Celebrating Innovation Year of Publication 5th in Healthcare Technology: January 2010 Issue

ANNUAL SPECIAL ISSUE 2010

A Monthly Magazine on Healthcare ICTs, Technologies & Applications vo l u m e 5 | is s u e 0 1 | J A N U A RY 2 0 1 0 | I N R 7 5 / U S D 1 0 | ISSN 0973-8959

Celebrating Innovation in Healthcare Technology

8. Dr. Sundeep Sahay, NHSRC | 12. Dr. Sanjay Bijwe, Govt. of Maharashtra | 15. Dr. Ajit K. Nagpal, Batra Hospital & Medical Research Centre, Delhi | 19. Dr. Karanvir Singh, Sir Ganga Ram Hospital, Delhi | 24. Dr Denham Pole, Swiss Red Cross, Sri Lanka | 28. Joerg Klingler, InterSystems Corporation | 35. Dr. Kevin Fickenscher, Dell Perot Systems | 37. David Thomas, Matrix Knowledge | 43. Harbir Sawhney, Wipro | 45. Comm. Girish Kumar, HP | 47. Prabir Chatterjee, Carestream | 50. Dr. Dinesh Tripathi , 21st Century Health Management Solutions | 55. Prof. Howard Bolnick, Kellogg School of Management

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Year of Publication

CONTENTS w w w . e h e a l t h o n l i n e . o r g | volume 5 | issue 01 | January 2010

ISSN 0973-8959

8

“We have a much stronger information base in place now”

12

“Cost of this project will come out from saving pilferages”

15

National IT Backbone for Healthcare

19

Patient Safety – How Hospital Computerisation Can Help

24

“Biggest support we have had has come from the clinicians”

28

“We are moving towards a direct business model”

35

Critical Issues in a National Healthcare Discussion

37

Transforming through Innovation

40

Pushpanjali Crosslay Hospital deploys acuVena™ Software

43

“Wipro HIS product is under implementation in government sector projects such as ESIC”

45

“Business technology will become a key enabler for healthcare organisations”

47

“Carestream is the only company in India offering a complete range of medical imaging products”

Dr. Sundeep Sahay, Advisor – Health Management Information Systems and Monitoring, NHSRC

Dr Sanjay Bijwe, Project Director & Officer on Special Duty (HMIS Project), Medical Education & Drugs Department, Government of Maharashtra

Dr. Ajit K. Nagpal, Convener, Task Force on Health Sector Reforms, J & K State, Chairman, CII Healthcare Committee on Public Private Partnerships, Group Chairman, Wellogic Information Technologies, USA, Chairman, Healthcare Advisory Council, Feedback Ventures, India

Dr. Karanvir Singh, Consultant Surgeon & Head, Medical Informatics, Sir Ganga Ram Hospital, New Delhi

Dr Denham Pole, Consultant - Medical Informatics, Swiss Red Cross, Sri Lanka

Joerg Klingler, Group Director and Managing Director, InterSystems Corporation

Dr. Kevin Fickenscher, Executive Vice President - International Healthcare, Dell Perot Systems

David Thomas, Managing Director, Matrix Knowledge India

Harbir Sawhney, GM-Healthcare IT, Wipro

Girish Kumar, Practice Head - Healthcare & Life Sciences, HP India

Prabir Chatterjee, Managing Director, Carestream Health India Pvt. Ltd.

50

Healthcare IT Projects - Issues and Opportunities

52

ezEMRx: Manipal Cure and Care Enabling World Class Healthcare, Aided by Technology

55

Health Insurance: Ensuring a Healthy Future

Dr. Dinesh Tripathi , Associate Domain Consultant ,– Healthcare Informatics, 21st Century Health Management Solutions Pvt. Ltd., Mumbai

Prof. Howard J. Bolnick, Former Adjunct Professor, Kellogg School of Management, USA

January 2010

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INTEGRATED EMR Helps you eliminate paper charts Faster document processing Easy storage and retrieval of data Instant access to patient records Support for Charts and Schematics

EASY TO USE User friendly interface Simple mouse-click access Quick learning curve

CUSTOMIZABLE Designed for individual requirements Integration with existing applications Workflow based technology Selective modules

SECURE Access control passwords Encrypted data for confidentiality HIPAA compliant Audit on all transactions HL7 transactions

ADVANCED FEATURES Publish Charts/EMR Follow-ups Referral Management Voice Recognition Workflow Management Correspondence Manager SMS and Email Alerts Centralized/Distributed Implementation

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Editorial Guidelines eHealth is a print and online publication initiative of Elets Technomedia Pvt. Ltd. - an information research and media services organisation based in India, working on a range of international ICT publications, portals, project consultancy and highend event services at national and international levels. eHealth aims to be a rich, relevant and well-researched information and knowledge resource for healthcare service providers, medical professionals, researchers, policy makers and technology vendors involved in the business of healthcare IT and planning, service delivery, program management and application development. eHealth documents national and international case studies, research outcomes, policy developments, industry trends, expert interviews, news, views and

market intelligence on all aspects of IT applications in the healthcare sector.

Contributions to eHealth magazine could be in the form of articles, case studies, book reviews, event report and news related to e-Health projects and initiatives, which are of immense value for practitioners, professionals, corporate and academicians.

We would like the contributors to follow the guidelines outlined below, while submitting their material for publication: Articles/ case studies should not exceed 2500 words. For book reviews and event reports, the word limit is 800.

An abstract of the article/case study not exceeding 200 words should be submitted along with the article/case study.

All articles/ case studies should provide proper references. Authors should give in writing stating that the work is new and has not been published in any

form so far.

Book reviews should include details of the book like the title, name of the author(s), publisher, year of publication, price and number of pages and also have the cover photograph of the book in JPEG/TIFF (resolution 300 dpi).

Book reviews of books on e-Health related themes, published from year 2002 onwards, are preferable. In the case of website, provide the URL. The manuscripts should be typed in a standard printable font (Times New Roman 12 font size, titles in bold) and submitted either through mail or post.

Relevant figures of adequate quality (300 dpi) should be submitted in JPEG/ TIFF format.

A brief bio-data and passport size photograph(s) of the author(s) must be enclosed.

All contributions are subject to approval by the publisher.

Please send in your papers/articles/comments to: The Editor, eHealth, G-4, Sector 39, NOIDA (UP) 201 301, India. tel: +91 120 2502180-85, fax: +91 120 2500060, email: info@ehealthonline.org, www.ehealthonline.org

January 2010

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EDITORIAL Volume 4 | Issue 12 | December 2009

A new destination ..and just as new a beginning president

Dr. M P Narayanan editor-in-chief

Dr. Ravi Gupta PRODUCT MANAGER

Dipanjan Banerjee mobile: +91-9968251626 email: dipanjan@ehealthonline.org Principal correspondent

Divya Chawla email: divya@ehealthonline.org Sa les & MARKETING

Arpan Dasgupta Executive Officer - Business Development mobile: +91-9911960753, +91-9818644022 email: arpan@ehealthonline.org Bharat Kumar Jaiswal Sr. Executive - Business Development mobile: +91-9971047550 email: bharat@ehealthonline.org Sr Gra phic Desi gner

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editorial correspondence

eHEALTH G-4 Sector 39, NOIDA 201301, India tel: +91-120-2502180-85 fax: +91-120-2500060 email: info@ehealthonline.org does not neccesarily subscribe to the views expressed in this publication. All views expressed in the magazine are those of the contributors. The magazine is not responsible or accountable for any loss incurred, directly or indirectly as a result of the information provided.

As we bid adieu to another successful year for healthcare, we have much to look forward to in the new year 2010. The year gone by saw the healthcare industry undergoing major transitions. While, countries all across were plagued with the swine flu pandemic, there was a major thrust in research activities to control its spread.

The good news is that despite the economic meltdown, the healthcare industry continued to grow and evolve in 2009, and it is expected to follow the same trend in 2010 as well. Governments across the globe have put healthcare on top of their charts and are making enormous efforts to incorporate latest technologies with the hope of a healthy future for all. Taking charge of the US Government, President Obama is committed to bring healthcare reforms for the country, especially through large scale adoption of ehealth.

Talking specifically about ehealth market in India, things are looking bigger and brighter than ever before. With a market projections shooting by the day, health IT vendors have all the reasons to make merry. The year gone by witnessed the beginning of one of the biggest government sector ehealth projects in India – that of US$ 300 million (Rs. 1182 crore) worth of ESIC’s ‘Project Panchdeep’ (awarded to Wipro) and two of the biggest private sector health IT projects – namely, Max Healthcare’s 10 year long US$ 90 million IT outsourcing program (with Dell Perot Systems) and Fortis Healthcare’s US$ 15 million IT initiative (with HCL).

In line with our commitment to offer you the latest in ICT applications in healthcare and medical technologies, this issue is a comprehensive compilation of perspectives and experiences of stalwarts of the healthcare industry, including senior government officials, policy makers, health IT experts and global thought leaders in ehealth. The issue also includes a few case studies focussing on successful implementation of some of the best health IT solutions offered by leading vendors.

This new year, we celebrate innovations in healthcare technology by bringing you eHEALTH’s Fourth Anniversary Special Issue. On this occasion, we feel exceedingly proud for having completed four successful years of publication and being the leading monthly print and online magazine on healthcare ICTs and technologies, not only in India, but across the whole of Asia, Middle East and Africa.

Our sincere appreciation goes out to all the authors and contributors of this magazine, our special thanks for all the advertisers from the industry, and our deepest gratitude for every reader and subscriber of this publication who have time and again reposed their faith and belief in our purpose, by being our biggest supporters and advisors.

We wish all of you a very happy and healthy 2010!

is published by Elets Technomedia PVt. Ltd in technical collaboration with Centre for Science, Development and Media Studies (CSDMS).

Owner, Publisher, Printer - Ravi Gupta.

Printed at Vinayak Print Media, D - 320, Sector - 10, Noida, UPs, INDIA and published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP Editor: Dr. Ravi Gupta

Dr. Ravi Gupta Ravi.Gupta@ehealthonline.org

January 2010

4TH anniversary special Issue

“We have a much stronger information base in place now”

Dr. Sundeep Sahay Advisor – Health Management Information Systems and Monitoring, NHSRC

January 2010

National Health Systems Resource Centre (NHSRC) provides technical support to the NRHM, which works towards strengthening India’s public health systems. The NHSRC has been actively involved in assisting states and national centres in establishing functional, effective, state-of-theart health management information systems.

A Professor of Informatics at University of Oslo, Dr. Sundeep Sahay is the Advisor – HMIS at NHSRC. From conceptualization to implementation, Dr. Sahay gives an overview of the entire HMIS project, in an interview with eHEALTH. Excerpts from the interview.

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How did the genesis of HMIS project take place?

The first step was to bring architectural corrections under NRHM, which required thorough evaluation of the system that was already running in place. There was a need to identify the data being collected, the method being used for collection of data and finally its usage.

Further, there was a need to identify the challenges and problems being faced, on the basis of which a situation analysis of the existing system was done and a procedure to reform the entire system was devised. This marked the beginning of the project in early January 2008.

What were the challenges faced during the integration of this project?

Some of the major issues faced were— collection of too much data, generation of very few indicators, weak utilization of data for planning and action and extreme fragmentation of information systems running independently of each other, and so on. A major problem was to collect data available in different formats and include it in files of different formats. We felt that the only way to address these issues was to redesign the entire system.

The first step to redesign the system was to study it and identify the problems. The next step involved the process of consultation at the Ministry with various program managers, who were directly overseeing these consultation processes and various directors from different states, who had direct knowledge of these programmes. Our role was to mobilise different relevant

stakeholders and consultations.

What steps did you take to ensure the quality of data, especially in terms of transferring data already available in paper format?

Data, available, was in a nonstandardised format—excel files, word docs, papers, etc., which made it extremely difficult to transfer it into a standardised electronic format.

Further, the files were not named in a consistent format, which made it difficult for us to identify the file just by looking at its name. Prior to the implementation of software in October 2008, the legacy data was required to be imported into the new format.

Also, we needed to map the existing data into the new format.

Mapping was a very difficult step

because converting the data into the revised format was a big issue.

What are the key features and highlights of the HMIS project?

A significant progress has been made in getting data from sub-state levels which was not possible earlier. In contrast to the state consolidated reports being sent earlier, we re now getting district reports from almost 99 percent of the districts. From 1012 states, we are getting data from the block level, while from 5-6 states we are getting data from the primary health centre level. Thus, there is scaling down in terms of origin of data, which is a part of decentralization as

we are getting data from several levels below the state. A number of states are now getting involved in analysing information and the quality of data.

I think we have moved in a positive direction but there is still a lot of work left to be done.

What is the total budget outlay of the project?

There are different components to this project. The web portal has been developed by the Ministry of Health and Family Welfare and they have funded this component.

NHSRC has been providing customization services to the states as per their local needs. The states have free access to these services and the funding for this comes from the national budget. Further, the national budget provides funding for the training and capacity building activities, which are again free for the states.

Thus, for the states did not have to make any investment except for providing local logistics / accommodations during training and capacity building programmes.

The HMIS has been integrated across various states. How did you design and customize the system to meet the needs of different locations?

It is basically a server based software, so, there is one application running on the server and various districts have access to it. Thus, in that way the programme gets integrated in terms of access.

I think the whole idea was to enforce the incorporation of uniform

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standards and formats across all districts of the country.

What is the current status of the project?

As of now, data is on flow from all districts including 30 percent of block and 10 percent of PHCs. Our next step focusses on strengthening data quality and utilization of information to allow data to go through planning, monitoring and evaluation processes.

Much more work is required to be done on integration with other programmes.

What benefits has the project provided so far and is expected to provide in future?

A significant benefit has been to get a broader picture of the entire situation across the country. For instance, we now have data on child immunizations, deaths in a particular area and availability of funds for the improvement of such conditions. The program managers can effectively use this data to improve the interventions, be it improved immunization coverage, reduced maternal deaths, or reduced infant deaths.

A new system has, now, been made mandatory by the government which involves tracking the entire data. This will include tracking of data pertaining to pregnant women, child immunizations, etc. by capturing data name-wise.

We, now, have a much stronger information base in place. However, we still need to build that culture in which people learn to use the information available, which will be a major job for us.

As of now, this is a major step that we have in front of us.

What is the usage right now and how can it be enhanced in the future?

Right now the usage is very limited and only a few states are making use of the data available. We believe the usage can be increased by training, capacity building, providing better tools so that people can easily look at drafts, charts, maps, etc.. People are only used to sending information up the hierarchy but they don’t really use it for themselves and for their local actions. A change in mindset is required which can actually come through long term education and training and capacity building programs.

Is the government organising any programmes right now for enhancing data usage?

As of now, some states like Kerala, Gujarat and Manipur are using it. So, we can actually see examples now of states using the data. Various states are now looking at customized data while planning ahead and that, I think, is a big step forward.

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4TH anniversary special Issue

“Cost of this project will come out from saving pilferages�

The HMIS project was implemented in Maharashtra under the eGovernance policy decision to improve standards of healthcare delivery and medical education.

Dr. Sanjay Bijwe, Project Director & Officer-on-Special-Duty, in an interview with eHealth, provides insight into the major project highlights.

How was the RFP for HMIS project raised? On what basis was the vendor selected?

RFP of this project is now like a bible for many state governments and different organizations. A unique aspect of this is the penalty clause on the government for late payment, which gave a lot of confidence to the vendors.

Dr Sanjay Bijwe Project Director & Officer on Special Duty (HMIS Project) Medical Education & Drugs Department Government of Maharashtra

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We incorporated all the healthcare standards while creating the RFP, taking guidelines from the standards laid by the Ministry of IT. We allowed consortium of three partners to bring out a well balanced RFP. We decided that it should be a working software, which can be customized according to our needs. We also wanted it to have the healthcare standards like HL7, DICOM. While deciding on the software, fifty percent weightage was given to the capability of the vendor to implement the project, financial capabilities and other technical capacities and fifty percent weightage was given to the type of software.

We decided on a fixed and variable model where the company will get a fixed amount every month against the service providers. The plan was to have distributed architecture, which

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is not dependent on connectivity and is only within the institutions and LAN. Thus, the hospital is self sufficient and the data is stored in a centralized location.

Out of the five responses we received, HP and Amrita as a consortium were the ones to qualify.

We used certain tools available on the internet to check the compliance of the software. A committee under the finance secretary was also formed, led by Dr. Deepak Phatak, to verify the cost of the project.

For us, HP is the single point of contact and its their responsibility to implement, while Amrita is their sub-contract partner.

The entire funding for the project has been done by the Department of Health and Family Welfare.

What is the current status of the project?

The total time period allotted for the project is eight years, out of which the first year is pilot. Once the pilot is successful, implementation will take place at all 19 locations over the next two years. During this period, three institutions will go online every four months. In the remaining five

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4TH anniversary special Issue

Computer-on-Wheels (COWS) in JJ Hospital, Mumbai

years all these institutions will start functioning. The project started on January 3, 2007 and went live only on October 18th, 2008 because of certain difficulties. Thereafter, the project will be online for the next seven years.

As of now, the Nagpur, Pune, Aurangabad and Mumbai institutions have gone live, except for JJ Hospital, Mumbai. Implementation process is being carried out at other six locations. The delay is because of some unfortunate circumstances.

One of the major problem is that the financial model is very complex in the government and whatever is available in the system needs to be customised properly. So, unless everything is integrated the cycle remains incomplete.

Further, our detailed guidelines are also ready. The beauty of the system is that a lot of pilferages can be saved and I am confident that the cost of this project will come out from saving these pilferages. Being in the last lap of completing the project, we want to issue the guidelines once the finance module is complete.

Who will take the onus of the project after this eight year span is over?

Indeed, we have included this point in the contract. In the 6th year, that is two years prior to the end of the project, the process of what happens after that will start. If we are satisfied with the services of HP, we will give

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the project to them. If they don’t want to continue we will float another RFP and will continue either with the current software or take another one.

We have taken enough precautions to ensure that all data and generated EMR could be easily transferred to the new platform or database.

What were the challenges faced for implementation of this project?

The challenges are tremendous and customization was one of the major ones. Many people from IT do not understand the health domain, while many doctors are not aware of international standards. There is absolutely no standardisation for clinical pathways and I am still trying to find out if there are any international set of best practices available. There has to be business process re-engineering to change all medical processes and the main challenge is to have standardization.

Another challenge is to align IT with clinical process and make the process simple.

Guidelines on usage also need to be issued for the benefit of people who are using it. For instance, a unique ID will be generated for every individual, who is visiting any of these 19 locations. It was a very tough task to create this kind of a unique ID. The problem is that biometric identification also needs to be incorporated in that. In all government hospitals the OPDs

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are extremely crowded and there is hardly any time for verification of the details provided by the patient.

If the unique ID is not developed, the whole purpose of the project will be defeated. So, there has to be a biometric ID but there needs to be a simpler process for creating that.

Computerisation of the OPD is the biggest challenge. There are other challenges in the wards as well.

While doctors are on rounds, nurses write down the details in a register.

For computerisation of this process, either there should be computer on wheels (COWs) or PDAs. So we need to have something like this but the cost factors also need to be kept in mind.

What are the benefits of this project?

Benefits of the project are mind boggling because the fundamental framework is very solid and robust.

Because of this, procurement becomes simple and in an instant you will know the requirement of all colleges. The next step would be to analyse the data that will be made available through data mining. The beauty of our model is that there is no issue of any instrument or technology getting obsolete.

The vendors were told to make the HMIS available 99 percent of the time. All desktops and hardware are provided by them and in case of any break down, replacement has to be made within one hour, else a penalty will be charged. This makes it necessary for the vendors to keep their engineers and spare parts at all locations. In case of queries raised, the response should be available within 3 seconds. The time period for an image to be received is 10 seconds. We have also deployed various tools at different locations to constantly record, measure and report the time taken for these processes.

This makes the functioning of the project very efficient and has proven to be beneficial overall.

4TH anniversary special Issue

National IT Backbone for Healthcare Information and Communication technology has revolutionized the way medicine is practiced and the way healthcare information is documented, archived and retrieved at the point of care. While information technology is facing challenges of adoption, communication technology is striving to create health information exchanges for connecting providers within multi-org environments and across disparate geographical boundaries, using secure and fail-safe internet connectivity for high speed data, voice and video communication.

This article on National IT Backbone is a synthesis of diverse but related issues that facilitate access to clinical information at the point of care promptly and securely.

Framework:

Dr. Ajit K. Nagpal MBBS (AIIMS), MHA (AIIMS), MPH (Harvard) Convener, Task Force on Health Sector Reforms, J & K State Chairman, CII Healthcare Committee on Public Private Partnerships Group Chairman, Wellogic Information Technologies, USA Chairman, Healthcare Advisory Council, Feedback Ventures, India

National IT Backbone is essentially a broad band, ultra high speed, multi-protocol, multi-gigabit per sec internet connectivity with nation-wide network topology, multi-nodal distribution system and multiple points of presence.

It is a security-enabled cohesive framework that provides security services like authentication, data confidentiality, integrity, and non-repudiation with the best cryptographic techniques available.

Therefore, National IT Backbone must offer a comprehensive and integrated framework to enabling models that address today’s business demands and economies of scale with higher speed links, carrying more traffic at substantially lower costs with integration of several subnetworks, providing secure and private means of data transport, with effective, time sensitive and distributed voice, data and video applications.

Objective:

The objective of the National IT Backbone for Healthcare is to facilitate secure and reliable exchange of clinical and health related information amongst public & private hospitals, clinics & ambulatory care centers, clinical laboratories, imaging & diagnostic centers, pharmacies and drug store, and insurers, payers and third party administrators; and most significantly empower the policy makers and regulators to capture statistical data and trends, assess epidemiological and economic burden of disease, facilitate prospective planning, and take public policy initiatives to reform the health sector to incentivize investment in healthcare infrastructure and to achieve technical efficiency, clinical effectiveness and quality in the delivery of healthcare.

Standards Framework:

for

Interoperable

Standards for creation a reliable interoperable framework include data security standards, data communication standards, data

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Figure1: National IT Backbone - Components & Stakeholders

archiving and retrieval standards, and precise reconciliation rules to avoid data duplication and redundancies.

Standards for data exchange in healthcare include classification of disease like ICD 9 and ICD 10, catalogues for procedural terminologies including CPT, LOINC, SNOMED, and data communication standards such as HL7 and CDA protocols.

While barcode scanning and biometric systems are used for maintaining data security, CPOE, Care Plan alerts and CCR are used as standards for data integrity.

Further activity logs, audit trails, and data recovery are used as standards for data archival and retrieval.

The Healthcare Information Technology Standards Panel (HITSP) which is a cooperative

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partnership between the public personalized healthcare, and private sectors of healthcare consultations and transfers of industry was constituted for the care, immunizations and response purpose of harmonizing and management, public health case integrating standards that will reporting, patient-provider secure meet clinical and business needs messaging, remote monitoring, for sharing information among and clinical research. organizations and systems.

HITSP is engaged in developing standards with specifications for interoperability in the areas of lab results browsing, emergency responder, consumer empowerment for access to clinical Information, quality of care, medication Figure2 : Labs and Diagnostic Imaging Orders and management, Results

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4TH anniversary special Issue National Information Data Bank (Central Data Repository) Non-availability of essential clinical information at the point of care is the most leading cause of Medical Errors. While HIPAA guarantees strict handling of sensitive personal information, Master Patient Index (MPI) with a reconciliation logic process based upon good factors and identifiers is the hallmark of successful development and maintenance of MPI at regional and national levels.

One-patient-one record created and reconciled on the basis of factors such as name, date of birth, address, associated with public identity using smart cards, driving license etc, and biometric identification including finger print and retinal image help relate

Figure 4: Community-wide Referrals

the patient to their health record for accurate accessibility at the point of care.

Access to Clinical Information: Patient Records include patient demographic and clinical data including sensitive information.

Patient data archive, retrieve and exchange within and across organizational and geographical boundaries depends upon data content, formatting standards, and data exchange mechanism.

It is therefore essential to define the role relationship of

Figure 3: Rx Orders and Status Updates

the authorized users through consent management protocols, and freedom to access sensitive information through break-glass functionality.

In this process the defined role privileges with right to access patient record for view, add , edit and delete functions must also be defined on the basis of role relationship between the patients and the providers of care, as primary, attending and consulting physicians, nurse practitioners, technicians or pharmacists, the administrators, and the patient’s relatives and care takers.

at the point of care, the Care Providers have the opportunity to make critical clinical decisions, and multiple organizations within communities can collaborate with each other to provide better care services The ICT technology has the challenge to create these miltiorg environments with option to share or restrict information between and within communities based upon personal preferences and HIPAA compliance.

The following Figure 1 shows the components and stakeholders of the National IT Backbone.

Solicited and Transactions:

Unsolicited

The clinical information exchanged between various

Patient Confidentiality in a Multi-Org Environment: Environments where instant access to clinical information of patients is available

Figure 5: Import from Health Information Exchange

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stakeholders fall into the categories of solicited and nonsolicited transactions. Solicited transactions are explicitly requested transactions with known origins, workflow and destinations, which may or may not be stored within the Central Data repository (CDR). These transactions include lab and diagnostic imaging requests and results, Rx orders and status updates, communitywide referrals, and import of patient record from the Health Information Exchange (HIE).

The un-solicited transactions also include explicitly requested transactions based on timed events/data received routed to known destinations such as medication histories and discharge summaries, etc.

The following figures show the components and stakeholders of the solicited and un-solicited transactions.

Summary & Conclusion: Healthcare information technology has had a late start in its adoption by healthcare delivery networks and most organizations in the private as well as the public

Figure 6: Discharge Summaries and CCR

sector of healthcare industries have either home grown of basic IT solutions addressing backend functions with some front desk applications for appointment scheduling, admission/discharge/ transfer functions, and billing and claims management.

Since healthcare industry has seen a substantial growth during the past decade and the pace of development is growing rapidly, there is an increasing awareness

Figure 7: Medication History

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of the role of information and communication technology in facilitating better clinical care and enhancing efficiency and quality in the delivery of care.

While the healthcare industry is taking major initiatives in upgrading their IT platform, the ICT industry has to respond urgently and aggressively to meet the challenges of IT adoption and upgradation.

It is in this context the role of National IT Backbone assumes great significance in creating accredited and certified multi-org environments to facilitate adoption of ICT through the establishment of health information exchanges and central data repositories within communities.

While there are many impediments to rapid adoption of information and communication technology in healthcare, there are indications that the Central and the State Governments are engaged in taking public policy initiatives to incentivize investment in this sector and facilitate establishment of Regional IT Backbones for flow of clinical information across disparate geographical boundaries for access to patient record by authorized users at the point of care.

4TH anniversary special Issue

Patient Safety – How Hospital Computerisation Can Help Enterprise wide computerisation in hospitals not only helps in minimising treatment errors by eliminating mistakes made while prescribing medicines, but also helps in reducing the overall costs of the care provided.

A

Dr. Karanvir Singh Consultant Surgeon & Head, Medical Informatics Sir Ganga Ram Hospital, New Delhi

dverse incidents in hospitals compromising patient safety cost the governments billions of dollars each year.

Indian statistics are not that easily available. This does not include the actual value of loss of life, when it occurs. It has been the aim of every ‘medical organisation’ to improve its safety record. Human beings make mistakes because the systems, tasks and processes they work in are poorly designed.

The ideal solution is to improve processes and ensure adherence to the extent that no care provider, in any situation, can cause a patient related adverse incident.

Enterprise wide computerisation can help to a certain extent in achieving this aim. In fact, there are many scenarios where enterprise wide computerisation is probably the only possible way of avoiding adverse incidents.

The most immediate barrier to widespread adoption of computerisation is cost. According to a study by RAND Health, the U.S. healthcare system could save more than USD 81 billion annually, reduce adverse healthcare events, and improve the quality of care if health information technology is widely adopted. It then makes sense to implement such technology early.

The most common—and deadly—treatment errors occur when physicians make mistakes prescribing medicines. Clinicians are most likely to make the following errors: • Prescribe drugs that interact with other medicines the patient is already taking, or with food the patient commonly eats.

• Give patients a drug they are allergic to.

• Give an incorrect dose or use an inappropriate frequency.

• There are problems with manual medication order processing that are obviated with electronic ordering.

Illegible handwriting, use of abbreviations (drug name, dosage, drug form, etc.), insufficient knowledge of drug-drug interactions, inadequate information on patient allergies and duplicate orders are some of these.

Allergy Alerts Once a patient’s allergy to a certain drug has been enquired into and documented by the care providers, it becomes the responsibility of the hospital to ensure that a drug, or related drugs, are never inadvertently administered. This applies not just to this particular

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4TH anniversary special Issue admission episode but also to any subsequent ones. Mistakes do occur and it is not humanly possible to remember this allergy during subsequent admissions unless the patient informs this each time. A good computerised drug order entry system will display alerts whenever a care provider orders a drug to which the patient has been recorded to be allergic. This will be across episodes, i.e. even if the allergy documentation was done during a previous episode years ago. Drug class allergy alerts can warn in case a drug belonging to another class with allergy cross reactivity is given.

Other Alerts Other common alerts are for metal implants (avoid MRI), pacemakers (avoid electrocautery) or pregnancy (avoid ionising radiation and many drugs). While it may be difficult for hospital information systems (HIS) to manage alerts in such cases, a prominent display of such alerts in the patient record can help prevent adverse incidents. It should be possible to predefine end dates for such alerts, e.g. the LMP date in case of pregnancy, after which the alert will be automatically removed from the patient’s records.

Drug to Drug Interactions With increasing specialisation, there are a larger number of doctors looking after a patient during the inpatient stay. Often each doctor prescribes medicines without full awareness of how this will interact with the other medications prescribed by other doctors. A good drug to drug interaction system will throw up an alert if it detects an interaction.

Drug to drug interaction systems are somewhat complex to set-up and the efficacy of this system will depend on the pains that have been taken to configure this. No single off-the-shelf database is currently available in India that can be simply plugged into the HIS to provide this functionality.

A drug to drug interaction warning system will be more effective if it is doctors who are performing the drug prescribing directly in the HIS rather than nurses, as commonly happens, since they are more likely to respond to such warnings.

Drug Monographs and Dosing Alerts Availability of full drug prescribing information at the time of ordering in the HIS is useful for the doctors.

This itself can prevent, to a large extent, adverse drug interactions and dosing errors. Many systems are able to alert the care provider

if the prescribed dosage is outside acceptable range although paediatric dosing alerts are found in fewer systems.

Batch Recall of Medicines from Wards It often happens that a particular batch of medicines is found to be defective, sometimes in another hospital. With a HIS maintaining a track of all locations where that batch is currently stocked, it is possible to recall stock of that batch immediately. In such situations drug controllers often require details of all the patients to which that batch of medicine was administered. While this is not possible in a manual system, this should be easily possible in a hospital that has a HIS.

Sample Mix-ups Patient sample mix ups are something that a good hospital policy set-up should be able to avoid. For instance, it should be mandatory to label the sample container before collecting the sample. There are other situations where a sample mix up can occur, e.g. while reading an illegible label or while transferring a sample to a machine.

A HIS can print out a label that is legible and is bar coded. All labels should also have enough human readable information on it to clearly identify the patient, specimen to be collected and the laboratory it is to be sent to. Further authentication can be done by requiring double scanning at the actual time of sample collection, one of the sample barcode and one of the patient ID barcode on the patient’s wrist.

A mix up at the time of loading the sample container in the autoanalyser machines can be avoided by using bidirectional interfacing of the machines where the sample container is directly plugged into the machine which

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4TH anniversary special Issue is able to read the barcode and directly communicate with the HIS to get information of the tests to be performed and then send the test results back. Sometimes laboratories manually split the sample into different tubes when the samples are to be loaded into more than one machine. This negates the very advantage of bidirectional communication. The hospital policy should be able to avoid this by insisting on separate collections where such a sample splitting is anticipated.

Patient Confidentiality Currently, there are no strong patient confidentiality laws in India but they could arrive very soon. A HIS can have an impact on patient confidentiality in many ways.

The main aim of a good HIS is to allow doctors to have immediate availability to all information about the patient that would be useful in treatment. A necessary trade off is in confidentiality. It is difficult to devise policies that would restrict patient data on the grounds of confidentiality and at the same time allow even junior medical and paramedical staff access to patient information.

Even labelling a patient as a VIP patient, which allows restricted access of records to senior physicians only in our scenario, was counterproductive since it reduced the quality of medical care that essential medical staff could provide to these patients.

It is mandatory by law to keep the results of certain tests confidential, e.g. tests for HIV, and a good HIS should allow this. For instance in our system it is possible to not only mark the result as confidential, i.e. visible only within the laboratory performing the test, but also mark the very request for this test as confidential so that care providers cannot see if such a test had even been ordered for. We have had problems in this with the nurses

placing orders for the test again and again, not being able to see that it has already been ordered.

alerts to be sent to patients as well as care providers.

Clinical Guidelines for Disease Management

There are certain types of errors that have started occurring after the introduction of computerisation in hospitals.

These constitute the flip side of computerisation. Some such errors represent the electronic version of “traditional” errors, such as a patient receiving the wrong drug dosage due to a human error.

Now, in the computerized world, this can occur simply because the user clicked slightly away from the actual place on the screen. Another error is if the wrong patient is selected and orders placed. It is recommended that patient name, gender, and date of birth or age must be visible throughout the ordering process. Shortcut or default dosage selections can get ordered even for elderly, paediatric or underweight patients, resulting in toxic doses. Care providers may be led to a false sense of security that when technology suggests a course of action, it is always right.

But on the whole, overall patient safety is likely to improve with installation of a computerised hospital information system.

Inappropriate / incorrect medical care, not according to internationally accepted care guidelines can leave to patient morbidity and mortality and open the hospital to lawsuits. A good HIS with an electronic medical record that incorporates clinical pathways will act as a ‘mentor’ to the care provider and ensure that patients receive accepted care.

These systems will outline the day to day activities to be performed in the form of a check list, for example they could prompt for anticoagulant therapy prior to any operation and check X-ray and mobilization on day one after an orthopaedic operation and so on.

Reminders Improved medical care by timely reminders of tests to be performed and vaccination schedules, though not strictly in the realm of patient safety do help improve the delivery of medical care. There are systems available in India that allow SMS

The Flip Side

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“Biggest support we have had has come from the clinicians” Multi Disease Surveillance System (MDSS) is an open-source health information system, running in 27 government hospitals in Sri Lanka. Developed on Linux operating system, using InterSystem’s CACHE database, MDSS has shown tremendous success in improving healthcare delivery and hospital operations. eHEALTH recently caught up with Dr. Denham Pole from Swiss Red Cross in Colombo, who is the mastermind behind this achievement. Excerpts from the interview.

Please tell us about the genesis of your work in Sri Lanka.

Dr Denham Pole Consultant - Medical Informatics Swiss Red Cross, Sri Lanka

I came to Sri Lanka in the end of 2001 to work as a healthcare consultant in a Japanese project to improve blood transfusion services. We built up a new blood transfusion service centre in Narahenpita, Colombo and started training the staff on cell matching and modern blood transfusion activities. The high point of my work was to involve in the development of a new blood transfusion centre, which was finished about a year ago.

After the completion of that project, just as I was about to leave Sri Lanka, Tsunami hit the country and I stayed on. When WHO’s Tsunami activities finished, the Red Cross came up with a project to install computers in hospitals in Tsunami affected areas.

WHO transferred me to the Red Cross and since the last three years we have been installing systems in hospitals in the Eastern province.

How was the multi surveillance system developed?

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disease (MDSS)

WHO believes that surveying into individual diseases is not one of the best ways. You can check on diseases like malaria or dengue, but the best way to go, from a public health point of view is to look at all diseases.

WHO is always pushing the hospitals to record all diseases of patients admitted, which will generate a simple patient record of all patient admissions with their diagnosis. I was involved in the development of some of the early systems that WHO produced. We installed the system across 6-7 hospitals but WHO did not have the resources to follow up these systems. So they sorted other firms and that’s where the Red Cross came in. It was essentially a WHO project to start off with, but it was later taken over by the Red Cross.

How big was the team that worked on MDSS? In WHO, we just had a team of three people for installation in about 6-7 hospitals. We had to rely on commercial companies for hardware.

Certain computer schools provided

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training and the program was written by a software house. However, we soon realised that a more efficient way would be to have this done under one team. So, when Red Cross came with their budget we took up a team of about 14 people.

With around 27 hospitals installed we had around 16 people, which we gradually reduced to 8 and at the end of the project, all these people will be absorbed in government services.

Is MDSS an open source solution?

It is open source, in the sense that we are using Linux, which is an open source operating system. The Cache database is a proprietary database and it uses very standardised data bases like SQL, Java and so on.

The design of the system and the methods that are used are pretty obvious to anybody. The Swiss Red Cross has funded this system and they own its rights and they would want it to be used worldwide. They would be pleased to let people adopt the system, provided they are aware of using the Cache.

What factors led you to choose the Cache database?

Cache has a very long history and the technology that underlies Cache is about 30 years old. It started being used a lot in the medical area. When I was in Switzerland, I came across the predecessors of Cache, which gradually developed from a simple command language system to an SQL system with a data dictionary.

The modern versions of Cache are very powerful indeed. In Switzerland Cache and its technology are used widely by the government and industry. Later, in Egypt I used the experience of Cache to encourage the development of a Cache system over a 3 year period.

When I came to Sri Lanka, I was a bit concerned about using Cache because it was unknown in this part of the world. However, with experiment and experience using other systems, we found that Cache was a much

more powerful solution than any of the others available. Finally, we contacted InterSystems and with their help we gathered enough courage to install Cache in Sri Lanka.

The University of Colombo, the PGIM and various other institutions have now started to looking at it. It is only a matter of time before Cache would move into the mainstream.

Did your system inspire others to take up Cache in Sri Lanka or adjacent areas?

At the moment, it is starting to take off. We gave a course to 30 doctors in the post graduate institute of medicine and they were all very enthusiastic about Cache. In fact, all of them developed a little database during the course and I am sure they will start using it more and more in their work. Now, some groups including the University of Colombo are considering to adopt it.

So far, its only in Sri Lanka and the Swiss Red Cross project will come to in 2009. We are hoping that it would start to spread across other Sri Lankan provinces. The northern province has shown some interest and we are now looking at Colombo, because that is the place where things happen in this country.

What were the challenges faced in designing the system?

Our biggest problem was that we were trying to computerise something that almost did not exist. However, the positive thing was that the doctors realised that this was a big weakness as they did not have any record of the patients. So there was a pressure on the staff to start keeping records and that made our job easy. The challenge was that we were dealing with a very low level of development, to start off, with the medical records.

Was there lack of record keeping culture or were the records maintained in paper format?

I think that it is partly culture.

The doctors here keep a lot of information in their heads. Records,

in Asia, are not seen as a very central part of transactions, but that has to change as medicine becomes more complex and treatments become more sophisticated. The doctors are now realising that they can not carry on like this for long and I already see a cultural change happening.

What are the medico-legal issues involved in storing electronic medical records?

When it comes to documentation, people working in the hospitals are not very aware of the legal situation.

We, obviously, had to take guidance from the legal people in the health ministry and they came to the conclusion that although keeping records in books is a good idea, yet it is not legally binding to keep records in books. The records need to be maintained, whether you write them in books or type them into the computer, provided the user is identified, time of input is recorded and the records do not disappear.

So there were essentially no legal hassles in maintaining records in an electronic format.

How can the implementation of health informatics be facilitated?

The government has a big role to play in providing leadership.

For instance, in using electronic records in hospital, if we look at the American approach, there are financial incentives and if the hospitals don’t use electronic records they are penalised. In this country, the government needs to take a more positive role in increasing the use of computers in maintaining medical records. I don’t think they need to push in standardisation in terms of having systems that interact with each other. Cache is a system which can very easily communicate with the other systems. The Ensemble, for instance, is specifically designed to communicate with other systems.

So I think it is too early to standardise because we don’t know what to standardise on.

Can the challenge of standardisation

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4TH anniversary special Issue be overcome if the data can be bypassed from one format to another?

Yes, I think standardisation was a problem with computers about a decade ago but with modern computer techniques it is no longer much of a problem. I think, as of now, the government just needs to encourage the use of computers.

Clinicians often face a lot of difficulties in using HIS. How have you addressed this challenge in your system?

The biggest support we have had in the last three years of development has come from the clinicians. In fact, we have not received this kind of support from senior administration and the central government. Its the clinicians who see the real benefits of having the electronic records because it is something they have never had before.

How do you see the future of health

informatics? How will health IT change healthcare forever?

D e v e l o p i n g countries can often make a lead in technology from doing nothing to using modern techniques in different areas without going through the intervening steps, which is certainly the state with computers and we have already seen computers spreading to banks, insurance agents and other areas.

There is very rapid development in this part of the world as they leap over all the steps that Europe and America have to go

through. We can not predict the future but I would say that we will soon have electronic records in most of the hospitals in this part of the world.

CATCH UP WITH latest news, articles, interviews and case studies at

@

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Can we help make the Hospital Paperless?

Certainly!

4TH anniversary special Issue

“We are moving towards a direct business model” InterSystems Corporation, one of the leading vendors in health information technology space, is dedicated to offering top notch innovative health IT products including TrakCare, CACHÉ, Ensemble, HealthShare, and DeepSee. In a chat with eHEALTH, Joerg Klingler, Group Director & Managing Director at InterSystems Corporation, talks about InterSystems’ growing presence in India and the world over.

What has been new in InterSystems in terms of business or geographical areas that you cover? What have been your major projects or achievements?

Joerg Klingler Group Director and Managing Director InterSystems Corporation

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InterSystems is a very flat and functional organisation. Therefore we decided, that a two-step approach to enter new markets or market segments is what serves our customers best. Step one means to support each country, market and customer with all necessary resources. In a second step, we find the right people to provide each region with its own InterSystems team and senior management to develop and advance long-term business relations with our partners. As a company, we are very aware that people’s lives are depending on the performance and stability of our software. Therefore being able to address all upcoming issues immediately is a necessity.

We strive constantly to live up to this responsibility.

The InterSystems healthcare portfolio offers a full range of software products, ranging from local in-patient and out-patient

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solutions to structures that are able to integrate and connect regional or even national health systems. To pass the challenge, that comes with all these obligations, we are currently in the final stage of changing and expanding our business model for InterSystems TrakCare, our health information system. We are now moving towards a direct business model, which is an important step for InterSystems and we pursue this approach with few exceptions currently worldwide.

One, if not the most exciting region for TrakCare is India. That’s why we have set up our own subsidiary in Gurgaon this year. India is one of the most active countries when it comes to developing and improving their healthcare systems and we, as a company, are growing tremendously being part of this process.

Two other areas, where InterSystems has been very successful in the last year, are the Middle East and China. In the UAE, we have recently signed our first direct customer, the Sharjah University Hospital. We will also soon be signing deals with

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some new hospitals in Saudi Arabia.

China, where we started about two years ago, is developing nicely. Two examples there are United Family Hospitals and Clinics, a privately held hospital chain, with multiple facilities in Beijing and Shanghai.

There we are currently in the final stages of implementing TrakCare and interconnecting all those facilities.

We have also signed up with the biggest private hospital, Baptist Hospital in Hong Kong, where we have just started the process of implementation. So there is a lot of activity going on in and around India.

Can you elaborate on the strategies and approach in the Indian market. Is there any customised approach?

We have so far signed five projects including Fortis and Manipal in India. Our most important objective is to complete the implementations in these hospital chains successfully. One interesting thing is that implementation in a chain of hospitals is quite different from implementation in a single hospital.

There are, for example, issues pertaining to data security making data integration a very challenging topic. Therefore, implementation for institutions owning multiple sites requires a lot of work. On the other hand, there are tremendous opportunities in terms of increasing quality of healthcare, if you are able to compare the performance of two or more hospitals. It’s undoubtedly a way to run them more effectively. I see this as an opportunity to examine whether or not, we as a manufacturer, can really have an impact. So we are really excited about the opportunities to work with these hospitals.

The challenge for healthcare around the world is, that the demand is very high and still increasing, but the money to fulfil that demand is not always available. At least not, if we continue to provide this service the way we did in the past. To deliver more for less, forever is the challenge.

I have always been excited about India and am very pleased now that

we have put in enough resources here. The task for us is to do even better in the future and to create a model that we can use all around the world.

What are the challenges faced by you?

There are very few companies in the world that are developing patientcentric, enterprise-class healthcare information systems. To have an integrated system working seamlessly with every department is a tough task. In a fully integrated system you will have a look at your business, like you have never seen it before and you have to put pressure on certain people to behave in a way they never did before. So it comes with quite a lot of transformation. The true challenge is that, for implementation of such an approach, you really have to commit yourself. Without having the management backing up a process connected with so many changes, it’s an impossible task. It has also to be done in a reasonable way, integrating the input of the doctors, that have later to work with it, winning the nursing and administrational staff and have a real commitment from senior management. Part of what we did before we came to India, was to make sure that we have the maximum possible support from the owners of these organisations. They have to believe, that these systems will

initiate a positive transformation and therefore show the commitment and the support for this transformation.

That is something which is totally unique, because usually in the government there are only a few people who are willing to take this ”ownership”. Key is, that those in charge of healthcare need to have a vision for their business; an idea - how they would like to do it in the future. Therefore they need to have an understanding for and finally the trust into IT and software, that those implementations can help them achieve their goals.

Do you think that change has already occurred in India?

If you look at the progress regarding healthcare India made in the last 15 to 20 years, the country has gone through a tremendous transformation. It is successful and it is growing. Still, if you look at the private hospitals, there is an enormous lack of capacity.

To deliver quality healthcare, India in general needs more beds and more doctors. So in a way it is more of a social responsibility to try and make a difference. Society in general also has to deal with something which is an absolute necessity. There are more and more people in this country, who can afford reasonable healthcare.

If you have this kind of economic progress you need to give something back as well and I believe healthcare

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is one of those areas where it can easily be done. With the government stepping up and making investments in healthcare, I expect this industry grow very rapidly.

How soon do you expect the government sector in India to open up?

I believe it’s already happening.

Healthcare is on the agenda of every single government in the world.

There are some really dedicated people in every government, trying to make a difference.

Moreover, people are travelling and everybody is afraid of the pandemics, such as swine-flu. There is the possibility of an outbreak of some kind. People are connected and aware of the kind of delivery models which have worked in other places. A few years ago, there would not have been that level of knowledge, which is available today. Some governments have already made significant progress and recorded successes. For instance, the state of Andhra Pradesh is a positive example in healthcare in its decision for a public-private coordinated model. But it is important to keep in mind, that if one model is successful in one area, it may not be successful everywhere. Still it’s a fertile environment where a lot of smart people are coming up with new ideas and some of them do work.

The great thing for healthcare in India is that, uniformly across hospitals, all CEOs believe that good care should be provided at affordable costs and that I think is phenomenal.

Are all these models based on publicprivate partnerships?

Public-private partnerships are everywhere nowadays. The difficulty with a pure private model is that sooner or later, people get greedy.

So PPP is a good model and the government is proactively getting involved in it. In Hong Kong, for instance, private hospitals will take care for one part of all cases and the remaining part is taken care of by the government. In Chile, we are

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implementing TrakCare for primary care and there are 29 regions in Chile with only two possible suppliers on the panel. There we have signed with private hospitals, public hospitals, and primary care clinics. Chile has an incredibly innovative government and at the moment, the President of the country is a doctor and she is really pushing to put a proper healthcare model in place.

Do you think there is a sustainable growth potential in India compared to countries like Brazil and Chile?

Yes, the potential here is huge, particularly with 1.2 billion people needing medical care in all its various forms. Several governments in India are already providing funding. In Brazil there is a similar situation with every state/province making its own decision. Healthcare is anyway so diverse - doctor-to-doctor, site-tosite, country-to-country.

Is there a need for a body in India to set some kind of standards or policy for health IT? Hospitals, at least the private chains, are all asking for standard based software and awareness about newer technologies. So, the need for standardization is high. Because it’s clear that there can not be one HIS system for everybody, a set of standards can be approved, to give a bird’s-eye view or a nation-wide/ group-wide view to make a wise decision. To be fair, the government is already aware of that and there is a lot of work underway in this arena.

Everybody knows the need for Healthcare IT standards, and a lot of people are working on it. There are standards which are needed to define which information can be stored, what people need to agree upon, what can be shared in these systems.

Today, everybody feels in some way insecure about sharing information, even within the group.

If you don’t have someone to head this standardization topic, pushing international standards that have been created to provide a basis, becomes very difficult. For example,

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look how the UK government manages delivery of care by simply regulating the standards. All decisions that they have made apply to all citizens and not just a few. So, they make sure that they can share all information. They have set up a network that makes use of resources wherever available to take care of patients in a timely manner. So, there are standards and I don’t think anybody is ignoring the need for them.

Are there any new technologies or applications from InterSystems in pipeline?

We are developing something new every day. We are continuing work to further improve the administrative capabilities of TrakCare and help hospitals better understand their business processes and create measures to improve efficiency. We are also focussed on driving clinical adoption, which is essential for hospitals to ensure high quality of care in the future and avoid clinical errors. In response to the universal need for reporting, business intelligence and analytics in today’s environment, we are enriching the functionality of ‘DeepSee’ - our realtime embedded business intelligence platform, and enhancing the Zen Reporting engine.

Given how our platforms are being used in mission-critical applications, in large (often nationwide) environments, we continue to focus our efforts on making all our platforms even more scalable, and easier to administer, while continuing to improve performance.

For example, Ensemble - rated #1 interface engine in Healthcare

by KLAS for 3 years running, now handles message processing approximately 30 percent faster than previously due to improvements in various areas including SOAP, XML and HL7 message processing.

When you work with our innovative software products – Cache, Ensemble, DeepSee, TrakCare and HealthShare - you’re working with the premier platforms for connected healthcare.

Company Profile

Anantharaman S. Iyer Regional Director- India Global Foyer, 6th floor, Golf Course Road, Sector 43, Gurgaon 122002 (Haryana)

InterSystems provide the premier platform for connected healthcare, and its innovative products are widely used in other industries that demand the highest software performance and reliability. InterSystems TrakCare™ is a connected healthcare information system that is Web-based and rapidly delivers the benefits of an Electronic Patient Record. InterSystems CACHÉ®is a high performance object database that makes applications faster and more scalable.

InterSystems Ensemble® is a rapid integration and development platform that enriches applications with new functionality, and makes them connectible.

InterSystems HealthShare™ is a platform that enables the fastest creation of an Electronic Health Record for regional or national health information exchange.

InterSystems DeepSee™ is software that makes it possible to embed real-time business intelligence in transactional applications, enabling better operational decisions.

Tel: +91 124 4738400-4 (board) Fax: +91 124 4738405 Email: anand.iyer@intersystems.com

achievements

Website: www.intersystems.com

•

Acquired the TrakCare business from the Indian partner MTech India Pvt. Ltd.

Worldwide HQ:

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Winner of the “Healthcare IT Company of the Year for Asia Pacific -2009” and “2009 European Hospital Information Systems Customer Value Leadership” recognitions from Frost and Sullivan

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Ensemble has been ranked by KLAS as the #1 Interface Engine in HealthCare for third consecutive years.

Fax: +1.617.494.1631

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TrakCare being recognized by Gartner as “one of the few global CPR systems that provide all its functionality on a single database”

Start-up Year: 1978 – Started in India in 2006

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Turnover in Previous Year: Globally ~265 Million USD

InterSystems is recognized in the SD Times 100 in the SOA and Middleware category which highlights companies that have “demonstrated leadership and innovation in the areas of SOA enablement and in creating enterprise middleware.”

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Principal/Channel Partners: More than 1300 partners globally

All 21 hospitals listed in the US Hospital Honor Role ’09 are using InterSystems Technology

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Making the Swedish National Electronic Health Record system live in record time using HealthShare

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Ensemble has been placed in the Leaders Quadrant of the Garnter’s Magic Quadrant Report for the “Application Infrastructure For SOA Composite Application Projects”

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Category for consecutive two years.

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TrakCare being selected for the Public Health Reform Project in Chile

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Completed the initial TrakCare deployment to 22 Victorian Community Health Agencies in Victoria, Australia

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Large number of wins and implementation completion for various products/technology stacks across the globe including but not limited to the Federal Govt. of Brasilia, various countries in the Middle East and APAC region, various NHS trusts in the UK, China, Italy, many states/ counties in the US etc.

InterSystems Corporation One Memorial Drive, Cambridge, MA 02142, USA Tel: +1.617.621.0600

Number of Employees: 18 in India, More than 900 globally

Branch/Overseas Offices: Offices in 22 countries in the world

Product details/Solutions •

TrakCare – Connected HealthCare Information System

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Caché® - World’s fastest Object Database

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Ensemble® - Rapid Integration and Development Platform

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DeepSee™ - Embedded Real Time Business Intelligence

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HealthShare – Health Information Exchange (HIE) platform

InterSystems Caché database continues to be used as the database for the VistA EHR developed by the US Dept. of Veteran affairs and also the US Dept. of Defense healthcare systems.

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Two hospitals/Chains in India went live this year

o

Puspanjali Crosslay Hospital, Ghaziabad, UP

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Manipal Hospital, Bangalore

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State of Victoria, Australia

u Increased efficiency u Better resource

allocation

u Improved healthcare outcomes

State of Victoria Uses TrakCare to Improve Community Healthcare In the Australian state of Victoria an A$360 million project called HealthSMART is under way to refresh and replace existing information and communication technology across the Victorian healthsystem.

The goal is to create an integrated state-wide information system that will improve healthcare quality,efficiency,and out comes fora population of over 5 million.

The Victorian Department of Human Services selected InterSystems TrakCare™,in its community configuration,to be implemented by 22 community health agencies throughout the state.

The decision to use TrakCare came after it was evaluated by a panel of over150 healthcare professionals. One of the Department of Human Services’ key requirements was the ability for the community health information solution to integrate with Victoria’s state wide healthcare integration architecture.

TrakCare is meeting this requirement with its powerful embedded integration technology. The TrakCare solution provides community healthcare professionals with fingertip access to client information that supports improved coordination between agencies,more efficient delivery of

services,and better health outcomes for the residents of Victoria.

For the first time hundreds of community health staff in each of the 22 agencies are able to manage their clients through a central case management system that removes duplication, enhances efficiency, and removes the need for both staff and clients to repeatedly enter and supply their demographic information and past clinical history.

Benefits to agencies that have implemented TrakCare include efficiency gains,improved client experience,better resource allocation to meet current and future community health needs, and improved healthcare outcomes through preventative health initiatives.

“We achieved those business benefits and benefits for clients very early on,” said ClareAmies, CEO of Western Region Health Center, the first agency to implement TrakCare under HealthSMART,with 13 different sites around inner and outer Melbourne.“TrakCare is already leading to efficiency gains.

“We achieved those business benefits and benefits for clients very early on. TrakCare is already leading to efficiency gains, with improved coordination of resources.” Clare Amies, CEO,Western Region Health Center

Lothian NHS Board, United Kingdom u Increased efficiency u Comprehensive care u More secure exchange

of patient information

TrakCare Provides Connected Care Every Patient at NHS Lothian Lothian NHS Board (Lothian) operates four main acute hospitals – the Royal Infirmary of Edinburgh, the Western General Hospital, the Royal Hospital for Sick Children,and St. John’s Hospital–plus primary and community services for a population of 800,000 in and around Edinburgh, Scotland. In a typical year, Lothian generates137,000 in patient admissions, 551,000 outpatient attendances,170,000 accident and emergency (A&E) attendances, 105,000 day cases, 480,000 radiology exams, and 8 million laboratory tests. Like many healthcare organizations with multiple facilities, each with its own electronic and paper-based patient record systems, NHS Lothian found it impossible to achieve a single, up-to-date view of patient activity.“We wanted to implement a single,integrated Patient Management System,”says Martin Egan, e-Health Director at Lothian.“The solution needed to capture and present all information relating to an individual patient–referral and attendance details, diagnostic test requests and results, treatment details, and comprehensive discharge information.”Lothian met these goals by deploying a single instance of InterSystems TrakCare™ supporting all four acute hospitals and a number of specialist facilities across the region. The TrakCare solution has helped Lothian: Allow Practitioners to refer patients to hospitals • electronically through interoperability with the Scottish National e-Referrals service.

Increase the use of NHS Scotland national • patient numbering conventions by provision of a single patient index within TrakCare

and integration with the Scottish National Demographic database.

• Meet Emergency Department waiting time targets by efficient admission, triage, and the use of visual alerts to ensure prompt attention to patients.

Provide complete and accurate patient • information to authorized care professionals at all Lothian locations, reducing duplicate data entry and enhancing overall care.

Implement electronic ordering of lab tests and • radiology investigations including transcription of radiology reports and clinician access to PACS images.

Securely exchange patient • “Today, TrakCare helps information including us to provide better diagnostic results and comprehensive care for clinical correspondence our patients with a for use within the wider single product.” healthcare community.

Martin Egan, e-Health Director, Lothian TrakCare is being used by more than 12,000 Lothian staff in A&E, inpatient, outpatient, radiology, and maternity settings and is now being deployed to support community healthcare staff. “In the past, it would have been necessary to buy separate systems for us to support these different departments,”says Egan.“Today, TrakCare helps us to provide comprehensive care for our patients with a single product.

The ability to extend the benefits of a single Patient Management System from the acute environment into the community is a real advantage.”

4TH anniversary special Issue

Critical Issues in a National Healthcare Discussion Deliberations on access, transparency and efficiency should guide the process Dr. Kevin Fickenscher is a global leader of international healthcare for Dell Perot Systems.

A physician executive and a leader with extensive experience in strategic and operational development with complex healthcare organisations, Dr. Fickenscher has provided leadership for various organisations related to organisational transformation and development, physician management, health policy analysis, leadership development, information management, clinical quality and care management, among other areas. eHEALTH recently caught up with Dr. Fickenscher to know about his vision of the future of health IT in India and the necessary strategies for avoiding pitfalls along the way.

I Dr. Kevin Fickenscher Executive Vice President - International Healthcare, Dell Perot Systems

ndia has emerged as a global economic force, and this has led the public to demand changes within India’s healthcare system.

This is a natural development that I have seen during my travels around the world. The demand for better, more available healthcare for all, is truly at the forefront of public debate in India, and decisions about healthcare now will impact all the entire Indian population for decades to come.

While change can be daunting, India is accustomed to accepting and excelling at challenges. In healthcare, India has the opportunity to “leap frog” the current status quo and make investments that truly improve the nation’s ability to meet society’s healthcare needs.

However, to transform this promise from potential into reality will require India to focus attention on several critical issues. These issues will not only affect the quality and

accessibility of healthcare, they will determine the sustainability of the healthcare system itself.

Issue number one is about access to healthcare services. Will it be limited, or will it be universal?

While this will be a major debate, no doubt, it is an important discussion for a nation that is assuming a major profile on the world stage. The issue of universal healthcare access continues to be of critical concern to the citizens of my home country, the United States. Having the dialogue and debate on the basic healthcare package that should be available to all citizens is an important discussion. In fact, it could be the most important discussion a society might have.

Another crucial issue regards transparency. From my experience and travels, nothing creates more energy around reaching solutions than providing information so stakeholders can compare themselves to one another. Holding up a

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4TH anniversary special Issue mirror is a very powerful force for change.

A major risk is the issue of waste and duplication of resources.

As a nation that is consciously moving beyond the subjugation of poverty to an enhanced economic status for its people, India should realize that allowing unfettered development also creates unfettered costs. Nation’s around the world ultimately pay a significant price for inefficient healthcare systems.

For example, in the United States, an estimated 25 to 30 percent of our healthcare spending is wasted due to duplication, inefficiency and other problems. Imagine if India had $500 billion to allocate for healthcare today. That’s about 25 percent of the current US investment in healthcare services. Today that may seem like a huge sum, but in 10 or 15 years, India almost certainly will be investing at this level.

In terms of healthcare information technology, the development of national standards for interoperability and connectivity are crucial. This will eliminate waste and duplication while ensuring that patient information is available at the point of care, eliminating unnecessary tests, enabling more informed decisions and improving the quality of care.

At its core, medicine is about using information. Generations ago, the “sharing” of health information was limited to physicians in the backrooms of healthcare. Then, the sector realized that documenting information could benefit individual patients as well as society as a whole.

So, medical records were created to make sharing information about patients much easier to do. In the 21st Century, IT will be the great enabler for information sharing and for helping achieve broad goals for healthcare access, affordability and quality. The ability to “share” is no longer based on the quality of the paper but the quality of our ability to move data in structured ways. Indian physicians are very sophisticated - they are among the very best in

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“A more reasoned approach will help make India an international leader in promoting best healthcare practices, creating appropriate societal incentives, and deploying systems that actually provide the foundation for enhanced care, better access and lower cost.” the world. They know that sharing information fosters better care. India should embrace this principle and pursue it with policies and financial support. Last but certainly not least, making decisions on the issues mentioned above will shed light on which approach will best support a national healthcare information infrastructure for India. Without consciously choosing a direction, scarce resources will be wasted, and goals will be at severe risk.

One of the key lessons, I have learned as a clinical consultant with Perot Systems, is that success in modern healthcare requires more than just re-engineering a process.

Success requires a profound cultural transformation. Consequently, a more reasoned approach will help make India an international leader in promoting best healthcare practices, creating appropriate societal incentives, and deploying systems that actually provide the foundation for enhanced care, better access and lower cost.

While many people believe that the United States is the world leader in healthcare, we are actually playing catch up in the IT area. We literally spent billions of dollars to support IT systems over the last several decades. Despite those investments, we still have a very low percentage of hospitals and physicians using Electronic Health Record (EHR) systems – less than 10 percent! And

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yet, key studies strongly show that electronic information systems in healthcare settings do enhance quality, allow for better service and, reduce the overall cost. Recently, the U.S. Government committed over $27 billion in federal funding towards the advancement of health IT, including EHR systems. So, we are embarking upon a journey, but the final path is not yet clear. There is much debate over how the funds should be used, where they should be used and even what constitutes “meaningful use” of these new investments.

I would encourage India to be more circumspect, to deliberate on the path before funding it and to invest wisely. In these deliberations, India will be well-served if key issues are thoroughly addressed. Doing so will help India continue moving forward to assume its status as a leader across all areas of healthcare.

To meet these objectives, India should address these basic needs: 1. Create standards for excellence that are openly exchanged across society.

2. Invest in an IT infrastructure that supports interoperability and open connectivity at all levels – within the profession and among individuals.

3. Support privacy standards so that individuals have confidence in the system.

4. Create a payment system that encourages the use of efficient and productive information systems as a foundation for support of healthcare.

5. OTHER IDEAS India is among the great nations of the coming century. The country has an opportunity now to stand on the shoulders of those who have gone before, to benefit from their hard-learned lessons and to adapt those lessons to the needs of its society. Postponing inevitable deliberations runs the risk of – as we say in the United States – arriving a “day late and a dollar short.” By setting a course now thoughtfully and intentionally, India can control its own healthcare destiny.

4TH anniversary special Issue

Transforming through Innovation - Redefining Indian Healthcare through Advanced Informatics

Matrix Knowledge India - a subsidiary of Matrix Knowledge Group, UK, is equipped with a multidisciplinary team of healthcare specialists, technologists, clinicians, researchers and practitioners, and backed with strong knowledge partnerships with some of the finest universities, research organisations, hospitals and insurers. The company is poised to embark on a novel journey to transform Indian healthcare by bringing innovation and world-class practices in health informatics. eHEALTH caught up with David Thomas, Managing Director, Matrix Knowledge India to capture his views about the future of healthcare in India and understand the value-proposition of his company towards actualising the vision.

What was the genesis behind formation of Matrix Knowledge India? How would you define the essence and core strength of the organisation?

David Thomas Managing Director Matrix Knowledge India

Innovation in India - Transforming Healthcare blends world class healthcare expertise with Indian experience and talent, in an Indian company with an Indian private and public sector track record. It accelerates innovation and development to support the development of Indian world class healthcare businesses.

Our Intelligent Development Program (IDP) supports the delivery of World Class Healthcare Performance.

Matrix Knowledge India supports health organizations across the globe deliver clinical and financial success. The challenges faced by

health communities are local, but are being tackled globally. There is substantial opportunity for world class innovation expertise and Indian talent to leapfrog established healthcare markets and become the world leaders in health service delivery. We work collaboratively with clinicians and executives to open new opportunities, reach new markets and set higher standards of performance.

IDP has four delivery themes to support the transformation of health organisations in India, and maximize their potential – turning ideas into tangible and delivered improvements in performance. • Hospitals and Health Systems of the Future: The old hospital is gone, embracing new models is the only way to meet the pressures for change and clinician and public requirements.

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Investment Sourcing, Planning & Implementing: The key to change and ongoing growth.

The only means of growing is through investment and the only way of securing growth is to generate surpluses from the business of clinical services in both private and public sector.

Partnering for Success: Why • reinvent the wheel? We can all learn from those who have achieved success, we just need the right formats to interpret best practice to right practice.

Creating the Intelligent • Organisation (and Workforce): Knowledge is the lever for innovation and transformation.

Utilising technology is the means. The successful service organization will be an agile one, able to spot and deliver improvement rather than just react to it.

We combine world class/global expertise in healthcare business and clinical evidence with Indian knowhow. Indeed our clients frequently save more than we cost.

•

What is your view about the quintessential role of informatics in healthcare delivery and outcomes?

What and where does it need the most improvement?

The case for investing in expert informatics in healthcare is overwhelming.

Successful hospitals have great information which is timely, accurate, transparent, focused on managing risk, quality and performance.

Expert information requires an informatics approach. It need not be expensive to get the most out of existing IT systems.

Many hospitals and healthcare organizations have objective of implementing; paper less Hospitals, Satellite connectivity, Live Video Conferencing, Highend Telemedicine etc.

The Expert Informatics design should ideally deliver: Strategy Mapping - plotting •

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objectives by service/ department by year.

SMART objectives inter-related across the organisation Matched by key performance indicators (KPI’s)

What is your offering in terms of value-adding existing IT systems in healthcare organisations? How do you propose to bring a fresh perspective out of usual data practices and legacy systems?

Matrix initially developed the AspiraHub platform over 10 years ago, in response to an increasing number of clients, across a range of sectors, desiring a much more effective way to measure performance and manage results.

The ever-expanding code library which comprises the AspiraHub platform provides extensive Data Analysis, Data cleaning, Data Warehouse and business intelligence features and functionality which is built to be configured and customized for individual clients.

Matrix continues to build upon the success of the AspiraHub platform through the enhancement and addition of features and functions, leveraging technological advances, and embedding effective performance management practices identified on a global basis.

The AspiraHub platform can be thought of in three “tiers” or “layers”: Presentation layer, which • provides the web-based interfaces for users Logic, or application layer, • where a set of modules provide the features and functionality integral to a Accreditation & Data Warehouse and business intelligence solution Data layer, where all of the • data in the Accreditation & Data Warehouse is imported into and stored Data Import: Methods and

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Capabilities. We provide three methods of collecting data either directly & integrated with existing systems, extracts derived from existing systems, databases & spreadsheets or directly from people where the information/ data is entered directly into a form.

Direct Interfaces with external • systems developed using Web Services; Extract Upload for data where • automated importing is not feasible; Provides a fast and reliable • way to integrate large amounts of data quickly and securely over https or ftps Can be combined with • sophisticated data validation Web Forms & Questionnaires • providing an effective means for consistent collection of small amounts of data from numerous, disparate sources; streamlines data collection efforts and ensures consistency Ability for non technical users • to create quick forms based on a library of questions The system provides tools to transform the extracted data, using rules or lookup tables, or creating combinations with other data, to convert the extracted information to the desired state for loading into the system database.

Following tools and the processes used to transform data into the format needed by the system as well as how exception cases are handled during transformation.

Data from the data warehouse • is transformed and transferred in batch to the reporting mart, in the form of dimensions and facts. We use a Slowly Changing Dimension approach which supports saving any number of past values of a record, such as an address, and the appropriate value is selectable, typically based on an effective date

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range.

Finding the right value becomes a more complicated query, but is a straightforward activity. This is the standard approach in many general warehouses and adds extra rows to the dimensions to track the changes to the record over time.

When adding additional datasets to the data warehouse via an upload it validates the data import against data within a preset parameters Any data that is found to be invalid, out of parameters, or non-standard would be flagged to an error log for investigation, thus avoiding the intrusive failure of an entire datasets import to the warehouse.

Exceptions do not obstruct the import of the entire dataset; just the erroneous or flagged fields of data are excluded from the data import. This enables the accurate data to be instantly impactful and the broadest set of results to be available.

What is your application service delivery model for customers?

How does it benefit them in gaining better business efficiency, avoiding technology obsolescence and reducing IT cost?

Our approach to configuration is the same as new development.

The configuration requirements is agreed in the system specification and supplemented by the application of an ‘Agile’ development methodology. This approach helps us be flexible to evolving requirements inherent in the systems development phase of a project. This approach incorporates refinements to the requirements at an early stage and ensures we stay within agreed costs. In this way we provide fast and thorough responses to changes in requirements and new ideas whether that is developing

a new piece of functionality not resident within our application suite or configuring existing functionality.

The timing and content of delivery iterations is under the control of the user but cannot extend beyond scope already agreed. Each delivery iteration involves all team members working very closely – sometimes consulting daily – and always begins with the full team planning the contents of the delivery iteration, agreeing the periods for analysis / development / testing and reviewing / identifying / prioritising risks. The result is an ‘iteration work plan’ for producing a quality business product or function in a short period of time, and the activities for managing, or avoiding, any risks identified in the iteration.

The key principles of ‘Agile’ are: Customer satisfaction by • rapid, continuous delivery of useful software; Working software is delivered • frequently; Working software is the • principal measure of progress; Clear requirements in the form • of “user stories” rather than long and complex technical specifications Close, daily cooperation • between business people and developers; Continuous attention to • technical excellence and good design; and, Regular adaptation to • changing circumstances.

How would you reflect on the need for having standard-based practices in healthcare organisations? What initiatives would you wish from government and regulatory bodies towards achieving this objective?

Providers of modern healthcare services across the globe are increasingly challenged to improve performance and demonstrate the effectiveness of their services to a

range of stakeholders including boards, payers, service users and regulators.

This is equally the case in India due to the growing demand for quality healthcare and hospital facilities from the increasingly discerning and health-aware middle class and with medical tourism now a reality, new boundaries of performance are being achieved and the level of competitiveness for patients is touching new highs.

Management and leadership teams have found difficulty in timely access to key performance indicators. We have found that much of the critical data is available within organisations; however mechanisms to make this data more accessible in a flexible, affordable way have not been found or fully utilised.

Interestingly the introduction of this type of technology into healthcare is slower than some other sectors. This may be due to the labels that have been attached to ICT and IM known as Informatics. They are linked but the technical ‘bits and bytes’ expertise in ICT is a wholly different discipline from IM or Informatics which is about designing relevant information to inform clinical and business decisions. In healthcare it is only relatively recently that the informatics discipline has come into focus, meaning that the emphasis on the commissioning of large and relatively cumbersome systems has overwhelmed what value could be delivered by making existing data more readily available to the right people.

Demands for patient choice, regulatory requirements, benchmarking, evidence based medicine, knowledge management, risk management and the massive drive to ensuring clinical quality and high business performance in an era of needing to get more for less – now one cannot ignore the case for developing advanced informatics.

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4TH anniversary special Issue

Pushpanjali Crosslay Hospital deploys acuVena™ Software Pushpanjali Crosslay Hospital Pushpanjali Crosslay Hosptial, a tertiary care facility, is the flagship hospital of the Pushpanjali Healthcare Group which is a dynamic, fast growing Indian healthcare group. It offers an unparalleled spectrum of preventive, diagnostic and treatment facilities with followup care, in virtually all medical specialties. The hospital has a blood bank where quality checks ensure that the blood is of the desired standard. The blood bank is well equipped to provide services like blood collection, testing for blood transfusion, cross matching and issue of whole blood and its

various components like packed cells, saline washed packed cells, fresh frozen plasma, platelet concentrate and cryoprecipitate.

Background The HIS (hospital information system) chosen by the hospital to carry out its routine clinical and administrative functions was a standard product from a reputed international vendor that has successfully deployed their HIS across various locations in and outside India. The key leaders at Pushpanjali, who contributed to the IT vision chose to employ a ‘best of breed’ approach where auxiliary functions of the

hospital may choose to install specialized software that better suit the degree of complexity of the working of their departments with an understanding that these software products would eventually interface with the core hospital software viz - the HIS. Therefore, specialized software products were chosen for backoffice operations, laboratory management as well as radiology image management.

Problem Statement After a detailed review, Pushpanjali chose not to go with the blood bank module that was offered within the HIS. The reason for doing so

Pushpanjali Crosslay Hospital, Ghaziabad, Uttar Pradesh

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4TH anniversary special Issue was that most specialty modules in the HIS focused on order entry management. While this concept works well for most departments whose functionality essentially meant servicing requests from the wards, blood banks were far more complex as they involved management of donors and manufacturing of components as well as a detailed traceability to ensure the concept of haemovigilance from the standpoint of a donor and the recipient.

At this juncture, Pushpanjali began to review some of the bestof-breed blood bank software products available in the world and arrived at a solution from an Indian company by the name – acuis™. The name of their blood bank software product was acuVena™. The team behind acuVena™ had concentrated on the complexities of the workflows of independent and hospital based blood banks. Their solution had been successfully running at many of India’s leading blood banks and they had been working with veterans from the Indian blood bank industry for the past five years. acuVena™ had been showcased at industry conferences in India and the USA and had evolved best practices from the industry over the years. Being an enterprise class, multi site, webbased software; it seemed to fit in line with Pushpanjali’s IT vision of enabling stakeholders to login from beyond the IT firewall.

Software Overview acuVena ™ presents itself as a process-driven, feature-rich blood bank software that has been built on a Service Oriented Architecture.

The key to its success has been the inputs given by the core R&D team consisting of domain experts who are stalwarts of the Indian blood bank industry. acuVena™ has mapped key stakeholders like donors, blood drive organizers and care-providers in its design

from the ground-up. This insures that these stakeholders can actively interact with the system rather than the system being run essentially by technicians and data entry operators. The software can be broadly classified into 3 subsystems mentioned below: Donor Centricity One of the key stakeholders in the system is the donor. The system helps mark donors as eligible and defers those who are not eligible. The entire donor workflow has been traced onto

acuVena™ presents itself as a process-driven, feature-rich blood bank software that has been built on a Service Oriented Architecture. acuVena™ process map. Donor questionnaires are completely customizable. Donors can have the option of self-registration either via the web or an interactive touch screen module. It records history of previous donations and restricts donors from donating before their eligible period. acuVena™ has the added advantage of not losing track of donors who are temporarily unfit for donation by reminding them to come back when eligible.

Bag Lifecycle acuVena™ maintains the detailed history of a bag right from the time the stores officer receives it, till it is finally issued to the intended recipient. The system accepts donors of whole blood as well as aphaeresis. It allows component preparation depending on the type of bag chosen. acuVena™ enables typing of blood for Red Cell, Leucocyte and Platelet Antigen. One can

view the transfusion centre’s stock according to stock location, blood group or component. Every stage of the blood bag from collection, component preparation, storage, stock movement, cross-match, issue, return and discard are traceable within the system. The system has an option of automatic as well as manual discard of blood components.

Transfusion Care The system allows both internal and external blood requests. In case of tertiary care centers, the blood banks also serve external requests from neighboring hospitals and nursing homes. The system supports bulk issues to storage centers, emergency issues, cross-match, issue, return and billing of blood components in stock. acuVena™ enables adverse transfusion reaction reporting from the point of care.

In addition to the above 3 subsystems, acuVena™ has a comprehensive blood drive (blood camp) organization module that helps blood banks organize blood drives (camps). Since Pushpanjali was not planning on organizing external blood drives, this module was not focused on.

Benefits of acuVena (a) Donor Loyalty: acuVena™ stores information about donors who are eligible as well as those who may not be eligible to donate today. This eligibility is automatically calculated by an intelligent questionnaire system that calculates the number of days a donor may be deferred due to a pre-existing condition. Since such a system is rule based, it allows the blood center to change the eligibility days depending on the rules set forth by the governing regulatory authority. Storing data of ineligible donors not only helps the blood center call them back when they are next eligible, it also enables the blood center from

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4TH anniversary special Issue pro-actively knowing the status of the donor if he/she re-visits before they are next eligible to donate. In addition, this helps the blood center convert (motivate) replacement blood donors into voluntary blood donors by calling them when they are next eligible to donate blood. (b) Process Driven: Having been built with inputs from domain experts of the blood transfusion industry, the software has covered the various stages of blood banking in a comprehensive manner. It covers red cell antigen, platelet antigen and HLA typing.

It takes into account informed consent of donors depending on the type of collection (whole blood or aphaeresis), exhaustive information related to blood collection, donor reactions as well as various stages of the component manufacturing process depending on the kind of bag used. These process driven stages can be traced per blood unit and technicians can also generate worklists corresponding to these stages that they choose to do in batches. (c) Enhanced Trace-ability: In a regular blood bank module of an HIS, most of the stages

mentioned above are carried out offline (not in the system)

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since the HIS essentially focuses on order entry management and billing. However, since the above mentioned processes are an integral part of acuVena™, the blood bank personnel using acuVena™ can trace back any blood unit to the donor medical history or to the date of purchase of the blood bag from the vendor.

The intelligent labeling system also displays the test results of

the Transfusion Transmittable Infectious markers carried out on the blood unit for enhanced safety.

Any adverse transfusion reaction can be documented in the system and is once again traceable to the donor and blood bag.

low stock levels and expiring units of blood. (e) Greater Compliance : The system generates most of the essential reports required to be submitted to the authorities.

Many blood banks either dedicate personnel for this activity or spend a lot of time collating this data again as most of the processes and consumables of the blood bank are not fed into the blood bank

module of the HIS. acuVena’s process driven approach not only captures the essential information, it generates most of the reports required by the authorities who seek this information. These reports can be generated in addition to the manual registers being maintained by the blood bank.

(d) Faster TATs (Turn -AroundTimes) : Since the stock levels are instantly accessible within and outside the system, the blood bank staff are able to attend to

(f)Focus on Point of Care: Deploying a best of breed blood bank software like acuVena™ ensures that senior officials concentrate on using the data

blood requests in an efficient manner. The system allows blood reservation in advance. The system has in-built email and sms alerts for adverse transfusion reaction,

effectively to achieve their quality initiatives rather than creating the reports. By freeing up their time from report generating activity, it also enables the care-providers in a blood bank focus more transfusion care and research related activities.

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4TH anniversary special Issue

“Wipro HIS product is under implementation in government sector projects such as ESIC” Wipro HealthCare IT, a division of Wipro technologies, is a dedicated health information technology company offering a suite of products for healthcare providers. The company is backed with the experience of implementation at various hospitals, globally. Harbir Sawhney, General Manager of Health-IT division of Wipro, shares his perspectives on the health IT scenario and Wipro’s initiatives in this space.

What are the current offerings of Wipro for the healthcare industry in India? How do you address the mix of small, medium and big healthcare enterprises existing at present?

Harbir Sawhney GM-Healthcare IT Wipro

Wipro offerings address the provider space. Our products cover the needs of hospitals, clinics, and medical diagnostic centers. For medium size hospitals, which are typically between 50 and 150 beds, and to large hospitals with beds exceeding 150, we implement the Wipro HIS product (Hospital Information System). Certain modules like ‘Blood Bank’, ‘Diet & Nutrition’ would typically apply to large hospitals. For small hospitals, which are less than 50 beds, we implement the Wipro HIS Lite product. For certain medium size hospitals we can also provide a combination of HIS Lite and the Materials (MMS) module of HIS. For enterprise class hospitals, which we designate as hospitals with multi locations we also have a product called the CDR – Clinical Data Repository. The CDR can consolidate

a patients clinical data from various hospitals and present a single view of patient history to the doctor.

Among the emerging markets how do you gauge India with respect to IT uptake in the healthcare industry?

What measures need to be in place to facilitate the market growth?

The government sector in the Indian market space has taken the lead with projects such as ESIC and Indian Navy hospitals, wherein Wipro HIS product is under implementation. Several state governments have announced large e-Governance projects with a large eHealth component. In the corporate sector also we have seen announcements by Fortis and Max. Legislation making EMR, PHR & ePrescription mandatory will ensure wider adoption of IT technology.

Also consumer awareness towards electronic medical records needs to be increased through advertisements.

Earlier this year, Wipro bagged the Rs. 1182 crore IT outsourcing contract

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from Employee’s State Insurance Corporation of India. What is your perspective regarding the scope and opportunities of this project in terms of modernising healthcare delivery?

What are the inherent challenges involved in this kind of a project?

The ESIC project is one of its kind e-Governance project in the world wherein over 2000 locations comprising around 1500 dispensaries and hospitals will be integrated into a single eHealth environment.

Data center will be centralized and all locations will be connected through a MPLS cloud. This project will ensure a near paperless health management of patients. Patient registration, identification, medicine prescriptions, clinical observations, billing, lab investigations, etc. will be completely electronic in nature. The HIS product will interface with Insurance, ERP and Campus Management systems.

The deployment of the CDR system

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will ensure that a patient’s clinical record, popularly termed an EMR or Electronic Medical Record will be accessible from any of the ESIC hospital locations.

Fundamental challenges will be HIS product training to a large population, dealing with change management, last mile connectivity issues and roll out of the system to such a large number of locations in a short timeframe.

Wipro has been relatively slow in tapping the domestic healthcare enterprise market over last few years.

What were the challenges faced therein and what are the strategies in capitalising on that segment in coming years?

Upgradation of technology is always a challenge in a large enterprise class product. It took a while to upgrade from our VB based code to a .Net 3 tier architecture. We have seen great success with our version 3.x

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product with installations at AMRIKolkota, Sagar Hospital-Bangalore, Rainbow Hospital-Hyderabad, Rockland Hospital-Delhi and many others. Enhancement of features and functionality, moving to a SOA architecture, availability of the product with multiple databases, making available a‘Cloud Computing’ or ‘SaaS’ model, greater sales and marketing coverage, aligning with partners with complimentary products would be the strategies to increase our market share.

What percentage of healthcare industry business of Wipro comes from overseas? What are your most successful target geographies outside India?

Overseas business accounts for 40-50 percent.We have seen great success in Saudi Arabia and Asia Pacific.

For the Middle East region we have an Arabic version of the product available.

4TH anniversary special Issue

“Business technology will become a key enabler for healthcare organisations” Hewlett Packard offers a plethora of health and life sciences solutions that help transform patient care delivery.

Girish Kumar, Practice Head of the Healthcare and Lifesciences division at HP provides key insights into the business of HP in the healthcare space.

What difference in complexity and functionality of IT solutions signifies the healthcare industry?

Girish Kumar Practice Head - Healthcare & Life Sciences HP India

The healthcare industry has some very unique attributes in the way it operates internally, within the ecosystem, and also how it relates with the external world including customers. This has a lot to do with the profession and criticality of the industry.

‘Medicine’ as a science lacks the exactitude of other sciences.

Because of this skill based nature, standardization of care has always been the biggest challenge of this profession. It is not necessary for two patients to show the same response to a specific treatment; nor is it necessary for two doctors to make same decisions to a similar case presentation. Though there are lots of advancements in medicine the element of “I treat and THY cure” is not fully out of the core clinical practice.

Whereas, ‘computing’ is an exact science, program based and deterministic, the complexity lies when this is applied as a tool on the practice of a profession which is not

so deterministic in its functions.

This basic mismatch coupled with the fact that the profession deals with ‘life and death’ situations add tremendous complexity to the IT solutions provided. That is the reason why most of the hospitals can easily use IT solutions in areas like billing, inventory management etc but not so in clinical areas of functioning.

However, healthcare as an industry practice encompasses, much more than hospitals (providers). IT solutions are being more successfully used in many other components of the eco systems like the payer segment, diagnostic and therapeutic segment, medical equipments and gadgets, pharma industry, medical transcription, etc.

On the other hand, healthcare has often been viewed as ‘Not for Profit’.

However, healthcare organisations face the same operational efficiency, and productivity challenges as other industries. Even in a digital environment, administrative costs can eat up about 25 percent of every dollar spent on healthcare. However, administrative costs represent only a fraction of the total healthcare

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4TH anniversary special Issue challenge. Finding new, cuttingedge approaches that improve health status while managing benefit expenditures is also critical.

With advancements in medical science, there has also been a tremendous growth of information.

Today, more and more healthcare providers understand the value of electronic health or medical record, medical archival and business intelligence.

As we go forward, business technology will become a key enabler for healthcare organizations in providing quality services to its clientèle, as well as a key to their competitive differentiation.

What solutions and products are currently offered by HP for healthcare sector?

The healthcare industry is a key focus area for HP. The acquisition of EDS has augmented our capabilities, bringing rich domain experience, strong intellectual property and multiple solutions to the table. HP’s vertical expertise touches healthcare providers, healthcare payers, pharmaceutical and life sciences segments all around the world.

Cross-industry solutions, such as health information exchange and health information management and analytics, bring additional value in allowing the health industry to utilize collaborative, best-practice knowledge to set new operational standards.

Our healthcare solution has also been awarded full URAC accreditation in health utilization management (URAC, an independent, nonprofit organization, is a leader in promoting healthcare quality through its accreditation and certification programs). HP products like ‘MetaVance’ interchange and ‘Atlantes’, are used globally by hospitals, third party administrators (TPAs) and health insurance companies. Our process automation and data repository products form the data management backbone of numerous pharmaceutical and life science organizations. If you have visited a hospital recently, chances

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are you would have seen HP’s tablet PCs and handheld devices being used to capture patient data at their bedside.

Our medical archiving solution (MAS) is widely used for archiving the whole gamut of digital images delivered from a host of medical imaging equipment and gadgets. We also use our business intelligence expertise to help healthcare providers transform the way they use information for daily use.

What are some of your notable healthcare projects in India?

HMIS for Medical Education and Drugs Department, Govt of Maharashtra is the largest healthcare project that we are currently into.

This is one of the pioneering efforts of any state government in India in healthcare. We are providing end-to-end IT solution and system integration in 18 hospitals and 14 medical colleges within the state of Maharashtra. We are also creating a central repository of patient data at the state level. All compatible medical equipments and gadgets are interfaced with the HMIS solution providing universal access within the system. The biggest advantage this project is that it is delivered as an outsourced service in BOOR (Build Own Operate and Refresh) where there is no upfront investment for the government and the payments are made on installment/transaction basis for seven years. We have successfully completed the pilot at Sir JJ Hospital and Grant Medical College in Mumbai and also rolled out and gone live in GMC & Hospital Nagpur, BJ Medical & Super Specialty Hospital Pune, and GMC & Hospital Aurangabad. The GT, Cama and St. George hospitals in Mumbai are almost ready to go live in the next phase.

From a corporate hospital stand point, we are currently implementing the HCIS solution at a leading corporate hospital in Mumbai. This is one of the most prestigious and technologically advanced state-ofthe-art hospitals, which is poised to be the first digital hospital in the

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country. We are also implementing a TPA solution in the country.

What is your view regarding the growth pattern in Indian health IT market? What share of it do you target over next 2-3 years?

Driven by the country’s growing middle class, India is seeing a ‘health transition’ in terms of shifting demographics, socioeconomic transformations and changes in disease patterns. A PricewaterhouseCoopers study ‘Healthcare in India: Emerging market report 2007’, estimates that the revenues from the healthcare sector accounts for 5.2 percent of the GDP, making it the third largest growth segment in India. IT will become a key enabler for healthcare organization to manage these levels of growth. Industry analysts estimate that IT is expected to approximately grow at a CAGR of 22 percent to USD 254 million by 2012.

At HP, we’d like to play a key part in helping our customers realize this transformation.

What is your business strategy for the short and long term market opportunities? What forms of new technologies/applications are expected to emerge in future?

Apart from bringing rich intellectual property, at HP we bring together a large pool of resources with strong domain experience who are based in India and serve customers globally and locally. Our strategy has been focused on delivering innovation in the market and we are seeing Indian customers more than keen to leverage this. By bringing together the breadth of portfolio, we can also help customers bring down the cost of healthcare. HP understands the value of innovation in the health and life sciences market and is working with customers and local partners to develop new solutions that enable organizations to access information, integrate processes and transform how they collaborate in order to lower costs, function more efficiently, and most important, provide a better quality of care to individuals.

4TH anniversary special Issue

“Carestream is the only company in India offering a complete range of medical imaging products” Carestream Health, Inc., is a leading provider of dental and medical imaging systems and healthcare IT solutions; molecular imaging systems; and x-ray film and digital x-ray products.

In conversation with eHEALTH, Prabir Chatterjee, MD of Carestream Health India Pvt. Ltd., provides insight into the company’s business operations in India and provides an overview of the overall medical imaging market.

Please tell us about Carestream Health’s operations worldwide as well as in India.

Prabir Chatterjee Managing Director Carestream Health India Pvt. Ltd.

Carestream Health, Inc, is a dynamic new company that leverages 100-plus years of market leadership and an innovative suite of solutions to meet the critical needs of the markets it serves. It serves a global customer base in 150 countries. Globally, Carestream has thousands of healthcare information management solutions installed worldwide.

The company sells nearly 40 percent of all new CR systems in the U.S. and Canada, and is a key player in the DR systems market.

The Carestream dental digital radiography equipment and practice management software installed base, is the largest in the world. Carestream is the acknowledged world leader in all categories of film: digital output, radiology, mammography, dental and molecular imaging. With an installation base of more than 60,000 laser imaging systems around the world, and more than 1,000 patents for medical and dental imaging and information

technology. Carestream Health can be found in approximately 90 percent of hospitals and dental practices around the world.

Carestream Health India leverages the strengths of its global parent to offer the same standard of product, technology and service to medical imaging community in India. The India Corporate Office of Carestream Health is located in Mumbai. There are three other regional sales offices – in Delhi, Kolkata and Chennai. The sales organisation is buttressed with a network of about 155 channel partners across the country. It is the only company in India offering a complete range of medical imaging products ranging from CR, DR, PACS, dental imaging and medical printing. Its marketleading laser imagers print medical images of all types. Its flexible CR and DR solutions solve workflow, budget and space challenges and reduce procedure times.

Please tell us about your company’s turnover and revenues in the previous year?

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Carestream Health, Inc., originated in 2007 when Onex Corporation purchased Eastman Kodak Company’s Health Group and established it as an independent company. Since then, Carestream Health has grown consistently and we are planning substantial growth in coming years in India as well as worldwide. The company’s 2008 revenue was approximately USD 2.5 billion.

Carestream Health’s whollyowned subsidiary company in India - Carestream Health India – also has a comprehensive portfolio of medical imaging and healthcare IT products, services, and solutions, as well as the latest in x-ray films, laser films, computed radiography (CR) systems, digital radiography (DR) system, PACS, dental imaging products and medical laser printers. Starting off as the erstwhile health group of Kodak India, which commenced operations in 90’s, Carestream Health India had a revenue of about Rs 200 crores in 2008.

What are your latest product and service offerings in the Indian market?

Carestream continues to introduce innovative and market-leading imaging products in various segments. Some of our powerful recent introductions in India have been: Carestream DRX-1 is the • world’s first cassette sized wireless DR detector, which fits in to existing systems.

Being an extremely costeffective digital solution, it can help the imaging labs shift to digital radiography without revamping their existing system.

Carestream DRX Evolution • is the world’s first integrated DR suite powered by the innovative Carestream DRX –1 system. This remarkable system matches the world’s first cassette sized DR

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•

detector DRX-1 with fully automated suit of precision X-ray equipment. The DRX Evolution is designed with a solution that can grow to fit the needs of radiology facilities over a longer period. The DRX-1 and the DRX Evolution systems address the needs of large healthcare facilities with heavy workloads.

The most advanced 3D Dental Imaging machine – the Kodak 9500 3D. Reflecting Carstream’s industry leading position in the field of dental imaging, the 9500 3D is a flexible and easy to use 3D dental imaging system that enables dental professionals to obtain localized, highresolution three-dimensional images, as well as panoramic examinations, at a very affordable price point – making the power and utility of 3D technology available to general practitioners and specialists alike. In India, three focused field units (Kodak 9000 3D) and a Cone Beam CT (Kodak 9500) have been installed. This system is targeted at endodontists, implantologists, and other dental specialists performing complex procedures.

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Which segments in radiology do you focus on? Have you pioneered any technology in radiology?

Carestream Health markets offer a broad portfolio of CR and DR systems that equip hospitals, outpatient imaging centers, orthopaedic practices and other healthcare providers with digital image capture for x-ray imaging studies.

Carestream Health’s laser imagers range from desktop systems designed for imaging centers, small hospitals and clinics to fully featured units designed for high volume, multimodality output at hospitals of all sizes. These imagers offer output from PACS, CT, MRI, computed radiography and digital radiography systems, and other grayscale imaging applications.

Carestream Health has a proud history inherited from its previous identity as the Health Group of Eastman Kodak Company, comprising over 100 years of innovation dating from almost the time of discovery of X-rays by W.E. Roentgen. A recent example of pioneering technology from Carestream has been the DRX-1 – the world’s first cassette sized wireless digital DR detector. It fits in to existing systems without any modifications so that the users can conveniently shift to Digital

4TH anniversary special Issue

Radiography cost.

at

an

affordable

Please tell us about the after-sales services and customer support provided by Carestream Health.

Carestream recognises the need of busy imaging facilities for high-level of service that enables minimal disruption of their patient-care and diagnostic operations. The features of Carestream’s service support are: • An experienced and highly qualified team of over 60 service engineers in the country, who have been trained at overseas manufacturing facilities directly on equipment they are required to support.

• Easy access to service and registration of service requests through a countrywide toll-free telephone number (1 800 209 0190), as well as e-mail (service-india@ carestreamhealth.com).

• Practice of using only genuine spare parts with spares being dispatched from mother warehouse only after QC checks.

• To minimise down-time, there are 15 stocking points for spares (warehouses) across India. Regularly required spares are maintained in sufficient quantities at the warehouses to enable prompt

•

response.

The spares management network is a dedicated operation, separate from manufacturing and sales, to ensure prompt delivery.

• Global Technical Support operates round-theclock through the Carestream Technology and Innovation Centres located in China, Italy and the US. • Our current and upcoming products come with remote management service.

Application specialists on different product lines train users for optimum practices to assure best image quality and equipment care for troublefree long-term operation.

What market opportunities and trends do you witness in Indian radiology market? How do you plan to tap them?

The overall growth in healthcare sector presents a great opportunity.

The standards of healthcare and related diagnostics services have shown a sharp improvement in recent years. Modern hospitals in bigger cities adopt the latest innovations in imaging so as to be able to provide worldstandard care to their patients.

Such medicare facilities are in fact driving the increasing flow of overseas patients coming to India to avail healthcare services.

Now we are witnessing another trend with the next level cities and towns (B&C category locations) displaying a more mature and aware market and shifting to digital imaging solutions.

Carestream Health has led the market with its innovations and cutting edge technology products in the imaging segment almost

since the very birth of X-rays over a hundred years ago. We carry a highly respected name in the medical imaging community and it will be our effort to continue to build on that brand by providing innovative and high quality imaging solutions; world class service and support for our entire product range; and bringing latest technology to India almost simultaneously with worldwide launch of products with minimum time lag.

What are your expansion plans?

What strategies do you plan to adopt for expansion?

Carestream Health in India will focus on growing the market through a multi-pronged approach. We will continue to introduce innovative new products and bring the latest technology to India as fast as possible. We will provide scalable solutions that enable growth and connectivity and thus the expandability built into our products itself will lead to growth. Carestream Health will also be flexible in communicating with customers to understand their needs and develop solutions that meet those needs. The emerging markets from second-third tier towns will provide the drivers for further market expansion.

As a leader in the medical Imaging industry Carestream Health believes in growing together with the customers. We proactively contribute to the growth of medical imaging market by developing and introducing innovative and state-of-the-art products improving the quality of patient care. As a knowledge sharing initiative Carestream Health carries out several training and development initiatives for radiology professionals in the country, including orientation programs, student workshops, patient awareness campaigns such as for breast cancer awareness etc.

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Healthcare IT Projects Issues and Opportunities

“Be it the hospitals, pathology laboratories, diagnostic imaging centres or for that matter even pharmacy outlets, today all are strategizing to be different from others and dream of being market leaders. And in order to be able to realize this explicit objective they have started looking at healthcare IT solutions as a critical differentiator.�

Introduction

Dr. Dinesh Tripathi Associate Domain Consultant –Healthcare Informatics 21st Century Health Management Solutions Pvt. Ltd., Mumbai

The vibrant and dynamic healthcare market of contemporary times continues to thrive in an environment of severe cut-throat competition and enormous uncertainties. On the one hand is the opportunity to cash in on the tremendous growth opportunities, while on the other hand there is intense pressure to survive against young, lean and innovative players. Acknowledging this reality, majority of the market players have undergone a dramatic transformation in their attitudes. Be it the hospitals, pathology laboratories, diagnostic imaging centres and for that matter even pharmacy outlets, today all are strategizing to be different from others and dream of being market leaders. And in order to be able to realize this explicit objective they have started looking at healthcare IT solutions as a critical differentiator.

This paradigm shift has significantly paved a way for increased percolation and utilization of healthcare IT products and solutions in healthcare delivery. There is a clear and unanimous understanding among all the stakeholders about the benefits of information technology in improving the operational efficiency, quality of patient care and image branding.

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Thus, in the recent times healthcare IT is undergoing serious boost in its acceptance. However while acceptance signals a triumph; the flip side is that the very decision of deploying IT solutions by healthcare delivery providers exposes a raw wound and thus reveals issues and challenges associated.

If we categorically target the hospital sector, as a general observation, most of the hospitals venture in the adoption of IT solutions keeping in minds the above mentioned benefits. Once decided the process encompasses a whole gamut of activities which ranges from vendor selection to software implementation.

Issues Vendor selection is not the end For most of the hospitals, a myth prevails that selection of a big IT company is synonymous to a robust system and a successful implementation. Hence, a significant amount of time and energy is devoted in selecting an IT vendor.

In fact, majority of the hospitals managements believe that once the budget is allocated and vendor selection is done, their role and responsibility for the remainder of the project becomes passive and is limited only to providing data, infrastructure and some resource.

4TH anniversary special Issue However, in my opinion it is this mindset which is responsible for most of the failures in software implementations in healthcare.

Indeed vendor selection constitutes a critical step but hospitals should look at the project beyond it and with a broader spectrum.

Select solution partners, not vendors The second biggest issue is that hospitals in general select vendors as against solution partners. There could be a non-exhaustive list of vendors in the healthcare IT market but what hospitals should look for is a solution partners and not a vendor.

Generally it is found that vendors come with a technical perspective and thus a very confined knowledge of healthcare domain. This limits them from addressing many such issues which are crucial from the hospital management’s perspective.

On the contrary a solution provider with its rich and varied knowledge of the domain appears more promising and provides both the IT solution as well as the required expertise of the field.

Focus on project management approach Another issue is the practice of neglecting the important role of project management.

Project management approach holds the key to sustained success for any software implementation.

Hospitals should prioritize this concept, both while constituting the in-house plan and also while evaluating the solution partner’s charter. Similarly, adequate attention should be paid while forming and evaluating the project team of both the sides.

Emphasize on people management Yet another issue, which needs to be tackled is people management.

It is a universally accepted fact

“Healthcare IT projects involve a galaxy of management techniques and skills. These projects offer a tremendous learning opportunity to all stakeholders involved.” that success of a software project is highly people dependent. Therefore, in case of healthcare projects, like all other parameters, equal and strong emphasis should be laid on people management as well. It becomes highly imperative for project heads of both sides to keep the team morale significantly high throughout the project. Project delays and apathy at management levels could lead to people disillusionment, which in turn may lead to attrition and thus affect the project outcomes.

Opportunities As discussed above, healthcare IT projects involve a galaxy of management techniques and skills. These projects also offer a tremendous learning opportunity to all stakeholders involved.

Opportunities to the healthcare providers Healthcare providers of any group are the biggest beneficiaries of the IT solutions. They not only get the direct advantages of automation, which the systems offer, but gain much more from other opportunities during the process of IT solutions deployment. Some of such interlaced opportunities include: Business Process Engineering • (BPR): Majority of implementations today involves some kind of re-engineering in the existing processes and

•

•

work flows. By undergoing such changes and improvements, healthcare systems adopt the standard best practices and thus improve their operational efficiency.

Accreditations: With quality the dictum in today’s times, implementation of IT solutions provide an opportunity to healthcare providers in getting their information systems and operations aligned with the standard requirements set for accreditation.

Similarly there exist many such hidden opportunities, which can be explored and exploited in the best interest of the organisations.

Opportunities to solution partners Healthcare IT projects often become a demanding proposition on the solution partners. The difficulties and challenges that accompany any new project can be taken as opportunities of continuous improvement.

Invariably projects of any size can be taken as a canvas to improve and grow on: New improved processes • Innovative use of technology • Expectation management skills • Change management skills • Time and resource management • skills Risk management skills •

Conclusion At 21st century health management solutions, we address the problems of 21st century healthcare with a unique blend of innovation and expertise of domain and technology. With solutions catering to a vast market segment and implementations done using professional and knowledgebased project management skills, we catalyse the healthcare delivery systems. With a strong core team of subject matter experts, it is a very exciting place to work with highly passionate fellow experts as healthcare IT solution partners to some of the leading healthcare providers in India and abroad.

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ezEMRx: Manipal Cure and Care Enabling World Class Healthcare, Aided by Technology Introduction / Vision The project was envisaged during the early part of year 2007 to support a new business unit of the Manipal Group called Manipal Cure and Care (MCC). This project had distinct goals of using technology to automate retail business operations in a healthcare environment, as well as to incorporate best practices and a process based care management solution.

The first steps The whole vision was finalised around mid-2007, and after evaluations on multiple products and solutions, it finally came to light that there does not exist a single solution that can be used in a retail healthcare environment. The challenge was not only in retailing medical services, but also in automating all the front/backoffice functions, integrated with a comprehensive care management system. Something like this was never done before, and/or there weren’t any such past implementations to draw references from.

Multiple ‘best of breed’ products against a single end-to-end solution Though MCCs initial goal was to choose a vendor to provide an endto-end solution; but during the process of evaluations, it was clearly identified that there did not exist any ‘single’ end-to-end solution which could fully be qualified as the ‘best’ on both counts of business operation management and clinical information management. Always a solution was found to be very good

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on the business operations part, but lacking in clinical information management or vice versa.

Over a period of time, it was abundantly clear that if MCC were to automate their new business with ‘best’ technologies; then the same was not achievable using an end-toend solution from a single vendor.

This fact threw open an option of identifying multiple solutions to run their operations. A decision was made and there were no second thoughts in getting to the task of planning, strategizing and going ahead with the vision of getting multiple solutions to work together.

There began a journey in looking for different systems that can cater to the needs of a retail environment and to the needs of a clinical data/care management and co-exist.

MCC evaluated and zeroed in on 2 different products which could be a perfect fit to automate healthcare operations of MCC. But, the challenge began right there, though the products were identified as perfect fits, both these products were radically different in all aspects, ranging from technology, implementation methodology, licensing and functions. While the clinical management system was a web-based product incorporating latest technology offerings on JAVA; the retail management system was a Microsoft based solution. ezEMRx, a practice/care management product from ezEMRx, Inc, Chicago USA, was selected for clinical operations, data management and for EMR; while

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Microsoft Navision/LS Retail, with PwC as the implementation partners were identified for retail and ERP functions.

The act of together!!!

getting

everybody

MCC engaged in a discussion with all the solution providers and shared their vision, and made a strong case for all the partners to work and contribute in the right earnest and get distinct products/solutions to work as one single unit; while at the same time it was also highlighted that the effectiveness and the specific functions of distinctly different solutions were never to be compromised.

Bringing in a method A Project Steering committee consisting of top management resources from MCC, ezEMRx and PwC were formed to set goals, oversee the project and provide direction. This committee met once every month during the initial stages and met once every 2 weeks as the implementation date neared.

A Project Management office consisting of IT personnel, functional heads from MCC and project managers/coordinators from ezEMRx and PwC were established to manage the project.

This team met once every week, and then met twice every week and moved on to meet once every day to discuss, plan and make decisions to ensure on-time rollout.

Project Implementation teams consisting of resources, end-users,

4TH anniversary special Issue technical leads, functional leads and other resources was established to implement the project directives and goals. These teams interacted on a daily basis, identified the touchpoints between both products and went about getting them to work seamlessly.

A clear communication mechanism, reporting structure, risk management, escalation structure and progress evaluation methodology, and other critical procedures were established. This fostered for a very healthy situation where resources and members from different organizations with diverse products and technologies worked as one single unit with razor sharp determination to accomplish the goals that were set for the project.

Go-Live!!!

Within a span of around 5 ½ months after the vision was finalised, the solution was fully implemented in one of the MCC retail healthcare outlets in Bangalore and within a short span of 4 weeks, around 6 other MCC units in different cities including Mumbai, Pune, Ahmedabad and Bangalore were rolled out successfully.

All the initial issues were ironed out within a matter of another 4 weeks and from the 3rd month on the entire solution was moved onto a maintenance mode.

Brief Highlights ezEMRx, is used for guest management, guest medical condition management, guest care management and also has an advanced integration with lab/ medical equipments. This automates the processes of care management.

Microsoft Navision/LS-Retail, is used for POS, billing and back-office operations like inventory, finance, purchase, sales and all other ERP functions.

Integration and Communication Built on a hybrid model of centralised and decentralised operations and management, both these systems integrate with each other using

a web services (SOAP) based communication methodology. The integration happens at the store level as well as at the central level and this drives the business operations of MCC. ezEMRx also integrates with CIMS – a detailed database of drugs and enables for critical care management features like drug interaction information, electronic medical records, e- Prescriptions, schematics, schedule management and process management.

“ezEMRx, is used for guest medical condition management, guest care management and also has an advanced integration with lab and medical equipments.”

Enhancing the experience One of the objectives was overall enhancement of patient experience in MCC, a patient walking into avail medical services, or wanting to purchase retail medical merchandise, goes through a wonderfully transforming experience to a world of SMS alerts, prompts on appointments, prescriptions and medications and retail offers.

Between ezEMRx and Microsoft Navision/LS retail, MCC has more than met its match for whetting its appetite of using the best of the breed technology to improve business operations, enhance customer experience and to offer the healthcare services that can be benchmarked with international standards and practices.

What was bold or radically different The very fact that a strategy was envisaged to streamline healthcare operations in a retail environment with the use of technology was bold and radically different.

Broadly, retail operations

worldwide deal with a POS for its front-office, and a variety of ERP like features for the back-office.

Clinical operations/data management/EMR, include highly secure data management and patient condition management features and EMR, apart from other data points like demographic details, medication history, allergies, family and social history and the like.

It’s these functions that were radically different, and a bold step was made to get both these radically different pieces of the business operations to be automated with 2 distinct solutions/products that were also radically different in their technology.

Risks and Challenges Technology: One of the biggest risks and challenges were to integrate radically different products into a single solution for the business operations.

The second was the risk in terms of integrating products/solutions built on two diverse technologies such as Java/ J2EE and Microsoft. One of the primary challenges was to identify a mechanism, or a methodology wherein both the products/solution could talk to each other without affecting the operating parameters of each other. Other challenges include, getting both the solution providers to agree on the desired integration mechanism – HL7 based Web services communication.

Finally It’s a foregone conclusion that MCC reaped the benefits for choosing disparate, different; but, ‘best of the breed’ solutions to automate their business operations.

The integrated solution is now well entrenched into the MCCs business operations and has now been in operation for over 16 months now.

It was finally realized that the challenge of having to deal with the issues and risks of getting multiple products and vendors to work together was a challenge only up

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4TH anniversary special Issue to the point of getting everybody together and motivating them to work towards a common goal. Once MCC got past this stage, it was all about establishing methodologies to direct, manage and implement.

By choosing ‘best-of-the-breed’ products and getting them to work together, MCC today is reaping the benefits of having implemented best practices and solutions on its business operations as all operations.

Customer Speak “Manipal Cure and Care has always been committed to adopting technology that complies with international standards. The entire experience of our guests from the point where they register themselves are driven by technology, most of the typical concerns that our guests come with are addressed by technologies like our ezEMRx deployment. For

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instance, if a guest is transferred from one diagnosis department to another, there is a fear that he/she might be asked to do the same round of tests again. ezEMRx alerts the doctors if a test prescribed has been carried out before and flashes the results in front of him. Even for research purposes, the archived EMR information can be easily accessed from ezEMRx.” Somnath Das, COO, Manipal Cure and Care “ezEMRx has primarily helped us in three ways. Firstly, ezEMRx starts functioning at a level where it allows us to create an electronic image of the patient (whom we call guests); secondly, from a doctors point of view, it spares him/her the task of writing/typing down every guests case history as ezEMRx provides us with a very powerful ‘aim and click’

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feature to make detailed clinical notes and create an EMR within a few minutes; thirdly, ezEMRx is compliant to international standards and incorporates support for delivering evidence based medicine.”

Dr. Satish Amarnath, Director – Medical Services, Manipal Cure and Care.

“From a technology point of view, ezEMRx is easy to deploy and maintain.

The fact that the architecture and backend technologies have been built using open sources tools makes it easy to manage. With all our centers being enabled with ezEMRx, there is a certain consistency in the information collected as dialects, accents and language are not interferences any more.”

Hanuman Jayaram, Information Technology Department, MCC.

4TH anniversary special Issue

Health Insurance: Ensuring a Healthy Future Professor Howard J. Bolnick , Former Adjunct Professor at the Kellogg School of Management is known to be an international authority on health insurance.

During his recent visit to India for conducting an Executive Development Programme organised by Insurance Foundation of India (attended by senior officials from reinsurance companies, insurance companies, insurance brokerage firms, and HR consulting firms), Prof. Bolnick shared his perspective on the emerging health insurance environment in this country vis-a-vis the world, and discussed some of the opportunities and challenges in wake of increasing adoption of IT in healthcare industry. Excerpts from the interview.

How important, from a healthcare insurance point of view, is to have a national health IT policy or standard based IT practices in health insurance?

Prof. Howard J. Bolnick Former Adjunct Professor Kellogg School of Management USA

To have standard based IT practices in health insurance is fundamentally important. Health insurance is all about data gathering, analysis and dissemination and it is imperative for the Indian health insurance industry to have standardised health IT practices. My understanding is that currently there are not any standards and this is affecting the growth of the industry. The US, for instance, has made tremendous investments in the past decade in developing electronic platforms for data and most transactions are now made by electronic means from hospitals and other providers to the insurance companies.

These changes were encouraged and supported by the federal government.

What is the response that you have seen from the healthcare provider segment in terms of collaborating with insurance providers in making a seamless working environment feasible. What are the challenges that you see?

My most relevant experiences have been in countries that have a well formed healthcare market. The US, for example, has a large number of hospitals, each dealing with a large number of insurance companies, making it difficult to deal with insurance company-specific administrative requirements. Providers, then, have a natural convergence of interest with insurance companies to develop data transmission standards.

In India, on the other hand, the private health insurance sector is not very large and, therefore, it is less obvious for the providers to be co-operative. The insurance

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A lot of companies in India are faced with the challenge of marketing their health insurance products and our healthcare insurance penetration is very low. Why do you think health insurance is still not working in India?

sector is undergoing tremendous growth but lack of standardised data transmission protocols can make the process very inefficient.

I understand that work, here, is being done on papers and this delays payments. The hospitals and insurance companies will benefit from co-operating in the development of protocols for efficient workflow.

Do you think government can play a role in making the two ends meet.

What have the countries in the west done?

Private health insurance in India is developing mainly in general insurance and life insurance companies; but health insurance is different. In the US, health insurance is dominated by companies selling only health insurance. General and life insurance companies will continue to struggle if they do not learn how to manage health insurance. I came to India with the hope of making companies aware of these issues and provide them with ideas about what they can do. However while I am a proponent of marrying International health insurance practices with local culture, it is difficult to mould western ideas to suit Indian culture.

As of now, I am aware of a few

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international health insurance organisations that have ventured into the Indian health insurance market. Ventures like these will help the entire industry as they will raise the bar and address many existing issues, which may otherwise take a long time to get resolved.

In India some of the traditional healthcare companies have ventured into health insurance. Do you think they may be able to run the business better?

I feel, in India, some of these ventures are going to do well because they have very helpful health expertise. In US, however, there are examples of where this is not working.

There is an inherent conflict between providers and insurers and it is difficult to built coorperative relationship between them.

In India, the providers of care tend to overprovide care. Will this problem get corrected if the provider itself provides health insurance?

If the healthcare provider itself provides health insurance, this problem will get automatically corrected, particularly if the provider views insurance as a facilitator of abundant medical care.

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This is a problem with most developing nations, And solutions drawn from the developed world would not work here. In India, insurance agents may well play a significant role in distribution, as they do in developed nations. In addition, health insurance in India may also end up being distributed through banks, cell phones, etc. I have seen a lot of creativity here and a unique Indian solution to the health insurance distribution problem almost certainly will be created.

Microfinance / microinsurance is a big thing in India, particularly in the south. What are the challenges and pitfalls of a microinsurance project?

Microinsurance for health is very interesting. My sense, is that micro- health insurance is a viable option. Clearly the issue is viability and to provide meaningful benefits at reasonable prices.

There are important issues such as whether health insurance can be voluntary or made mandatory; this needs to be thoroughly explored.

Do you think making health insurance mandatory for everyone can address the issue of low health insurance penetration?

With the exception of the US, healthcare systems in the developed world are mandatory.

However, if health insurance is mandated in India, what would it cost? What healthcare services would it cover? And, how would it be paid for?

Ultimately, making healthcare mandatory in India may be a solution, but the course of introducing a mandatory system is very questionable and impossible to predict.

4TH anniversary special Issue

Exploring eHealth innovation in Asia eHEALTH Asia 2009 (part of eAsia 2009), 2-4 December, BMICH, Colombo, Sri Lanka For most of us, the island country of Sri Lanka is known for its pristine beaches, thick rainforests, historical monuments, gigantic elephants, finest tea plantations, and of course, the characteristic Sinhala way of greeting – ‘Ayubowan’.

However, for those who took part in ‘eAsia 2009’ (held between 4-6 December 2009 in Colombo) there is one additional identifier

Presidential Secretariat, Sri Lanka, this event marked the 4th annual edition of Asia’s most premium ICT for Development conference and exhibition.

First day of the conference saw a grand inaugural ceremony consisting of launch by Sri Lankan President Mahinda Rajapaksa.

The ceremony was followed by plenary sessions consisting of eminent experts, commenting on

Sri Lanka is moving ahead in ICT literacy with national IT literacy crossing the level of 30 % in comparison to 4% in 2004 and assured that the Government was committed to ensure that it goes up to 60% by 2012. Rajapaksa said: ICT is the future driving force of economies. It is the tool and the enabler that will push the boundaries of socio-economic development in countries such as Sri Lanka. It is with this aim

H.E. Mahinda Rajapaksa, President of Democratic Socialist Republic of Sri Lanka delivering his Keynote Address at the opening ceremony of eASIA 2009in Colombo.

for this wonderful country – ‘IT Enthusiasm’.

Organised by Centre for Science, Development and Media Studies & Elets Technomedia from India, in association with ICT Agency of Sri Lanka, under the patronage of H.E. Mahinda Rajapaksa, President of Democratic Socialist Republic of Sri Lanka and the

importance and advancements of Information and Communication Technology (ICT) in fields of learning, governance, health and telecentre forum, in addition to emerging technologies.

that Sri Lanka has given priority to ICT, and mainstreamed ICT in all its development activities. It is in this regard that Sri Lanka firmly pushes ahead with pioneering initiatives such as e-Sri Lanka.

Delivering the keynote address at the inaugural ceremony, the Hon’ble President of Sri Lanka, Mahinda Rajapaksa averred that

He underlined that these efforts have resulted in numerous achievements and successes in the field of ICT in Sri Lanka, given

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4TH anniversary special Issue

the fact that country’s percentage ranking in the Network Readiness Index has moved up from 72 to 53 in a span of three years. Voicing his concern over the impact of Internet on young population of the country, he cautioned, “Our children must be protected from the dangers in the cyber space at any cost. Our culture also should not be harmed due to any advances in ICT. I am therefore appealing to all the Asian leaders to take precautions in this regard.”

While information technology is rapidly modernising all areas of human life, healthcare posses one of the biggest potential for bringing a paradigm. Use of technology aides for better healthcare management, accurate clinical decisions, improved medical outcomes and universal medicare access is fast becoming a reality.

Historically, Asian region suffered from poor public health conditions caused due to acute shortage of medical facilities, unequal distribution of healthcare resources and dearth of efficient care management systems. Over the last few decades, proliferation of IT and modern communication tools has provided exploitative capabilities for changing this grim situation.

Emphasizing the benefits of technology driven healthcare reforms and the commitment of Sri Lankan government in this direction, Hon’ble Minister of Science and Technology of Sri Lanka, Prof. Tissa Witharana delivered an elaborate opening address of the eHealth track of eAsia 2009 conference. Urging his fellow colleagues across the region for promoting best-use of ICT in healthcare, Minister Witharana thoughtfully underlined the need for bringing standardization and interoperability for realizing the actual success of ehealth.

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Hon’ble Minister of Science and Technology of Sri Lanka, Prof. Tissa Witharana delivering Keynote speech of eHealth track of eAsia 2009

Focusing on the topic - ‘eHealth Policy, Strategy & Infrastructure’, the first technical session of the conference witnessed some excellent presentations

by Prof. Rizvi Sheriff, Director, Postgraduate Institute of Medicine, Sri Lanka, followed by Dr. Vijay Kumar Soni, CEO, reveiwarticle. net; and Dr. Roshan Hashantha Hewapathirana, CoordinatorBiomedical Informatics, Post Graduate Institute of Medicine, University of Colombo, Sri Lanka.

The focus of all the speakers revolved around the dire need for introducing national eHealth policy across the region and creating enabling environment for its adoption and execution.

The second technical session based on the theme - ‘Telemedicine & Telehealth Initiatives in Asia’ was marked by thought provoking presentations of Mridul Chowdhury, CEO,

www.ehealthonline.org

Clickdiagnostics, Bangladesh; Ms. Saatviga Sudahar, Researcher, University of Colombo School of Computing, Sri Lanka; and Sherif el Tokali, ICT for Development Specialist, United Nations Development Programme, Egypt.

With experience sharing from Bangladesh, Sri Lanka and Egypt, the session turned out to be highly invigorating and insightful.

While healthcare is essentially scientific in nature, its social implications are far reaching and wide spread. Furthermore, technology aided healthcare delivery is bringing completely new dimension in terms of its social construct. The third technical session focusing on ‘Social Transformation of Healthcare’ touched upon this vital element through insightful presentations of Dr. Keith Chapman, Consultant General Surgeon, UCSM, Sri Lanka; B.M.W.U.C.B Jayasundara,

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4TH anniversary special Issue

Researcher, University of Colombo School of Computing, Sri Lanka; and Dr. M. N. Karunatilaka, Medical Officer, Colombo South Teaching Hospital, Sri Lanka.

While ICTs provide a great leveler for bringing uniformity in health sector development, partnerships play a crucial role in optimizing technology utilisation.

Bringing focus on this vital aspect was the session – ‘Building Multistakeholder Partnerships for ICT in Health’. With captivating presentations of Anir Chowdhury, Secretary to Prime Ministers’ Office and Jit Warnakulasuriya, Chairman, Just In Time Group, the session brought to life the fundamental need for fostering successful partnerships among public, private and civil society stakeholders for making ehealth work for the masses.

The second day of the conference started with the session – ‘Emerging Technologies in eHealth’, marked by a captivating presentation by Dr. Aloke Mullick, Head, Clinical Transformation Solutions, OHUM Global Solution Center, India, followed by Mohammad Taha Khan, Research Fellow, Centre for Development of Advance Computing, India; M.A.S.D. Perera, Researcher, Sri Lanka Institute of Information Technology, Sri Lanka; and Nuwan Waidyanatha, Senior Researcher/Project Director,

LIRNEasia, China. The session had paper presentations focusing on open source healthcare solutions, intelligent wheelchairs for disabled patients and webbased real time bio-surveillance solutions.

The following session focused on ‘Data and Information Management in Healthcare’ with presentations of Low Li Kiang, Alliance Director, Hitachi Data Systems-APAC and Hanwoo Sun, Senior Consultant, Samsung SDS. The presentations showcased some the latest technology offerings available in storage devices, networking solutions, archiving and retrieval.

The session on ‘Wireless and Mobile Applications in eHealth’ had some exciting deliberations on emerging technology solutions available for healthcare organisations through the use of wireless and mobile applications.

Dr. Vajira Dissanayake, President, Health Informatics Society of Sri Lanka talked about m-applications in bio-medical informatics; W.M.A.S.B. Wickramasinghe, Researcher, University of Colombo School of Computing, Sri Lanka presented a paper on use of mobile devices in surveillance of communicable diseases and Dr. P. K. Amarnath Babu, State Coordinator, Tamilnadu Health Systems Project, India presented the HMIS project implemented in

the state of Tamilnadu in India.

The concluding session of the conference focused on the topic ‘eHealth Applications for Developing Countries’. The session was underlined by an entrancing presentation by Dr. Denham Pole, Consultant-Medical Informatics, Swiss Red Cross-Sri Lanka, in which he delivered a live demonstration of his open source Multi-Disease Surveillance System (MDSS) by showing real time data from the Trincomaly General Hospital on the east coast of Sri Lanka. Adding to the deliberations were Malmi Amadoru, Researcher, MIT-Sri Lanka talking about the Ayurvedic Information System – ‘AyurConsulter’; Dr. B.J.C. Perera, Consultant Paediatrician, Sri Lanka College of Paediatricians, Sri lanka, talking about the medical journal online initiative of Sri Lanka; Dr. Pramod D. Jacob, Chief Consultant, D J HealthTech Consultants, India talking about EHR best practices and Reetesh Handly Chandrashekar, Associate Consultant, Siemens talking about Monitor Adherence to Dosage and Alert at Mobile devices.

With a plethora of deliberations and a gamut of expert presentations over the three hectic days of the event, eHealth Asia 2009 turned out to be an adventurous exploration for eHealth initiatives in the Asian region.

Catch up with more of such exciting exploration and thoughtful deliberations in our forthcoming eIndia 2010, to be held between 4-6 August 2010 at Hyderabad and the eAsia 2010 to be held in Manila, Philippines in November. Hope to see you there.

Speakers at a panel discussion at eHealth Asia 2009

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January 2010

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(For detailed report of the event please visit www.e-asia.org)

events Dairy

4 – 5 March 2010 Cost-Effective Healthcare Conference

15 – 18 June 2010 CommunicAsia 2010

The Westin Kuala Lumpur, Malaysia

http://www.communicasia.com/

Singapore Expo, Singapore

The Westin Kuala Lumpur, Malaysia

4 – 6 August 2010 eHEALTH India 2010

4 – 6 May 2010 Qmedic Doha Exhibition Centre, Doha, Qatar

Hyderabad International Convention Centre, Hyderabad

http://www.conexqatar.com/qatarmedic/

http://www.eindia.net.in/2010/

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January 2010

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