A Population-Based Laboratory Information Strategy

M. McNeely APIII 2006M. McNeely APIII 2006 11

A Population-Based A Population-Based Laboratory Information Laboratory Information

StrategyStrategy

Michael McNeelyMichael McNeely MD FRCPC MD FRCPC

Consultant in Medical Informatics, Consultant in Medical Informatics, Victoria BCVictoria BC


OverviewOverviewThere will be an ever-increasing need for laboratory results to There will be an ever-increasing need for laboratory results to be knowledge-based: to be interpreted, to guide treatment, be knowledge-based: to be interpreted, to guide treatment, and to smoothly integrate with the medical record.and to smoothly integrate with the medical record.Canada Health InfowayCanada Health Infoway is a government of Canada project is a government of Canada project whose goal is to have electronic medical records (EMR) for whose goal is to have electronic medical records (EMR) for 80% of Canada’s population by 2010. 80% of Canada’s population by 2010. The The Provincial Laboratory Information SolutionProvincial Laboratory Information Solution is a BC is a BC project to provide a unified database of all laboratory results project to provide a unified database of all laboratory results produced in the province. These two projects are at an early produced in the province. These two projects are at an early stage but eventually (phase III-IV) will incorporate knowledge stage but eventually (phase III-IV) will incorporate knowledge support.support.The presentation will, by way of a review, discuss the The presentation will, by way of a review, discuss the potential for these initiatives to carry forward existing potential for these initiatives to carry forward existing programs involving laboratory utilization control, risk programs involving laboratory utilization control, risk management, chronic disease management, telepathology, management, chronic disease management, telepathology, epidemiology, genominformatics, and sample management.epidemiology, genominformatics, and sample management.


Canada Health Infoway Canada Health Infoway http://www.infoway-inforoute.ca/http://www.infoway-inforoute.ca/

What is Infoway?What is Infoway?– Canada Health Infoway Inc. invests with public sector Canada Health Infoway Inc. invests with public sector

partners across Canada to implement and reuse partners across Canada to implement and reuse compatible health information systems that support a compatible health information systems that support a safer, more efficient healthcare system. safer, more efficient healthcare system. InfowayInfoway is an is an independent, not-for-profit organization whose independent, not-for-profit organization whose Members are Canada's 14 federal, provincial and Members are Canada's 14 federal, provincial and territorial Deputy Ministers of Health. Launched in territorial Deputy Ministers of Health. Launched in 2001, 2001, InfowayInfoway and its public sector partners have over and its public sector partners have over 100 projects, either completed or underway, 100 projects, either completed or underway, delivering electronic health record (EHR) solutions to delivering electronic health record (EHR) solutions to Canadians – solutions that bring tangible value to Canadians – solutions that bring tangible value to patients, providers and the healthcare system. patients, providers and the healthcare system.



MissionMission– To foster and accelerate the development and To foster and accelerate the development and

adoption of electronic health information systems with adoption of electronic health information systems with compatible standards and communications compatible standards and communications technologies on a pan-Canadian basis, with tangible technologies on a pan-Canadian basis, with tangible benefits to Canadians. benefits to Canadians.

– To build on existing initiatives and pursue To build on existing initiatives and pursue collaborative relationships in pursuit of our mission. collaborative relationships in pursuit of our mission.



VisionVision– A high-quality, sustainable and effective Canadian A high-quality, sustainable and effective Canadian

healthcare system supported by an infostructure that healthcare system supported by an infostructure that provides residents of Canada and their healthcare provides residents of Canada and their healthcare providers with timely, appropriate and secure access providers with timely, appropriate and secure access to the right information when and where they enter to the right information when and where they enter into the healthcare system. Respect for privacy is into the healthcare system. Respect for privacy is fundamental to this vision. fundamental to this vision.

GoalGoal– To have an interoperable EHR in place across 50 per To have an interoperable EHR in place across 50 per

cent of Canada (by population) by the end of 2009. cent of Canada (by population) by the end of 2009.


Components of the HERComponents of the HER– Patient and provider registries Patient and provider registries $110 m$110 m– Laboratory Results Laboratory Results $ 150 m$ 150 m– Medical Imaging Medical Imaging $ 220 m$ 220 m– Drugs Drugs $ 185 m$ 185 m– Interoperable EHR Interoperable EHR $ 175 m$ 175 m– Telehealth Telehealth $ 150 m$ 150 m– Public Health Public Health $ 100 m$ 100 m– Innovation and adoption Innovation and adoption $ 60 m$ 60 m– Infostructure Infostructure $ 25 m$ 25 m



Evolution of EHREvolution of EHR

Patient demographics Provider demographics Location demographics Encounters

Order entry and results viewing for laboratory tests, medications and images.

Alert notification (eg. duplicate tests, drug interaction)

Provisioning of leading practices (i.e., CPG’s)

Scheduling

Generation 3 plus complex Decision Support

EnablersEnablers

The Foundation

Generation 1

The Documenter

Generation 2

The Helper

Generation 3

The Mentor

Generation 4

End of 2009End of 2009

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Includes investments to support project management, user-adoption, change management, knowledge transfer, standards and benefits evaluation, representing 30% of program investments overall

Results Viewing

Laboratory test results

Dispensed medications

Diagnostic image results



Progress to dateProgress to date– Standards adoption:Standards adoption:

HL 7HL 7

LOINCLOINC

SNOMED CTSNOMED CT

– Provincial ProjectsProvincial ProjectsOntarioOntario

OthersOthers

British ColumbiaBritish Columbia


BC - The Provincial StrategyBC - The Provincial Strategyhttp://www.healthservices.gov.bc.ca/cpa/publications/ehealth_framework.pdfhttp://www.healthservices.gov.bc.ca/cpa/publications/ehealth_framework.pdf

An HER provides each British Columbian with a An HER provides each British Columbian with a secure and private lifetime record of their key secure and private lifetime record of their key health history and care within the health system.health history and care within the health system.The record is available electronically to The record is available electronically to authorized health care providers and the authorized health care providers and the individual anywhere, anytime, in support of high-individual anywhere, anytime, in support of high-quality care.quality care.For more information on the Electronic Health For more information on the Electronic Health Record, please see:Record, please see:http://healthnet.hnet.bc.ca/index.html

http://healthnet.hnet.bc.ca/index.html


Provincial Laboratory Information Provincial Laboratory Information Solution (PLIS)Solution (PLIS)

Planning and development activities to support Technology Planning and development activities to support Technology Transformation are being led by a dedicated PLIS Office within the Transformation are being led by a dedicated PLIS Office within the PLCO, working with the Ministry of Health’s Knowledge PLCO, working with the Ministry of Health’s Knowledge Management Branch. A joint PLCO/Ministry strategy which will lead Management Branch. A joint PLCO/Ministry strategy which will lead to the creation of a to the creation of a Provincial Laboratory Information Solution Provincial Laboratory Information Solution (PLIS)(PLIS) for British Columbia. for British Columbia.The overall guiding vision behind the creation of a Provincial The overall guiding vision behind the creation of a Provincial Laboratory Information Solution (PLIS) for British Columbia is to Laboratory Information Solution (PLIS) for British Columbia is to provide access to clinical laboratory information (results, orders and provide access to clinical laboratory information (results, orders and decision support) to care providers at the point of care anywhere in decision support) to care providers at the point of care anywhere in British Columbia. PLIS is also a leading initiative within the Ministry British Columbia. PLIS is also a leading initiative within the Ministry of Health's broader E-Health strategy to develop the Electronic of Health's broader E-Health strategy to develop the Electronic Health Record and support IT infrastructure for health care in BC. Health Record and support IT infrastructure for health care in BC. The Provincial Laboratory Information Solution (PLIS) will:The Provincial Laboratory Information Solution (PLIS) will:provide a standardized province-wide approach to presenting a provide a standardized province-wide approach to presenting a patient's lab test results patient's lab test results



electronically distribute lab test results to ordering and/or copied electronically distribute lab test results to ordering and/or copied physicians physicians make historical lab test results from both public and private laboratories make historical lab test results from both public and private laboratories within the province available to physicians within the province available to physicians create an electronic lab test ordering system with decision support tools create an electronic lab test ordering system with decision support tools improve the ability to aggregate laboratory information in order to support improve the ability to aggregate laboratory information in order to support both administrative and clinical decision-makingboth administrative and clinical decision-makingprovide a provincial capacity to measure and manage the provision and provide a provincial capacity to measure and manage the provision and utilization of laboratory services utilization of laboratory services contribute to the realization of the provincial Electronic Health Record contribute to the realization of the provincial Electronic Health Record (EHR) (EHR) Through the use of technology and standards, the new system will Through the use of technology and standards, the new system will ensure laboratory information is: of a high quality, available to authorized ensure laboratory information is: of a high quality, available to authorized health care providers and administrators throughout the province, part of health care providers and administrators throughout the province, part of each patient's provincial Electronic Health Record each patient's provincial Electronic Health Record



FeaturesFeaturesOrganizational structureOrganizational structureUnique bid process – Joint Services RFPUnique bid process – Joint Services RFPDevelopmentDevelopmentTime frameTime frame

FUTURE COMPONENTS OF INTERESTFUTURE COMPONENTS OF INTERESTData MiningData MiningClinical Decision / Knowledge SupportClinical Decision / Knowledge SupportTelepathologyTelepathology


Data MiningData Mining

Utilization ControlUtilization Control– Reduce unnecessary Reduce unnecessary

duplication of testingduplication of testing– Ensure adherence to Ensure adherence to

utilization protocolsutilization protocols– Facilitate data Facilitate data

evaluation in order to evaluation in order to design utilization design utilization strategiesstrategies

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1500

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2500

3000

3500

4000

4500

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<40

40-50

50-60

60-70

70-80

>80


Chronic Disease ManagementChronic Disease Management– Clinical Practice GuidelinesClinical Practice Guidelines

Provide objective data for CPG developmentProvide objective data for CPG developmentOutcomes analysisOutcomes analysisFollow-up of adherenceFollow-up of adherenceFollow-up for outcomes studiesFollow-up for outcomes studiesMakes more elaborate CPGs possibleMakes more elaborate CPGs possible

– Disease epidemiologyDisease epidemiology– Assist individual physician’s patient tracking (e.g. lists Assist individual physician’s patient tracking (e.g. lists

of diabetics in a physician’s practice).of diabetics in a physician’s practice).– Provide physician reminders re chronic disease Provide physician reminders re chronic disease

patient reviewspatient reviews– Provide availability to a “package” of physician Provide availability to a “package” of physician

specific database searches on their own patients (e.g. specific database searches on their own patients (e.g. a list of all “registered” diabetics in a given practice a list of all “registered” diabetics in a given practice with statistics on their frequency of A1C testing with statistics on their frequency of A1C testing compared to provincial norms).compared to provincial norms).

– Patient remindersPatient reminders


Special Disease Registries/ServicesSpecial Disease Registries/Services– Automated development of registries of diseases characterized by Automated development of registries of diseases characterized by

laboratory test results (e.g. hemoglobinopathies, hypercholesterolemia, laboratory test results (e.g. hemoglobinopathies, hypercholesterolemia, diabetes, hemochromatosis, and many others as genetic testing diabetes, hemochromatosis, and many others as genetic testing expands)expands)

– Specialized knowledge support tools and information for both physicians Specialized knowledge support tools and information for both physicians and patientsand patients

– ““Mailing list” of physicians/patients to be informed when new information Mailing list” of physicians/patients to be informed when new information becomes available.becomes available.

EpidemiologyEpidemiology– Classic infectious disease epidemiology (but closer to “real-time”)Classic infectious disease epidemiology (but closer to “real-time”)– Real-time epidemiology for epidemics (e.g. SARS) and bioterrorismReal-time epidemiology for epidemics (e.g. SARS) and bioterrorism– Chronic disease epidemiology (non-infectious)Chronic disease epidemiology (non-infectious)

Health Care System ManagementHealth Care System Management– Outcomes dataOutcomes data– Utilization managementUtilization management– Population trendsPopulation trends– Test usage and deployment of resources Test usage and deployment of resources – Physician ordering profilesPhysician ordering profiles


In 1982 I gave a talk on this very same subject. I In 1982 I gave a talk on this very same subject. I covered the following types of automated covered the following types of automated interpretations.interpretations.

Level 1:Level 1: Standard comment on every report of a specific Standard comment on every report of a specific test.test.Level 2:Level 2: Result specific comment: 1-test. Result specific comment: 1-test.Level 3:Level 3: Result specific comment: 2-or more tests, over Result specific comment: 2-or more tests, over time, or other clinical informationtime, or other clinical informationLevel 4:Level 4: More sophisticated approaches. More sophisticated approaches.

Now, in 2006 we haven’t managed Levels 1-3 Now, in 2006 we haven’t managed Levels 1-3 completely but we’re now looking at Level 4 completely but we’re now looking at Level 4 and various projects may bring Level 4 to and various projects may bring Level 4 to fruition within the next few years.fruition within the next few years.


““Canned” CommentsCanned” CommentsGOOD THINGSGOOD THINGS

Demonstrated ability to change physician behaviourDemonstrated ability to change physician behaviourDemonstrated ability to enhance use of laboratory Demonstrated ability to enhance use of laboratory testing (e.g. testing (e.g. utilization, utilization, diagnosis)diagnosis)

CAUTIONSCAUTIONSLimited clinical information Limited clinical information Comment added whether needed or notComment added whether needed or notConsume space on a paper reportConsume space on a paper reportPaper report has a rigid formatPaper report has a rigid formatSome doctors feel threatened/insultedSome doctors feel threatened/insultedPatient overreaction (patient access)Patient overreaction (patient access)


Human Generated CommentsHuman Generated CommentsQuestions:Questions:– Are the interpretations part of the legal report?Are the interpretations part of the legal report?– Should the interpretations be added to EMR?Should the interpretations be added to EMR?– Who should be permitted to prepare such interpretations?Who should be permitted to prepare such interpretations?

Human generated reports have error rate of up to 50% Human generated reports have error rate of up to 50% (Lim Clin Chem 2004)(Lim Clin Chem 2004)

Marshall & Challand Marshall & Challand (Ann Clin Biochem 2000)(Ann Clin Biochem 2000)

– Variation amongst interpretersVariation amongst interpreters– Communication style variableCommunication style variable– Clinical information available is not always appropriate to the test Clinical information available is not always appropriate to the test

being interpretedbeing interpreted– Little feedback regarding usefulnessLittle feedback regarding usefulness– Interpretations should be recipient specificInterpretations should be recipient specific


LaposataLaposata (Clin Chem 2004; 50: 471)(Clin Chem 2004; 50: 471)

Laposata has championed the need for human-Laposata has championed the need for human-generated, patient-specific narrative generated, patient-specific narrative interpretationsinterpretations

He has criticized the “canned” commentHe has criticized the “canned” comment

BUT BUT he compares he compares ApplesApples and and OrangesOranges

Laposata makes the case for why Knowledge Laposata makes the case for why Knowledge Support is needed.Support is needed.


Knowledge SupportKnowledge Support

a.k.a. Clinical Decision Supporta.k.a. Clinical Decision Support

Two forms:Two forms:– Static: PubMed, Lab Tests On-Line, ARUPStatic: PubMed, Lab Tests On-Line, ARUP– Dynamic or CARTKS (Context Appropriate Dynamic or CARTKS (Context Appropriate

Real Time Knowledge Support)Real Time Knowledge Support)

Specific InterpretationsSpecific Interpretations


The “Case” for Knowledge The “Case” for Knowledge Support / Clinical Decision SupportSupport / Clinical Decision Support

Hundreds of publications have Hundreds of publications have demonstrated its potential usefulnessdemonstrated its potential usefulnessSeveral publications have pointed out Several publications have pointed out potential problems but none has undercut potential problems but none has undercut the basic premise.the basic premise.Clinical Practice Guidelines: Clinical Practice Guidelines: – Ever increasing numbersEver increasing numbers– Poorly applied (Poorly applied (~ 25% adherence)~ 25% adherence)– Limited complexityLimited complexity


““It is likely that when electronic knowledge support tools It is likely that when electronic knowledge support tools become a standard feature of medical practice, the become a standard feature of medical practice, the protocol and CPG approach will be maximized.” protocol and CPG approach will be maximized.” McNeely Clinics of Laboratory Medicine 2002; 22: 1-10McNeely Clinics of Laboratory Medicine 2002; 22: 1-10

““It is so apparent that computerization will enhance the It is so apparent that computerization will enhance the application of CPGs that it may be unethical to continue application of CPGs that it may be unethical to continue to perform trials to answer this question.” to perform trials to answer this question.”

Ellson and Connolly JAMA 1998; 279: 989.Ellson and Connolly JAMA 1998; 279: 989.

“To be widely accepted by practicing clinicians, computerized support systems for decision making must be integrated into the clinical work flow. They must present the right information, in the right format, at the right time, without requiring special effort.” James BC NEJM 1999; 340: 1202.James BC NEJM 1999; 340: 1202.


Ripple-Down RulesRipple-Down Rules

Developed by Paul Compton and Gordon Developed by Paul Compton and Gordon Edwards of St. Vincent’s Hospital, Sydney AUEdwards of St. Vincent’s Hospital, Sydney AU

Original system PIERSOriginal system PIERS

Now marketed by Now marketed by Pacific Knowledge Systems Pacific Knowledge Systems http://www.pks.com.au/ asas LabWizard™LabWizard™ Rule-Based but no knowledge engineerRule-Based but no knowledge engineer

http://www.pks.com.au/


Ripple-Down RulesRipple-Down Rules

Lab Completes Test

Verified ResultCombination?

LIS Reports: Result And Interpretation

Yes

Result Combo Interpreted

Knowledge Base &Inference Engine

Integrator

No


LabWizard (example)LabWizard (example)


BloodLink

Marc van Wijk MD PhDDelft, The Netherlands

Clin Chem 2002; 48: 605.

M. McNeely APIII 2006M. McNeely APIII 2006


Number of

Requisitions

Number of Tests Requested

BloodLink Restricted CONTROL

12,786

87,634

BloodLink Guideline TEST

12,700

70,479

Test reduction

of 19.6%

BloodLink – EvaluationBloodLink – Evaluation

50 GPs Two Groups1-Year


Laboratory Advisory SystemLaboratory Advisory System

Chang E, McNeely MDD, Gamble K. Strategies for Chang E, McNeely MDD, Gamble K. Strategies for choosing the next test in an expert system. Proceedings choosing the next test in an expert system. Proceedings of the congress on medical informatics. AAMSI 1984; of the congress on medical informatics. AAMSI 1984; 2:198-202.2:198-202.McNeely MDD, Smith B. An interactive expert system McNeely MDD, Smith B. An interactive expert system for the ordering and interpretation of laboratory tests to for the ordering and interpretation of laboratory tests to enhance diagnosis and control utilization. Canadian enhance diagnosis and control utilization. Canadian Medical Informatics. May/June 1995;16-19.Medical Informatics. May/June 1995;16-19.Smith BJ and McNeely MDD. The Influence of an Expert Smith BJ and McNeely MDD. The Influence of an Expert System for Test Ordering and Interpretation on System for Test Ordering and Interpretation on Laboratory Investigations. Clinical Chemistry 1999; Laboratory Investigations. Clinical Chemistry 1999; 45(8): 1168-1175.45(8): 1168-1175.Clinical-Laboratory.com Old Marlebone Rd, London, Clinical-Laboratory.com Old Marlebone Rd, London, EnglandEngland


Results of a trialResults of a trial

PaperPaper ComputerComputer

Mean # of tests Mean # of tests 32.732.7 17.817.8

Mean # of samplesMean # of samples 7.57.5 5.85.8

Cost ($ CDN)Cost ($ CDN) $ 232$ 232 $ 194$ 194

Turnaround time (days)Turnaround time (days) 3.23.2 11

Diagnostic accuracyDiagnostic accuracy 66%66% 100%100%

Referrals to specialistsReferrals to specialists 1212 00


The LAS – Study ConclusionThe LAS – Study ConclusionThe developmentThe development of test ordering of test ordering strategies can be enhanced.strategies can be enhanced.

The interpretationThe interpretation of the test results can of the test results can be enhanced.be enhanced.

A statistical databaseA statistical database of diagnosis, clinical of diagnosis, clinical information,information, test orders, and resultstest orders, and results can be can be readily derived. Such informationreadily derived. Such information is unique is unique and is availableand is available for optimizing and for optimizing and developing testingdeveloping testing strategies and for strategies and for laboratorylaboratory management.management.


The LASThe LAS – study conclusion– study conclusion (con’t)(con’t)

An appropriate search of the databaseAn appropriate search of the database

would enable clinician-targetedwould enable clinician-targeted

education and utilization feedbackeducation and utilization feedback to be to be derived.derived.

Examination of the database at the timeExamination of the database at the time

of ordering wouldof ordering would enable the enable the development of a module to identifydevelopment of a module to identify

unnecessary, duplicateunnecessary, duplicate testing.testing.


Contextualized ReportContextualized Report Dr. Jonathan Kay (Oxford)Dr. Jonathan Kay (Oxford)

Drs. Bruce Friedman and Jules Berman Drs. Bruce Friedman and Jules Berman Lab Medicine 2006; 37: 121. Lab Medicine 2006; 37: 121.


Smith, John H. Male 46 yoa 23957988-1

Dr. Louis Pasteur DOS June 7, 2006

Test Name Result Reference Interval

Alkaline Phosphatase 128 20 – 105 U/L






Analytical Information – Alkaline Phosphatase

1. Laboratory validation studies2. Method reference3. Instrument validation studies4. Proficiency testing record5. Complete Bibliography –Click here

ALERT !! Patient is taking Chlorpromazine which is known to cause Cholestasis with increased Alk Phos.






Analytical Information – Alkaline Phosphatase

1. Laboratory validation studies2. Method reference3. Instrument validation studies4. Proficiency testing record






Reference Interval – Alkaline Phosphatase

1. Literature Reference2. In-house studies3. Notes4. Graphical Presentation






Interpretation – Alkaline Phosphatase

1. Causes of an increased Alkaline Phosphatase2. Causes of an decreased Alkaline Phosphatase3. Specific Interpretation of this result4. Request a personal consultation on this result


GenoinformaticsGenoinformaticsScreening testsScreening tests

PCR TestingPCR Testing

ProteomicsProteomics

Physician UnderstandingPhysician Understanding

Patient Information - CounsellingPatient Information - Counselling

Family StudiesFamily Studies

Long-termLong-term

Follow-upFollow-up

New KnowledgeNew Knowledge


Knowledge AssemblyKnowledge Assembly

Major problem is the creation/assembly of Major problem is the creation/assembly of Knowledge Support tools (e.g. 1 rule per hour or Knowledge Support tools (e.g. 1 rule per hour or committee)committee)

Must have Must have AUTOMATED AUTOMATED knowledge assemblyknowledge assembly

Must have generic Inference EnginesMust have generic Inference Engines

Must rely on the integrative intelligence of the Must rely on the integrative intelligence of the useruser


Inference Engine

IF Alkaline Phosphatase > ULN

AND Age > 70

THEN Consider Paget’s Disease 3+


Knowledge AssemblyKnowledge AssemblyFacts:Facts:– From Electronic Medical RecordFrom Electronic Medical Record– Added at time of orderingAdded at time of ordering– Added during interpretationAdded during interpretation

RulesRules– Grunt approachGrunt approach– Formal Committees (worldwide?)Formal Committees (worldwide?)– CPGsCPGs– Wikipedia formatWikipedia format– Medical Literature Medical Literature – DatabaseDatabase

Constructed

Automated

2ND most important

slide


Wikipedia


Medical Literature


Data Mining


TelepathologyTelepathology

Goals of Province-wide program – VISIONGoals of Province-wide program – VISION

Organizational structureOrganizational structure

OverviewOverview

StandardsStandards

63

Evolution StepEvolution Step InfrastructureInfrastructure STDSSTDS Accred RulesAccred Rules PrivacyPrivacy

•Feasibility trials of S&F

•Thinking about V

•Education

•Routine S&F

•Some trial virtual

•Mature use of S &F

•Some HA use V routinely for

limited APS trial HA-HA

•Mature S&F

•Routine, limited ApV, routine HA-

HA

•Additional Aps & more common use

Linkage to API LIS

HL7SNOWMED.CT

LOINC

HL7SNOWMED.CT

LOINC

DICOM2009

DICOM2009

Intra DeptStorage

ImageRepository

PACS

PLIS PACS

Record of image (not image)

Existing

Licensing ?Licensing ?


ConclusionConclusionThe EHR 2009-2010 – Clinical Decision The EHR 2009-2010 – Clinical Decision Support: If Decision Support is expected in 2 - Support: If Decision Support is expected in 2 - 4 years then planning 4 years then planning MUSTMUST start now. start now.If Knowledge Support is to be meaningful then If Knowledge Support is to be meaningful then building the Knowledge Bases must begin soon building the Knowledge Bases must begin soon – but, we will need to know how they will be – but, we will need to know how they will be executed and what the Inference Engine will executed and what the Inference Engine will look like.look like.If Laboratory Professiolnals expect to be If Laboratory Professiolnals expect to be involved in the interpretation of the results they involved in the interpretation of the results they produce they must get involved in the produce they must get involved in the development of the Decision Support modules or development of the Decision Support modules or risk being disintermediated.risk being disintermediated.

Most important

slide


ConclusionConclusion

A Population-Based Laboratory Information Strategy

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