J Med Syst DOI 10.

1007/s10916-006-9026-z

ORIGINAL PAPER

Barcode Technology in Blood Bank Information Systems: Upgrade and Its Impact
Bing Nan LI Sam Chao Ming Chui Dong

Received: 1 January 2006 / Accepted: 28 February 2006 C Springer Science+Business Media, Inc. 2006

Abstract This paper desires to explore the role of barcode technology in blood bank information systems via addressing its upgrade and the consequent impact. Firstly, it briefs the application and effect of barcode technology in blood donation and transfusion service. In the second, the barcode paradigms of Macau Codabar and ISBT 128 are carefully examined and compared in accordance with the procedure and specications of barcode upgrade. Then, the impact due to upgrade is assessed from the perspectives of blood bank information system, blood banks, and even blood donation and transfusion service. It nally discusses the considerations on implementing the upgrade of barcode technology in blood bank information systems. Key words Barcode label . Blood bank . Information system . Codabar . ISBT 128

Introduction Blood donation and transfusion service involves collecting, processing, storing and providing human blood intended for transfusion, performing pre-transfusion testing and nally, infusing into a patient. The life-critical nature of blood and blood components entails the most rigorous administration
B. N. LI ( ) S. Chao M. C. Dong Institute of System and Computer Engineering of Macau, Block 3, 1/F, University of Macau, Taipa 1356, Macau e-mail: bingoon@ieee.org M. C. Dong Department of Electrical & Electronics Engineering, Faculty of Science & Technology, University of Macau, Macau

so as to secure the entire procedure from blood donors to nal recipients. Fortunately, the advances of contemporary computers and information technology facilitates the mentioned procedure substantially. Coming to blood banks, they have greatly beneted from the computerized blood bank information systems and barcode labeling technology. A blood bank information system is to automate information acquisition, preservation, retrieval and circulation in the procedures of collecting, processing, testing and producing blood products. At the same time, the blood bank information system is designed to streamline diverse procedures taking place in a blood bank such as donor screening, component testing, inventory management and blood distribution etc [1]. Consequently, the Macau Blood Transfusion Center (CTS-Macau), cooperated with the Institute of System and Computer Engineering of Macau [INESC-Macau], began to deploy its blood bank information system SIBAS c in 1999, and then upgraded to current AB+ MIS c in 2005 [2]. As to the barcode technology, it is comprised of the machine-readable symbols used to encode information in order to automate a business process. Barcode enables the machine to acquire data via scanning and recognizing automatically, which can not only improve working efciency but also avoid the errors due to manual entry. In health industry, other than information processing efciency, the barcode technology is prevalent for its intrinsic capability to categorize, track and manage the life-critical medical materials including blood products. As the consequent, SIBAS c at CTS-Macau has built in the complete barcode technology at the beginning. In other words, the operation procedure within CTS-Macau was fully organized and coordinated with the help of barcode technology titled as Macau Codabar [3].

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Lots of important information is presented on a blood product label. The information varies from country to country in accordance with the licensed regulations, language differences and local transfusion practices. However, in face of the accelerating globalization, it turns obsolete that various self-designated barcode labels maintained in different countries and regions. In other words, an ofcial international standard is called for barcode technology. ISBT 128, reecting the choice of barcode symbology Code 128 and the sponsor organization International Society of Blood Transfusion, plays such role to specify the globally unique donation numbering system, reference coding tables, and the barcode system for information interchange [4]. Therefore, CTS-Macau has decided to deploy the new ISBT 128 barcode labeling technology in its blood bank information system since 2005. The purpose of this paper is to explore the role of barcode technology in blood bank information systems via addressing the upgrading specication and its consequent impact. In the following sections, we rstly brief the role of barcode technology in blood donation and transfusion service; Then, the barcode labeling technology is examined and compared in detail through the different paradigms of Macau Codabar and ISBT 128 at CTS-Macau; All aspects of impact due to the upgrade of barcode technology will be examined in detail, including blood bank information systems, blood banks, and blood donation and transfusion service. In the nal section, we discuss the concerns on system implementation related to upgrading barcode technology to ISBT 128 in blood bank information systems.

CTS-Macau, once a donor comes to the donation site, his/her donor number and donation number will be assigned uniquely. Then, beneted from the printed barcode labels, the subsequent processing in parallel, such as testing and screening in laboratories, manufacturing in components and validating in stocks, can contribute to working efciency fairly.

Managing Blood and Blood Components The barcode technology comprised of barcode and labels provides an effective method to manage the confusable blood and blood components in that it is impractical to distinguish them by naked eyes. Firstly, the machine-readable barcode labels enable information automation so that the human errors could be excluded. Similarly, it enhances information security to acquire and validate information without human intervention. Finally, the barcode label including readable texts improves the sorting and settling capability in terms of massive storage and management of blood and blood components.

Tracking Blood Donation and Transfusion Service Besides its applications in blood management, barcode labeling technology acts as a critical role throughout the procedure of blood donation and transfusion service, which effectively prevents the potentially incompatible blood transfusion. In blood banks, the critical information about blood components, such as donation number, blood group, product code and expiration date, has been printed out as the barcode label attached to that blood bag. Then, from the initial blood bank to the nal therapeutic institute, the circulation procedure can be organized and coordinated in a whole with the help of machine-readable barcode labels. The information about blood usage in that therapeutic institute can also be sent back to the initial blood bank with those unique donation identication numbers. Finally, in therapeutic institutes, barcode labeling technology should be deployed as in blood banks. Not only for information feedback, but also it is necessary for the security of blood transfusion practice [6].

Role of Barcode Technology According to the barcode labeling guideline in blood banks, the objective of uniform blood component label is to reduce the danger of incompatible transfusions caused through human errors via presenting important information in a clear, logical and easily recognizable format [5]. Nowadays the barcode labeling technology has participated in most divisions of a blood bank from the areas of reception and collection to laboratories, stocks, and even subsequent blood distribution, etc. In summary, the role of barcode technology in blood donation and transfusion service can be concluded as follows:[3]. Controlling Workow

Methods Rationale of ISBT 128 Given the biohazardous nature of some blood products with potential virus, the procedure of blood donation and transfusion service should be controlled rigorously in every step. Barcode labeling technology has been proven effective to coordinate and control the mentioned processes. At
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This study is concerned with upgrading the paradigm of barcode technology at CTS-Macau from Macau Codabar to ISBT 128. Why ISBT 128? ISBT 128 is superior because it not only provides a more secure barcode symbology but also

J Med Syst Fig. 1 Barcode in Macau Codabar and ISBT 128 (Barcode content: 24003908)

prescribes the normalized barcode labels. Nowadays it has been widely accepted as an international standard of barcode labeling technology for blood donation and transfusion service. However, right because of the punctilious specication in ISBT 128, the mentioned upgrade is far more than substituting the barcode symbology of Codabar with Code 128. It involves the special considerations on both of hardware and software, including database, barcode printers and scanners, etc. Coming to the barcode label itself, two critical steps are in the cutting edge of transformation: barcode symbology and barcode label. Barcode Symbology It is known that barcodes are composed of wide and narrow vertical lines separated by wide and narrow spaces. A pattern of bars and spaces makes up a character in the barcode alphabet. The symbol is represented by a linear sequence of wide and narrow bars and spaces. When a bar/space is compared to an adjacent bar/space, narrow bars/spaces represent binary zeros, and wide bars/spaces represent binary ones. For instance, each symbol of Macau Codabar is made up of four bars and three spaces for a total of seven bits of information per character, while each Code 128 character is comprised of three bars and three spaces, with each bar or space containing one to four elements printed as part of either a bar or a space. Figure 1 illustrates the mentioned discrepancy in the level of barcode symbology. Similar as ABC Codabar [5], Macau Codabar has been outdated for contemporary blood banks due to the following limitations, which make it doomed to be superseded by ISBT 128 [7]: Capacity Codabar can merely encode 10 numeric characters with several control characters. In contrast, Code 128 is a linear symbology capable of encoding the full ASCII character set. The full alphanumeric coding capability is necessary due to the expanding catalog of blood products. Efciency The barcode length is subjected to its content rigorously. Code 128 provides the unique exibility by enabling the user

to switch from one subset to another even within the same symbol. And the subset C of Code 128 is one of the most space-efcient linear symbologies. Such efciency is very important while printing the extended donation identication number for sampling tubes. Data Security Different from ABC Codabar, Macau Codabar even does not provide any control character or data identier to secure the transferred information. In other words, Macau Codabar is susceptible to the substitution errors and has to depend on the printed barcode content texts. On the contrary, each character in ISBT 128 has three separate self-checking features beyond data identiers. In addition, each symbol requires a modulus 103 check character designed to ensure that the entire message has been scanned correctly. Barcode Label There are a number of technologies such as Radio Frequency ID (RFID) to deliver barcode information. However, barcode label is the most competitive one as a cost-effective method. At CTS-Macau, there are two kinds of barcode labels serving different roles: donation label and component label. The label of donation is designed to track and control workow within a blood bank. With the concern on its lifecycle, there is no particular specication on such kind of labels in ISBT 128. Beneted from the space-efcient symbology of Code 128, the label of donation can keep compact as in Macau Codabar paradigm. However, the label of blood component in ISBT 128 has been normalized from the dimension of label, barcode and text to their layout. From Macau Codabar to ISBT 128, most modication related to the label of blood component can be surveyed from Fig. 2 and Table 1. Implementation There is a series of transformation from Macau Codabar to ISBT 128 in different hierarchies. Firstly, the component label of ISBT 128, comparing with the one of Macau Codabar, is in a thoroughly different style. It is necessary to rearrange the format of barcode label including font typeface (from Helvetica to San Serif) and content layout as shown
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Fig. 2 Illustration of component labels

in Fig. 2. In the second, to comply with ISBT 128, more critical information, such as donation type and blood bag, will be encoded in the label of blood component. Finally, due to different barcode symbologies and standards, major transformation is related to the barcode itself, including barcode format as well as barcode content shown in Fig. 3 and Table 2. Donation Identication Number This number to identify a blood donation uniquely takes two different roles in a blood bank. The rst one is to organize and coordinate all procedures related to this donation. Its other role is to identify a blood component so as to facilitate the globally uniform management. Then, as to its rst role, it is recommended to merely update the barcode symbology for

the least impact on workow. In terms of its second role, the donation number will be combined with the unique facility identication number designated internationally.

Blood Group Generally speaking, there are totally 8 types of ABO/Rh combinations as the blood groups. Hence, 1-bit digit is reserved for blood-group codication in Macau Codabar paradigm. Besides 8 blood groups, the code 0 is designated for any uncertain or invalid blood group. Nevertheless, in ISBT 128, the blood group of a component will be coded with the type or status of this blood donation. In other words, there will be more than 128 different codes for encoding and interpretation of blood groups.

Table 1

Comparison of contents in component label Content Macau codabar ISBT 128 Barcode; Text Barcode; Text Barcode; Text Barcode; Text No Text Text Text Text Text Text Text Barcode; Text Optional Optional

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Donation Identication Number (DIN) Blood Group (BG) Blood Component (BC) Expiration Date (ED) Complex (DIN + BC + BG) ABO Rh Component Name (CN) Expiration Donation Type (DT) Blood Bag (BB) Special Testing Label (STL) Facility Identication (FI) Prescription Collection Date (CD)

Barcode Barcode; Text Text Text Text Text No No Text Text Text Text

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J Med Syst Fig. 3 Comparison of barcodes in component label

Product Code One of causes that Macau Codabar paradigm was superseded by ISBT 128 is that its product code structure had not been updated to reect the proliferation of new blood components. The original Macau Codabar merely provides 1-bit digit for product encoding and interpretation. Obviously, it is too limited for the expanded classes of blood components, let alone the combination of various modier(s) and/or attribute(s). Instead, ISBT 128 uses a scheme of Class, Modier(s), Attribute(s) and Core Conditions to identify the specic component. In the meantime, the new coding scheme can optionally encode the information about donation type and whether the product has been further processed.

Expiration and Collection Date The expiration date, and even collection date, is of paramount importance for any blood component. Hence, their roles are pinpointed in both of barcode labeling paradigms. The only difference is that expiration date is directly coded as string in Macau Codabar while the Jilian date is adopted in ISBT 128. Finally, as mentioned in the beginning, barcode labeling technology should be integrated in the blood bank information system as an essential component. Take CTS-Macau for example, it equips the professional Zebra r printers for barcode label production and variety of barcode readers for information acquisition. Demonstrated by Fig. 4, these barcode printers and readers, in spite of distribution in different divisions, are actively linked to the central database.

Table 2

Comparison of barcode contents in component label Format Macau codabar ISBT 128 appppyynnnnnnff ggre aooootds cyyjjj appppvvvvvvvv vvvvvvvv appppuuuuu Bits Macau codabar 7 1 1 10 7 3 ISBT 128 15 4 8 6 21 10 Content Macau codabar year + SN ABO + Rh PDC day + month + year SN SN ISBT 128 FIN + year + SN + FF ABO + Rh + DT PDC + DT century + year + Julian day FIN + SN FIN + SN

Donation no Blood group Product code Expiration Donor no Staff no

yynnnnn g o dd-mm-yyyy vvvvvvv uuu

FIN: Facility Identication Number; SN: Serial Number; FC: Flag Characters; DT: Donation Type; PDC: Product Description Code. Springer

J Med Syst Fig. 4 Barcode technology in a blood bank information system

Consequently, all information will be rigorously checked and veried in the procedure of barcode label production. At the same time, to secure the high delity, all barcode labels are dynamically generated and produced in virtue of the proprietary programming language ZPL II c [8].

Impact of Upgrade Barcode label is essentially a medium of information transfer. So Macau Codabar, in some sense, can be considered as a pure barcode labeling paradigm to facilitate information acquisition. Nevertheless, ISBT 128 serves as not only a technical specication for uniform barcode labels but also a comprehensive operation guideline for blood donation and transfusion service. Therefore, upgrading from Macau Codabar to ISBT 128 will result in a series of impact on, other than the barcode label itself, the blood bank information system, the blood bank, and even the whole blood donation and transfusion service. Impact on the Blood Bank Information System With the concern that Macau Codabar is a facility-designated barcode labeling paradigm, inevitably, there is incompatible and even conict coding information between Macau Codabar and ISBT 128. In contrast with Macau Codabar, ISBT 128 entails more critical information and follows the different barcode labeling mechanism. Shown as Fig. 4, the blood bank information system is intrinsically coherent due to integration with the operation procedures of the blood bank. Then, the modication due to barcode upgrade will no doubt impact the whole blood bank information system. It is hereby a challenging issue to keep information consistent while compliant to the new ISBT 128 standard.
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It is known that a database can be considered as a collection of relational tables. These tables keep coherent through various constraints such as reference keys. Coming to the database for a blood bank information system, most of the tables are organized and coordinated through the unique donation number or donor number, which is clear in Fig. 5. Here a series of new tables are rstly created to map Macau Codabar with ISBT 128. Consequently, new barcode labels can be produced in accordance with the ISBT 128 standard. At the same time, the blood bank information system provides the self-adaptive user interfaces to facilitate blood bank staff while keeping information consistent. As to the individual table in database, there are two schemes to guarantee the information consistency. The rst one is to update all records in accordance with the new ISBT 128 standard at a time. On the contrary, the alternative will build the new coding system; meanwhile, it remains the original coding paradigm, too. Both of them work well in terms of the conict coding information. However, once coming to the incompatible information, the latter scheme is the only choice because there may be no corresponding codes. For example, as to Macau Codabar, there is a special code QI in the reference table of blood components for quality assurance. Nonetheless, it has no valid code in ISBT 128. Impact on Blood Banks The blood bank information system is integrated with various blood donation practices within a blood bank. In other words, the information in blood bank information system depends on the activities performed in that blood bank. Now the blood bank information system has to be modied so as to support the new ISBT 128 barcode labeling standard. Consequently, the mentioned practices of course should be adjusted accordingly in that blood bank.

J Med Syst Fig. 5 Partial data models of a blood bank information system

In the rst, it has been pointed out that ISBT 128 entails more critical information. Naturally, the required information comes into being only from the practical operation procedure of blood bank staff. For instance, in original Macau Codabar paradigm, there are total 10 classes of blood components without any modier(s) and attribute(s). To comply with the ISBT 128 standard, the required information, such as the modier Frozen Rejuvenated and the attribute Additive/Volume/Temperature, should be provided in the division of processing blood components. On the other hand, the blood bank staff has to adjust their operation practices shown in Fig. 6 so as to avoid the incompatible information. Originally, there was a designated type of donation as PLP in Macau Codabar. As a matter of fact, it should be the component code Apheresis PLATELETS in ISBT 128. The former scenario stems from the fact that only the blood component platelets was retained during apheresis at CTS-Macau. Obviously, in ISBT 128, such simplied procedure of blood donation is not allowed any longer. Impact on Blood Donation and Transfusion Service ISBT 128 stems from the vision that every blood product can be specically identied and tracked anywhere in the world. In face of the advancing globalization, it is necessary to implement such international standard for contemporary blood donation and transfusion service. Coming to the Macau society, it annually accommodates hundreds and thousands of tourists from all over the world. At the same time, de-

spite the close relationship with Hong Kong, Taiwan and the Mainland of China, Macau follows different administration systems including the independent health guidelines. Hence ISBT 128 is particularly welcome at blood transfusion centers like CTS-Macau. ISBT 128 provides two schemes to serve its mission. In the rst, ISBT 128 prescribes the uniform barcode labeling standard so that most of vital information about the blood products could be clearly, concisely represented. Then, regardless of the discrepancy of languages and customs, the marked blood products can receive timely treatment in a safe way. The second manner is that ISBT 128 provides a series of standard reference tables for encodation and interpretation. Such uniform coding strategy denitely contributes to the quality of blood donation and transfusion service. For instance, it is pointed out that ISBT 128 is compatible with the Electronic Data Interchange standard HL7. Then, thanks to ISBT 128 and HL7, blood donors, with their unique donor identication numbers, can enjoy the consistent blood donation service anywhere in the world. Similarly, the whole procedure of blood donation and transfusion service can be effectively recorded and tracked no matter where the individual step is performed.

Conclusions In this paper, the role of barcode technology was rstly addressed: for blood bank information system, the barcode
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J Med Syst Fig. 6 Process models of a blood bank information system

labeling technology facilitates information acquisition and circulation; for blood banks, it helps to coordinate the operation procedure and manage blood products; nally, it promotes the security of blood donation and transfusion service. In the following, this paper focused on the implementation specication of upgrading from Macau Codabar to ISBT 128. ISBT 128 is superior to Macau Codabar because of the more secure barcode symbology, the normalized barcode label, and the standard reference tables. Consequently, the mentioned upgrade involves, other than the transformation of barcode label itself, the modications of the blood bank information system and blood bank operation procedure. Then, it mainly explored the impact due to the upgrade of barcode technology. In the sight of blood bank information system, information consistency should be in the rst priority during implementing the transformation. As to blood banks, the staff should adapt themselves to the new operation procedure in accordance with ISBT 128. Finally, thanks to the new ISBT 128 barcode labeling standard, the quality of blood donation and transfusion service can be improved substantially. Of course, there are several points yet mentioned to upgrade barcode technology in blood bank information system:

r From the viewpoint of information science, barcode technology facilitates information acquisition, preservation, retrieval and circulation. Therefore, other than software, hardware support should also be in consideration including barcode printers and scanners. Fortunately, the symbology of Code 128 has been widely accepted and deployed. In

general, the printers and scanners supporting Codabar are also applicable to Code 128. r Proper evaluation is an essential part of implementing the new ISBT 128 barcode labeling standard. In the rst place, information consistency should be guaranteed while accommodating the updates for ISBT 128. On the other hand, both of hardware and software should be approved compliant to the ISBT 128 technical specication. The viability and applicability must be rigorously tested by both of system developers and blood bank staff. r ISBT 128 is a living system, namely, subject to the continual revision process. Unlike Macau Codabar, ISBT 128 is open to all. The participation of new members no doubt brings the necessary revision and update. Furthermore, ISBT 128 is ready for the advances of contemporary technology for collecting, testing, and processing blood products. r In the last, it should be pointed out that Macau Codabar is merely a special case as the barcode technology in blood bank information system. Nevertheless, although this paper is based on Macau Codabar, the introduced upgrade and consequent impact can still embody the general philosophy of ISBT 128 barcode labeling standard. References
1. British Committee for Standards in Hematology (BCSH), Guidelines for blood bank computing. Transfusion Med. 10:307314, 1999.

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J Med Syst 2. Li, B. N., Chao, S., and Dong, M. C., SIBAS: A blood bank information system and its 5-year implementation at Macau. Computers in Biology and Medicine, accepted, 2006. 3. Li, B. N., Dong, M. C., and Vai, M. I., From Codabar to ISBT128: Implementing barcode technology in blood bank automation system. In Proceedings of 27th Annual Conference of IEEE EMBS: 542545, IEEE Press, New York, 2005. 4. Ashford, P., Butch, S., Distler, P., Goergsen, J., and Larson, P., ISBT 128 Standard Technical Specication (Version 2.1.0). ICCBBA, PA: New York, 2004. 5. Center for Biologics Evaluation and Research (CBER), Guideline for the Uniform Labeling of Blood and Blood Components. http://www.fda.gov/cber/guidelines.htm 6. Turner, C. L., Casbard, A. C., and Murphy, M. F., Barcode technology: Its role in increasing the safety of blood transfusion. Transfusion 43(9):12001209, 2003. 7. Wray, B., Why Code 128? The Rationale behind ISBT 128. ICCBBA, PA: New York, 2001. 8. ZPL II Programming Guide. Zebra Technological Corporation, IL: Vernon Hills.

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