Telemedical System in the Blood Transfusion

Service: Usage Analysis

Marko Meza, Jurij Tasic, and Urban Burnik

Faculty of Electrical Engineering,Trzaska 25, 1000 Ljubljana, Slovenia

{marko.meza,jurij.tasic,urban.burnik}@fe.uni-lj.si

http://ldos.fe.uni-lj.si

Abstract. Partners FE, KROG and ZTM (alphabetical order) as statedin acknowledgemetns, have developed, manufactured and installed a tele-medical system into the blood transfusion service of Slovenia. The systemwas installed in eleven hospitals, offering blood transfusion services andtwo blood transfusion centers. The system was in use for nearly sevenyears. After period of operation, system state snapshot was performedand analyzed. The analysis was focused on per hospital usage preferencesthrough time. Distribution of patients ABO RhD blood typing was alsoanalyzed. In the paper the telemedical system is presented. The methodof data collection and data analysis methods are described. The finalsection presents results accompanied with discussion where economicalimpact of the telemedical system in comparison to the manual operationis briefly presented.

Keywords: telemedicine, blood transfusion, teleconsulting, telemedi-cal system, blood typing, pre-transfusion testing, economical impact oftelemedicine, usage analysis.

1 Introduction

The blood transfusion service is a distributed service. Blood products are deliv-ered from the central blood bank to the final consumer – local hospitals. Beforea blood transfusion is given, obligatory pre-transfusion tests are performed atthe hospital laboratories for confirmation of the donor/patient compatibility.They are normally performed by specially trained personnel. Normally, theseagglutination-based compatibility tests have straightforward results, enablingeasy diagnostic decisions of the local staff. In approx 1-5% of tests, various sero-logical difficulties and ambiguities occur [1]. In these cases, transfusion is delayedand an expert opinion is needed for the resolution of test results. In such cases,patient’s blood samples are sent to the reference transfusion laboratory to a qual-ified immunohaematology expert by a courier. The expert performs additionaltests and interprets them. The consultation between the expert and local techni-cian is then performed by telephone or fax. Notably, this method is error proneprocedure with a poor safety, quality and traceability performance, resulting ina time consuming and expensive operation.

S. Markovski and M. Gusev (Eds.): ICT Innovations 2012, AISC 207, pp. 173–182.DOI: 10.1007/978-3-642-37169-1_17 c© Springer-Verlag Berlin Heidelberg 2013

174 M. Meza, J. Tasic, and U. Burnik

In case of Slovenia, transfusion service is provided by two central nationaltransfusion centres with reference laboratories (with Blood transfusion Centerof Slovenia - ZTM being main one) and 9 hospital transfusion departments withtheir transfusion laboratories [5][3]. Transfusion centers are expert centers co-ordinating all transfusion actions on national level. They are responsible forblood collection, testing, production of blood components and performing pre-transfusion tests. Hospital transfusion departments with their transfusion labo-ratories are responsible for blood collecting and pre-transfusion testing [2]. Onthe average, transfusion service of Slovenia handles 400 transfusion cases perday [1]. Since it is impossible to predict when transfusion services are required,it is necessary to provide transfusion experts 24/7 in all hospitals dependingon transfusion service. Therefore an adequate number of experts are required.It is difficult to satisfy these demands due to lack of the qualified experts andlack of funds. Furthermore, in smaller hospitals only a few transfusions per dayoccur. In these hospitals transfusion expertise is provided without dedicatedpersonnel by expanding a set of assignments of other on duty doctors. Thesedoctors attended additional transfusion medicine training course. They are ableto solve straightforward cases occurring during their shift, when dedicated trans-fusion specialist is not present. But these doctors solve relatively small amountof transfusion cases and an obvious problem is lack of practical experience ofthese multipurpose doctors.

The core problem, addressed by our telemedical system is the remote read-out and interpretation of the agglutination tests, performed prior each bloodtransfusion (pre-transfusion tests), following the EU Directive 2002/98/EC thatintroduced quality management and haemovigilance into the practice of the cur-rent blood supply [7]. The ability to perform remote readout and interpreta-tion of pre-transfusion tests solved the problem of the delayed pre-transfusionprocedure in cases of ambiguous cases which required attendance of referencelaboratories. Another problem addressed by the system is provision of remoteimmunohaemathology expertise to laboratories with insufficient personnel re-sources. Furthermore, the law requires issue of a signed document as a result ofthe pre-transfusion test. Since the telemedical system does not transmit signedpaper documents, our system had to provide legally sound documents. To pro-vide documents, legally equivalent to their signed paper counterparts, a digitalsignature infrastructure was introduced into the system.

We analysed seven years of telemedical system usage in Slovenian transfusionpractice. The paper presents the telemedical system [6], methods of system usageand results of usage analysis.

2 Telemedical System

Our system enables remote interpretation of pre-transfusion tests performedon gel-cards. Considering advantages of both store-and-forward [12] and real-time approach [8][9] a hybrid telemedical system was developed using store-and-forward as base mode of operation with possibility to switch to real-time mode

Telemedical System in the Blood Transfusion Service: Usage Analysis 175

when necessary. In real-time mode audio/video communication between its usersis offered. A special device Gelscope was developed to capture images of gel-cards[4].

Our system follows high level of security, user identification and data pro-tection requirements. The result of the system usage is prompt exchange ofimmunohaematology expertise in form of legally valid electronic document con-taining the pre-transfusion test readout, interpretation and diagnose.

2.1 System Usage Workflow

The system usage workflow can be explained on the following use case scenario.Let us assume that in a hospital transfusion laboratory there is no immuno-haematology expert present and a need for pre-transfusion testing emerges. Sinceno expert is present, a remote pre-transfusion test interpretation is required.Users involved into the process are divided into two roles. Users belonging tothe role consulting user are laboratory technicians. These are users requestingthe remote interpretation. Users belonging to the consultant role are immuno-haematology experts. They are legible to issue legally valid pre-transfusion testinterpretations. Technicians as well as consultants both use the terminal withthe teleconsulting application. Screenshot of the teleconsulting application canbe observed on Figure 3. All users must log into the application using theirunique credentials. Based on the credentials the system determines user’s roleand rights to access different data. Roles and rights for each user are defined onthe teleconsulting server. On Figure 1, a laboratory setup of the technician sideis photographed [6].

At first the laboratory technician prepares the required samples accordingto the protocol of the pre-transfusion testing [13]. Result of sample prepara-tion is a series of gel-cards with administered blood samples after centrifugationwith agglutinates fixed in the gel of gel-cards. After gel-cards are prepared, thelaboratory technician sets up a teleconsulting session by setting up a question.Teleconsulting session consists of a question and if answered of the answer tothat question [6].

Setting up the teleconsulting question is divided into several steps. The firststep is entering a blood sample number into the teleconsulting application bymeans of scanning sample number from the sample vial, using the barcode reader.After capturing the sample number, patient’s data is automatically obtained bythe teleconsulting application and appended to the teleconsulting question. Inthe next step, the technician uses the Gelscope device to capture images of all gel-cards used in the test. For each gel-card, card type is selected and inserted intothe teleconsulting application from provided dropdown menu. Users can add upto 10 gel-cards to each question. In the next step of the question setup, the casespecific question is typed into the teleconsulting application. Then the availableimmunohaematology expert - the consultant is selected from the list of availableconsultants. After all question data has been entered, the technician finishesquestion data entry. The teleconsulting application then relays the entered datato the teleconsulting server [6].

176 M. Meza, J. Tasic, and U. Burnik

All teleconsulting applications continuously pool the server for any new ques-tions/answers. When a new question to the currently logged consultant emerges,the teleconsulting application immediately notifies the consultant about the in-coming interpretation request. Notification is accomplished by displaying an alertwindow on the terminal and by sending an SMS to the consultant’s mobile phone.Using the telemedical application, consultant reviews the question. He/she inter-prets the test results for each of the gel-cards and enters them into the telemed-ical application. After all gel-cards are interpreted, consultant determines andtypes the answer to the test case specific question set by the technician. After alldata has been entered, the consultant can decide to digitally sign the answer. Incase of digital signature the answer becomes signed document, which is legallyequal to the paper document required for the blood transfusion procedure. Af-ter data has been entered into the teleconsulting application it relays it to theteleconsulting server [6].

Since all active teleconsulting applications pool the server for new ques-tions/answers, a new answer to his/her question is noticed by the technician’steleconsulting application. When new question is noticed, the telemedical ap-plication immediately notifies the technician about the incoming answer by dis-playing an alert window on the terminal screen. It also sends an SMS messageto his/her mobile phone. Technician then reviews the consultant’s answer alongwith the question. He/she can then verify the digital signature of the documentand proceeds with the transfusion procedure as if the consultant was actuallypresent in the laboratory and has signed the paper document. In cases, whenimmediate response is needed and verbal discussion is required between the tech-nician and the consultant, users can establish a videoconference call using thetelemedical application [6].

2.2 System Architecture

The basic telemedical system architecture is client-server architecture. The sys-tem consists of several components, illustrated on Figure 2. The first componentof the system is the telemedical terminal, comprising of a personal computer,running the MS Windows XP SP3, running the telemedical application. Screenshot of the telemedical application can be observed on Figure 3. Telemedicalterminal component is used at the hospital laboratories (consulting side) and atthe transfusion centre (consultant side). Along with standard PC peripherals,the telemedical terminal is equipped with special propose hardware for captureof gel-card images - Gelscope device, shown on Figure 1, web camera, head-phones with microphone, bar code reader, colour laser printer and VPN router.Existing hospital information system also exists in all hospital laboratories andis also shown in Figure 2. Since consultant side does not need the equipment forquestion set up, terminals are lacking the Gelscope device and the connection tothe existing hospital information system [6].

The second component is the server side of the system with main server run-ning Debian Linux operating system, running the telemedical server application,certificate authority server application and database. The server also has GSM

Telemedical System in the Blood Transfusion Service: Usage Analysis 177

Fig. 1. Laboratory setup of the telemedical system. Main application window can beobserved on the terminal. Gelscope device is visible right next to the terminal monitor.Videoconference call is not established.

Fig. 2. Teleconsulting system structure. Three terminal setups, server setup and con-necting infrastructure are illustrated.

178 M. Meza, J. Tasic, and U. Burnik

module attached to it and runs SMS notification application. The server sidealso includes VPN server - router. All nodes of the system are securely con-nected through the secure virtual private network (VPN) tunnels via the publicInternet established by the VPN gateways and the VPN server [6].

The telemedical system is integrated with the existing hospital informationsystem through a special integration module to obtain patient basic data (namesurname, birth date, and blood type), previous patient anamnesis and patienttransfusion history. Basic operation mode of the telemedical system is a store-and-forward mode. If required, users can switch to the real-time mode by es-tablishing a videoconference call. Videoconference calls are established using thevideoconference module which is a part of the telemedical application. A digitalsignature infrastructure was also developed and integrated into our telemedicalsystem. Therefore through system issued readouts, interpretations and diagnoseshave the same legal value as their signed paper counterparts [6].

Fig. 3. Telemedical application user interface. Main user interface window with a video-conference in progress is shown.

3 Data Analysis

This section describes working system usage analysis. Analysis was performedby first capturing a snapshot of the system’s database, preprocessing the datafrom the database and analyzing the data using IBM SPSS Statistics, version19.

Telemedical System in the Blood Transfusion Service: Usage Analysis 179

3.1 Methods

In order to perform data analysis and to obtain the data we formally requestedthe access to the data from the Blood Transfusion Center of Slovenia - ZTM.Since the data contains personal data about patients, the access was grantedunder strict conditions. Results were reviewed by the Blood Transfusion Centerof Slovenia prior publication.

The data was captured from working system using Heidi SQL tool and ex-ported in form of csv (coma separated values) file. Interesting tables fromdatabase were selected. Since we analyzed patient data and system usage datathrough time, tables containing patient data and session creation data were se-lected for analysis. For each of the selected tables csv files were imported intothe SPSS tool for further analysis.

Patient Data Analysis. Patients blood type and year of birth distributionwere analyzed.

Blood type data is clearly indicated in the system’s database and is one ofmain pieces of information regarding blood transfusion process. It representsclassification of blood based on the presence or absence of inherited antigenicsubstances on the surface of red blood cells [14]. Our data was classified usingcombination of ABO blood group system and RhD blood group system. ABOgroup system is the most important blood–group system in human–blood trans-fusion, which provides possible classification of blood as O, AB, A and B. RhDsystem is the second most significant blood-group system in human-blood trans-fusion where the most significant Rh antigen is the D antigen, because it is themost likely to provoke an immune system response of the five main Rh antigens[14]. Blood type classification Using RhD is marked either positive either nega-tive regarding the presence of D antigen bodies. Our data had RhD classificationsuperimposed on ABO classification, thus we had O-NEG, O-POZ, AB-NEG,AB-POZ, A-NEG, A-POZ, B-NEG and B-POZ possible classifications.

Blood type analysis was performed by computing the histogram of blood typesin our database.

To analyse patients year of birth, new field containing only year of birth wascomputed from patient’s birth date. Then histogram was computed and drawn.

System Usage Data Analysis. System usage spread across time across differ-ent institutions was analyzed by counting teleconstulting cases handled by thesystem. For each case in the system, creation time, session origination institutionand session destination institution are recorded in the session data table.

At first overall telemedical system usage was analyzed by computing casefrequency across time. In order to do that cases were at first clustered by onmonthly basis using their creation time stamp. Then frequencies of cases foreach month were calculated. Using already on monthly basis clustered data,frequency of system usage among different institutions was also analyzed. Theanalysis was performed the same way as in overall system analysis with additionof clustering by session originating institution.

180 M. Meza, J. Tasic, and U. Burnik

At last overall system usage per institution location was analyzed by countingnumber of sessions originating from institutions.

3.2 Results

Using our system 35650 cases of teleconsultation were performed in timespanfrom September 2005 to middle of June 2012, based on data obtained from theBlood Transfusion Center of Slovenia - ZTM. Originating institution can beobserved in table 1.

Table 1. Per hospital system usage

Hospital BR CE IZ JE MS MB NM NG PT SG TR

Number 2698 57 2551 4682 7205 65 2183 77 4980 5208 3098Ratio 8,22% 0,17% 7,78% 14,27% 21,96% 0,20% 6,65% 0,23% 15,18% 15,88% 9,44%

3.3 Patient Data

In our system recorded patients birth data is indicated on figure 4a.Patient blood type distribution can be observed in figure 4b. As can be ob-

served from figure 4b, the most common blood type of with our system handledpatients is A-POZ followed by O-POZ. On the other side, the rarest blood typeis AB-NEG blood type.

(a) (b)

Fig. 4. (a) Patient year of birth distribution and (b) Patient blood type distribution

Telemedical System in the Blood Transfusion Service: Usage Analysis 181

3.4 System Usage Analysis

Per hospital system usage analysis can be seen on figure 5a. Data represent everysingle workstation location. In some hospitals, several workstations are present.Per location aggregated data can be observed in table 1. Overall telemedicalsystem usage can be observed on figure 5b.

createdDate

01.1.2013

01.1.2012

01.1.2011

01.1.2010

01.1.2009

01.1.2008

01.1.2007

01.1.2006

Fre

qu

en

cy

2.000,0

1.500,0

1.000,0

500,0

0,0

ZTM

TRBOVLJE

Trbovlje

TR

TK-ZTM

SLOVENJ-

SL-GRADE

S.Gradec

Ptuj

Novo

NGORICA

N.Mesto-

N.mesto-

N.Mesto

N.mesto

MB

Maribor

M.Sobota

LJ-L4A

LJ3-Zun.

LJ3-Dezu

LJ2-Dezu

LJ2

LJ1-Zuna

LJ1

LJ_LAB

LDOS

LAB4AVTO

JESENICE

Jesenice

IZOLA-r

Izola-r

IZOLA

Izola

Celje

CE

Brezice

location

(a) (b)

Fig. 5. (a) Per hospital system usage dynamics. (b) Overal telemedical system usage.

4 Discussion

Seven years of system usage proven that it is a helpful tool in the blood transfu-sion practice of Slovenia. The system was well accepted, and is being regularlyused which can be observed from steady increase in number of cases/month.Using our system, a significant savings of were introduced to the blood trans-fusion service of Slovenia. In study [15] authors analysed economical impact ofthe telemedicine for four transfusion wards and found out that savings of usingtelemedical system were 609.000 EUR per year, for year 2009. The cost analysiswas not final, since not all transfusion wards were included in study.

By observing results from our study presented in figure Overall telemedicalsystem usage can be observed on figure 5b we can observe, that volume of per-formed telemedical sessions in year 2009 when the study [15] was performedwas relatively small compared to the current volume of performed telemedicalsessions. Therefore we can claim, the telemedical system is mature and helpfultool in the blood transfusion service of Slovenia, appropriate for use in othernational transfusion services organized similar than Slovene (according to theEU Directive 2002/98/EC).

Acknowledgments. The system was financed and developed within coopera-tion of the Faculty of Electrical Engineering, University of Ljubljana, KROG-mit

182 M. Meza, J. Tasic, and U. Burnik

d.o.o. company and the Blood Transfusion Centre of Slovenia. Special thanks goto mag. Marko Breskvar, prim. Irena Bricl and prof. dr. Primoz Rozman. Thiswork is supported in part within the research group “Algorithms and optimiza-tion methods in telecommunications”.

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