Laboratory Information Systems

in CIinicaI Laboratories:
What to Iook for?
PedrIro Y. Tagayuna, MD
BobongMD
®
Io c·· i. nvnvn, Io {ov[
ìninv. v¡..
,ov nccv v .on¡vìc·
Computers are GOOD at:
Givinc (e:u|I: Ic c :eI cf in:I(ucIicn:
Computers are BAD at:
(incinc c(ce( Ic chcc:
FuI Ihinc: in c(ce(. when Ihey c(e ncI
Chcnce :Icff Lehcvic(
!re-requisites to computerization:
cecucIe inf(c:I(ucIu(e
C(ccnizcIicnc| :I(ucIu(e
Cuc|iIy :y:Iem
SIcffinc
Laboratory Information
The sole product of any laboratory, serving
any purpose, in any industry, is
information
Laboratory Informatics
The specialized application of information
technology to optimize and extend
laboratory operations
Data FIow in the Laboratory
ab Automation
& Robotics
Equipment
Ìnterfacing
aboratory
Ìnstruments
aboratory Ìnformation
Systems (ÌS)
Data
Analysis
Data
Mining
Data
Warehousing
Data Acquisition Ìnformation Processing Knowledge Management
FunctionaI Hierarchy
in Laboratory Informatics
c c|c:: cf :cfIwc(e IhcI (eceive:.
p(cce::e:. cnc :Ic(e: infc(mcIicn
cene(cIec Ly mecicc| |cLc(cIc(y
p(cce::e:
cfIen mu:I inIe(fcce wiIh in:I(umenI: cnc
cIhe( infc(mcIicn :y:Iem: :uch c: HlS
hich|y ccnficu(cL|e cpp|iccIicn which i:
cu:Icmizec Ic fcci|iIcIe c wice vc(ieIy cf
|cLc(cIc(y wc(kf|cw mcce|:.
Basic Concept of LIS
%he generaI requirements
of an LIS:
as a subsystem of an HIS incIude
onformity to domestic and international
standards.
Binding of EMR/HÌS primary data and
laboratory data.
Support clinicians with test results and their
dynamics, and managers with statistic reports.
Access restriction control to laboratory data on
ethics and functional rules
GeneraI requirements for an
LIS shouId aIIow for:
integration (interface with and health information networks, as well as other
local and national organizations).
security (configured to address the extremely confidential nature of the
database).
Easy-of-use for staff.
input of data manually and from analyzers.
· Ìnstrument integration/interfacing
unified, scaIabIe and customizabIe pIatform for any
specialization (microbiological, clinical, bacteriological, cytological, etc.).
Remote order creation from cIinics (physicians) as well as
from inside (laboratory registrar).
Data export in various data formats.
GeneraI requirements for an
LIS shouId aIIow for:
ability to manage input data flows of remote orders.
ability to control the traffic of samples and the status of
analyzers.
Registering checkpoint analysis times.
/H visualization and calculated indexes support, norms bounds
checking in accordance with patient' age, gender and used
reagents.
generation of laboratory workbooks and operation plans on the
basis of analysis data (order, results, laboratorians).
Provision for accounting of time expenses of test performing.
Preparation of operational and statistical reports in different
slices.
Basic LIS Features
ollection Management
Patient heck Ìn
Order Entry
Specimen Processing
Result(s) Entry
Reporting
Patient Demographics
Physician Demographics
Tracking
· Samples, orders, reports
Scheduling
· Tests, equipment maintenance
Quality assurance
· Validation, QA/Q
Data access and sharing
· Ìnstrument interfacing
Basic LIS Features
Basic LIS Features
lexibility
· Sample types, tests, methods, reports
Traceability
· Audit trails, on-the-fly notation
Security
· Very limited access, but with lateral authorization
Time
· Response time
AdditionaI Features
Web based results inquiry
Quality ontrol Management
ustom report creation
Preliminary reporting
inal reporting
Med tech worksheets
Workload balancing
Public health reporting
Sample
abeling
Job
Assignment Progress
Tracking
Results
Entry
Results
Verification
Reporting
IN
OUT
FaciIitation of Routine
Laboratory Operations
Sample
abeling
Job
Assignment Progress
Tracking
Results
Entry
Results
Verification
Reporting
IdeaI Lab Information System
$.alability & Flexibility to support the laboratory's unique needs
aboratory
VaIidation &
Report
SampIe
Reception &
Dispatch
Reliability
..essibility
Turnaround time
Production cost
"UAITY
Test Request
and SampIe
Extraction
SampIe Processing
ResuIts
ConsoIidation
DO YOU NEED a Laboratory
Information System?
aboratory provides most of the
information used by clinicians in the
treatment of patients
it is also an auxiliary service where
opportunities exist for cost reduction
blameyko S., Mozheyko D, Belarusian State University, United Institute of Informatics
Problems of the National cademy of Sciences of Belarus, 6, Surganova str., Minsk,
220012 Belarus, Design and Development of the Public Healthcare Laboratory
Information, http://informatica2009.sld.cu/conferences/design-and-development-of-the-
public-healthcare-laboratory-information?set_language=en
Increased Revenues
hospitals that introduced a ÌS were
significantly greater than those of the
hospitals that did not
.S. Park, S.Y. Yi, S.. Kim, J.S. Song, Y.H. Kwak, ssociation
between the implementation of a laboratory information system
and the revenue of a general hospital, rchives of Pathology and
Laboratory Medicine, 129(6), 2005, 766-771.
R. Seaberg, B. Statland, R. Stallone, Planning and implementing
total laboratory automation at the North Shore-Long Island Jewish
Health System Laboratories, Medical Laboratory Observer, 31 (6),
1999, 46-54.
Laboratory Information
Management
· aboratory .ontributes in 80 % in
obje.tive data to the .lini.al re.ords
(1)
· Influen.es 60-70% of .riti.al de.ision-
making about patients
(1)
Rodney orsman, linical laboratory news ÷
July 2004
Laboratory Information
Management
. Patient care & Patient safety.
· % of aboratory errors harm patients
(1)
· % of errors leads to higher .ost
(1)
· Example : Result trans.ription errors measured as
% with 8.8% as ina..urate
()
· t least 000 and up to 98 000 meri.ans died ea.h
year as a result of medi.al errors in hospitalization
(3,)
Source (1): Mistakes in a Stat aboratory: Types and frequency- linical hemistry 1997,
Source (2): Variation in the transcription of the laboratory data in a Ì& ÷Anesthesia- ugust 2004
Source (3): To Err is human, Building a safer Health system, Nation Academy press, 2000
Source (4): Patient safety: achieving a new standard for care, Nation Academy press, 2004
UniversaI Need for LIS
Regardless of focus, all labs need:
· Quality assurance and control
· Error reduction
· ast sample turnaround
· Management of information ÷ from test
request, result validation, printing through
management statistics
EvaIuating Your Needs
Based on System features:
· onsider the end users
· What features you need in your ÌS?
· What features would improve your lab process?
Based on Technology:
· What technologies will work in our
environment?
· What technologies can improve ÌS
operations, management, functionality?
EvaIuating Your Needs
Needs Assessment/Analysis (do SWOT)
· Generic approach
· Gather information from each area that uses
or will use the ÌS
· Approach it at the "bench-level¨
· Meet with users outside selection team
meetings
· Share information with team members
EvaIuating Your Needs
Key factors that need to be evaluated in the needs
analysis to serve as basis in system selection
· unctionality of the system
· ompatibility with other systems and ÌT environment
· Scalability
· ost
· Version Management
· Ìnteraction with other vendors systems and health system
vendor portfolio
· Support and maintenance costs and human resources
· Vendor stability
EvaIuating Your Needs
ChaIIenges
Needs analysis is poorly understood
process for most labs
Technophobia can hamper progress!
System is often blamed for poor operations
or workflow design
EvaIuating Your Needs
DetaiIs
System Selection-General Ìssues
· ab Environment
· Volume of testing
· Number of users
· Number of sites (geographic)
· More than one hospital/satellite clinics
· Ìnpatient, Outpatient
· Billing processes
· Support team
EvaIuating Your Needs
DetaiIs
System Selection-General Ìssues
· ÌT environment
· Data center vs. department hosted vs. ASP
· Support process
· Ìnterface engine
· EMR vendor
· Orders versus results only
· Hardware platform expertise
· Software platform orientation
EvaIuating Your Needs
DetaiIs
linical Pathology System Selection
· ist of instrument vendors and interfaces
· Areas of laboratory currently on system
· Ìf there are any
· Number of users
· Number of locations
· Single versus multiple sites
EvaIuating Your Needs
DetaiIs
AP System Selection
· Are you using an AP system?
· Data conversion issues
· Ìnterfaces to equipment
· ess of a challenge than P system
· Ìnterfaces to other systems
· Need for integration with private practice
· Ìmaging capability
Why do system seIections faiI?
ailure of selection process
Poor planning
Poor communication
Wrong people involved
· Too many people involved
· Too few people involved
ack of alignment with institutional goals
· Budget
InstitutionaI !Ianning
InstitutionaI !Ianning
SWOT Analysis can lead to justification for
capital purchase
ÌS purchase is a capital request for a lot of
money: who do you need to convince?
· Does lab have its own ÌT budget?
· hairman
· Ìs capital for ÌS part of institutional pool?
Some level of lobbying for capital should
precede development of process
· No money, no ÌS
InstitutionaI !Ianning
Ìf ÌT budget is part of central ÌT group,
there may be a desire for ÌT to select a
system for you
· not a good thing
· Get ÌT on the selection team
· Show ÌT you know what you are doing
· Ì ÌT is going to lead the process, make sure
lab has a leadership role on the selection
team
InstitutionaI !Ianning
Develop a concrete budget and allocate ample funds for
system design, selection, implementation
· This may need to occur prior to submitting a request for
proposal to vendors
· &se system cost of similar colleagues to get close
· request for quotation
· Plan to revise budget as proposals come in and vendor is
selected
· Build in significant contingency money
· Don't forget the cost of ongoing support
There will be budget shortfalls regardless of how you
proceed
· ontingency funds of 10-20%
. Mc(k IuIhi||. MD. Hen(y Fc(c Hec|Ih Sy:Iem. Divi:icn Hecc.
FcIhc|ccy lnfc(mcIic:. Lec:Evaluation of Needs, Association for
Pathology Ìnformatics Advanced Ìnformatics 9/9/07
mIuIhi|1@hfh:.c(c. {313) º1ó-2524
System SeIection %eam
System SeIection %eam
reate a formal team to participate in system
selection
· May be different than implementation team
· Make sure there is some overlap with implementation
team
· As you form this team make sure you consider who
would be involved in implementation
· Participants should be able to marshal end users
· ook for member who are committed to the process
· Ìnclude the "nay¨ sayers
System SeIection %eam
Educate the team
· Selection process
· Technology issues
· eature selection issues
· Don't assume anything
· People bring great ideas and talent
· Work to separate technology, system features
and workflow issues
· Demo's and site visits
System SeIection %eam
Schedule meetings
· Plan how long you expect to engage in pre-planning
· Schedule meetings formally in advance
· Weekly or bi-monthly minimum
· Adhere to the schedule
· Keep and publish minutes
· Over communicate process issues
· ommittee charge!
· Where in the process are we?
· What have we done?
· What is next?
· Time will be a problem!
System SeIection %eam
Who?
· Ìnvolve the Director!
· Pathologists
· Medical technologists
· lerical staff
· ab administration
· ÌT teams: ÌT steering committee? ÌT Ìntegration ommittee?
· onsultant
Participants can drive data collection from other personnel
· Not every person needs to be on the team
atch out for becoming top heavy
· Get people who use are expected to use the system
System SeIection %eam
Plan who will have final say in selection
· Process should be formal
· Decide in advance how vendors and systems will
be ranked, compared
· Objective
· Subjective
· Or..BOTH
Choosing the Right Vendor
Best of Breed
1. ommitted to the Development of the System
- Willing and able to provide fast and ready support/maintenance
2. Vendor Strong Domain Knowledge and Experience
3. Well implemented solution means access to industry best
practices covering wide geographical zones
4. ocal experience and presence
5. ompliant to industry standard, H7 and now ÌHE
6. Open policy to instrument integration
Ìdentify need
Justify need and get
budget support
Ìdentify solutions
Request information
Request Proposals
Select system
ÌMPEMENT
OutIine of System SeIection
!rocess
%imeIine
laboratory
objectives
laboratory
operations
functional requirement specifications
product
selection
installation
lab personnel
vendors
customers
administration
ÌT department
validation
TÌME (months)
4
+6
+8
+9
+3 = 2.5 years
EOP
vvnvn ^v[vnvì.

%40778:2,3 %414: 938:5 4:300/,.425:907

425:9078,70  

,9 

;3708:9894,809413897:.9438

425:9078,70 ,9 
  

73347/0794.,48 !:9938347/07 0390,70349 ,3089,11-0,;47

!70
706:890894.425:907,943 
   

/06:,90317,897:.9:70 7,3,943,897:.9:70 ":,988902 $9,113

.947 807.943 .94731472.3 .35:75480 3.3.943  %0840574/:.33/:897 8 31472.-47.-47.941.

9438 ..-47..9474507.0/.8  %0850.3449445920.-47.94731472.9434131472.9.55.943 90.3/0903/ ..

8 .-47.-47.943 #4-49.3.3 .9.943!74. 3. .-:942.02039 .947 3897:20398 .-47.9.9..9.6:8943 31472.0883 340/0.4390.88 6:52039 39071.94731472.704:83 .943 $89028 $ ..9.. 33 .947 .

943.7.9.8 .:3.94731472. 3.-47.07.

.-47.943 0307.08808 419032:8939071.431:7./0.093897:20398.709.3/89470831472.70941 ..943.947471424/08 ..8 .-47.8$ .0.08808 .:89420/941.9438890288:...9..-0..88418419..8.947 574.08  574.90.3/ 490731472.90/-20/.970.55..43..05941$    .

8:-8890241.943.3$3.3/39073. 89.7/8  3/341#.:/0     431472994/42089.%00307.8..3$ .706:7020398 41.3/.

3.3899089708:98.9.7054798 ..$572.947/.943.3/2..8 .  $:55479..4397494.7/.8.3.43 09.078989.7:08 .-47.3/ .-47.943.08870897.9.3/907 /3.3/1:3.989.2.947/.9.

943309478 .9:704190 /..3.078 W 3897:20393907.:79 .2.931472.3/0.431/039.0307.706:7020398147.943.09.943.4147        3907.//708890097020.11 35:941/...80 .-.9.3/3.3/1742.943 39071.9.3.3 $84:/.84907 4.80..3.9438 80.8 41 :80 14789.47.431:70/94.3:.

943 2.39071.98  .8 58.1472...3 850.90744..91472147.3/.3.9. -.-0..74-44.7  .74:8/..-05..9..3.3 :310/ 8.-47.:8942.38 ..94770897.8 174238/0 .9431742.  #0249047/07.80. 09. ..054793..70..944. ..

035:9/.439749097.0.4147        .1484170249047/078  .3.9.5439.3 $84:/.706:7020398147.0307.-9942.418.3/9089.-994.9:841 .11.3.3.2508.889208  .078  #089073.

88/.94341.33.0..3/89..:. 47/07 708:98 .8:.-47.3/:80/ 70.38  !74.843147.90/3/0088:55479 34728-4:3/8 ..0398  0307.70547983/1107039 8..3/.943.8841.47/..095.384390 -.3/4507.9.08 .947.9039 .989.7.3..943414507.3..4:39341920050380841908950714723  !705.943.94747-448.0 03/07..-47.9435...

.8.0883 #08:9 8 397 #054793 !.90390247.3 7/07397 $50..90390.30247.943.02039 !.8 .$0.3.8 !8.203!74.5.9:708         40.5.

3 W  $.3903.0 '.2508 47/078 7054798 %0898 06:520392./.9:708  %7.8.3.$0..943 "..

9.9.3/8." 3897:203939071.088..3 $.3.0/:3 W  ":...73 W ..0 W  .88:7.

-9 W  $0.943 #0854380920 %7.088 -:99.9:708  0-9 W  $..2509508 90898 2094/8 7054798 :/997.943 '07290/.:79 W  %20 W .8..907.0...8 43 90 1349..:947.$0.

77054793 3.3 !:-.80/708:9836:7 ":.4780098 474..70.9:708         0--.02039 :8942705479.//943.0.7054793 0/90.3.943 !7023.97054793 ./-.943974.3.0.

-47.943 #08:98 397 ..-03 48832039 !747088 %7.9438  $.94341 #4:930 .947 507.9.3 &% #054793 #08:98 '071..250 ...

.-31472...943$8902 $.947 8:36:0300/8 .-9 0-9948:5547990./0.-47.

0883 .943  #0.943 '.943.088-9  %:73.947 $..05943  85.3/$.250!74.250 #0. #08:98 4384/.489 "&% $.9.-9 ../.943 #05479  .%089#06:089 .74:3/920  !74/:.250 97.-47.

943$8902 .-47.947 31472..  &.

7:8.3/0./0824894190 31472.38390 970.0070 455479:3908089147.48970/:.7:8  $:7.34.90398 98.:.204$ 404 0.-47.3.  ..897 38   0.7807.-47.70...92039415.943./0241$.3.943 -.03.9.0789 &390/3899:904131472.90&3.943:80/-.947574.7:8 083..8 !74-0284190..0.9.84.3$9.943 995.04520394190!:-..08410.947 31472.

.

:..31472.9.  8/ .

08..4310703.

943809*.003 .3/ /0.947 31472.. 0.70 ./083 .9.0452039 41 90 5:-.-47.3:.

94388902 .07       ..3/25020393 949.943 -09003902502039.94708 0/.3. 7.94341.$070 831.0/.89.70.:942.80/#0.430 !.3/ # $9.30       # $0.9470/.947..03:041..4859..333.93974/:. 884..0307.944.990479$470 438.0841!.-47.9$8902.394804190 4859.9079.3/08 0.947 -807.9.-47.-47.-47.3/ ..-07  $9.89.3/9070.-47.7 $   $  2  $ $43   .94731472.943.3970.03:08  4859..9//349  $ !.

02039 W .947308 :  .-4:95.47/8  W 31:03.843 2.-47.. 9490.0/.94731472.70.-47./0.08  41.79.9.9...3..947..90398  #4/304782.3.3.-47.3 3.943 .4397-:9083 3 4-0.

759434190..38.02039  !.8 9 .-47.083.3089.70 !.8.70 .7 .9.94339097.0 $4:7.94731472.109.8.90398  410774780..725.109 W W W W $4:7.8:70/.3/:594 207..708:94120/.:7.947077478..38.0.0     41..943. ::89  %4778:2.0 $4:7..83.947/.90398.9.489  .3.-47...947%508./0257088  !.943 .0 $4:7.988902 .90398.38 /0/0.9039.-47.3.943   89. 0.07747834859..3 :/3..250#08:997. 3.& 308908.3/.-47.1070..7594307747820.7./0257088   ..3.02897 '.89 .943.$9.7/147.3/1706:03./89407..90  90.

078.9.-8300/ W W W W ":.3.88:7.8 .74:3/ ..3.43974 774770/:.989.0.7/0884114.:8 ./.943 57393974: 2.3/.943 17429089 706:089 708:9.0203989.3.&3.020394131472..2509:73.943 .00/147$  #0.898.

02039 1:3.344 W .04:7.934:700/8  .:.910.-574.80/43%0.990...7432039 ..088  .32574.80/43$890210.3.910.0$ 4507.9438 2.34408.9:7084:300/34:7$ W .990.9:708 W 438/079003/:8078 W .9 .943.9:7084:/2574.344084734:7 W 03.

.934:700/8  00/8880882039..:.

943990.70.9.5574.90731472.88 /4$ % W 0307.94390.2 W 200938 $.94317420.7031472.0 W 0099:80784:98/0800.3...9.9:808 47:8090$ W 5574. 0...2202-078 .990 -03.. W .

943 W W W W W W W W :3.:.90/390300/8 ...-9 489 '07843.7432039 $.02039 3907.3/2.8-.934:700/8  01..94394907.88388902800.03/475479144 $:55479.4898.3/%03.3903.3.943..37084:7.3/0.-9 .08 '03/4789.9300/94-00.3/:2.03/478889028.8894807.988902 .0.94789.9419088902 425.3.0..:.9-994907889028.3...

.-8 %0.0881472489.20/14754474507.8885447:3/078944/ 574.:.934:700/8 .3.3454-.3.9438 474714/083 .25075747088 $8902841903-....0308    00/8.

-3.88:08 W .8  $8902$00.943 0307.. W 4709.934:700/8 09.:.34304859.7432039 W '4:204190893 W :2-0741:8078 W :2-07418908 047..5..

9090.8.2 .9039 W 3574.3.8 W 35.08808 W $:5547990.9039  :95.

.934:700/8 09.03907.88:08 W %03.7432039 W .7/..8  $8902$00.088 W 39071.914720507980 W $419.943 .705.00330 W #.078:8708:9843 W .9.943 0307.8 /05.8 $! W $:55479574.705.7920394890/..9147247039..:.03/47 W 7/078.

9438 W 19070.841..08 W 70.8  3.944$8902$00.078:82:9508908 ..3/39071.:770394388902 W :2-0741:8078 W :2-07414.943 W 89413897:2039..03/478.-47.!..:.934:700/8 09.70.947.3 W $30..

..3!88902 W 39071..08944907889028 W 00/1473907.8  !$8902$00.943957.0784388:08 W 39071.9..0 W 2.934:700/8 09.943 W 704::83..089406:52039 W 08841.-9 ..:.43.0309...9.5.3..3!88902 W .9057..

4.94381.:7041800.3504503.8 W .0/ %4410504503.41.4.     ./488902800.943 743504503..4.0/ :/09 .4.333 !447.0/ W W  %442.088 !4475..943574.422:3.3203993899:943.

333 .3899:943.!.

.88.706:089147..3..333  $ %3.59.84:/ 570.088 W 42430 34$ .79413899:943.0/0/0.045203941574.4941 24304/44:300/94.!..0414--3147.3899:943.5:7.544  $4200.-.943147 ..43.59./94:891..3 8.30.59.09843%-:/09 W .0  W W 408.72..80 $5:7.147$5.59.808....

2 W $4%4:34.333  1%-:/0985.44/93 W %843940.088 2.943 90./07857404390800.!.9./0870147%94800. 889021474: W 349./90574.0.-0.%74:5  90702.94:.0397.08:70 .2 W 09%4390800.8.94390.3899:943.70/43 .-.7941.

4894143438:55479  %070-0-:/0984791.39.90/ :/3831..7090-:/09.9.8.7%:9  03747/0.4894182.03/478 800.8/.0/31472..00/ W 439303.480 706:0891476:49.8574548.3/.300/944.9$8902 .943147 !.:...:089409.706:089147 574548..943 !.8 0.90.7.40.9434100/8 884..8.870.7/0884144: 574.943 2502039.39470.43.2430 43 91470990.9.8430.3/.2501:3/8147 88902/083 800.3.03/478 W W W &8088902.439303..94431472.80-:/09./  !.4203.9.045.333  0.943 W W W %82.1:3/841    .!.:75747948:-2993.4.3899:943..94431472.94.

.

 29:918 47     .

$8902$00.2 .943%0.

 8.08:704:.4.03/:8078 44147202-074.90.422990/9490574.-0942.94390.943 90.07.22.943 !.5.2945.79.:/090 3.08:709070884204.-0/11070399.2 .1472.088 3.32502039.90.39884:/-0.70.2 W 84:14729890.943 W W W W W .2  70.90388902 800.0/32502039.592502039.943%0.79.5.078 .78.$8902$00.438/074 4:/-03.

9:708 W !0450-7370.$8902$00.3/890.393 W .2 W $00.344 8890210.9:70800.7.943574..9/0.898 W 4794805.2  /:.039 .088 W %0.8.3/471488:08 024 8.3/9.943%0.94388:08 W 43 9.909090.9090.88:20.34488:08 W 0.

700 W .0/:0200938 W W W W W !.3.2  $.9.70 W 070390574.08888:08 W W 4229900./.34434:050.90574.333 $.98309 %20-0.03570 5.943%0.$8902$00.422:3.99403.0/:0 005.07.0/:02009381472.088.3/5:-823:908 ..0 W 0047- 2439232:2 /07094908.574-02 .3..00/430 W ...

0/.947 !.2  4 W W W W W W W W W 3.4239450..89.4:9147-0..9.11 .79.398. 09504504:80.$8902$00.5.28%890073.07507843300/894-0439090.3/7.4.344898 07.9434229900 438:9.9431742490750784330 490./23897.09070...40.39  !.-.944898 0/.9.2 ..90/94:809088902 .4229900%3907.943 %90.70050.90.943%0.

70/ W -0.0 W $:-0. W 0..943%0.08884:/-01472.3.0 W 7  % .8./.3800.9.34.$8902$00./03.04..013.03/478.30/ .943 W !74.9.2  !.425.3/889028 -07.

448390#9'03/47 .

08941700/  422990/ 94 90 0.3/ .0452039 41 90 $8902 3 .-0 94 574./ 8:55479./0 1.3/ 70.89 .

0  0 25020390/ 84:943 20.38 ..0  425.7/  .. 4308  4.0 .3 340/0 .3/ 34   503 54. 94 3897:2039 3907.0  '03/47 $9743 42..39 94 3/:897 89.3903.088 94 3/:897 -089 57.2.943 .3/ 50703.3/ 570803..3/.3.08 .9.073 /0 047.5.4. 050703..

8 #06:08931472.988902 !%:891300/.943 !74.:93041 $8902$00.088 /0391300/ $00.943 .3/09 -:/098:55479 /039184:9438 #06:089!74548.

9438 1:3..947 4-0.943 ..03/478 .-47.943 .9.%2030 % 24398   ./23897.943  .-50784330 .947 4507.-47.943.:8942078 574/:.78 389.9438 ./.792039    0..08 .706:702039850.9 800.943 %/05.1.

9 ... ! .3$.2.