Re-engineering the clinical laboratory. An overview.

This article provides an overview of processes involved in re-thinking the clinical laboratory. The author, also the Guest Editor of the issue, alludes to the work of the other authors in this issue and provides his own views on this increasingly important subject.

Global healthcare and the flux of technology.

For Medinfo '98, as an exercise in technological forecasting and analysis, we volunteered to project the direction of healthcare informatics into the next century. This paper is an extended discussion of that presentation. We open with the observation that healthcare informatics is merely one of the many endeavors that is following a turbulent but nearly inescapable path into a digital future. Our objective is to describe as best we can the overall geography of the general path we appear to be on, to anticipate some of our future checkpoints along the way, to identify some of the roughest transitional passages as they apply to healthcare, and to present this as one guide among many to those who have offered to do the steering into this exciting, electronic unknown. Emphasis is placed on the growing importance of information networks, the particular nature of complexity as applied to healthcare communications and healthcare itself, and the impact of the rising costs of what is medically possible in a technological age. Certain evident recent changes in computing technology are singled out for their present and expected importance. The whole is considered from a broader organizational perspective to better understand the turbulence of present times, and what medical informatics might address to ameliorate the most onerous healthcare issues.

Global healthcare and the flux of technology.

We begin with the inescapable observation that healthcare informatics is merely one of the many endeavors that is following a turbulent but nearly inescapable path into a digital future. Our objective in this paper is to describe as best we can the overall geography of the general path we appear to be on, to anticipate some of our future checkpoints along the way, to identify some of the roughest transitional passages, and to offer this as one guide among many to those who have volunteered to do the steering into this exciting, electronic unknown.

Focal fibrocartilaginous dysplasia in the upper extremity.

Focal fibrocartilaginous dysplasia is a benign lesion known to cause tibia vara in young children. To date, this lesion has been recognized in only the proximal medial tibia. This study reports two additional cases of focal fibrocartilaginous dysplasia occurring in the long bones of the upper extremity. The clinical presentation, radiographic appearance, histopathology, and natural history of focal fibrocartilaginous dysplasia in the humerus and ulna are analogous to published descriptions involving the tibia. Spontaneous resolution of the lesion and the resultant angular deformity is possible but not entirely predictable. Limb-length discrepancy should be anticipated.

Clinical laboratories are laboratories for re-engineering.

The concept of re-engineering rests on computer coordination of information. As a management tool, it has been tested and found to be ambiguous. At best it sharpens laboratory objectives, but at worst it fragments skills and threatens the community attitudes needed for teamwork. Experience with its most fruitful components has long been a part of laboratory management.

Implementing a low-cost computer-based patient record: a controlled vocabulary reduces data base design complexity.

In order to build a computer-based patient record (CPR) system suitable for use in solo and small group practice settings it is necessary to use development methods that minimize cost. Design complexity is a major source of high cost. Reducing complexity should result in lower development, deployment and maintenance costs as well as higher reliability. We have developed a simplified relational model and have used that model, in conjunction with a controlled vocabulary, to implement a CPR that can capture and store patient examinations and other forms of clinical notes as well as laboratory and other test results. The information can be viewed in a familiar document format and it can accessed for other types of processing using standard Structured Query Language (SQL) techniques. The database, as implemented, uses inexpensive components resulting in a system that is not prohibitively expensive for solo practitioners and small groups. In addition the architecture is scaleable and can accommodate very large numbers of patients and practitioners.

A document processing architecture for electronic medical records.

An Electronic Medical Record System (EMRS) requires a deep analysis of the clinical workplace and of the character and uses of the medical record itself. Charts are a diverse and useful collection of loosely structured specialized documents, each with an orderly outline, but widely divergent and unpredictable contents--the more critical the case, the more unpredictable the details. This can be achieved by adapting an underlying information architecture that is based on document processing (rather than data processing), using the logic and conventions of text tagging, as in Mosaic, the Standard Generalized Markup Language (SGML), and HyTime.

Preventing postlaminectomy adhesion. A new experimental model.

STUDY DESIGN: The efficacy of various interpositional membranes for prevention of extradural adhesion was investigated by a new animal model that quantified the biomechanical effect of scar formation. Twenty-one dogs were treated with autologous free fat graft, hyaluronic acid or no interpositional membrane after undergoing two-level laminotomy, nerve root exploration, and disk injury. An additional 11 dogs that did not undergo spine surgeries served as control animals. OBJECTIVES: Inter-animal variability in inherent propensity to form scar was first measured before any spine surgery. Twelve weeks after spine surgery, the lumbosacral spine of each dog was harvested en bloc for biomechanical testing of extradural adhesion ultimate load. Scar stiffness coefficient was also calculated. SUMMARY OF BACKGROUND DATA: Adhesion ultimate load was significantly less in the nonoperative control group when compared with the fat graft and no interpositional membrane group, but not when compared with the hyaluronic acid group. A beneficial effect of hyaluronic acid in lowering adhesion ultimate load was demonstrated, although a statistically significant difference from the fat graft and no interpositional membrane groups was not reached. No difference in scar stiffness coefficient was found between the four groups. METHODS: A new experimental model allowing objective biomechanical quantification of the effect of postoperative scar was described. Ultimate load of adhesions to both nerve roots and dura was measured. A biochemical assay that determined collagen content was also used to assess inter-animal propensity to form scar after a standardized surgical insult. Results were compared with other relevant studies. RESULTS: Findings suggest a beneficial effect of hyaluronic acid in decreasing the biomechanical strength of extradural adhesions following laminotomy, nerve root exploration, and disk injury when compared with use of fat graft or no interpositional membrane. These results support other recent investigations that study the use of hyaluronic acid treatment in a laminectomy model. The adverse consequence of intraoperative epidural bleeding was also demonstrated. CONCLUSIONS: The new experimental model described in the current study was reproducible and permitted objective quantification of the effect of postoperative adhesion rather than measuring its mere presence. A beneficial effect of hyaluronic acid treatment and a lack of such beneficial effect of free fat graft interpositional membrane was suggested. The importance of avoiding active epidural bleeding was also evident.

"Isolated" traumatic radial-head dislocation.

A delay in diagnosis of a traumatic radial-head dislocation in the absence of a concurrent ulnar fracture is common. Published reports of this injury imply an isolated injury to the radius without involvement of the ulna. This hypothesis is challenged by a retrospective study of all cases over an 8-year period that demonstrates an identifiable injury to the ulna in every case. A new radiographic sign, the "ulnar bow sign," is described to assist in the proper recognition of this injury pattern. A radial-head dislocation or subluxation should be suspected if the posterior border of the ulna on a true lateral radiograph deviates > 0.01 mm from a straight line.

An information model for medical events.

Information gathered during the healthcare process is lost when forced into rigidly structured record-oriented databases. By contrast, content can be difficult to manipulate if stored as unstructured text. Spurred by the requirements of electronic publishing, military procurement and the Internet, new robust standards for structuring documents have been developed and deployed. These standards can provide a foundation for a document-based Electronic Medical Record System. In order to fully exploit this added flexibility, an information model is necessary to define both the direct and contextual content of documents. Once context, as well as fact, are recorded in formal structures, inferential techniques can either selectively extract knowledge and data from documents or aggregate data to create summaries so that all interested and authorized parties have a better chance of meeting their information needs from a single, permanent data source.

Information technology, health care, and the future: what are the implications for the clinical laboratory?

As new information systems are offered for the clinical laboratory, advanced applications and improvements in computer hardware continue to dominate marketing presentations and fascinate the decision maker. However, the most important issue for all of our clinical information systems is not the speed of the hardware, the reliability of the systems software, or the ability of applications to carry out routine tasks in some novel or elegant manner. Rather, it is "coping"--the ability of a system to manage new issues that arise as information requirements change over time and to manage all the unexpected events that occur in the course of regular work but that do not follow the usual sequence of procedures. The need for new processing conventions to cope with unexpected situations without creating new problems is not unique to health care. The need is present wherever the real world intrudes directly and significantly into critical operations. Moreover, the pressure to adjust to changing external circumstances continues to grow as the rate of change in our information-based society increases. The lack of general coping procedures, although long ignored, has become such a pervasive handicap that marked improvements in this type of flexibility will be introduced over this decade. New software designs that deal with coping issues are already beginning to appear and to bear fruit. When purchasing any new laboratory computer system today, software that demonstrates an effective coping flexibility should be given more weight than fascinating innovations in hardware or software that are the favorites of vendor marketers. It is now possible to test for such flexibility on a site-specific basis.

Acquiring a laboratory computer system. Understanding the issues.

This article reviews the issues involved in introducing or upgrading computer automation in the clinical laboratory. The strengths and weaknesses of computers and computer systems are discussed. Information on selecting and educating the laboratory team who will use the computer and analyzing the needs of a particular laboratory is included.

Acquiring a laboratory computer system. Vendor selection and contracting.

The steps involved in acquiring a computer system, from writing the request for a proposal to signing the contract, are discussed. Guidelines for selecting a system include information on the merits of different hardware and software available for use in the laboratory.

Programming languages.

This article focuses on the strengths and shortcomings of application languages as they are used in general purpose computers, on the strategies for their use, and on how they impact laboratory and medical systems. The author describes the reason why we are where we are at the present stage of computer languages and suggests where we might expect to be in the foreseeable future.