clinics of the Veterans Administration promise a major improvement in patient care. A comprehensive, integrated hospital computer system --the VA's first--is now being installed in all but three of these 172 facilities. (The remaining hospitals are installing commercial, off-the-shelf products under a Congressional mandate for purposes of comparison.) The heart of the system, called Core, consists of three main software modules: pharmacy, medical administration, and laboratory.

The VA is planning other modules related to patient care, including nursing, dietary, patient histories, operating room scheduling, and psychological testing. There are also administrative modules for supply and fiscal services. Installation of each module represents a massive amount of time, preparation, and coordination --in the laboratory as in every other department. We will describe the development and characteristics of the VA computer system's laboratory module and how it may grow even more useful in the future.

Developing a laboratory information system for close to 200 hospitals is a daunting proposition. The project began in mid-1982 with a meeting of pathologists, technologists, and laboratory scientists who were among the VA's most vocal advocates of computerization. This advisory panel, called the laboratory Special Interest Users Group or SIUG, was charged with devloping functional criteria for the laboratory module. Prior to this, several unofficial groups within the VA had worked on portions of a lab system based on the computer language called MUMPS.

In 1983, the laboratory SIUG intensified its efforts. Members of the group met frequently with programmers of the lab system to elaborate on functional requirements, review progress, test the systtm, and offer guidance for alterations and enhancements.

Responsibility for program development was shared between the VA's Information Systems Center in Salt Lake City, Utah, and the developers in Albany, N.Y. Each of the VA health care system's six regions has its own ISC and one SIUG representative for each hospital service. The Salt Lake City group worked on order entry, accessioning, reporting, and modules for work lists and load lists, while the Albany ISC programmed anatomic pathology, microbiology, and blood banking.

The two centers stayed in close touch through transfer of program tapes and liberal use of telecommunications. SIUG members also provided frequent input by testing and commenting on the software through electronic mail links with the ISC in Salt Lake City. This pre-existing computer mail system, called Mailman, enabled SIUG members to participate in program development without leaving their own laboratories.

In mid-1983, portions of the laboratory system were tested at the Martinez, Calif., VA Medical Center lab. The next major test came in December 1984, when an entire laboratory module was tried out at the VA's largest medical center in Long Beach, Calif. Here, the newest and most comprehensive version of the software replaced an existing Honeywell computer system and began functioning in real time, for real patients.

Since then, the laboratory software has been verified for conformity with established programming conventions at the ISC in San Francisco. It was cleared for release and began national distribution in July of last year. Implementation is under way throughout the system, with several medical centers using the laboratory module already.

At this point, two hospitals have the system completely up and functioning; about 10 more are well advanced into implementation; and the remaining centers are proceeding more slowly and expect to be on line by the middle of this year. In those hospitals that have fully implemented the system, the flow of information has already improved, although it is too early to evaluate the system's long-term effect on costs or productivity.

The laboratory module is the largest in the entire hospital information system, using almost half of the resources allocated for the Core unit. It's a total laboratory information system, functioning in all parts of anatomic and clinical pathology. All major clinical laboratory divisions are covered, including chemistry, hematology, microbiology, immunology, and blood banking, along with cytology and surgical and autopsy pathology.

Users can order tests from terminals located on the wards and clinics, or send specimens directly to the laboratory for accessioning. A typical VA facility will eventually have one or two terminals for every nursing unit, along with terminals in the clinics and some physicians' offices. Nursing units will also have computer printers.

Tests may be ordered on a routine or Stat basis, or on a number of other intermediate urgencies. The system will print collection lists and prepare specimen labels for phlebotomists to use when picking specimens up from the wards. Once specimens are obtained, the computer assigns them accession numbers and can print accession lists and work lists on which technologists can write the results of manual tests. Core can also prepare load lists for automated instruments. Results enter the computer either automatically through a direct instrument interface, or manually by keyboard.

Before test results are reported, a technologist validates them by using a number of quality control algorithms imbedded in the computer programming. These include the Shewart-Westgard multirule algorithm and a delta check that compares the current result with a previous one from the same patient. The computer alerts the technologist to unusual or out-of-range results. Reports on quality control data are prepared and maintained by the system.

Test results can be obtained from terminals on patient floors, from interim reports generated by printers throughout the hospital, or from daily cumulative reports printed in the laboratory and distributed to the appropriate patient wards. Stat reports can be printed automatically on the patient's ward. Users can also inquire via a terminal whether a specimen has been collected or if a test is pending, and get information on test reference values or the logistics of test ordering.

Through the File Manager, a data base management program within Core, it will be possible to search patient data for information useful in research, clinical studies, and education.1

The anatomic pathology functions can accession specimens, print specimen logs, and create reports discribing gross and microscopic features along with diagnosis.2 The system also provides for diagnostic coding by SNOMED, medicine's systemized nomenclature, and for automatic search and printing of a patient's previous diagnoses. When a pathologist examines either surgical pathology or cytology specimens, correlation between the two is automatic.

Other system features include an on-line SNOMED dictionary, indexing of diagnoses, and file searches to retrieve lists of specimens according to diagnosis. The Core software also includes a text editing function with basic word processing features. Other commercially available word processing programs, written in MUMPS, can be integrated into Core if desired.

The laboratory module is but one component of the entire hospital information system. From the project's onset, programmers were required to use common conventions and make sure that all modules were compatible. The development of each module is directed by a user group composed of representatives of the appropriate hospital service. Recently, the various user groups have begun regular communication to insure module compatibility and tackle cross-disciplinary problems.

Each module can work from shared files. For example, patient demographic data used in both the laboratory and pharmacy modules depend upon information supplied from the medical administration service module. By designing a fully integrated system from the ground up, the VA programs should avoid the common pitfall of having some parts of the hospital system unable to mesh with others.

How does Core differ from other laboratory computer systems? For one thing, it was designed to function in a variety of hospitals and freestanding clinics. Since VA laboratories vary tremendously in size and complexity, the software is by necessity highly flexible and can be configured by users to meet many personal preferences. Despite this unprecedented flexibility, the SIUG members have set down specific functional criteria which all systems must meet.

The system's File Manager was developed by VA programmer George Timson to be a highly so-phisticated, versatile, and userfriendly data base management program. It provides many features of MUMPS language, yet can be learned quite quickly by nonprogrammers. As a result, users can develop new programs with File Manager and convert them to MUMPS later.

The laboratory module is designed to fill all of the laboratory's needs--unlike much currently available commercial software, which does not include anatomic pathology, microbiology, or blood banking. And the VA lab software is fully integrated into other parts of the hospital information system, unlike many stand-alone commercial lab systems that cannot communicate with other hospital departments or accept test orders entered on the wards.

Another unique feature is the system's independence from any specific brand of hardware. Because of their strict adherence to American National Standards Institute MUMPS, the programs can be used on any computer of suitable size that has a standard MUMPS operating system. This allows VA Medical Centers to take advantage of the continuing dramatic improvements in computer hardware and to avoid being held hostage to one vendor.

Already, VA computer system users have grown into a large group with strong camaraderic, due to their regional training and the sheer number of their facilities. Users, especially laboratory computer specialists and site managers, can quickly share relevant news with their counterparts at other VA Medical Centers through the Mailman system. Committees and task forces can also hold conferences and problem-solving meetings through Mailman. Just as important, the VA itself has made a strong commitment to the system's success and continued support.

Since the Core software was developed by the Veterans Administration, a Federal agency, it is in the public domain. It may be obtained at minimal charge through the Freedom of Information Act. The VA Information Systems Centers are not in a position to support nongovernment users, however. To fill this need, at least one private computer service has been established to provide VA software and support services to the public.

Future enhancements of the laboratory module will undoubtedly arise from the collaboration of the Salt Lake City ISC, the laboratory users' group, and local talent in VA Medical Centers throughout the nation. User participation is encouraged, and the nationwide system is set up to incorporate useful innovations at the local level.

In years to come, the laboratory SIUG will emphasize the system's management and decision support functions. One top priority is a program to capture and record workload data so that uniform, accurate workload statistics can be provided to VA and local laboratory management. Another program development goal is to capture data on laboratory utilization and origin of test requests.

Other important programs will determine and analyze test turnaround times, test queuing, and workload scheduling throught the day. One innovation to emerge from the VA Central Office Pathology Service has been the development of laboratory DRGs, an approach intended to provide optimal testing algorithms for a variety of common clinical problems. Computer programs that will assist test selection are being developed as part of this project.

Several joint programs between laboratory and pharmacy are also possibilities for the future. One task force is working on a pharmacokinetics program to predict optimal drug dosage based on diagnosis, height, weight, and hepatic and renal function. Such a program will be able to alert physicians that dosages should be altered if renal function is abnormal. A therapeutic drug monitoring program under consideration would notify physicians to alter drug dosage if TDM or other relevant tests so indicate.

In conclusion, the VA lab module is an inventive, comprehensive, and integrated lab computer system. Its implementation in the laboratories of the VA health care network is a leap forward in technology and information management. Perhaps the software's most unusual benefit is its unprecedented flexibility. The user can configure the system to the needs of an individual laboratory, and modify and enhance it without involving the software developer.

1. Ginsburg, R.E. and Tatarczuk, J.R. Laboratory computerization: Anatomic pathology, J. Clin. Lab. Automation 4: 429-436, 1984.

2. Krieg, A.F. "How to Make a Computer Work for You.' Bethesda, Md., National Association of VA Physicians, 1984.
COPYRIGHT 1986 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1986 Gale, Cengage Learning. All rights reserved.

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Title Annotation:Veterans Administration
Author:Baer, Daniel M.
Publication:Medical Laboratory Observer
Date:Jan 1, 1986
Words:1992
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