A Case Study on Laboratory Information System

Procedia Technology 11 ( 2013 ) 740 – 747

2212-0173 © 2013 The Authors. Published by Elsevier Ltd.Selection and peer-review under responsibility of the Faculty of Information Science & Technology, Universiti Kebangsaan Malaysia.doi: 10.1016/j.protcy.2013.12.253

The 4th International Conference on Electrical Engineering and Informatics (ICEEI 2013)

Telehealth Model Information Flow: A Case Study on Laboratory Information System

Dian Pradhana Sugijartoa,*, Nurhizam Safieb, Muriati Mukhtara, Riza Sulaimana aFaculty of Information Science and Technology, Universiti Kebangsaan Malaysia, Bangi 43600, Malaysia

bUnited Nation University International Institute for Global Health, Kuala Lumpur 56000, Malaysia

Abstract

This paper presents a methodology to design an information flow telehealth model with an initial model designed based on standard of Laboratory Information System (LIS) in Malaysia. Ministry of Health (MoH) Malaysia‘s vision is to have an integrated telehealth system for telehealth services within Malaysia. The idea of telehealth integration has been raised a long time ago and the progress is relatively slow. The recommended information flow model is to strengthen the foundation of the integration model. This paper proposes the methodology to achieve the goal, which is to design an information flow model for Malaysia. Initial study has been done to design the information flow model in LIS. The designed model is a preliminary step prior to achieve the bigger scale for Malaysia. Ubiquitous technology is also taken into consideration to be the strong point of the model. In conclusion, this paper shows the significance of information flow model prior achieving integration. © 2013 The Authors. Published by Elsevier B.V. Selection and peer-review under responsibility of the Faculty of Information Science & Technology, Universiti Kebangsaan Malaysia.

Keywords: telehealth model, information flow, Malaysia, ubiquitous.

1. Introduction

Information technology has been utilized in health care environment in many aspects. The following implementations are the examples of the use. A nurse who use a badge with voice commands recognition that is used to call medical personnel immediately [1], a seamless communication in which patient’s location data is transferred to a care centre server using wristband for elderly people [2] and diabetes management system in rural

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© 2013 The Authors. Published by Elsevier Ltd.Selection and peer-review under responsibility of the Faculty of Information Science & Technology, Universiti Kebangsaan Malaysia.

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741 Dian Pradhana Sugijarto et al. / Procedia Technology 11 ( 2013 ) 740 – 747

area using telehealth technology [3] are examples that telemedicine has been significantly improved within the past few years [4].

Telemedicine is a practice of medical care using audio, visual and data communications, which include medical care delivery, consultation, diagnosis, treatment, education and transfer of medical data [5]. World Health Organization (WHO) defines telemedicine as “the delivery of health care services, where distance is a critical factor, by healthcare professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interest of advancing the health of individuals and their communities” [6]. Telehealth has similar but broader definition than telemedicine [5].Telehealth covers the management, literature and knowledge of both healthcare and the information technology.

One of the reasons of the telehealth improvement is the emerging technology of ubiquitous computing. Ubiquitous computing emphasizes that human is able to communicate naturally with the devices and the computers are embedded to devices [7]. Ubiquitous computing is not a new idea. Vision of ubiquitous computing has been existed since 1991 in which human interacts seamlessly with computer in daily life until they are indistinguishable from them [8, 9]. Furthermore, ubiquitous computing has been widely used in the world of healthcare [10]. It began with utilizing the advantages of smart home concept, for example managing diabetes by monitoring blood glucose [11].

Although telehealth has been significantly improved and has been proved to reduce cost [12], each telehealth service stands on their own. They do not integrate with other telehealth services. This situation is happened because of services that are provided by private companies do not have connection to other companies and to governments’. Examples of private companies that offers telehealth services are Intel [13] and Philips [14].

Malaysian government understands the necessity of integration. Ministry of Health (MoH) has designed an integration model which called Integrated Hospital Information System (IHIS) [15]. IHIS initially was proposed in 1997 [16] and has been enhanced for several times to adapt with the advancement of technology and to cater the local needs. IHIS is crucial to the telehealth development in Malaysia.

Although IHIS has improved, the progress of the development is relatively slow. There are many projects to be integrated and they create complications such as standards and rules that must be complied.

This paper proposes an information flow telehealth model and presents a monitoring point of care testing service model as an intial result. The model is designed as part of Laboratory Information System (LIS), which is one of the core system of Total Hospital Information System (THIS). Section 1 will introduce about the background of this paper. For Section 2, it describes the implementations of ubiquitous computing in telehealth and in Section 3, will be explains about the chronology development of IHIS in Malaysia. Section 4 will explains regarding the methodology and inSection 5 will shows an initial result. Finally, section VI concludes the paper.


2. Telehealth Implementation in Ubiquitous Technology

The implementations of telehealth using ubiquitous technology can be categorized into several categories. Varshney reviewed applications and requirements to provide healthcare with ubiquitous technology (the author referred it as pervasive healthcare) [17]. The author divided healthcare applications to the following categories: prevention, healthcare maintenance and checkups; short-term monitoring (or home healthcare monitoring); long-term monitoring (nursing home); personalized healthcare monitoring; incidence detection and management; and emergency intervention, transportation and treatment. G. Hong, A. Fong, and B. Fong categorized ubiquitous healthcare through their ubiquitous healthcare framework [18]. The framework comprised of medical education, support personnel, remote treatment, emergency response, visit record, health monitoring, health management, and patient home.

Regardless of the category, ubiquitous telehealth research most likely are conducted in hospital environment. Hospital is considered as a condusive location to introduce ubiquitous technology [19-21]. One of the popular implementation of ubiquitous technologies is a wearable device using radio-frequency identification (RFID). O'Connor used an RFID technology to monitor and track the patients [22]. Stanford reported a communicator badge system that was piloted at St. Vincent’s Hospital in Birmingham [1]. Pentland developed a wearable sensor hub interface, a compliance to a personal digital assistant (PDA) to measure physiology of a patient [23]. Anliker et al. described a wearable medical monitoring and alert system for high-risk cardiac or respiratory patients [24].

Several researchers used Near Field Communication (NFC) technology, which is the technology that is considered as an answer of the vision of ubiquitous computing [25]. D. López-de-Ipiña, I. Díaz-de-Sarralde, and J. García-Zubia used NFC to transfer the information from elderly patient’s wristband to healthcare staff. The information is stored and integrated with social network system. Another popular implementation using NFC technology is a smart poster. A. Prinz, P. Menschner, M. Altmann, and J. M. Leimeister created a smart poster that was used as a questionnaire. They asked elderly people to answer the questionnaire by ‘touching’ the questions and answers using a NFC phone. These ubiquitous technology improves the service and helps to assist the healthcare experts to conduct their job.

3. In The Journey to Integrate Hospital Information System

Malaysia has started to concern about telehealth since 1997 under the name of telemedicine [16]. Telemedicine refers to the provision of healthcare and related services and components such as consumers, healthcare provides, suppliers and other agencies.

By this definition, government planned to focus on several healthcare services that include: information & education, consultation, support and governance. All of the healthcare services were designed to achieve eight Malaysian government goals in telemedicine: promote wellness, provide user-friendly virtual services and accurate information, increase individual ability to transfer knowledge, provide home care, provide seamless and continuous care, customized services according to individual needs and provide the service with affordable cost.

3.1. Chronology of IHIS

IHIS was started in 2000, when the Mutimedia Development Corporation (MDeC), the custodian of Multimedia Super Corridor (MSC)'s flagship established a Telehealth Unit [26]. The unit’s goal was to develop four pilot projects: Mass Customized / Personalized Health Information & Education, Continuing Medical Education (CME), Teleconsultation (TC) and Lifetime Health Plan (LHP) [16]. In 2004, the project scope was reorganized. It was consisted of Lifetime Health Record (LHR), Personalized Lifetime Health Plan (PLHP), Health Online, Continuing Professional Development (CPD), Teleconsultation (TC) and Call Centre and Group Data Service (GDS) [27]. Until today, the visions and goals are still carried by the Minister of Health (MoH), the IHIS project main stakeholder. In March 2010 and May 2012, Hisan [15] presented the development of telehealth project in the Malaysian Health Information Exchange Symposium. He presented the integrated health information system (IHIS)


as shown in Fig. 1a. IHIS is a continuation of the telehealth flagship of 1997. It is a model which describes integration of several telehealth projects in Malaysia.

3.2. Hospital Information System (HIS)

The main purpose of each component in IHIS is to provide healthcare services to customer and to share the services with other healthcare providers [15]. Healthcare services was provided by Hospital Information System (HIS). Whereas, other components in IHIS provide the ability to share data and functions to other care providers, such as LHR, LHP and health data warehouse (HDW).

According to [28], implementation of HIS in Malaysian hospitals can be divided to three domains: basic HIS, intermediate HIS and total HIS. Basic HIS consists of HIS basic features which includes: patient management, patient billing, order & result management, medical records management and discharge summary. Intermediate HIS comprises of basic HIS features, pharmacy, laboratory and blood transfusion managements. Total HIS comprises of intermediate HIS, clinical documentation, medical imaging, and reporting tools.

3.3. IHIS Components

IHIS consists of five major components: Lifetime Health Record (LHR) & Services, Personal Lifetime Health Plan (PLHP), Health Online, Teleconsultation (TC) and Continuous Professional Development (CPD).

LHR is a collection of health information of an individual to be used for himself and healthcare providers that contains all the health record while alive [29]. LHR and PLPH are connected to Clinical Support System (CSS) to obtain and update the data. A complete CSS comprises of several components, which are merged in Total Hospital Information System (THIS) [30]. The components consist of pharmacy information system, laboratory information system, radiology information system, person management system, blood bank information system and operating theater management. By 2010, THIS has been implemented in eight hospitals in Malaysia [31].

Health Online was developed to promote individual’s wellness by providing health information and education [32]. MyHealth portal has been launched in 2006 and has more than 600 topics related to children, adolescent, nutrition as well as medication [33]. CPD enhances the capability and knowledge of medical professionals. It uses Credit Point (CP) for medical professionals to maintain up-to-date knowledge. TC helps the specialist to communicate with hospitals as if they are present in the hospital. Teleconsultation sites has been implemented in several hospital in Peninsular Malaysia and Sabah [34]. These hospitals have advanced teleconsultation equipments such as terminals for patient data capture and for diagnosis purposes.

3.4. Problems in IHIS

The IHIS model (refer to Fig. 1a) focuses on the integration of several telehealth projects in Malaysia. IHIS describes the basic relations among the components without explaining the information flow. To integrate those telehealth projects, it is necessary to have a clear information flow among them, especially from HIS (the operational components which deliver health service to customer) to the integration components (the shared components that enable services to be shared with other healthcare providers).

The idea to integrate telehealth projects of IHIS is similar with report by Hsu et al. [35]. In Taiwan, they successfully integrated three projects: home care, community care and residential model. IHIS consists of many components. As number of components and projects increase, the complexity of the integration is also increase. However, MoH is aware of this matter and several solutions have been proposed, such as standardization of data, document, messaging and protocol [15]. Without supervision from Information Technology departments, healthcare experts and a good collaboration with the government, the integration is difficult to be achieved [36].

Although the government concerns about increasing the usage of Information and Communication Technology (ICT), telehealth in Malaysia has not highlighted the needs of ubiquitous technology. Out of five components in IHIS, the only component related to ubiquitous technology in IHIS is teleconsultation (TC). In order to facilitate government’s commitment towards universal access to provide affordable and high quality care [37], IHIS must have connectivity to ubiquitous model or integration of ubiquitous telehealth project. IHIS ability to support ubiquitous telehealth technology will greatly boost the impact of telehealth development in Malaysia.


Analyze HIS

Construct entities

Construct model for each hospitals / clinics

Validate the models

Construct the baselinemodels

Analyze IHIS

Map the baseline modelwith IHIS

Analyze ubiquitous / POC devices

Ubiquitous telehealthmodel for Malaysia

4. Telehealth Model Methodology

Section III explains the important role of HIS, as it directly interacts with customers. Therefore, the initial stepin the methodology is to analyze the current HIS. The focus of this step is to get the information flow: input,process and output of the system. While analyzing the HIS, we also start to discover the possible ubiquitouscomponents within the process.

Several phases of the methodology are adapted from [38]. The Methodology is taken into consideration becauseof the similarity of idea in designing an integrated telehealth model. The adopted methodology begins from constructing entities phase until constructing baseline model.

Fig. 1. (a) Integrated Health Information System (IHIS) [[15]; (b) Telehealth Model Methodology.lth Model Methodology

The results of the first phase are entities and the relationships. Knowing them, the model for each specificprocess can be designed. Validation of the models through questionnaires and revision are done accordingly. Thevalidated models are used to construct the baseline models.

IHIS model is analyzed in more detail. The purpose of the analysis is to uncover the connection between thebaseline model and the IHIS. The analysis results in a decision to merge the proposed model with IHIS or to attachthe proposed model as a complimentary component of IHIS model. The ubiquitous components that have been analyzed in earlier stage are used to create a ubiquitous layer in the proposed model. The final result of thecombination is the ubiquitous telehealth model for Malaysia. The proposed methodology is shown in Fig. 1b.

5. Initial Result: Case Study on Laboratory Information System

A Preliminary study has been done by analyzing health informatics standard that is used in public hospital inMalaysia [28]. Health informatics standard consists of six information systems which each of them are publishedseparately [39]. Each of the standards is a core application under HIS: person management system, laboratoryinformation system, pharmacy information system, operating theater management system, radiology information system and blood bank information system.

Person management system standard discusses information flow that is required of person management withinand across the hospital [40]. Doctors and nurses are categorized as a person within the hospital environment. If atask is handled by staff in hospital but they are not doctors and nurses, the person is considered as a healthcareprovider. People that are not categorized within the hospital are patient and client.


Pharmacy information system standard describes procedures to prescribe medications, pharmacist regulations, drugs dispensing, pharmacy system capabilities and information flow in a pharmacy [41]. Laboratory information system standard describes the information flow that requires end-to-end transmission of the medical officer order [42]. Blood bank information system standard provides online information flow for the management of blood donors and recipients and also supports the production, storage and issue of blood and blood products [40]. Operation Theater (OT) is a location where surgical operation is performed. The OT management system standard provides documentation of procedures performed, the availability of monitoring equipments, procedure-specific instrumentation [43]. Radiology information system standard describes the standard guidelines of work for diagnostic imaging department [44].

Preliminary study is implemented by analyzing laboratory information system (LIS). LIS focus on laboratory services which are included the following functionalities: receive orders and collect specimen, process orders, create testing work orders, lab equipment interface, actual testing, generate transmitted results, generate management reports [42]. The main user of the system is a medical officer, their work concentrates on diseases investigation. LIS is chosen to be the preliminary study because diseases investigation is closely related to obtaining results. For a user, either a patient or a medical doctor, result is an important outcome of a system. Second important reason of choosing LIS is because some information flows in LIS involve ubiquitous devices, which is a Point of Care Testing (PoCT) which is a diagnostic testing device near the site of patient care.

The following subsection will discuss onthe process of designing a model using the methodology described in the previous section. Subsection 5.1 shows the background of LIS. Subsection 5.2 describes the process to construct entities based on the process of how PoCT device is used to analyze a specimen using PoCT device. Subsection 5.3 describes the proposed model based on the entities.

5.1. Analyzing LIS

The scopes of processes in LIS that is studied are receiving order & collecting specimen, processing order, and monitoring PoCT services. However, this paper focuses on monitoring PoCT services. Table 2 shows the result of the analysis. The result consists of input, output, the actors and roles of the actors related to the processes.

Section 5.2 and 5.3 discuss about creating the model based on the process of monitoring PoCT services. PoCT is usually can be performed by healthcare professional or patient. However, since PoCT device is used within the hospital, MoH issues a policy which stating that the usage of PoCT can be done only by trained and authorized personnel [45]. This policy is developed to ensure the quality of the result.

5.2. Entities Construction

Actors and roles that are discovered from the previous phase are converted into symbols. The symbols, representation of the actors, act as entities in the proposed model. Ten entities were identified as being present in monitoring PoCT services. Table 1 shows the symbols and the meaning.

Table 1.Symbols Used to Draw Telehealth Model


5.3. Proposed Model for Monitoring PoCT

A model (refer to Fig. 2) was deduced from the process in monitoring PoCT service. The model shown in Fig. 3 is only one of the models that will be designed to complete the baseline telehealth model. This specific model will be combined with other similar models in LIS. The model of LIS will be combined with other information system models to be a baseline model.

Fig. 2. Information Flow Model for Monitoring PoCT Service

6. Conclusion

In short, this paper attempts to present a methodology to design a ubiquitous telehealth model. It started with analyzing current HIS while analyzing ubiquous components, construct entities, construct and validate models, construct baseline model, lastly, map the baseline model with IHIS model. Thus, an information flow model for monitoring PoCT service has been designed. The model further shows an initial study before reaching the overall goal of this study, which is designing an ubiquitous telehealth model for Malaysia.

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