LABORATORY MANAGEMENT
Original Article
A Clinician's Workstation for Improving
Laboratory Use
Integrated Display of Laboratory Results
D O N A L D P. CONNELLY, M D , P H D , BRUCE H. SIELAFF, P H D ,
A N D KEITH E. W I L L A R D , M D
Physicians are often forced to make decisions about the use of laboratory resources without adequate access to earlier results and related
supporting information. Less than optimal use of the laboratory may
result. The authors developed and deployed a clinical workstation
meant to provide ready access to laboratory information that is presented in a format well-matched to the patient monitoring task. The
workstation was one element of a multifaceted effort to improve blood
component use in adult and pediatric bone marrow transplantation
units. It was the sole intervention focused on improving laboratory testing. In the 2 years since the introduction of the workstation, median
charges of bone marrow transplantation cases for laboratory tests fell
by 32%. This reduction in charges has been maintained for 2 years.
Better informed physicians appear to use laboratory resources more
sparingly. (Key words: Laboratory use; Physicians; Clinical workstations; Feedback) Am J Clin Pathol 1995; 104:243-252.
Beginning in 1991, the Medical Decision Support Unit
and the Laboratory Information Systems Division of
Laboratory Medicine and Pathology at the University of
Minnesota worked together to develop the Clinician's
Workstation (CWS). The underlying goal was to develop
clinical information management tools that clinicians
would choose to use because the tools help them perform
their clinical tasks more efficiently and effectively. More
appropriate use of clinical laboratory resources, such as
blood components and diagnostic tests, was a key objective of this effort. First, we briefly describe the conceptual
basis and strategy underlying our approach to helping
our medical staff more optimally use clinical resources,
and then give a detailed account of the laboratory results
reporting functionality of CWS. In a subsequent report,
the order entry feedback and blood product processing
component of CWS are described.
flow is poorly timed and coordinated, the data poorly
assembled, integrated and presented, and the chart—the
principal repository of this—illegible, unwieldy, or unavailable. Because of the relative inaccessibility of this
plethora of data, the physician must frequently rely on
the vagaries of memory when making important decisions about the use of expensive medical resources. Less
than optimal choices and oversight can result.1"3 Our
strategy has been to develop workstations to be used directly by physicians near the site of care to (1) make it
easy to get and use the data needed to make the right
decision and (2) promptly remind clinicians of pertinent
events, actions, or guidelines in sufficient time that the
issue can be appropriately addressed. Our focus has been
to improve the systems clinicians must work with and
thereby facilitate better decisions at the time they are
made rather than to retrospectively find and report fault.
Our experience gained in the development of a series
of successful clinical systems is that physicians will very
willingly use computer systems directly for laboratory results lookup if it makes their work easier and faster. In
1978, work began on a touch-screen microcomputer system for the delivery of laboratory results, which included
time-trend graphic displays.4 Through careful attention
to the user interface, excellent clinical acceptance resulted. This project demonstrated that clinical users will
use computer systems regularly for patient care decision
making. In 1985, our group developed and deployed a
special touch-screen terminal for our neonatal intensive
CONCEPT AND STRATEGY
In the current hospital environment, the physician is
barraged with data from multiple sources. Often the data
From the Department of Laboratory Medicine and Pathology University of Minnesota, Minneapolis, Minnesota.
Supported in part by grants from the National Heart, Lung, and
Blood Institute (HL-41086), the National Library of Medicine (LM07041), and the University of Minnesota Hospital and Clinic.
Manuscript received February 28, 1995; revision accepted May 1, 1995.
Address reprint requests to Dr. Connelly: Laboratory Medicine and
Pathology, Box 609 UMHC, 420 Delaware Street SE, University of
Minnesota, Minneapolis, MN 55455.
243
244
LABORATORY MANAGEMENT
Article
care unit (NICU) that provided more rapid and easy access to laboratory data.5 This system was used by physicians and nurses more than 500 times a day. In a survey
of physician users of the NICU reporting system, 70
questionnaires were returned (80% response).6 The physicians were unanimous in agreeing or strongly agreeing
that the system was "easy to learn" (57 reported it taking
less than 5 minutes), "easy to use," and "integrates
smoothly into patient care activities." More than 94% of
the physicians agreed or strongly agreed that the system
was "fast," "saves time," or was "reliable and dependable." Sixty-three physicians reported using the system
two or more times per day with 53 physicians using it
more than five times daily. Overall, strong physician acceptance of the NICU reporting system was noted and
continues a decade after its introduction.
Once physicians judge that a clinical workstation
provides enough value to outweigh the inconvenience
and effort associated with its use, they may choose to
use it directly in their clinical work.7 By getting physicians to interact directly with a clinical workstation, a
most important opportunity to help improve the quality of those decisions related to the use of costly clinical
resources presents itself. This opportunity can be used
to deliver one of the interventions shown to be most
effective in changing practice, feedback.8 To be most
effective, feedback must reflect consensus,9 be delivered as close in time to the decision as possible,10 and
be recurring. The delivery of such feedback may best
be done through computers that the physician may be
using at the time a decision to use a resource is being
made. Our feedback is based on our medical staffs
consensus guidelines, which are guidelines for transfusion practice developed by our Blood Bank and refined
and fostered by our Transfusion Therapeutics Committee." The feedback is provided as the decision to
order blood components is being considered. Finally,
through a tireless expert system that matches indicators to guidelines, the feedback promptly recurs night
and day, objectively and privately. In this way, the
CWS is meant to remind our housestaff of what our
faculty has defined as preferable practice. The Clinician's workstation supports ongoing medical education near the bedside, which is probably the most
effective site for clinical learning.12
However, physicians have not generally embraced direct computer-based order entry.13 It can be cumbersome, time-consuming, and may be seen as an activity
that is best done by others.14"16 Considerable effort may
be required to gain physician acceptance.17 However, a
substantial minority of our NICU housestaff responding
to the earlier survey6 recommended the addition of order
A.J.C.P.-
entry and stated they would use such a feature. We reasoned that by making access to results even more functional than was the case for the NICU workstation, and
by providing methods that facilitated decisions related to
resource use and order entry, the potential for fostering
direct order entry by physicians would be made even
greater. This would make possible the delivery of timely
feedback about the appropriateness of the ordering decisions in hope that laboratory usage patterns would improve. In this report, we describe the laboratory results
presentation component of our workstation and then assess clinical patterns of its use and functionality.
The endeavor to develop clinical information management tools for clinicians must embrace a commitment to change. A commitment to change is the only
realistic way to cope with the external and internal demands that are confronting those who deliver healthcare.
Currently, there are computer tools and resources that
can have an important positive impact on clinical care.
However, the best way to use these tools for the most
important problems in a way that is humane and accepted remains unknown. Through the use of realistic
prototypes and iterative development, we can begin to
find those answers rapidly and economically, and at the
same time, increase clinical benefit. These systems must
be molded closely to the real task at hand. This close
matching makes work easier and people more produc-
MATERIALS AND METHODS
To enable change andflexibility,the clinical workstation has been developed using a state-of-the-art objectoriented development environment (NeXTSTEP, NeXT
Computers, Redwood City, CA), a client-server architecture and a high performance relational database server,
SQL Server (Sybase Corporation, Emeryville, CA). An
existing commercial laboratory information system
(Ameritech Knowledge Data, Chicago, IL) was enhanced to include networked communication to and
from other computers using the HL7 protocol, Version
2.1.19'20 Communications associated with the following
laboratory information system (LIS) functions were implemented; specimen receipt, completed results, blood
product ordering and patient admission date.2' The existing LIS communicates patient admission, specimen
receipt, and completed results information to the SQL
Server, which operates in a UNIX environment (SCO,
Santa Cruz, CA) on a specialized 486 computer configured for database processing and network communication (Tricord Computers, Plymouth, MN). Clinical
workstations operate in a client-server configuration
with respect to the database server and communicate
:r 1995
CONNELLY, SIELAFF, AND WILLARD
245
Clinician's
with it via the hospital's network backbone that supports
TCP/IP and Ethernet. The client-side software that runs
in the workstations was written in Objective C, a variant
of C with extensions that support object-oriented programming. Orders originating on the workstations are
communicated to the LIS via the same network. The
hospital network is connected to the University's network that provides access to the Internet. Thus, each
clinical workstation has ready access to a wealth of information sources beyond our hospital. Direct access to one
of these, a national weather information service, was provided as a general monitor of use unrelated to patient
care.
Extensive prototyping sessions with physicians,
nurses, and clinical laboratory personnel were conducted to define functional needs and the general approach to interaction. Interface design emphasized two
key criteria, presentation of relevant data in a clinically
usable form, and minimization of physical effort on the
part of the user to obtain this information. Specialized
laboratory data displays were developed to match the
clinical task as closely as possible. As the system was developed, early versions were reviewed by clinical users
and appropriate changes made. Ten workstations have
been deployed and operational in clinical areas since November 1992. Workstations are in adult and pediatric
bone marrow transplant units and adult and pediatric
hematology/oncology units at the University of Minnesota Hospital and Clinic. These four units were chosen
as they account for the highest use of platelet transfusions in our setting, approximately 54% of all platelet use
in the aggregate. The hospital is a 526-bed tertiary care
referral center.
A formal training program was offered to all nursing
and clerical personnel immediately before the system became continually operational. This program lasted 30
minutes. New nursing employees are provided individual instruction as part of the new employee orientation
program. The initial group of housestaff were provided
individual instruction by one of two physicians associated with the project team. Subsequent to that, housestaff have taught one another how to use the system.
Housestaff are on a particular service for approximately
1 month.
To study the usage patterns of CWS, an embeddedusage monitoring and reporting system was developed
and integrated into the workstation's software. The monitoring system sensed key events and logged their occurrence in a file. This file was subsequently processed to
determine event rates. The study period reported here
covers the first 24 months of clinical operation. It is
based primarily on the automatically logged usage data
Vol.
and data on laboratory volume, charges, and patientdays derived from the hospital's fiscal database. For 1991
through the first half of 1994, median charge per case
for bone marrow and renal transplantation cases for our
hospital were obtained from the University Hospital
Consortium's Clinical Information Network (Oak
Brook, IL).
RESULTS
CWS Operations Overview and Screens
The "resting" CWS screen is the alphabetized patient
roster of a patient care unit (PCU). The patient of interest is selected by clicking the computer mouse on the
right name or the patient roster of another unit can be
displayed by selecting the PCU button. Once a patient is
selected, a staff roster then appears allowing the user to
click his or her own name. This provides access to the
Primary Results screen, one of two screens for viewing
laboratory test results. The Other Results screen is the
other laboratory screen. The order entry and feedback
functions are selected from the Primary Results screen.
In addition, nurses are provided two additional screens
to help them manage transfusion tasks on their PCU.
One screen allows them to schedule blood resources, the
other provides an overview of upcoming transfusion
tasks. A blood resources management screen is made
available to blood bank personnel to support their review
of requests for special blood resources (eg, irradiated
blood, or assignment of patients to research studies). A
daily, weekly, and monthly summary of event log records are automatically developed and circulated by
electronic mail. This report allows system use to be studied and measured.
Patient roster screen. This is the first and resting screen
of each workstation. Normally it shows the alphabetized
patient roster for the PCU in which it is located. Upon
selecting a patient name, the clinical user is presented a
pair of staff rosters that overlay the lower half of the patient roster. One staff roster shows doctors' names, the
other shows nursing staffs names. Each staff roster has a
selector for displaying a short list that shows only those
physicians and nurses that have recently used the workstation. Alternatively, a long list can be displayed that
lists for physicians all current medical staff at UMHC.
Once selected from the long list, the staff name subsequently appears in the short list until 7 days after the last
use of CWS. Once the clinical user selects the appropriate
name from the appropriate staff roster, the workstation
begins retrieving laboratory results from the database
server for display in the Primary Results screen.
• No. 3
246
LABORATORY MANAGEMENT
Original Article
FIG. 1. The Primary Results screen provides integrated display of those
laboratory results most frequently requested in the patient care units
that were being studied (ie, Bone Marrow Transplant and Hematology/
Oncology). The most recent four measurements for each test are shown
in columns to facilitate the patient monitoring task. The ensquared c
symbol indicates a laboratory comment that can be viewed by selecting
that line. Radio buttons provide access to items of interest in certain
clinical situations. The Test Name buttons at the top of each column
provides access to reference range information, time trend graphs, and
for blood components, access to order entry panels.
Two additional objects appear in the roster screen. In
the upper left corner is a dynamic icon that indicates the
current time and date. In the upper right corner, there is
a button labeled Twin Cities Weather. When selected,
the weather button causes the workstation to communicate via Internet to a "weather server" at the University
of Michigan. This feature was originally introduced
largely as a symbol of the workstation being connected
to an international network of potentially important information resources.
Primary results screen. This screen is used for displaying the most important and frequently used test results
(Fig. 1). The top banner of this screen has four components: the active time/date icon, a Current User section,
a Patient Selection button used to display a patient roster
so that another patient can be selected, and the name and
key demographic data of the currently selected patient.
The Current User portion of the banner includes two
buttons. When the Suggestion Box button is selected, a
panel appears that directs the user to enter a message to
be sent to the laboratory. The electronic mail service is
used to transport this message back to the laboratory
where it is automatically routed to a number of project
staff for proper disposition. The button labeled in gray as
New Messages is not currently activated, but is intended
to serve as a means of notifying physicians of special alert
messages and other electronic mail.
The main body of the Primary Results screen has been
carefully designed and tuned to the principal clinical task
of these PCUs, patient monitoring and management, not
diagnosis. We were able to borrow heavily on the general
reporting layout that had been very well accepted by physicians in the NICU.6 First, the right tests for monitoring
the progress of patients with bone marrow transplants
and hematology/oncology diseases are brought together
and integrated on this single screen. Once the proper data
is brought together, it is presented in a format aimed to
support the monitoring task. The most recent results are
displayed in context with related and three prior values.
Tests in process are displayed as "In Lab". The vertical
layout allows quick comparison of the most recent result
with earlier data. Laboratory comments have been compressed (ie, the C within a small square) to facilitate data
scanning and comparison. By clicking on the small
square, the text of the comment can be seen if it is of
interest. Bold typeface highlights especially aberrant test
results.
Additional supportive data are readily available. For
instance, the Differential panel includes radio buttons
that allow the clinical user to see the five-part differential
expressed as a percentage rather than as an absolute
count. Similarly, the user can choose the preferred form
by clicking the bicarbonate or anion gap radio buttons or
the preferred units of ionized calcium. The Earlier Results buttons associated with each panel of tests gives access to all prior results of tests named in that panel. For
the Hematology panel, the earlier results display also includes all of the derived results commonly reported. In a
similar fashion, blood gas and lactate results can be
quickly obtained by selecting the correspondingly labeled button within the Chemistry section. Less than
10% of patients in these units have blood gases monitored and so blood gas results are not routinely displayed.
A button with an abbreviated test name and a downward pointing symbol heads each column of data. When
a test name button is selected with the mouse, the button
expands into a drop-down menu of choices. If the Info
choice is selected, an electronic laboratory manual database is accessed and displays the specimen type, container type, specimen volume, and reference range for
that result (Fig. 2). If the Graph choice is selected, a 7-day
time-trend graph is displayed (Fig. 3). Three additional
variables can be plotted so that trends and data relationships can be seen more clearly. For the Blood Compo-
A.J.C.P. •September 1995
247
CONNELLY, SIELAFF, AND WILLARD
Clinician's
Together, these screens constitute the "carrot" intended to bring physicians to use CWS. The Primary Results screen, which contains more than 100 results, can
be obtained with two clicks of the mouse. To obtain and
use a comparable amount of data with the noncommer-
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20FIG. 2. The Laboratory Information screen provides reference range
and specimen procurement information.
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nents section, an Order choice can be selected that activates the order entry features of this system.
At the bottom of the Primary Results screen are three
control buttons. The Print button causes the primary results screen to be printed on an associated printer. The
Quit button logs off the current user and returns to the
Patient Roster screen. The Other Tests button, which is
the usual choice at this point in clinical interaction with
CWS, leads to the generation of the Other Tests screen.
Other Tests screen. Although the Primary Results
screen accounts for approximately 85% of the laboratory
tests used in the PCUs of interest, more than 1,000 additional different tests can be ordered. The data display for
other tests shows the tests in alphabetic order sorted by
time for any individual test (Fig. 4). The top banner of
the Other Results screen is the same as that for the Primary Results screen. Along the left side of the data display is a group of selector buttons that can be used to
rapidly focus the query. The default display for the Other
Results screen is the Today selection, which shows in alphabetical order the test results so far completed on that
day. This option is what is of most usual interest to the
housestaff. Other selections such as, One Day Back,
Heme/Coag, and Virology, can rapidly bring the test results of interest into view. Tests that have been received
by the laboratory and are in process are displayed as "in
lab" to make duplicate orders less likely.
Our physicians have found the means of results presentation in the Primary Results and Other Results
screens to be very helpful. Our nursing staff have determined that the presentations and interaction are so intuitive that formal training is not required for the results
display component.
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248
LABORATORY MANAGEMENT
Original Article
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FIG. 4. The Other Tests screen shows all laboratory results not on the
Primary Results screen. The tests are alphabetically sorted by test name
and collection date. The buttons on the left side allow the clinical user
to rapidly focus on tests of special interest. The default Other Results
screen is all of completed results for the day.
cial computer system otherwise available on these units
would take many minutes and considerable note-taking.
The order entry screens and blood product management
screens for nurses and blood bank personnel are described in a subsequent report.
done by physicians. After order entry was initiated, only
40% to 45% of the log-ins were by physicians, the remainder was mostly done by nursing and clerical staff with the
additional usage volume related to requesting and scheduling blood products. Usage of CWS would be expected
to be related to the number of patients being cared for
on those units. Since November 1993, usage has been
between four and five Primary Results screens per patient-day.
Convenience indicators. A design goal had been to provide physicians the needed information with a minimum
of effort on their part. The Primary Results screen
showed the last four observations for each of the most
frequently used tests for patients undergoing therapy for
blood and other oncologic diseases and bone marrow
transplantation. It was anticipated that this single screen
would provide the desired information in the majority of
cases. In those cases where the last four observations
were insufficient to meet the clinical need, one or more
of the Earlier Results buttons would have to be selected.
In more than 87% of the instances of use of CWS for
primary results review, the results of interest appeared
on the Primary Results Screen after a single click had
been made to select the patient of interest.
Similarly, the default Other Results screen was established to include all tests that do not appear on the primary screen that were reported on that day. If the information of interest is not on this default screen, another
Primary Result Screens per Month
Usage Patterns
10000 -
Volume of use indicators. The patterns of clinical use
of CWS for laboratory results review can be examined
first in terms of volume of use. The most direct approach
of assessing usage volume is to count the number of "login" operations. A log-in occurs each time a particular
user elects to use the CWS to examine the results of one
or more patients. Each log-in corresponds to one user
session. Over the first 24 months of use, the number of
monthly log-ins shows a rapid ramp-up from the date the
10 workstations were activated late in November 1992.
Because some users will look at multiple patients during
a session, whereas others may examine the records of a
single patient after a log-in, the number of primary
screen displays may be a better indicator of clinical usage
volume. This is shown in Figure 5. The increase, beginning in November 1993, corresponds to the initiation of
blood product order entry via CWS in addition to results
review. Before this time, more than 70% of log-ins were
6000
4000
I
2000
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FIG. 5. Monthly number of Primary Results screen accesses for 10 clinical workstations for the first 2 years of operation. The increment beginning in November 1993 followed the beginning of blood product
order entry and associated blood management functions. Data for
April 1994 were not collected because of an error in the event logging
system.
A.J.C.P. •September 1995
CONNELLY, SIELAFF, AND WILLARD
Clinician's
selection on the Other Results screen must be made. This
occurred in less than 22% of cases. The Other Results
screen was accessed at about 23% of the frequency that
the Primary Results screen was accessed.
Special features usage. Time trend graphs of results
appearing on the Primary Results screen can be obtained
with a mouse click-hold-release maneuver of a Test
Name button. Such graphs were requested in less than
5% of Primary Results screen use. In less than 1 % of cases
of Primary Results screen use were these graphs printed.
Feedback messages could be directed to the clinical
laboratory by use of the Suggestion Box feature. There
was some limited use in the first year of operation of this
feature, with about 20 messages a month being received.
In the second year, after we began requiring user-authentication of feedback messages so that the laboratory
could respond directly to individuals, there was almost
no use of this feature.
As a probe of general interest, the current regional
weather forecast could be obtained with a single click of
the mouse. This occurred in 6% of the log-ins.
As electronic databases of patient results become more
commonly available and used, issues of patient confidentiality become increasingly pertinent. One of the security methods that CWS employed was a security timeout feature. If the authenticated user made no use of the
mouse or keyboard after a pre-set period, it was assumed
the user had left the workstation and the session was automatically discontinued. Preferable to walking away
and leaving the workstation in a state of vulnerability,
the user should select the Quit button that terminates
the session. The preferred method of ending a session
occurred in 45% of logins.
Laboratory Resource Use Changes
Others have found that the better presentation of laboratory results in an outpatient setting can lead to a significant reduction in laboratory charges.22 When we
compare resource use for the 2 years after CWS was put
in place to the 2 preceding years, the median charge per
admission for laboratory tests dropped by 32% (Fig. 6A).
Median charge for blood transfusion components
dropped by 39% over the same time period. If these reductions were applied to the number of patients classified to belong in DRG 481 at UMHC, the estimated annual charge reduction would be $2.8 million. For DRG
302, Renal Transplantation, the pattern of charges for
blood products and laboratory testing showed more
year-to-year variability, but no trend toward reduction
in use (Fig. 6B). There were approximately 185 bone
marrow transplantations performed per year and 205
kidney transplantations.
Vol.
249
Documentation Effects
The Blood Bank's quality assurance program incidentally noted that the rate of properly completed requests
for irradiated blood components went from 85% to 95%
after CWS was put in place. Requests via CWS were virtually assured of being complete because CWS pulled together all relevant information. Because a high proportion of patients requiring irradiated blood are on the
bone marrow transplant service, overall documentation
performance was improved.
DISCUSSION
If laboratorians are to effectively play a role in managing the demand for laboratory resources, they must become more involved in the result presentation, order entry, and order review processes. In attempting to do this,
we have found that considerable commitment is needed
on the part of the clinical laboratory, especially in a hospital that does not yet have an integrated electronic way
of performing order entry. To affect change at the work
boundary between two hospital organizational units (ie,
the laboratory and nursing), requires close communication, adoption of mutual goals, and continued voluntary
cooperation. These do not come without considerable
and sustained effort on the part of both groups. If the
responsibility of actually developing clinical workstations, deploying them and managing their upkeep is
added to this, the effort required of the laboratory can be
quite significant. Even if an integrated way for order entry were available, current standard order entry mechanisms offer little opportunity for affecting laboratory orders as they are being made. Thus, we are investigating
approaches that may eventually be incorporated into
commercial systems and help promote the more efficient
and effective delivery of healthcare.
However, the charge reduction pattern demonstrated
here suggests that the enhanced reporting intervention
probably had more effect than the order entry intervention. Very substantial reduction of laboratory and blood
product charges began and persisted coinciding with the
clinical placement of CWS in late 1992 (32% and 39%)
before a blood product order entry intervention was deployed in late 1993. After the order entry functionality
was deployed, the reductions persisted, but did not
markedly change in magnitude although the quality of
transfusion practice improved as will be shown in a subsequent report. For laboratory testing, there was no intervention other than enhanced reporting that corresponded to the sharp reduction.
An important secular trend was operating during the
period of study that would be predicted to lead to lower
•No. 3
250
LABORATORY MANAGEMENT
Original Article
Median Charges per Admission
DRG 481, Bone Marrow Transplantation
50000
40000
o
30000
O
I
20000-
10000
8000
Median Charges per Admission
DRG 302, Renal Transplantation
•
•
Blood
Lab
6000-
!
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1991
1992
1994
Year
FIG. 6. (Top) A, Reduction in median charges for laboratory testing
and blood component transfusion for DRG 481, Bone Marrow Transplantation, following the placement of CWS in late November 1992.
(Bottom) B, Median charges for laboratory testing and blood component transfusion for DRG 302, Renal Transplantation. The Clinician's
workstation was not available to clinicians caring for these patients.
charges. In Minnesota, prospective payment has become
the dominant mechanism of reimbursement in recent
years. This has raised the concern for more appropriate
use of medical resources among hospital administrators
and providers. For the analogous renal transplantation
DRG, which was not subject to CWS, there did not appear to be a generalized secular reduction in charges. In
fact, median charges for laboratory testing and blood use
continued to slowly grow.
For blood products, the case is somewhat more complex in that CWS was only one part of a multifaceted
effort to improve the appropriateness of blood use. Blood
bank fellows and staff physicians interacted closely with
clinical housestaff and attending physicians throughout
this period with a common focus being appropriate
transfusion management. Such personal intervention is
known to have a favorable effect on transfusion appropriateness.23 The clinical staff of the bone marrow transplantation units were also encouraged during a number
of group meetings to use transfusion products according
to institutional guidelines. With strong encouragement
from blood bank physicians, there was a movement
away from the transfusion of platelets obtained by apheresis toward platelets from fresh whole blood from random donors. Being the charge for an equivalent amount
of platelets obtained from fresh blood is only 60% that of
apheresis platelets, the hospital-wide reduction in
charges from the 1991-92 period to the 1993-94 period
because of the shift in blood component type alone was
21%. The nursing staff became more active in arranging
transfusions according to standing orders conditional on
platelet count and hematocrit levels that corresponded
to the levels expressed in the medical staff guidelines for
appropriate transfusion. Throughout the period of this
study, the proportion of allogeneic transplants remained
relatively constant being 67% in 1991 and 63% in 1994.
In any event, the multifaceted drive to improve transfusion practices, which included CWS, led to a significant
decrease in blood component charges, a reduction which
persisted into the second year as well.
It should be noted that the reductions in laboratory
testing and transfusion were not a result of coercive
forces directed at physicians or nurses. The very significant reduction in laboratory test use came about without
complaint of the medical staff, and perhaps with little
recognition of the reduction on the clinical staffs part.
Our emphasis was on improving the availability of information so that more informed decisions could be made.
We have developed our intervention strategy to be compatible with the professional culture of physicians.24
Despite the weaknesses of a longitudinal study of this
nature and despite the inability to control the multiple
external influences that impinge on clinical practice, the
magnitude and timing of the usage reduction in laboratory testing is strongly suggestive that improved results
reporting led to more informed decisions. Results reporting is considerably easier for laboratories to directly influence than targeting the physician order entry process.
Thus, our experience with results presentation may be
practical to replicate in other settings, be well-accepted
by physicians, and lead to considerable savings.
The Clinician's workstation enjoys good acceptance of
its laboratory results review function among the housestaff. This is despite the fact that not all relevant clinical
A.J.C.P. • September 1995
CONNELLY, SIELAFF, AND WILLARD
Clinician's
information is available on CWS. The Primary Results
screen and the Other Results screen seem to meet the
clinical need for laboratory results in the great majority
of cases (ie, 87% and 78%, respectively). The value of the
Other Results default screen might be improved by including yesterday's with today's results. During initial introduction of the system, we had some physician comments regarding the responsiveness of the primary result
screen. Following database tuning and recent upgrading
of the database server, we have had no performance complaints. Most physicians note that more than 100 results
are brought together on the Primary Results screen and
presented in a single view not available on a single page
of a paper report.
Graphic displays are requested infrequently. We currently provide our users noflexibilityfor modifying the
time window of the graphic display and this may blunt
its clinical value. But, as we have found before, housestaff who are usually very familiar with the day-to-day
course of hospitalized patients have much less interest in
time-trend graphic displays than do physicians called in
to consult regarding a focused problem that has developed in the middle of a complex case.
Of more concern to us is the minimal use of the direct
feedback to the laboratory through the electronic suggestion box. We were looking forward to receiving many
helpful suggestions and ideas through this channel besides garnering additional clinician good will and interest. It was particularly disappointing that use of this communication path was virtually extinguished after a year.
As initially envisioned, the Suggestion Box feature was
to be an integral part of an electronic mail system. Thus,
laboratory personnel would be able to use an electronic
mail return message to rapidly acknowledge any suggestions. It was felt that rapid response would have served
as an important reinforcement to subsequent use of the
Suggestion Box feature. However, at the request of the
nursing staff to maintain ease of use, electronic mail was
not instituted as planned and immediate replies could
not be sent that way. Although the workstation support
staff tried to respond by phone to suggestions as quickly
as possible, this did not have the same immediacy that
an electronic mail reply could have had. Although we
still believe that such a feedback mechanism has great
potential value, we recognize that we must make it easier
to use for both the sender and the receiver.
Initially, as a means of encouraging use of the Suggestion Box feature, we did not require user authentication
to use the suggestion box, thinking that anonymity
would encourage its use. Although this may be the case,
the inability to follow up with the actual originator of a
suggestion was found to impair the potential value of the
Vol.
251
suggestion box. Many suggestions as originally stated required personal follow-up for clarification and to gain a
better understanding of the concern. Without enforced
user authentication, we were unable to reliably identify
the true source of suggestions and correspond directly
with the originator. One might also expect that the quality of suggestions might be improved if users knew that
their name would be linked with their suggestion. Although we saw some evidence for this, the frequency of
feedback messages fell to such a low level after authentication was enforced, we cannot make a strong conclusion on this point.
The limited use of the printing option, on the other
hand, is encouraging. With rapidly changing clinical situations, a printed report can become obsolete within
minutes of its origination. As we strive to provide electronic reporting methods that rival the printed report in
terms of availability and usability, there should be even
less reason for printing results.
We can make little of the limited but continuing use
of the weather forecast feature. It did see a continual low
level of voluntary use that had nothing to do with patient
care. One might presume that it helped make CWS more
humane, but it is more interesting to conjecture on the
potential use of more clinically relevant information resources that are increasingly available via the Internet.
Such resources can provide a more attractive "carrot" to
clinical users so that the workstation would be more
likely to be used, and thereby provide more opportunity
for appropriateness feedback. Other network capabilities
such as convenient access to MEDLINE can contribute
directly to improved use of resources in their own way.25
Regarding security, it is interesting that the majority
of users walked away from the workstation without logging off, and thereby somewhat imperiled the confidentiality of patient data until the system automatically
timed out the session. However, it should be noted that
the workstations were all in place in areas only available
to the clinical staff. In addition, we did not make special
effort to encourage the staff to log out other than during
training sessions. We anticipate that with the coming
availability of e-mail to the individual clinical user, that
users will develop the habit of logging out or otherwise
put their own personal information at risk. Thus, a number of forces are coming about that should reinforce
proper logging out procedures. That coupled with somewhat more frequent reminders and education of the clinical staff about the ethical and legal requirements for patient data security, should control this problem.
Although the improvement in the documentation of
requests for irradiated blood was an unexpected benefit
of CWS, it does point out an additional area of great po• No. 3
252
LABORATORY MANAGEMENT
Original Article
tential savings related to facilitating the logistics underlying laboratory test ordering and processing.
The Clinician's workstation has proven useful in helping the laboratory bridge the gap between results reporting and the ordering of the next laboratory resource. Although few laboratories may have the capability or desire
to get as deeply involved in the informatics tasks of direct
results reporting to physicians to influence their patterns
of order entry, clinical information systems with physician order entry components will be becoming increasingly commercially available. Pathologists and other laboratorians interested in promoting appropriate clinical
use of laboratory resources should be involved in the
specification, implementation, and ongoing refinement
of such systems. Such systems promise to be of substantial help to the laboratory that wishes to more actively
manage the demand for laboratory services. The call for
more substantive training of pathology residents in Pathology Informatics to prepare them for such work is
very timely.26,27
Acknowledgments.
The authors thank those who made this project
possible: Drs. J. Jeffrey McCullough, Elizabeth Perry, and David
Stroncek who facilitated interaction with the medical staff and the
Blood Bank; Dr. John Kersey, Joanne Howard, and Sharon Roell supported our activities in the Bone Marrow Transplant units; staff from
the Clinical Laboratories and the Patient Care Units who worked together to define, implement, and improve the CWS led by Jayne Gillen,
Jan Lohman, Nancy Ward, Teri Nobbs, Sarah Griffin, Dayle Stubbs,
and James Duchow; the Health Informatics postdoctoral fellows and
graduate students, including Drs. Gerald Werth, Jeffrey Hertzberg, and
Joonho Kim. All of the staff of the Laboratory Information Systems
Division contributed to this work, but especially notable contributions
were made by David Dean, Peter Eisch, Jeffrey Hallgren, Bonnie Hultman, Shirley Engan Schultz, Michelle George, Robert Sastamoinen,
JoNan Wu, and Martha Ziehwein.
REFERENCES
1. McDonald CJ. Protocol-based computer reminders. The quality of
care and the non-perfectability of man. N EnglJ Med 1976; 295:
1351-1355.
2. Altshuler CH. Data utilization, not data acquisition, is the main
problem. Clin Chem 1994;40:16-20.
3. Aspden P. Making better use of health care information. Topics in
Health Information Management 1994; 14:57-73.
4. Connelly DP, Lasky LC, Keller RM, et al. A system for graphical
display of clinical laboratory data. Am J Clin Pathol 1982;78:
729-737.
5. Connelly DP, Dean DW, Hultman BK. Physician-oriented result
reporting in an intensive care environment. In: Salamon R.,
Blum B, Jorgensen M, eds. MEDINFO 86. New York: IEEE,
1986, pp 810-812.
6. Connelly DP, Werth GR, Dean DW, et al. Physician use of an
NICU laboratory reporting system. Proc Annu Symp Compul
Appl Med Care 1992; 17:8-12.
7. Curley SP, Connelly DP, Rich EC. Physicians' use of medical
knowledge resources: Preliminary theoretical framework and
findings. Med Dec Making 1990; 10:231-241.
8. Davis DA, Thomson MA, Oxman AD, et al. Evidence for the
effectiveness of CME. A review of 50 randomized controlled trials. JAMA 1992;268:1111-1117.
9. McDonald CJ, Hui SL, Smith D, et al. Reminders to physicians
from an introspective computer medical record. Ann Intern
Med 1984; 100:130-138.
10. Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventative care. Med Care 1986;24:659-666.
11. Sielaff BH, Scott EP, Connelly DP. Design and preliminary evaluation of an expert system for platelet request evaluation (ESPRE). Transfusion 1991;31:600-606.
12. Manning PR. Continuing medical education: The next step.
JAMA 1983;249:1042-1045.
13. Massaro TA. Introducing physician order entry at a major academic medical center: II. Impact on medical education. Acad
Med 1993;68:25-30.
14. Tierney WM, Miller ME, Overhage JM, et al. Physician inpatient
order writing on microcomputer workstations: Effects on resource utilization. JAMA 1993;269:379-383.
15. Tierney WM, Overhage JM, McDonald CJ, et al. Medical students' and housestafFs opinions of computerized order-writing.
Acad Med 1994;69:386-389.
16. Massaro TA. Introducing physician order entry at a major academic medical center: I. Impact on organizational culture and
behavior. Acad Med 1993;68:20-25.
17. Teich JM, Hurley JF, Beckley RF, Aranow M. Design of an easyto-use physician order entry system with support for nursing
and ancillary departments. Proc Annu Symp Compul Appl Med
Care 1992;99-103.
18. Hoffman GM. The Technology Payoff—How to Profit With Empowered Workers in the Information Age. New York: Irwin Professional Publishing, 1994.
19. Health Level Seven: An application protocol for electronic data
exchange in healthcare environments. Version 2.1. Chicago:
Health Level Seven.
20. Smith S, Dennis B. HL7: Facilitating multiple approaches to systems integration. Compul Healthcare 1991; 2:59-61.
21. Willard KE, Sielaff BH, Connelly DP. Integrating legacy laboratory information systems into a client-server world: The University of Minnesota Clinical Workstation (CWS) Project. Meth
Inform Med 1995;34 (in press).
22. Tierney WM, McDonald CJ, Martin DK, et al. Computerized display of past test results: Effect on outpatient testing. Ann Intern
Med 1987; 107:569-74.
23. Soumarai SB, Salem-Schatz S, Avorn J, et al. A controlled trial
of educational outreach to improve blood transfusion. JAMA
1193;270:961-966.
24. Cali DD. Cultural influences on physician communication in
health care teams. J Biocommun 1991; 18:22-27.
25. Klein MS, Ross FV, Adams DL, Gilbert CM. Effect on online literature searching on length of stay and patient care costs. Acad
Med 1994;69:489-495.
26. Buffone GJ, Beck JR. Informatics, a subspecialty in pathology. Am
J Clin Pathol 1993; 100:75-81.
27. Conjoint Task Force on Clinical Pathology Residency Training
Writing Committee. Graylyn Conference Report Recommendations for reform of clinical pathology residency training. Am
J Clin Pathol 1995; 103:127-129.
A.J.C.P.-September 1995