Since the 1990s, medical information systems have rapidly evolved around the order communication system (OCS), which consists of various components such as the hospital information system (HIS), electronic medical records (EMR), picture archiving communication system (PACS), and management information system (MIS). The laboratory information system (LIS) has also improved considerably, focusing on automation in response to the increased workload and the need to improve quality [1].

However, in the case of phlebotomy services, despite efforts at improving the workflow, the inconvenience to patients has not been completely mitigated. Until January 2014, patients in our hospital were required to obtain a queue number from a machine, followed by manual entry of the patient's identification number into the OCS in order of queue number and issuance of another queue number for the actual phlebotomy. These repetitive waiting steps increased the overall turnaround time (TAT) of the phlebotomy service and lead to patient dissatisfaction with the hospital service. Moreover, the automatic barcode labeling and test tube transfer system implemented in 2013 to improve work efficiency could not achieve its maximum performance because of the bottleneck at the manual reception steps.

To address these issues, we installed an automated reception machine and developed a TAT management system through which patient information and requested laboratory tests were transmitted directly to the actual phlebotomy site in a single step, and the TAT of each phlebotomy step could be monitored at a glance. This system has been functional since February 2014, remarkably decreased the overall TAT, and improved the workflow and efficiency at the phlebotomy room.

Our hospital is a 750-bedded tertiary care university hospital, with 95,711 outpatients (an average of 400 patients per day) availing the outpatient phlebotomy services in 2013. The GNT5 system ver. 2.2 (Energium Co., Ltd., Siheung, Korea) comprising of a Barcode Applicator (BA), Test Tube Transfer (TTA), and Medic Work Table (MWT) has been in operation in the phlebotomy room since June 2013 (Fig. 1). Installation of an automated reception machine and development of a TAT management program was achieved by July 2013 and fully operationalized in February 2014 (Fig. 2). By integrating the GNT5 and automated reception machine using a computerized order transmission program, laboratory order information received by the automated reception machine at the time of the patient's visit at the phlebotomy room is transmitted directly to the GNT5 system. As a result, the phlebotomist automatically received the barcode-labeled test tubes for corresponding patients and could verify the patient's information in the LIS program in a single step. A TAT management system for phlebotomy was concomitantly under development.

During this developmental phase, a preparatory committee that comprised of members from the laboratory medicine, outpatient, hospital administration, and data processing departments worked for addressing the following issues.

Quality can be defined as the ability of a product or service to satisfy the needs and expectations of a customer [2]. In the case of a hospital's outpatient phlebotomy room, waiting time is one of the most important factors affecting patient satisfaction with the service. Therefore, reducing the waiting time through more efficient workflow could improve the quality of the phlebotomy service.

Since 2013, we have operated the GNT system in our hospital's outpatient phlebotomy room to improve the efficiency of workflow. The GNT system is a phlebotomy assistance system that helps prevent medical accidents, reduces waiting time, and improves the convenience for both patients and phlebotomists. The system automatically provides phlebotomists with essential items required for a phlebotomy (the appropriately labeled specimen tube, a specimen label, a patient identification label) based on the phlebotomy information recorded in the hospital information system (i.e., HIS, LIS, OCS) [3]. However, despite the automated barcode application and tube transfer functions of this system, the manual reception step was a bottleneck that limited the efficiency of the phlebotomy services. Moreover, the risk of human error at the point of pre-phlebotomy reception performed by a phlebotomist unaided by automation was exacerbated by increase in outpatient attendance alongside a decrease in the number of laboratory personnel and the human error that resulted from physical and mental fatigue [4567].

To address this issue, we introduced an automated reception machine and developed a laboratory order transmission program connected to LIS and OCS with full consideration of the circumstances in our hospital. These included the desired phlebotomy date, processing of unpaid charges, and time period for noting unperformed or missed tests.

TAT is the most frequently used indicator of efficiency of the laboratory test ordering process [8]. We used a TAT management program developed to monitor the efficiency of our phlebotomy service. This program can monitor each step of the phlebotomy process from reception to actual phlebotomy; therefore, if a problem arises in the phlebotomy room, we can analyze and address the matter by examining each step of the process. Moreover, our program can be monitored remotely. This functionality can help improve system efficiency by allowing for real time identification and troubleshooting of problems. This functionality is of particular value in health care settings where the central laboratory is located separately from the phlebotomy room.

After installing the automated reception and TAT management system in February 2014, both the TAT for each phlebotomy step and the number of patients in the queue were significantly reduced. Moreover, there was a significant decrease in the defect rate, a parameter that we defined as the number of cases where the time between reception and phlebotomy exceeded five minutes, after implementing the system.

Laboratory services are an integral and essential part of clinical service delivery. The department of laboratory medicine must be centrally involved in the planning and implementation process, for these systems to bring about improvements in system efficiency. Moreover, successful implementation requires the building of new relationships and improved level of hospital-wide collaboration. Formal channels of communication between multidisciplinary groups are crucial for real time problem solving [891011]. We found that a consensus among the OPD, hospital administration, and data processing department was essential during the developmental process, because the heterogeneity in outpatient practices presents a unique set of challenges for harmonization of the system across various specialties and departments. For example, in the outpatient setting, days or even weeks may elapse between placement of an order and collection of the specimen [121314].

This is the first application of the automated reception and TAT management system to phlebotomy services in Korea. We expect that our system will provide a platform to streamline workflow in other hospital phlebotomy rooms. Additional details such as management of redundant orders requested from different OPDs should be discussed in the future to further improve the efficiency of the system and to enhance the satisfaction of physicians and patients.