V OL U ME 4 | I SSUE 2 | FEBRUARY 2 00 9
ISSN 0973-8959
A Monthly Magazine on Healthcare ICTs, Technologies & Applications Volum e 4 | I s s ue 9 | SEPT EM BER 2009 | I N R 75 / U SD 10
GWH portal development in supporting capacity building in the SE Asia region Dr Erna Surjadi, Regional Advisor on Gender, Women and Health, WHO/SEARO PAGE 27
Implementing an advanced hospital pharmacy information system Dr. Karanvir Singh, HeadMedical Informatics, Sir Ganga Ram Hospital, Delhi PAGE 30
Reformation of Healthcare Services through Workforce Development in Healthcare IT Prof. Indrajeet Bhttacharya, IIHMR, Delhi PAGE 34
Health Informatics @ Max Healthcare Dr. Dinesh Jain, Medical Informatics Specialist, Max Healthcare PAGE 38
Enhancing eHealth using m-Communications in developing countries V Dinusha, University of Colombo, School of Computing, Sri Lanka PAGE 43
ww w.e h e a l t h o n l i n e. o r g
EXCHANGING KNOWLEDGE EXPANDING OPPORTUNITIES An exclusive compilation of projects, case studies and best practices in healthcare in ICTs drawn from eHealth India 2009
CONTENTS w w w . e h e a l t h o n l i n e . o r g | volume 4 | issue 9 | September 2009
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eHealth India ‘09: Award Nominees
eHealth India ‘09: Key Speakers’ EHEALTH INDIA ‘09: EXPERT ARTICLES
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GWH portal development in supporting capacity building in the South East Asia Region Dr. Erna Surjadi, Regional Adviser on Gender, Women and Health (GWH), WHO/SEARO
ICT Enabled Hospital of the Year
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Enhancing e-Health using m-Communications in developing countries V Dinusha, Dr. SMKD Arunatileka, Dr. KRP Chapman, GP Seneviratne, S Saatviga, D Wijethilake and SYYD Wickramasinghe Hospital, Ahmedabad PERSPECTIVE
49
Transforming Healthcare through Technology Dr. Vijay Singh Chauhan, Lead Consultant – Clinical, 21st Century Healthcare Solutions
Government Policy Initiative of the Year
30
Implementing an Advanced Hospital Pharmacy Information System Dr. Karanvir Singh, Head-Medical Informatics, Sir Ganga Ram Hospital
34
Reformation of Healthcare Services through Workforce Development in Healthcare IT Prof. Indrajit Bhattacharya and Prof. RK Suri
38
Health Informatics @ Max Healthcare Dr. Dinesh Jain, Medical Informatics Specialist, Max Healthcare
Government Policy Initiatives
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EDITORIAL Volume 4 | Issue 9 | September 2009
P RESI DENT
Dr. M P Narayanan E D ITOR-IN-CHIEF
Dr. Ravi Gupta P RO D U CT MA NA G ER
Dipanjan Banerjee mobile: +91-9968251626 email: dipanjan@ehealthonline.org P RINCIP AL CORRESPONDENT
Divya Chawla email: divya@ehealthonline.org S R. CO RRESPONDENT
Harsha Chawla email: harsha@ehealthonline.org S ALE S & MA RKETI NG
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 S R GRAP HI C DESIG NER
Bishwajeet Kumar Singh GRAP H I C DESIG NER
Om Prakash Thakur WEB
Zia Salahuddin S U BS CRIP TIONS & CIRCULA TION
Manoj Kumar (+91- 9891752931) manoj@ehealthonline.org ED ITO RIAL CORRESPONDENCE
Conversations. Connections. Collaborations... In India, the healthcare sector has been a late adopter of IT. Most hospitals and healthcare organisations started their automation by installing disparate, in-house developed, small solutions and systems. Of late, the rising popularity of more sophisticated health IT solutions, however, has enabled the infusion of advanced information technologies and related developments in the healthcare domain. The change, though exciting, presents new challenges pertaining to affordability of technology, availability of IT skilled medical workforce, use of data standards and interoperability, and best regulatory framework (or the lack of it), among others. Overcoming these challenges and barriers will provide the necessary impetus for the advancement of ehealth in India. With several IT vendors indulging in development of ehealth solutions, and initiation of a number of government projects in this domain, the sector is poised for a consistent growth in future. eHEALTH India 2009 (India’s largest annual event on healthcare IT and communication technologies, being held during August 25–27, 2009 at Hyderabad International Convention Centre) brings together the entire community of this opportune through three-days of active conferencing and a lively exhibition showcasing the latest in technology. This annual event series primarily aim at bringing notable health IT experts, practitioners, technology vendors and stakeholders from the industry, and engage them through keynote addresses, paper presentations, panel discussions and exhibitions. The event acts as a platform for offering multiple opportunities of knowledge sharing among people from government, industry, academia and civil society organisations working in the domain of healthcare services and delivery. In this issue, we bring you an exclusive collection of some of the best eHealth projects and case studies being presented in this conference and those being nominated for our annual awards. Happy reading!
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. is published by Elets Technomedia PVt. Ltd in technical collaboration with Centre for Science, Development and Media Studies (CSDMS).
Dr. Ravi Gupta Owner, Publisher, Printer - Ravi Gupta. Printed at Print Explorer 553, Udyog Vihar, Phase-V, Gurgaon, Haryana, INDIA and published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP Editor: Dr. Ravi Gupta
Ravi.Gupta@ehealthonline.org
September 2009
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ICT ENABLED HOSPITAL OF THE YEAR
MUNICIPAL CORPORATION OF DELHI
M
unicipal Corporation of Delhi, has six major hospitals to provide tertiary patient care for the public including Swamy Dayanand Hospital (250 beds), Rajan Babu TB Hospital (1155 beds), Hindu Rao Hospital (980 beds), MVID Hospital (250), Kasturba Hospital (450 beds), and GLM Hospital (97 beds). The concept behind the HIS system, installed by Wipro Limited (Health Care), is to register the patient once in a life time, issue UHID and connect all hospitals for sharing the patient folder through electronic patient folder. The deployment architecture is decentralised and the product is modular. The database of each hospital has been connected to the central server of MCD through EPF (electronic patient folder), where the details on patient care, lab and radiology reports are available and can be accessed by the treating physician. Wipro HIS also been interfaced with lab equipments, which helps in avoiding re-entering the results in the laboratory system. Results from the equipment are captured and displayed in laboratory module automatically. Implementor: Dr. RC Patnaik, Chief Medical Officer (Health Informatics), MCD Website: http://www.mcdonline.gov.in/healthdetail.php?id=1
“HIS helps in better patient care by retrieval of records, reporting system, inventory control, online availability of patient record and generation of statistical reports.”
HIGHLIGHTS • Connects all the six hospitals catering to the needs of out patient and inpatient functionality within each hospital. • Includes patient registration with demographic details, out patient visits, doctors’ appointment scheduling, admissions/bed, transfers/discharges, order entry, laboratory/radiology/cardiology result reporting, operation theatre management, main stores, sub stores, pharmacy, etc. • Generation of timely census and other reports with accurate data. • Easier inventory management. • Generation of stock reports online and auditing of these reports. • Provision of browser based electronic patient folder.
ARAVIND EYE CARE SYSTEM
T
he integrated hospital management system at Aravind Eye Care System was designed to automate patients enquiry, registration, billing, admission, clinics management, counselling, inpatient admissions, operation theatre notes, laboratory, ward management, and credit services management process. IT has increased the accuracy of the billing, diminution of waiting time, easy retrieval of data for clinical studies and researches, planning, operational management and decision making. Embedded systems for investigations of patients helped to store the findings in the image for reference and also for comparison. For some investigations, it simplified the whole process and patients themselves could undergo test without the help of technicians. In the administrative areas side, accounting software helped to eliminate entire manual work and also preparation of legal documents up to balance sheet and schedules are automated.
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HIGHLIGHTS • Simple Message Service: Implemented to communicate with the patients to increase their compliance rate of surgery, follow-up, medications etc. • Telemedicine: Aravind applied ICT to provide over 500 teleconsultancies in a day. • Eyestalk: Developed for remote consultancy for second opinion using software platform; uses FTP for transferring the medical records between the ophthalmologists. • Medical Image Grading and Scoring: Implementation of ADRES (Aravind Diabetic Retinopathy Evaluating) to send images taken by junior level technicians at remote places to diabetologists for review and diagnosis. Wide Area Network has been setup at these camps using leased line to share the data between branches and the central hospital.
Implementor: Dr. P Namperumalasamy, Chairman, Aravind Eye Care System Website: http://www.aravind.org/
“HMS standardizes processes and improves operational efficiency and performance of the system and staff.”
ICT ENABLED HOSPITAL OF THE YEAR
KOVAI MEDICAL CENTRE AND HOSPITAL
K
ovai Medical Centre and Hospital (KMCH) is a 500-bed multidisciplinary super speciality hospital located in Coimbatore. The hospital has more than 50 medical disciplines managed by highly qualified and trained full time medical specialists providing round the clock service. KMCH is recognized by the Tamil Nadu Government and Central Government for providing medical treatment in specialized areas like open heart surgeries, kidney transplants, joint replacements etc. Hospital is also recognized for getting financial assistance for poor people through Prime Minister’s National Relief Fund and Chief Ministers Relief Fund. The hospital provides cashless treatment through all public sector insurance companies and reputed private sector insurance companies. KMCH has implemented the BackBone HIS for automating its operations. The successful outcome of the entire project has been a result of the great job done by its employees.
Implementor: UK Ananthapadmanabhan, President, KMCH Website: http://www.kmchonline.com/index.php
“Installation of BackBone at KMCH not only improved patient experience, but also reduced administrative work.”
HIGHLIGHTS • Paperless Patient Ordering System: The pharmacy, lab requests, supplies, surgical issues etc., are all done within BackBone thereby completely eliminating paperwork. • Text Messaging: Text messages are used in communicating vital information such as lab results, insurance pre-authorization and amount authorized etc. • Information Kiosk: A very simple to use touch screen kiosk in the hospital’s lobby providing information on patient details, bill details, certain test results and for general information and nonpatients, etc. Another feature offered by the kiosk is a patient self-registration. • Supplier Portal: This is a mechanism to generate purchase orders directly through the system for wholesalers and retailers.
SIR GANGA RAM HOSPITAL
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ive years ago, Sir Ganga Ram Hospital implemented an internationally acclaimed software (TrakCare) from TrakHealth (now InterSystems, USA). Implementation has been turbulent, largely because of large volumes of transactions at every location, which has necessitated the development of unique workflows very different from those originally configured in the software and the tremendous flexibility of the software has aided all this. The software allows tight integration between patient registrations, admissions, billing, discharges, ordering, prescription, pharmacy, laboratories, imaging, stock indenting, purchase, receiving, stores and finance modules. This has lead to better patient management and inventory and cost controls.
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HIGHLIGHTS • Integration of laboratory machines with the HIS. • The electronic medical records module allows patient data to be always available to doctors. • The pharmacy management system includes ordering of medication from the wards, with patient allergy alerts and drug to drug interaction warnings, intelligent drug substitution in the pharmacy from existing stock, inventory controls and MIS reports. • Patient billing is automated so that the bill is always updated and available at all times. • Tight integration between various activities relating to stock have resulted in a tighter inventory control as well as smaller inventory holding. • The volume of MIS data generated by the business intelligence tools has improved management decision making.
Implementor: Dr. Karanvir Singh, Head-Medical Informatics, Sir Ganga Ram Hospital Website: http://www.sgrh.com/
“Installation of TrakCare at SGRH has led to better patient management and inventory and cost controls.”
ICT ENABLED HOSPITAL OF THE YEAR
ARTEMIS HEALTH INSTITUTE
A
rtemis Health Institute is 500 bed state of the art multi-speciality hospital, focused on delivering world class healthcare with its state of the art facilities, spread across India. The first Artemis Health Institute, located in Gurgaon in the National Capital Region, is operational since July 2007. Artemis Health Sciences is promoted by Apollo Tyres Group, which is India’s largest tyre company and is highly regarded for its professional management. The hospital has an HIS (hospital integration system) in place that caters to the front office operations like IP, OP, ER, pharmacy, billing etc. However, the back office operations like procurement, accounts payable, accounts receivables, etc. were not there in the HIS. Hence SAP was implemented to meet the functional requirement of finance, procurement and management reporting. However, implementing SAP is a challenge which becomes even more complicated when integration with another heterogeneous system (HIS in this case) is required. There was a need to ensure that both HIS and SAP talk to each other seamlessly. Implementor: Dr. Kushagra Katariya, Chief Exective Officer, Artemis Health Institute Website: http://www.artemishospital.in/
“At Artemis Health Institute, integration of HIS and SAP has resulted in efficiently managing front as well as back office operations.”
HIGHLIGHTS • Implementation of international patients module is difficult as country and patient specific needs have to be met within the same HIS package and also in SAP. • Pushing the data from HIS to SAP, is one step and confirmation of delivery to SAP is the next step. Confirmation of posting of this information into SAP is another step and finally marking this record as an already read record and to stop it from getting pushed again is the most important step. • Here there are a lot of technical aspects involved like maintaining the sequence of records, maintaining the check of duplicate records, maintaining flag for read and unread records, maintaining the flag and log of erroneous records. • With HIS and SAP seamlessly integrated, there is a single point of data entry and duplicacy is avoided. • Also MRP (Material Requirement Planning) in SAP is done based on the inventory position in the HIS pharmacy locations.
DR. LH HIRANANDANI HOSPITAL
T
he ICT at Dr. LH Hiranandani hospital results in maximum patient safety and satisfaction and staff satisfaction. The inhouse development of hospital management system (HMS) was to have the source code for dynamic changes over a period of time as per operational requirements. The HMS is an operation friendly system which has resulted in reducing the waiting time for patients. The laboratory software interfaces with all equipments for automated data integration, and little or no manual intervention for minimum error. The lab reports can also be viewed online through a secure login that ensures confidentiality. To ensure hat the lab parameters are performing optimally, software for lab for QC checks has also been installed. Even the radiology images can be viewed by nursing staff and doctors through secured login during patient care in OPD and IPD.
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HIGHLIGHTS • Dedicated OPD appointments module. • Hundred percent integrated online Standard Operating Procedures (SOP). • In house developed research software. • Management Information System (MIS) helps management in taking marketing decision and helps the concerned authorities to associate or dissociate with doctors based on their performance. • Strong inventory management modules in HMS to block excess indents, and enabling ROL. • Live telecast of OT procedures to auditorium and even at far off locations for knowledge sharing. • Electronic discharge summary and a printed copy given to the patients.
Implementor: Dr. Sujit Chatterjee, Chief Executive Officer, Dr. LH Hiranandani Hospital Website: http://www.hiranandanihospital.org/
“The ICT at Dr. LH Hiranandani hospital complies with various NABH and international accreditation requirements.”
Technology Innovations in Healthcare...
GOVERNMENT POLICY INITIATIVE OF THE YEAR
DRUG LOGISTICS INFORMATION AND MANAGEMENT SYSTEM
T
he Drug Logistics Information and Management System (DLIMS) handles procurement, storage and distribution of medicines, drugs, injectables, surgical goods and medical equipments and distributes them to medical colleges, district and taluka hospitals, community health centres and municipal corporations (435 direct demanding offices). All activities of indenting, procurement, receipt dispatch, billing etc. are integrated in a single database, which helps maintain accuracy and integrity of data throughout the process. The system improves efficiency and effectiveness of the drug logistics and warehousing process by automated online indenting, monitoring of requirements versus availability of various processes. The existing modules include: indenting, purchase order processing, special programme monitoring, store issuable monitoring, store receivables monitoring, stock monitoring, bill payment and rate contract monitoring. Implementor: Central Medical Stores Organization, Gandhinagar, Gujarat Website: www.gujhealth.gov.in/cmso_initiative.htm
“Installation of DLIMS has helped in developing a different work culture with enhanced computer literacy leading to human resource development.”
HIGHLIGHTS • Centralised data base has increased accuracy, as all activities are inter-related and use the same data base. • As suppliers are also a part of the system, it is a very good example of Government to Business (GtoB) extension of egovernance and this has also enhanced transparency. • System is hosted in central server of NIC hence data disaster, backup etc. are all taken care by NIC’s technical resources. • Management of drug procurement and supply improved due to continuous online monitoring. • As the system is online and all concerned employees and officers use the system at their own.
HOSPITAL MANAGEMENT INFORMATION SYSTEM
T
he state Government’s vision for HMIS is to allow general hospitals to provide efficient and quality health services to build trust and confidence in the hearts of the citizens. The HMIS is a web-enabled system, which practically supports any time-anywhere access by the users. However, the user access has been controlled through GSWAN and role-based access has been imposed in order to protect security of patient records. The HMIS has been envisaged to not only help the administrators to have better monitoring and control over the functioning of hospitals across the state using decision support indicators and management tools, but also assist doctors and medical staff in improving health services with readily available patient data, work flow enabled less-paper processes and parameterised alarms and triggers during patient treatment cycle.
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HIGHLIGHTS • Benefits to citizens: efficient health services due to digitized health records, electronic patient data, organized record keeping and referral services, hospital related and health promotion, reduced per visit time, standardized charges. • Benefits for doctors and healthcare staff: increased efficiency due to easy access to electronic EMR, templatised treatment recording cycle and ICD10 codification support, parameterised SMS alerts for patients, recording observations, reduced timeto-serve patients, building knowledge-base for research & development support and keeping track of and manage biomedical waste as per FDA guidelines. • Benefits to state administrators and medical superintendents: getting real time data, getting state-wide holistic view of hospitals, monitoring pre-defined health indicators, decision support, management information system comprising of status update reporting, monitoring effectiveness of national programs and identifying areas of improvements and comparing data using state wide reports. Implementor: Commissionerate of Health, Medical Service and Medical Education; Gandhinagar, Gujarat Website: www.epch.com
“HMIS has established centralized helpdesk in health department, which helps in providing immediate solutions for resembling queries”.
GOVERNMENT POLICY INITIATIVE OF THE YEAR
AAROGYASRI HEALTHCARE TRUST
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n order to improve access of people, living below the poverty line, to quality medical care, Government initiated a pilot project in May 2004 to partly pay for hospitalisation and treatment from Chief Minister’s Relief Fund (CMRF). However the inability of this scheme to meet the expected needs led to the set up of Aarogyasri Health Care Trust scheme. As of present, following components of the Scheme are under implementation: • Aarogyasri I: for 15 districts and Aarogyasri (I&II combined) for 8 districts through insurance company and funded from medical department budget. • Aarogyasri II: for 15 districts and chief minister’s camp office referrals directly by Trust and funded from CM Relief Fund. All BPL ration card holders (white card) are eligible for benefit from the scheme. The total number of diseases covered under both Aarogyasri I and Aarogyasri II schemes is 942. The scheme is implemented online through an IT portal for efficiency, transparency and accountability.
Implementor: Babu A,CEO, Aarogyasri Health Care Trust, HM & FW Department Website: http://www.aarogyasri.org/ASRI/index.jsp
“Aarogyasri project is web-based project for which the workflow and design has been developed by Rajiv Aarogyasri Healthcare Trust.”
HIGHLIGHTS • A list of diseases for coverage under scheme is pre-identified; pre-existing disease load is covered; hospitalization for treatment is a pre-condition. • Cashless arrangement with network hospitals. • An insurance company undertakes the health insurance and provides risk cover. • Scheme provides coverage for meeting expenses of hospitalisation and surgical procedures of beneficiary members. • A separate fund is maintained as buffer / corporate floater to take care of expenses that exceed the original sum. • Choice of hospital for treatment from among empanelled hospitals is given to patient. • All primary health centres (PHCs), which are the first contact point, are provided with Aarogyamitra (health workers).
HEALTH IT MASTER PLAN
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n April 2008, Ministry of Communication and Information Technology, Egypt (MCIT) laid out the IT Health Master Plan for the Ministry of Health and Population (MoHP) to be implemented jointly with IBM. The project aims at analyzing the current situation of MoHP and identifying its key objectives and future vision, analysing the current situation of Egypt’s health sector vis-à-vis the international trends in the health sector outlining possible gaps and formulating tactical strategies for achieving so. The project has high priority as it concerns the IT strategy for health in Egypt, therefore it was followed up by the minister of communication and information technology, the ministry of health and several other ministers beside the working cooperation team between the two ministries.
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HIGHLIGHTS • MOH Business Vision • MOH IT Vision • MOH IT Implications • MOH Business Current State Assessment • MOH IT Situational Analysis • MOH Future State CBM • MOH Gap Report • MOH Strategic Initiatives & Study Areas - Sample Projects Prioritization • MOH IT Governance Model 10- MOH IT Governance Model • MOH Project Governance Model • MOH Information Model • MOH Conceptual Architecture.
Implementor: The Ministry of Health and Ministry of Communication and Information Technology, Egypt Website: ttp://www.mcit.gov.eg/ProjectDetails.asp x?id=LwoZAzlgsAg=&type=ICT%20for%20Health
“Health IT Master Plan has been developed keeping in mind the Egyptian health system and regulatory framework.”
GOVERNMENT POLICY INITIATIVE OF THE YEAR
TRIPURA VISION CENTRE, TELE-OPHTHALMOLOGY PROJECT
T
he tele-ophthalmology project is an initiative of the Department of Health aimed at offering primary and preventive eye care services to rural citizens of Tripura adopting advances in medical sciences, bio-medical engineering and its convergence with information and communication technology. Poised with the challenges of inadequate medical facilities and limited eye care specialists in the rural areas, this initiative has overcome all geographical, economic, social barriers earlier faced by the rural citizens and has helped them in obtaining quality eye care services from vision centres located at their doorsteps. The project serves a rural population size of 26,48,074 people in remote areas spread across 40 blocks of 4 districts in the state of Tripura. All patients visiting the vision centre are completely examined by an ophthalmic assistant and the medical record is uploaded electronically for doctor’s live tele-consultation from the IGM base Hospital in Agartala. Audio/Video conferencing tools seamlessly Implementor: Dr. Sukumar Deb, Department of Health, Govt of Tripura Website: http://ittripura.nic.in/Vision/TVC_About.pdf
“The application of ICT tools not only takes the eye care services to remote locations but also enables measuring the quality and effectiveness of the service offered.”
integrate with the medical information system in facilitating the quality consultation process. HIGHLIGHTS • Comprehensive model for providing eye care in a decentralized manner, located at all 40 block offices of the state. • Patients are examined by ophthalmic assistants and the medical record is uploaded electronically for doctor’s live tele-consultation from the IGM base Hospital in Agartala. • Audio/visual conferencing tools are integrated with the medical information system. • Network support system of private peer to peer VPN with redundant TSWAN connectivity is established for exchange of information.
TAMIL NADU HEALTH SYSTEMS PROJECT
T
he HMIS project was envisaged by the health department of Tamil Nadu as part of the ongoing World Bank project for IT enablement of the hospitals. The project was conceptualized to provide critical health data across the health chain for quick and timely intervention by the health directorates. The project includes the development and implementation of hospital automation of secondary care institutions across the state and a state wide health IT network for reporting on a uniform reporting platform. All the critical parameters are captured at the end user level and made available real time across the health chain for decision making. The Tamil Nadu Health Systems Project (TNHSP) has been set up to implement the World Bank aided project including the HMIS project under the TN Health Department.
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HIGHLIGHTS • In a short period of six months, 30 hospitals have gone live with the online system. • All respective end users are expected to use the system with NO data entry support. • All registration, stores, pharmacy, wards, lab, doctors’ out patient processes are fully online. • The doctors are directly entering diagnosis, ordering lab tests and giving prescriptions online for all out patients. • The HMIS reporting system covering clinical, program and administrative modules provides for immediate online access to the health administrators at state level on various critical data sets. • The HMIS project brought in the services of various agencies to provide a state of art solution, • Provided data centre support and critical connectivity to the hospitals across the state. Implementor: Department of Health and Family Welfare, Government of Tamil Nadu Website: http://www.tnhsp.org/
“The online system records show over 10,000 patient registrations, around 2000 lab investigations, and 8000 prescriptions being entered daily.”
GOVERNMENT POLICY INITIATIVE OF THE YEAR
NATIONAL NETWORK FOR CITIZEN HEALTH TREATMENT BY THE GOVERNMENT The National Network for Citizen Health Treatment by the Government is a project for cooperation between the Ministry of Communications and Information Technology (MCIT) and the Ministry of Health (MOH). It is providing the most recent automated systems to develop central management of treatment by the government, and direct patients to different therapeutic units, such as hospitals and specialized centres in the country. The project aims to develop quality control and performance evaluation systems to guarantee the delivery of subsidy to those for whom it is intended, and guarantee system efficiency. It also aims to develop the information systems and databases of the central department for citizen health treatment by the government, and connect all peripheral departments and hospitals through a web based application. The Information System of Citizen Health Treatment by the Government makes information instant, easy to access, easy to update, and always available for those who need to know, and exceeds to support decision taking.
Implementor: Ministry of Communications, Smart Village, Giza, Egypt Website: www.mcit.gov.eg
“Automation of 50 remote sites allows the citizens to access the service through the nearest remote site and avail all medical and financial information.”
HIGHLIGHTS • Automating and linking 50 remote sites to the headquarters in Cairo. • Processing around 8000 treatment requests daily from all the remote sites and the main centre. • Following up on the provision of state-funded healthcare services to prevent fraudulent use of these services. • Using the International Classification of Diseases and Related Health Problems (ICD) and Current Procedural Terminology (CPT) coding systems in treatment and diagnosis. • Providing accurate data and statistics regarding state-funded healthcare services. • Establishing collective integrated databases to serve the requirements of the Ministry of Health and researchers (contains round 7 million medical records).
HEALTH MANAGEMENT AND RESEARCH INSTITUTE
T
he Health Management and Research Institute is a registered not-for-profit organisation working with the Government of Andhra Pradesh, India, in a public-private partnership to transform the existing health care system through the innovative use of information technology. Through both physical and virtual interactions with its users, HMRI delivers a wide range of critical services: medical advice/counselling, detection/diagnosis, monitoring, health/hygiene education, and drug prescription/dispersal. The unique means provided by HMRI include: 104 Advice, providing free non-emergency medical advice on the ‘104’ number; and 104 Mobile, which offers services to remote rural populations by a networked fleet of 475 mobile health units (MHUs), which serve as one-day-a-month local health clinics. In addition to the radical improvement in the quality and access to health care for the rural poor, HMRI’s integrated digital system also permits better monitoring and response to disease trends and epidemics. Implementor: Balaji Utla, CEO, HMRI Website: http://www.hmri.in/
“HMRI provides unique means of reaching at-risk rural populations to supplement the existing traditional healthcare platforms.”
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HIGHLIGHTS • Caller Registration: each caller is provided with a unique id, so that beneficiary records of repeat callers can be retrieved. • Decision Support System: used to automate the diagnosis of the caller’s medical condition 83 algorithms are mapped to more than 550 disease summaries, enabling diagnosis of minor ailments by trained paramedics, allowing doctors to focus on complex cases only. • Direct transfer to emergency response system (ambulance service) for emergency cases. • SMS Prescription: Doctors prescribe over-the-counter drugs through an SMS sent to the caller’s mobile number. • Voice recognition of nuisance callers through a software.
CIVIL SOCIETY DEVELOPMENT/AGENCY INITIATIVE OF THE YEAR
AMBULANCE CALL TAKING, FILTERING AND TRANSFERRING SERVICES
T
he main objectives of the Ambulance Call Taking, Filtering and Transferring Services include: enhancing decision making process for emergency call requests; applying proper advanced tools to manage and supervise emergency call requests; developing the call taking process in the dispatching centre and digital recording of all parameters of incoming calls requesting emergency medical services; deploying reports application that provides tools to manage and retrieve all information needed regarding the call basic parameters; providing tools to record, manage, and analyse the statistical analysis for the call taking services as well as the process performance and the quality of service and assuring best effort and time saving, in handling emergency cases.
HIGHLIGHTS • Filtering the incoming calls at Greater Cairo ambulance from 130,000 calls per day to an average of 2500 calls per day. • The registration of all parameters of emergency call, generating daily reports and statistics. • Voice recording system for all calls to punish ambulance abusers. • All emergency ambulance service calls (123) are being answered as soon as the caller dials the number. The ability to search for any specific data or call at any time. • Building a database repository for all emergency calls for Greater Cairo. • The service is improved periodically to add more functions to handle the project like complains handling and patient surveys.
Implementor: Ministry of Communication and information Technology, Egypt Website: http://mcit.gov.eg/ict_health.aspx
“The service applies proper advanced tools to manage and supervise emergency call requests.”
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eHealth India ‘09: Key Speakers
Key Speakers The speakers at eHealth India ‘09 include luminaries from the government, healthcare, IT, academia as well as research sectors. The speakers will talk about a gamut of articles ranging from ICT best practices and innovative applications in healthcare to funding landscapes and emergence of technology in this sector. We bring to you, some of the key speakers at eHealth India ‘09.
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Dr. Ajit K Nagpal Chairman-Executive Council, Batra Hospital & Medical Research Centre, New Delhi & Former Advisor, Ministry of Health, UAE
J. Satyanarayana Principal Secretary Department of Health & Family Welfare Government of Andhra Pradesh
Dr. Girdhar J. Gyani Secretary General, Quality Council of India & CEO, NABH
Dr. Shakti Gupta Professor & Head Department of Hospital Administration, AIIMS
Surgeon Rear Admiral (Retd.) Dr. VK Singh, VSM Director International Institute of Health Management Research New Delhi
Dr. S Arhulraj President, Commonwealth Medical Association
Dr. V Balasubramanyam Domain Consultant-Medical E-learning & Professor, Dept. of Anatomy, St. John’s Medical College, Bangalore
Dr. Shafqat Khan OSD, Department of Health & Medical Education Government of Jammu and Kashmir
Divya Sehgal Executive VP & COO Apollo Health Street
Babu. A CEO, Arogyasree Health Care Trust Government of Andhra Pradesh
Praveen Srivastava Director (Stats), Ministry of Health & FW, Govt. of India
Dr K Ganapathy President Apollo Telemedicine Network Foundation
Dr. Erna Surjadi Regional Adviser-Gender, Women and Health WHO
Bhudeb Chakravarti General Manager National Institute of Smart Government
Dr. Balaji Utla CEO Health Management & Research Institute
September 2009
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eHealth India ‘09: Key Speakers
Dr. Suman Bhusan Bhattacharya VP-Clinical Services Karishma Software
Dr. Dinesh Jain Medical Informatics Specialist Max Healthcare
Dr. Rathan Kelkar Director, Kerala IT Mission Government of Kerala
Dr. Rana Mehta VP-Healthcare Practice Technopak Advisors
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Dr. Karanvir Singh Head-Medical Informatics Sir Ganga Ram Hospital, Delhi
Wg. Cdr. (Dr.) Sanjeev Sood Sr. Medical Officer Indian Air Force
Srikanth Muthya General Manager (Healthcare IT), GE Healthcare
Manish Gupta CIO Health Care Global Enterprises
Dinusha Vatsalan School of Computing University of Colombo, Sri Lanka
Vikram Gupta COO India Ventures
Vamsi C Kasivajjala Executive DirectorHealthcare, Sobha Renaissance IT
Venkat Changavalli CEO Emergency Magaement and Research Institute, Hyderabad
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Satish Kini Chief Mentor 21st Century Healthcare Management Solutions
Vishnu Gupta CIO Calcutta Medical Research Institute
Subramaniam Director Syntax Soft (ezEMRx)
Lt. Col. (Dr.) Salil Garg Sr. Cardiologist Command Hospital, Pune
UK Ananthapadmanabhan President Kovai Medical Centre & Hospital, Coimbatore
Vijayrajan A Chief Executive Officer Clinitics
Dr. Inderjith Davalur CEO Aosta Software Technologies
Dr. Pradeep Bhardwaj COO Ojjus Medicare Group
EXPERT ARTICLE
GWH portal development in supporting capacity building in the South East Asia Region The paper highlights the gender disparities in the South East Asia Region and the development of Gender, Women and Health Network to support gender and health programmes.
of the problem is not merely coming from the victims but the perpetrators; gender biased perspectives/ stereotypes and or environment as well; a gender sensitive health care approach is needed.
Dr. Erna Surjadi Regional Adviser on Gender, Women and Health (GWH),World Health Organization for the South East Asia Region (WHO/SEARO), New Delhi
Introduction The new paradigm of health development has shifted the curative and rehabilitation principles into prevention and promotion of health care; it is also meant to empower people for self care to have healthy life style. Health for all is meant for everybody over ages, demography, sex and society. However, the expectation of relation and position of men and women in the society has created gender disparities over generation from time to time. The lack of knowledge, access and opportunity of women as compared to men has brought implication to women’s health. Gender mainstreaming (GMS) in health in the South East Asia region has been implemented to address gender disparities in health, perform gender analysis and actions to support gender equality and health equity in the region. The gender responsive action is hoped to give better future for human welfare and development as well supporting health for all. However, since the root
The South East Asia Region (SEAR) has challenges to motivate men as leader to implement human’s rights including women’s rights, building capacity of gender focal points to raise the gender awareness for gender equality between men and women; perform gender analysis and actions to support health equity and advocate member states to perform gender mainstreaming in health to achieve gender equality and equity in health. Unfortunately, health information system is not using sex-disaggregated data most of the time; so the gender disparities in health are not shown or being recognized by decision/ policy makers. This becomes great challenges for all countries in the region.
Gender, women and health network (GWHN) To support promoting gender equality and women’s empowerment towards health for all as stated in Millennium Development Goals (MDG No.3, 2000) and World Health Assembly resolution (WHA60.25, 2007) on integrating gender analysis and actions into the work of WHO; human workforce is needed. However, there are limited human resources to work in gender and health; in addition the gender area is crosscutting issue so that multi-sectoral approach is considered important. The development of
Gender, women and health network (GWHN) in South East Asia Region (SEAR) is expected to empower as well as to catalyze the existing infrastructure within organization to support gender and health programmes in the region and country level. Members of the GWHN are various among United Nations agencies, government, non government organization, academic and professionals where WHO plays a role as facilitator. The fast growing technology on information and communication has proved its good impact on society and world development; thus it is hoped it may give benefits to GWH work as well. This E-health initiative has been started in the region to give services for country and supporting link to headquarters and other regions as well. The gender, women and health network (GWHN) portal development was developed based on intention to have sharing knowledge from the distance among members; create, consolidate and maintain the network; promote theories, practical issues, adaptation models, training modules, gender programmes/ activities, partnership etc. in the area of gender & health and to save time, energy, money but increase creativity, productivity, best practices and support the GWH network. The GWH portal will be used as distance learning for all gender focal points to fasten the process of capacity building but not necessarily eliminating the face-to face training. The material attached in the portal has function as one stop visit to GWH knowledge management for persons September 2009
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EXPERT ARTICLE
who have limited time or distance constraints for gaining information and communication on the area of gender, women and health.
The Gender, women and health portal knowledge management (GWH-PKM) The GWH portal knowledge management will play a role as centre for information and communication to support knowledge management across countries, institutions, multidisciplinary, multi-sectoral, WHO collaborating centers (WHOCC), available resources for similar programmes/ activities and open links to other United Nations (UN) agencies as well. Only members may access the facilities of papers, databases, resources etc; however public may read announcement, public information etc. This portal will give historical documents of GWH development landmarks, provide sharing and access to SEARO website/ others and limit the interactive query for certain documents/ information (not meant for back and fort/ long discussion on various topics).
Member facilities In principle, any professional who has registered as member of Gender, women and health network (GWHN) in region and country level may apply as member of this GWH portal knowledge management. Thus, this portal will run based on institutionalization and not by individualization as a management tools as well to advocate the development of GWH network in the region/ country level. Professionals who had attend any GWH WHO/SEARO meeting are automatically registered in the member list; unless the country has put up updating or objection to the list for accepted reason. The GWH portal has been introduced in the Regional consultation meeting on multi-sectoral approach for GWH work, in Colombo, Sri Lanka, March 2008. Ten out of 11 countries in SEAR (Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Sri Lanka, Thailand and Timor Leste) have supported and confirmed the need. Nepal at that moment had country
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restriction due to election period. GWH WHO headquarters, Geneva was also present and supported. The trial process for GWH portal is being accessed by participants in Colombo to get link to the temporary server at WHO/SEARO which is based in New Delhi, India. Participants could read formal documents such as resolutions, published paper as well as tools for gender sensitivity etc. from the distance. The GWH portal knowledge management has been considered as promising tool to support capacity building through gender and E health development. GWH-PKM is aimed to distribute immediately any important report and findings for the GWHN.
Report and Documents sharing Material for e-Learning Members may upload new published document and the secretariat in the regional office will confirm only after receiving the formal approval from sources. In the case it links to country website; the responsibility is given to country secretariat. The GWH portal will not receive un-published document and will receive announcement only from certified users. It is hoped that users will get faster distance learning on gender and health to support the GWH missions. GWH-PKM is also aimed to capture and share GWH events and important features to support gender equality and health equity in the SEA Region. Picture is a thousand words; gallery of photos and other images is developed to be shared within the GWHN. These could act as stimulant for other members for best practices and resource mobilization as well among the networks. Historical events and best practices GWH-PKM is aimed also to advocate the development of GWH Network in the region and country level; thus the media has given also information about the related institutions and open opportunities to be in the GWHN through GWH portal knowledge management in SEAR. Information
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and communication are considered important to create a bond among networks to support the GWH mission in eliminating gender disparities in health. In consideration to the fast growing technology, WHO/SEARO and GWHN may get advantage by this portal development for sharing scientific findings to eliminate gender-based violence, increase collaborative works with men/ boys for gender equality to support family advancement, distance suitable justification for decision/ policy makers to support world development, especially in gender sensitive health care.
GWH networks information Remarks This GWH portal knowledge management is planned to be fully implemented in year 2010 through finalization of the portal and training for region and country facilitators. It is hoped further supporting the process of gender capacity building and knowledge management development on policy, strategy and tools for gender mainstreaming in health through distance learning as well as sharing experiences for best practices, constraints and challenges among gender focal points and its stakeholders in the SEAR countries. This could be best supplement to face to face training which still needed to have alive-discussion and proper transfer of knowledge in gender and health. It is planned further to be linked also to country’s websites and headquarters’; so that it may empowered the GWHN within the global development on gender education and capacity building. It is hoped that this GWH portal development could also increase member-states collaborative works and GWH networks (GWHN) communication on gender and health to support gender equality and health equity in the South East Asia Region. To read the complete paper log on to the website: www.eINDIA.net.in
EXPERT ARTICLE
Implementing an Advanced Hospital Pharmacy Information System This paper discusses the problems encountered during implementation, how they were overcome, giving an inside view of one of the very good pharmacy modules currently available in the market.
Introduction
Dr. Karanvir Singh Consultant Surgeon and Head-Medical Informatics, Sir Ganga Ram Hospital, New Delhi
The pharmacy in a hospital is an area where the medical and non-medical components of a hospital information system (HIS) meet. Alongside inventory control are components relating to drug allergy warnings, drug-drug interaction alerts and intelligent pharmaceutical substitution of prescribed drugs from within current inventory stock. Sir Ganga Ram Hospital, New Delhi, went in for enterprise wide computerisation of its hospital, including its pharmacy in June 2007. The hospital has an in-house pharmacy with a daily turnover of over Rs 13 lakhs. Implementation of the HIS in our pharmacy has been turbulent but has resulted in a system that is meeting most of our requirements.
Our history Sir Ganga Ram Hospital had been running a FoxPro based system for over 20 years. The system had been custom developed by a local Delhi based team. It covered admission and discharges, had a basic laboratory module, a billing module where all charges had to be manually entered for most items, an inventory control system and a basic pharmacy system. Medicine stock was received by the hospital and batch level prices were entered at the time of receiving the stock from vendors. Requests for patient medication were sent to the pharmacy on slips of paper. The pharmacist typed in details of the medicines dispensed to the patient in the system which automatically
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reduced the stock and also billed the patient based on the price entered for that medicine at the time of receiving the stock from the vendor. There were however many lacunae in the system. There was no interface for the care providers to prescribe medicines, get real time drug to drug interaction alerts or get notified of patient’s drug allergies. In the pharmacy, the system did not allow substitution of an ordered drug with another similar drug from current pharmacy stock. There were security related issues also. Since FoxPro is not a very secure system, there was always the potential of manipulation of data directly in the transaction tables. Also a transaction history and audit trails were not maintained. Apart from the pharmacy module the other FoxPro modules were also getting antiquated. What was missing was a tight integration of the various modules running in different parts of the hospital. It was hence decided to upgrade the entire HIS and go in for a more secure and integrated system. We surveyed the market. There were many vendors supplying software. However at that time there were very few that were mature. Mature means an application that has been successfully implemented in at least a couple of hospitals other than the one it was originally designed for. We chose TrakCare (now with InterSystems, USA)
EXPERT ARTICLE
because it has a track record of over a hundred implementations worldwide, many of them in third world countries. There were some apprehensions about the vendor being not in India; however their implementation local partner turned out to be very competent and we had a successful implementation. An integrated pharmacy module was what we got along with the rest of the software.
Advantages Computerised Physician Order Entry (CPOE) This paper slip step of the FoxPro system has now been removed, with the care providers being able to place medication orders in the system at the ward level itself. This allows the hospital to also limit the number of medicines they can order. We can limit the list of medicines visible to care providers initially to only those that are listed in the hospital formulary. Since formulary drugs are available at a much lower price than non-formulary drugs, their purchase price having been negotiated with the vendor, it adds up to a substantial cost saving. In case the care provider does not find the medication in the formulary list, he has the option to uncheck the ‘Limit to Formulary’ box and see all medicines. Interaction alerts The HIS system warns of drug-drug interactions and gives details of each interaction type. However to be really useful, all medication prescription entries need to done in the system by the doctor who is more likely to attend to the alert than if the same entry is being done by a nurse on the behest of a doctor. Allergy alerts Allergy alerts are also provided by the system. In case the patient has been flagged to be allergic to a particular medication, even during a previous visit to the hospital, such alert information is carried forward during the lifetime of the patient, unless manually cancelled by a care provider. The system does not stop the prescription from going through; it simply warns the doctor.
Drug monographs Drug details (monographs) are available in the system. A doctor can click on a drug he is planning to prescribe and read up details on the indications, dosage, side effects, interactions, etc. This data had been provided to us as part of the drug database that we purchased prior to starting the system. Drug substitution Intelligent drug substitution works by substituting another drug only if the generic drug, strength, drug form, route and unit of packing are the same for both the drugs. Thus, tablet Crocin does not substitute with injection Calpol. Nor does tablet Crocin 250 mg substitute with tablet Calpol 500 mg. It also will not substitute Tetanus Toxoid vial with Tetanus Toxoid ampoule, since the packing unit is not the same. Drug substitution mapping has been a very laborious step and it took us many months even after the start of the system to get everything correctly mapped. Now it works flawlessly. Inventory control We have been able to stop ‘leaks’ from our stocks. At any time it is possible to know the medicine stock lying at various substores. This also allows us to move stocks from a location where they are in excess to areas where they are urgently needed. It also allows us to recall a batch from circulation should it be required since we can trace movements of each batch to various substores as well as patients to whom they had been dispensed. Billing for medication Each batch of a drug has a price attached to it at the time of receiving the drug in the hospital’s receiving section. This is what gets billed to each patient without any additional user intervention.
Problems Stock transfer on ‘go-live’ One of the biggest problems was transferring of stock quantities from the FoxPro system to the new system at the time of ‘go-live’. We realised that stock data in the old system had many inconsistencies. We did make mistakes
“There were some apprehensions about the vendor being not in India; however their implementation local partner turned out to be very competent and we had a successful implementation. An integrated pharmacy module was what we got along with the rest of the software.”
and had to upload the inventory twice before we got it right, necessitating the pharmacy to remain closed for a couple of days and putting a severe burden on the hospital. What we learnt from this was how to migrate stock from an older system into a new system differently. We have since then used this method for transitions in other stores and have had no problems. Drug database We tied up with the publishers of a popular printed drug database provider to get data in an electronic format that could be uploaded into our new system. Unfortunately, the structure of the database we received was more in keeping with the provider’s own requirement, which was to store the data in an easy to read format for their website and printed publications. For data upload into an intelligent drug substitution system, the data has to be as ‘granular’ as possible, i.e. broken down to its smallest component. Drug substitution requires the drug form (tablet, injection, drops, etc.) to be stored in a field separate from that of its strength (2 mg, 100 mg, etc.). The packing unit (ampoule, vial) also needs to be in its own separate field. What we received were combined fields with data stored like Injection Fortum 500 mg/1000 mg. We had to manually September 2009
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EXPERT ARTICLE
“The success or failure of the pharmacy system depends on how well the rest of the information system has been implemented. It also depends on how tightly the software vendor has integrated the systems.” split the Injection, Fortum, 500 and gm words into individual fields and also create an entirely new row for the 1000 mg injection. Another problem was that drug interaction data was maintained as a textual narration. A proper interaction warning system requires it to be in a tabular form, with the first column having the name of the first drug, the second column having the name of the second drug and the third column having the interaction details. The entire process of making the provided data conform to our system took months of manual data manipulation. It was not that our system was too demanding and had not been built in a user friendly way. Any system that provides intelligent drug substitution will need data in a ‘granular’ form. Another problem with obtaining data from a drug database provider was that updates were available on a monthly basis. For a hospital that inducts new drugs as and when they appear in the market, this was too much of a delay. We started entering drugs on our own when they appeared in the market. There was then an issue of duplicate drugs being uploaded into the system once the monthly update arrived, if we had already entered that drug on our own. And the work required to individually split the provided update data into individual fields each time was too daunting. We hence discontinued our subscription and now manage updates internally. A disadvantage of this approach is that
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we are not populating drug monograph and drug to drug interaction data. MIMS apparently maintains data in a granular form that is compatible with pharmacy systems. However for this to be practically useful, the system should have a comprehensive list of Indian drugs and should provide very frequent updates that can be simply uploaded into the system with minimum manipulation.
Inviting open tenders for medicines We maintain all data on drugs that come in a tablet form at a unit tablet level. Thus the stock count in the system is of the number of tablets and not number of strips. Similarly all price data in the system is of unit tablet cost and not cost of the strip. Although this system works well internally it creates problems when we invite quotations from vendors. Vendors prefer to quote prices as mentioned on the strip. To act as a bridge between how vendors maintain and quote prices and how we manage them internally, we made a stand alone software that vendors download from our website and use to send in their quotations. They enter quantities in strips and prices as mentioned on the strip. The software converts it into the formats we use and allows us to directly upload into our system.
How much has the new system helped us? Hospital profits Compared to the years before implementation of the current HIS, overall pharmacy profits have gone up by approximately 15%. Considering our daily turnover of about Rs 13 Lakhs, this is a fair amount. There are many possible factors leading to this. 1. Less ‘leaky’ inventories. 2. Intelligent drug substitution. 3. Better utilisation of stock leading to a smaller inventory and less capital tied up. For example if one substore needs an item they do not have, we can locate it from another substore and transfer it from there. 4. Complete billing. In the previous partly manual system, items were used for patients and sometimes
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5.
not billed. That does not happen anymore. Better MIS reports, leading to more intelligent decisions regarding functioning of the pharmacy.
Has it affected care providers and patients? The initial impression has been that the time lag between prescribing of medication and its delivery has not been changed much by the new pharmacy module. This implies that other bottlenecks exist in the delivery of medication to wards. To identify these bottlenecks and their dependency on each other, our hospital is planning an audit. Amongst other thing, this will include following up a large number of prescriptions originating from the wards and measuring the time taken between various activity benchmarks, e.g. time between doctors prescribing a medication and actual entry of that order in the HIS, time between packing of the medication in the pharmacy and its pickup from the pharmacy, and so on. Another aspect that is being studied is the effect the new system has on preventing prescription errors, allergy alerts, etc. The problem with such studies is that we do not have much historical data to compare it with, since such studies were not done in the past in preparation, as baselines, for future studies. A pharmacy information system is only part of an overall hospital information system. The success or failure of the pharmacy system depends on how well the rest of the information system has been implemented. It also depends on how tightly the software vendor has integrated the systems. For instance, in our hospital, purchase, good receiving, stock transfers, stock consumption on dispensing, billing to patients and their reflection in the finance module are all linked. Unless a hospital ensures that what they are getting is similarly linked, implementing a pharmacy information system may not give them the best returns on investment. To read the complete paper log on to the website: www.eINDIA.net.in
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
EXPERT ARTICLE
Reformation of Healthcare Services through Workforce Development in Healthcare IT The paper provides an elaborate description of ‘Cloud Computing’ and its applications and advantages in the healthcare domain.
e-Health in India
Prof. Indrajit Bhattacharya Professor, International Institute of Health Management and Research, New Delhi
Co-Author Prof. RK Suri Director General, Monrad University, UP
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e-Health offers some ready products for accelerating the health sector reforms in India. The shortage of infrastructure, manpower and services in health sector in India is mainly attributable to the large gap in overall development between rural and urban areas. This gap levies substantial disincentive on health manpower for working in rural areas. e-Health offers a good option wherein a significant proportion of patients in remote locations can be successfully managed locally with advice/ guidance from specialists in cities, without having to travel far. This allows linking patients in remote areas to urban standard services without delinking urban service providers from their environment. The arrangement offers easier, cost effective consultation, prescription mechanism and allows a referral chain. e-Enabling also improves depth, range and refresh rate for disease surveillance and response. However, this change over to digital way of thinking in the health sector has rather high initial costs. The licensing terms and conditions, bilateral and interconnection agreements, nonexistence of regulations, security and trade issues are serious bottlenecks which need to be addressed. India is the ideal setting for telemedicine assisted health care. We already have a strong fiber backbone and indigenous satellite communication technology with large trained manpower in this sector. Various state governments, departments of the Government of India, private institutions and NGOs have been running a number of e-Health projects over recent
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past with successful outcome. In this scenario, a country level e-Health plan is long due to steer e-Health. The enhanced allocations for e-Health over the XIth Plan can be used for the following major activities to accelerate and expand the reach of the architectural correction in the health system which is envisaged under the NRHM.
Reformation of Healthcare services in India While the government controls most of the health care resources and prices, hospitals are financially independent and make their own HIT choices. A growing healthcare services sector is leading to a significant imbalance in the HIT development between highly developed regions versus those at the country level hospitals or in rural settings. A late HIT development advantage that Indian infrastructure has to be equipped with more current and advanced hardware infrastructures and modern approaches to software development, such as service-oriented architectures (SoA) and the latest application development platforms. Since overall hospital HIT investment is small, much of the current software is of low quality and low cost.
Cloud Computing By accessing technology that handles various tasks, from electronic health records (EHRs) to on-line appointment scheduling, as a service through the Internet instead of developing, purchasing and maintaining technology on-site, it is possible to update clinical processes and increase key efficiencies
EXPERT ARTICLE
to improve patient care. For example, by digitizing health records and other processes, medical transcription costs can be reduced upto 80 percent and now can provide faster and more accurate billing to individuals and insurance companies, reducing the average time to create a bill from 7 days to less than 24 hours. In the United States, the new American Recovery and Reinvestment Act will infuse USD 19 billion into healthcare IT and calls for the utilisation of an EHR for each person by 2014. While EHRs help deliver smarter healthcare systems with real-time access to critical patient health information, only an estimated 38 percent of US physicians used partial or full EHRs in 2008. In current IT circles, the Internet is often referred to as The Cloud. Think of multiple computers in a giant mesh all inter-working together. Now think of many such meshes and step back … see The Cloud? The power of computing measured in terms of tens of trillions of computations per second is now applied to delivering personalized medical information, computational chemistry and biology over the web. The idea behind the concept is to network large groups of servers that have low cost PC configuration to do distributed data processing activities across the network using specialized connections. The industry has been always uncertain whether they need software that is located centrally or have software that resides on the user’s system. With the development of high speed networks and with highly sophisticated and ever evolving cheap server technology the computing capabilities are being shifted to data centres. Cloud computing is quite similar to grid computing but it is a more powerful, hybrid and a safer computing arena. Cloud computing can be defined as a set of virtual servers working in tandem over the internet. The applications are easily accessible through the internet and these applications use large data centres and powerful servers that host web applications and services. Grid computing involves dividing large tasks into smaller tasks and running those in a number of parallel
systems. In contrast cloud computing architecture is a collection of resources which are managed dynamically and can be provisioned, de-provisioned, monitored and maintained at any point of time. Cloud computing, also called Software as a Service or SaaS, has particular value in the healthcare industry. It is inexpensive, ubiquitous, and secure. All data and applications are stored on secure servers accessible from anywhere there is Internet access. Healthcare IT is, as usual is lagging behind the rest of the universe. In the early part of the decade, companies like Amazon began architecting their websites in such a way that you could utilize their services simply through the use of a browser like Netscape or Internet Explorer. Fast forward to now when companies like Google and Microsoft offer “in the cloud” services that do not require hardly any additional software on your local computer, beyond the operating system of the computer or device and a browser. Some services are offered for free by merely signing up, while others are offered as a recurring, monthly, per-seat subscription; schemes include Software-As-A-Service (SaaS) and Application Service Providers (ASP). It is a trend and a pattern that is quickly gathering steam.
Cloud Computing as it applies to Healthcare The trend appears to be irreversible. Many software applications, services, and data once in the realm of a local computer or local server safely secure in your building are now in the domain of the public Internet. Private health information once confined to these local networks is migrating, wholesale, onto the Internet. Patients voluntarily grant access to their health records every time they sign a waiver to the health insurer that then decides on the payment disposition to the doctor, pharmacy, or hospital. For the most part, the collection and organization of this data is completely legal. It then follows that companies want to automate and accelerate access to these records in order to then offer “in the cloud” products
and services to both patients, doctors, and institutions. The fact that Google and Microsoft are heavily invested “in the cloud” extends to their new offerings for medical records services, such as Microsoft’s HealthVault and Google Health. While still in beta testing, these software giants have partnered with large healthcare providers for their programs: Microsoft with Kaiser Permanente and Google with The Cleveland Clinic. Convergence of events can be envisaged considering the new Obama initiatives like “Transforming healthcare” and “Enabling Healthcare Reform Using Information Technology” — recommendations by the Healthcare Information and Management Systems Society (HIMSS) to the Obama administration and the 111th Congress. There would be a vast influence of cloud computing in healthcare. With healthcare providers looking at automating processes at lower cost and higher gains cloud computing can act as an ideal platform in the healthcare IT space. Cloud computing could be seen as a boon to healthcare IT services as a number of hospitals could share infrastructure with vast number of systems linked together for reducing cost and increasing efficiency. This also means real-time availability of patient information for doctors, nursing staff and other support services not within the country but possibly across various countries as medical professionals can access patient information from any internet enabled device without installing any software. In the cloud computing scenario the EMR (Electronic Medical Record) software or the LIS (Laboratory Information System) software and information are located in the central server and not on the users or computer. Patient information and data can be accessed globally and resources can be shared by a group of hospitals rather than each hospital having a separate IT infrastructure. Cloud computing would help hospitals to achieve more efficient use of their hardware and software investments and increase profitability by improving the utilization of resources to the maximum. By pooling the various healthcare IT resources into large clouds, hospitals can reduce the cost September 2009
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and increase utilization as the resources are delivered only, when they are required. The use of cloud computing architecture helps in eliminating the time and effort needed to roll a healthcare IT application in a hospital.
Applications of Cloud Computing in Healthcare: Some of the applications seen in Healthcare are as under : • Pharmaceutical Analysis: Researchers expected a protein analysis comparing 2.5 million compounds to take a week of processing on internal servers. Using hundreds of servers in the cloud, the job completed in one day. • Insurance Claims Loss Control: Systems for detecting fraudulent, improper or duplicate claims in batches of millions of claims required months of processing time to run and millions of dollars in capital outlay to build. Using the cloud, these batch runs now finish in a few days. • National Doctors’ Registration Database: This can be mandated for yearly renewal and hence location of doctors can be identified. With shortage of medical resources in the country, it may be useful to seek medical expertise of good doctors wherever they may be through tele-medicine. • Storage of Images: Interoperability will reduce overall costs as duplicate orders can be significantly reduced. Especially in Govt hospital scenarios, where referrals would be common, diagnostics can be completely filmless thereby savings significant money for the Government. Bio-surveillance: Online outbreak • of communicable diseases would be possible and even for lifestyle diseases it would be easier to launch health programs for specific areas. Research & Analysis •
Standardization of infrastructure of Healthcare IT The adoption of cloud computing would help standardize the
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infrastructure for healthcare IT solutions in contrast with the current highly disparate situation. In addition, vendors get to specify the infrastructure and leverage the implementation to adopt aspects such as SAN (Storage Area Network) storage. Since a lot of the hardware servers are virtualized, the cost is reduced tremendously and the only other requirement might be the use of middleware. Vendors could also offer hospitals the option of pay by use of resources in CPU (Central Processing Unit) hours, or gigabits consumed and transferred, which is quite compelling. Cloud computing also helps vendors with hospitals hesitant to sign longterm healthcare IT services contracts as with a cloud infrastructure there is no long term commitment. At the same time the clouds can support nearly any type of healthcare IT application the hospital might want to implement as long as it does not require any specialized hardware.
Cloud Computing affecting Physician’s Practice In the coming months and years several factors are converging into a “perfect storm” of opportunity and challenges. For most solo, small, and medium practices, Cloud Computing represents a juncture of significance. Do you invest up front and build your local computing infrastructure and keep your data local or do you amortize your investment over recurring monthly charges and keep everything “in the cloud,” including your data. Either choice presents additional challenges: What about backups, disaster recovery and 99.999 percent uptime to the Internet? What about HIPAA compliance of these services and applications offered both as local and “in the cloud”? What about hybrid applications that leverage both local infrastructure and the “cloud”? According to the Certification Commission for Healthcare Information Technology (CCHIT), there are over 300 vendors that currently offer some variance of Electronic Medical Records — some “in the cloud,” some locally, and some in both.
•
They include: Electronic Health Records (EHRs)
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• • • • • •
Electronic Medical Records (EMRs) Personal Health Records (PHRs) Payor-based Health Records (PBHRs) Electronic Prescribing (E-prescribing) Financial/Billing/Administrative System Computerized Practitioner Order Entry (CPOE) Systems
Conclusion As part of your SWOT analysis, the path of practice needs to be determined first : local, “in the cloud,” or a hybrid of both. Then and only then IT infrastructure needs to be procured to meet the software, hardware, and network requisites for that application, in that order. Correctly implementing and utilizing information technology will offer enormous benefits for improvement to the healthcare professional, local, cloud computing, or a hybrid of the two. This practice will have better access to healthcare services and information that would subsequently result in improved outcomes, fewer errors, and increased cost savings. Healthcare IT vendors need to evolve and introduce cloud computing infrastructure as it would prove a cost efficient model for automating hospitals, managing real-time workload, reducing IT complexity and at the same time introducing innovative solutions and updates. The versatile architecture makes it possible to launch web 2.0 applications quickly and also upgrade healthcare IT applications easily as and when required. With hospital across Europe cutting down on costs there is an eminent need for innovative solutions, which can be easily implemented and maintained. The cloud computing architecture can help healthcare IT vendors prioritize innovation of their applications and at the same reduce the implementation time of healthcare IT solutions. The automated framework of cloud computing would provide increasingly cheaper and innovative services. To read the complete paper log on to the website: www.eINDIA.net.in
Asia's Premier ICT Event 2 - 4 December 2009 Bandaranaike Memorial International Conference Hall Colombo, Sri Lanka
CALL FOR PAPERS eASiA 2009 seeks abstracts/proposals for speakers who illustrate innovation in using ICT in government, education, healthcare, rural development and allied areas.
Abstracts and Extended Abstracts Submission: September 15, 2009 Notification of Acceptance of Abstract: October 1, 2009 Full Paper Submission: November 3, 2009 Submit your abstracts/proposals at papers@e-asia.org
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EXPERT ARTICLE
Health Informatics @ Max Healthcare The paper provides an insight into the adoption of Information Technology by Max Healthcare to offer sustainable, cost-effective and quality healthcare services.
Introduction
Dr. Dinesh Jain Medical Informatics Specialist Max Healthcare
In today’s world, information has been considered as a strategic source of power – empowerment to make timely informed decisions. This fact cannot be overemphasized in healthcare, where an informed decision can be the difference between life and death (or disability) for a patient. Incidentally, most often we find ourselves rich in data yet poor in tools required to convert it to information. Max Healthcare has continuously invested in Information Systems, from the Hospital Information System (HIS) to Accounting and Financial System, Picture Archiving and Communication System (PACS), Quality Information System, Telemedicine and Business Intelligence. A crucial piece of information that is still missing within the broad picture of healthcare automation relates to the Electronic Patient Health Record, which would contribute, in a large measure to the attainment of medical excellence. Max experience has revealed quite a few insights to the reasons for adopting health informatics, expected end results and the hurdles on the way to achieving them.
Current State Max Healthcare group utilizes a Hospital Information System for the enterprise wide transaction handling and resource planning. A centralized database with an application running on server-client architecture promotes the aggregation of data from multiple
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hospitals and gives a unified view. Patient encounters are recorded on the information system with a trail of the services utilized, their consequent material consumption and billing. Flat reports are generated for a multitude of users both for operational tracking as well as for analysis, optimization and strategizing further growth plans for the hospitals. Business intelligence is beginning to play a larger role in the visibility of information and in its ability to drive objective and informed decisions, the ultimate aim of which is to deliver performance. DICOM compatible diagnostic images acquired from CT, MRI, X-Ray, Ultrasound, Gamma Camera, Echo-cardiology, C-Arm etc. are archived and accessed from the PACS. An HL7 (messaging standard for exchange of information in healthcare) engine generates messages from HIS to PACS transmitting the patient demographics, order details to the respective modality worklist. Accounting and Financial System handles the ledger entries for the transactions recorded in the HIS as well as other expenditure incurred by the organisation in setting up and running new facilities and services. Quality Information System is a unique endeavour to measure and monitor the quality initiatives undertaken by the organisation. A diverse set of parameters are recorded and measured under its ambit, to provide objectivity and transparency to the process of quality improvement.
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Drivers of Automation Amongst the multitude of reasons driving healthcare automation, these can be broadly classified as internal and external drivers. Internal drivers are those emanating from within the organisation as a response to operational challenges, quality initiatives and organizational drive. External drivers come about as a result of market competition, customer expectations and regulatory requirements. Quality which signifies a degree of excellence is integral to the vision for Max Healthcare. In its quest for excellence, a method for measuring and monitoring performance at every level is worked out, leading to a process oriented system with objective parameters of measurement. Quality pushes the adoption of information systems for reasons like parameterization, data acquisition, aggregation and analysis, performance measurement and monitoring. Parameters like time of action, reasons for delay in discharge process are measured at the point of action and analysed over a period of time to uncover the process & operational inefficiencies and then be able to optimize it. Monitoring of operational cost is mandatory for any organization to
Figure 1: Unlocking Value be able to survive in the competitive environment. This requires an Information System to be in place to support a secure way of handling transactions, store data and present information in an analyzable format. Audits (accounting, process, clinical etc.) depend on this data for assessing the state of affairs and finding gaps or loopholes. Flat reports and Business intelligence provide us the ways of looking at the enterprise data from multiple perspectives, thereby giving us an opportunity to find the inefficiencies and loopholes with an opportunity to improve the systems & processes.
Efficient utilization of organisational resources is promoted through resource planning which is brought about by the visibility of enterprise wide process and information. Trawling through the information systems, the operational reports capture the slackness in the processes and allow for constant monitoring. An example is a report to compare the admission waiting time and discharge process delay time over a period with bed occupancy and revenue per bed. Once this information becomes available, the decision makers are empowered to take objective & informed decisions, thereby resulting in
Table 1: Challenges to drive Strategy
Challenges
Examples
What can be done
Technological
• •
• • •
Follow open standards Open source development Greater involvement of Healthcare experts
•
Still evolving applications Point of care access in a distributed environment Fragmented clinical applications Lack of Interoperability / information exchange No Gold standards
• •
Costly solutions Low budget
• •
Break cost barrier Use open source
• •
Resistance to change Unwilling to enter data
•
Change management
• • • •
Lack of process maturity Industry standards still WIP Lack of usable clinical knowledgebase Balance between Security & Accessibility
•
Agree on open industry standards Build shared clinical knowledge base Define Standard industry processes
• •
Financial
User related Industry specific
• •
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measurable performance improvement (Fig 1). Information systems are called upon to support the practice of Evidence Based Medicine through the provision of Clinical Decision Support Systems, Clinical Pathways, Disease Protocols and Clinical Knowledgebase. Healthcare being an information intensive business, the dissemination of relevant information at every point of healthcare delivery in the process of patient encounter, assumes increasing significance. Market competition, especially at the high end segment, requires a visibility to the enterprise information and an ability to analyse it. In today’s dynamic market conditions, the business offerings are customized according to the customer’s demand, which needs an agile organisation, flexible and responsive to the changing landscape.
Stakeholders Expectations Once an organisation decides to adopt Information Systems for conducting its business, the stakeholders come to expect a few deliverables and advantages from technology adoption. An expectation of improved business insight, near real time monitoring of processes & consequent objective decision process
Figure 2: Clinical care maturity pyramid are at the very top of the stake-holder’s expectation list. All these are expected to lead to an organisation which is agile, responsive and most importantly performs to deliver on the expectations of its customers.
of information and application of knowledge are the pre-requisites for the practice of evidence based medicine, which is becoming almost impossible for an unaided physician to perform under the deluge of information.
Both clinical excellence programs and clinical research expect useful information through clinical outcome analysis which together with practice of Evidence based medicine is the ‘Holy Grail’ for clinicians (Fig 2). Availability
Challenges Why are the success stories so rare when it comes to Healthcare adopting Information systems to transform care delivery? We are aware of the expectations, there are all kinds of tools available, there are multiple drivers pushing automation, still there are major challenges which are proving to be insurmountable in many of the cases (Table 1). The challenges can be broadly classified into:
Learnings Healthcare today finds itself at crossroads facing three major moving targets: • Cost • Access • Quality
Figure 3: How to sustain Healthcare delivery
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For healthcare to be sustainable and be able to meet the patient’s requirements, it has to be cost efficient & provide access to quality care (Fig 3). Increasingly the Information Systems are called upon to support these objectives. The benefit of Information Systems adoption in achieving these
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Diagnosis on a chip will be enabled through the developments on Gene sequencing and gene activity profile of an individual, which will simplify much of the difficulties associated with remote diagnosis. Artificial Intelligence is going to aid the diagnostic capabilities of the Physicians, where an ECG interpretation will be built into the system based on the wave form, an image with its attributes would be amenable to intelligent interpretation, so as to link with the disease pathology. Now, more than ever, it is possible to translate the decades of AI research into medical applications which are intelligent enough to support the Physician. Figure 4: Transformation Methodology
objectives flows from the following • Time - Real time flow of information • Place - Remote dissemination of information • Standardization - processes & workflows • Coordination - care providers • Decision support – clinical knowledgebase, Clinical pathways & protocols • Telemedicine – making remote encounters possible • Retrospective analysis – trends, audits, outcomes • Predictive analysis – what-if, simulation & modeling Our past experience has shown that Information Systems themselves do not provide any benefits or answers to an organization’s needs without the simultaneous creation of an ecosystem which will lead and support the implementation of the system. A much greater responsibility rests on the shoulders of the Healthcare management in ensuring that the results match the stakeholder’s expectations.
Transformation Methodology Implementing an Information System entails wide changes to the organisa-
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tion, therefore managing the transformation is critical for the success of the endeavour. A planned approach to analyse the requirements and the changes desired, planning the approach to change, design of the change, execution of the change and finally monitor and control the changes effected so as to optimize the results (Fig 4). This cycle is repeated again & again to yield progressive results over multiple iterations. Key areas where this planned approach needs to be adopted are Governance framework, Technology, Systems & Processes, Change management and Business Transformation.
Innovations and Future Healthcare Technological innovations are changing the landscape of human society along with the way we interact and conduct business. Social networking has come up in a big way and is defining our relationship with the wider world. Such changes are also impacting the way in which healthcare is demanded and delivered. Yet on a cautionary note, there are inherent risks involved in these radical shifts, some of which are not too apparent at this stage.
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Unified communication is looking to connect an individual to rest of the world using any of the available modes of communication, viz; desk phone, mobile phone, email, sms, fax, public phone etc with a real time tracking of the individual. This would allow a patient to be able to connect to his Physician at the time of an emergency. Networking of devices and IP addressability enables devices like ECG, robotic arm to either broadcast its output to a remote location over the internet or to receive commands over the internet. Such possibilities have started making remote diagnosis and treatment possible. Increasingly remote care would be facilitated by the use of the existing telemedicine diagnostic capabilities married to robotic extensions for carrying out interventions. The hospital of the future looks increasingly a place where patient encounter is more and more virtual, resulting into an aggregation of resources from around the world onto a single platform for the time honored ritual of diagnosis and delivery of treatment. Yet, there would never be an alternative to the empathy provided by a Physician or a Nurse standing by the bedside, comforting a suffering patient. To read the complete paper log on to the website: www.eINDIA.net.in
EXPERT ARTICLE
Enhancing e-Health using m-Communication in Developing Countries This paper investigates the applicability of existing mobile technologies in the health sector and proposes an effective M-Communication (Mobile Communication) module to suit the Sri Lankan setting.
Introduction Mobile technologies are increasingly growing in developing countries. There have been several new researches and developments in this space. Now-adays, mobile phones are becoming an important ICT tool not only in urban regions, but also in remote and rural areas. M-technology is increasingly being used in the health care field. V. Dinusha University of Colombo School of Computing Colombo, Sri Lanka.
Co -Authors Dr. S.M.K.D. Arunatileka Senior Lecturer, University of Colombo School of Computing, Colombo, Sri Lanka Dr. K.R.P. Chapman Consultant Surgeon, Base Hospital Marawila, Sri Lanka G.P. Seneviratne University of Colombo School of Computing, Colombo, Sri Lanka S. Saatviga University of Colombo School of Computing, Colombo, Sri Lanka D. Wijethilake University of Colombo School of Computing, Colombo, Sri Lanka S.Y.Y.D. Wickramasinghe University of Colombo School of Computing, Colombo, Sri Lanka
Mobile health involves using wireless technologies such as Bluetooth, GSM/ GPRS/3G, WiFi, WiMAX, and so on to transmit and enable various eHealth data contents and services. mHealth and eHealth are inextricably linked—both are used to improve health outcomes and their technologies work in conjunction. For example, many eHealth initiatives involve digitizing patient records and creating an electronic ‘backbone’ that ideally will standardize access to patient data within a system. MHealth programs can serve as the access point for entering patient data into health information systems, and as remote information tools that provide information to patients, healthcare clinics, home providers, and health workers in the field. While there are many standalone mHealth programs, the main idea is the opportunity mHealth presents for strengthening broader eHealth initiatives.
Already, mobile technology is providing and augmenting healthcare initiatives throughout the world. The Opportunity of Mobile Technology for Healthcare in the Developing World is most widely recognised and over 50 of these types of initiatives have been undertaken throughout 26 countries. According to Terry Kramer, the strategy director at British operator Vodafone, there are 2.2 billion mobile phones in the developing world, 305 million computers but only 11 million hospital beds. This clearly reveals that we can harness the power of mobile technology as a high-impact, low-cost tool in order to compensate the scarcity of resources problem in the health field in developing countries.
MOBILE HEALTH IN DEVELOPING COUNTRIES According to the United Nations Foundation’s report on mHealth for development, it is summarized that the biggest adopters of mobile technology were India with 11 projects and South Africa and Uganda with 6 each. Examples of such mobile projects include: • Sending mobile phone owners updates on diseases via SMS. • Letting health workers in Uganda log data on mobile devices from the field. In South Africa, the SIMpill is a •
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•
•
•
sensor-equipped pill bottle with a SIM card that informs doctors whether patients are taking their tuberculosis medicine. In Uganda, a multiple-choice quiz about HIV/AIDS was sent to 15,000 subscribers inviting them to answer questions and seek tests. Those who completed the quiz were given free airtime minutes. At the end of the quiz, a final SMS encouraged participants to go for voluntary testing. The number of people, who did so, increased from 1000 to 1400 over a 6-week period. In the Amazonas state of Brazil, health workers filled in surveys on their phones about the incidences of mosquito-borne dengue fever. In Mexico, a medical hotline called MedicallHome lets patients send medical questions via SMS.
Though the mHealth field is still in its early stages, it has already begun to transform health delivery. Projects throughout the developing world are demonstrating concrete benefits, including: • Increased access to healthcare and health-related information, particularly for hard-to-reach populations. • Improved ability to diagnose and track diseases. • Timelier, more actionable public health information. • Improved compliance with treatment regimes: A 2007 Thai study showed that TB patients who received daily text message medication reminders jumped to over 90% adherence. A device called SIMpill is used that uses mobile technology to monitor and direct medication adherence. In the United States, a study found improved drug adherence rates among HIV SMS reminders to take daily medication compared to patients who did not. • Improved public awareness outcomes: In South Africa, project Masiluleke, which promotes an AIDS hotline through SMS messages, resulted in a 350% increase in phone calls to the hotline.
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Fig. 1: Technology and health-related statistics for developing countries (millions) Mobile communication offers an effective means of bringing healthcare services to developing-country citizens. With low-cost handsets and promotion of mobile phone networks globally, tens of millions of citizens that never had regular access to a fixed telephone or computer now use mobile devices as daily tools for transfer. A full 64% of all mobile phone users can now be found in the developing world. Furthermore, estimates show that by 2012, half of all individuals in remote areas of the world will have mobile phones. This growing ubiquity of mobile phones is a central element in the promise of mobile technologies for health. As illustrated in figure 1, developing world citizens have plentiful access to mobile phones, even while other technologies and health in phone usage has the potential to improve health service delivery on a massive scale. For example, mobile technology can support increasingly inclusive health systems by enabling health workers to provide re-marginalized areas where health services are often scarce or absent altogether.
THE PILOT PROJECT The pilot project being carried out by the authors in Sri Lanka is a mobile health solution to use Electronic Medical Record System and video conferencing to link the specialist in a general hospital in a city with a patient
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in a peripheral setting and to use mCommunication system to effectively and economically communicate with the patients. This makes the health service accessible as a mobile solution from anywhere. An Electronic Medical Record System (EMR) is used to transfer the information and a doctor is assisting the patient using easily acquirable relatively inexpensive technology that is currently being used. And as an enhancement, mobile communication system is used for sending important information such as the Clinic date, Operation date, appointment cancellation, investigations to be done, vaccination dates, etc. This project is designed to be implemented using an evolutionary approach in order to have a smooth eTransformation. The pilot project is named as ‘ViduSuwa’ and is presently implemented in two hospitals in Sri Lanka, a base hospital which will be the specialist e-consultation centre in collaboration with a peripheral hospital which will act as an e-care clinic. (www.vidusuwa.com). This simple mobile health concept is implemented with a very little extension to the existing technology. The EMR system is developed using open source technologies and the pilot project used an open source conferencing tool to carry out the e-Consultation. To enhance this setting by making use of highly available mobile technologies a research is carried out to incorporate an m-Communication system that would improve the patients’ communi-
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cation with the healthcare expert in an effective and efficient manner utilizing the existing mobile technologies and infrastructure. The m-Communication system is implemented making use of existing infrastructure and open source technologies. The paper further discusses about the m-Communication system model, architecture, technologies and it’s applicability in the context.
M-COMMUNICATION SYSTEM According to Sri Lankan Tele-Communications Regulatory Commission, out of 21 Million populations over 10 million people are subscribed to cellular mobile services. At the diagnosis stage a preliminary survey was done in a base hospital at Marawila, Sri Lanka, and the results show that over 51% of the patients have access to their own personal mobile phone, out of which 50% use SMS tool for communication. Nearly 80% of patients have access to mobile phones through an immediate family member. These results depict a high penetration of mobile phones in the peripheral sector which can be used very effectively for communication. Therefore, a two way m-Communication model as conceptualized in figure 2 is introduced as an mHealth initiative with the existing mobile technologies for sending important
information (appointment dates, vaccination dates, operation dates, medical tests, postponement or cancellation of appointments due to various reasons, checkup dates, etc) to patients and for the patients to communicate effectively with the hospital. Integrating the hospital’s EMR System, SMS reminders will be sent to the patients’ mobile phones on clinic appointments, operation dates, vaccination dates and other important tests dates. If an appointment is cancelled or postponed also the message will be sent to the patients’ mobile which cuts the unwanted travelling of patients. The mobile communication system will also receive SMS messages from the patients and forward to the administrator or consultant as an email and SMS. The model enhances the mobile health solution, provides a form of transparency between patients and healthcare by utilizing the existing telecommunications infrastructure in Sri Lanka, and ultimately supports a patient centric mobile health initiative which would be an effective and economic model for Sri Lanka. The paper focuses on the ongoing research on the applicability and development of the model in the Sri Lankan settings.
M-COMMUNICATION SYSTEM COMPONENTS For the pilot project carried out by the
authors, the following components were modeled in the m-Communication system (figure 3). • Sending Scheduled SMS: This component deals with sending automated scheduled SMS messages to the patients’ mobile phones as reminders on the clinical dates, operation dates, vaccination dates and other important tests dates. It also sends message postponements of appointments. When an appointment is booked an entry is made in the hospital’s Electronic Medical Record (EMR) system. Soon after the entry is saved in the database a SMS message is scheduled to be sent before the appointment time. Receiving SMS: The model sup• ports two way communication through the ‘receiving SMS’ component. Auto Replying/ Auto Forwarding: • This component makes it possible to reply to incoming messages and to forward these messages to administrator’s phone number. A function will be triggered by the system to send a pre-defined message to the patient as a response and also it will forward the message to the administrator. SMSToE-Mail: This component • converts the messages to email and forwards them.
THE ARCHITECTURE AND TECHNICAL SOLUTION If we plan to send/receive less than 15,000 SMS messages per day a good option may be to attach a GSM phone or GSM modem to the PC. The GSM phone/ modem must be equipped with a SIM card that has good tariff for SMS messages. The GSM phone/ modem can be attached with a data cable, with an InfraRed port (IR) or with a BlueTooth (BT) connection. With this setup we can use a computer program that can send/receive SMS messages. The computer program in this case uses the attached device to communicate with the GSM network. Fig. 2. Value Chain Model for two-way mCommunication Applications
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If a message is sent by the application running on the computer it is first sent
EXPERT ARTICLE
AWARENESS AND EDUCATION
Fig. 3. M-Communication System Components
to the attached GSM phone/ modem, and as a second step the GSM phone transmits the messages to the SMSC of the GSM service provider through a wireless link. In order to come up with an economically feasible model, the existing technologies were analyzed and a technical solution that is simple and economical is chosen. Sending an SMS message using a GSM phone/ modem takes about 5-6 seconds. Receiving takes about the same time. The connection methods are analyzed and justified that the best option to connect a phone to the PC in our setting is to use a standard RS232 serial cable. USB cables, InfraRed and Bluetooth connections are not that reliable. SMSLib is a Java Library for sending and receiving SMS messages via a GSM modem or mobile phone. It is free, open source and easy to integrate in an independent module manner (An Object- Oriented feature). It supports all the object orientation features and makes it possible to benefit from reusability and maintainability. The pilot project carried out by the author uses SMSLib Java library and a GSM modem connected using RS232 cables with the server to implement the m-Communication system. The SMS reminding component is running as a java thread daemon service in the server. In the EMR database, we have another table namely ‘SMSReminders’. This table
gets updated whenever an eClinic appointment or theatre operation is scheduled, rescheduled, cancelled or an investigation to be done is recorded to insert a new row with the patient mobile number, date to send, time to send, and status. The status field is used to set the status of the message (send, transmitted, cancelled). Hence, when inserting a new row to this table in order to send the SMS on a particular time, the status value would be as ‘send’. Once the message is sent the status would be updated as ‘transmitted’. The Schedular class in the component periodically gets the values from the SMSReminders table and checks whether the time to send is less than or equal to the current system time and the status is equal to ‘send’ and if these two conditions are met, a SMS message will be sent by invoking a sendMessage(String contactNo, String messge) method of the SendMessage class that is defined by the SMSLib Java framework. Once the message is send, the respective row in the SMSReminders table will get updated by setting the value of status to ‘transmitted’. This prevents sending duplicate messages. The gateway ID, Com Port, baud rate, manufacturer, and model should be passed as parameters so that the GSM modem can be detected by the application. The classes are written in java and thus object orientation functions are used to make the component totally independent of the EMR system.
In the pilot project, the M-Communication system is implemented only for the eClinic patients who will be treated through econsultation. The eClinic patients selected by the consultants are educated on how to read SMS reminders and how to respond to it. To make the SMS messages unambiguous and readable by patients, the SMS message format is defined in the most effective way. Once a patient is selected as an eClinic patient, he/she has to get registered him/herself to the system by giving all the details at the eclinical Management Centre (including the mobile number). When they get registered to the eClinic the instructions and information are given to the patients on m-Communication system to make them aware of the system and how to make use of it.
USER STUDY A post implementation analysis is being carried out by the authors to evaluate the usage, effectiveness and applicability of the M-Communication model in the Sri Lankan settings. This is being done through the means of survey studies. The survey focuses on the patients’ ease of access to the message, attitudes, accuracy, timeliness and effectiveness of the Mcommunication system.
CONCLUSIONS AND FUTURE WORK This paper describes the ongoing research, proposes an effective twoway m- Communication model for developing countries and discusses the mCommunication model components, architecture and design, critical analysis and the applicability and effectiveness of the model. Since this is a mobile health initiative in Sri Lanka, the research is limited to the mobile communication system in its first phase. As a future research, this can be extended to extensively use the existing mobile technologies and infrastructure in the healthcare filed. To read the complete paper log on to the website: www.eINDIA.net.in
September 2009
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AWARDS
JURY
M P Narayanan President CSDMS
Dr Ashok Kumar DDG & Director Central Bureau of Health Intelligence Ministry of Health & FW, Government of India
Ashish Sanyal Senior Director Dept. of IT, Ministry of Communications and IT Government of India
Ashish Garg Asia Regional Coordinator GeSCI (Global e-Schools Initiative)
Dr Basheer Ahmad Shadrach Senior Programme Officer Telecentre.org International Development Research Centre
Dr Gopi Ghosh Assistant FAO Representative India
Madhuri Parti HeadLearn India
Prakash Kumar Director Internet Business Solutions Group (IBSG) Cisco Systems India
Ravi Gupta Executive Director CSDMS
Rajen Varada Resource Person & Moderator ICTD communityUN Solution Exchange
Shashank Ojha Senior e-Government Specialist e-Government Practice – ISG Global ICT Department, The World Bank
S N Goswami MD and CEO Media Lab Asia
Dr V Balaji Global Leader Knowledge Management & Sharing ICRISAT, Patancheru, Hyderabad
Prof V N Rajasekharan Pillai Vice Chancellor Indira Gandhi National Open University
Sajan Venniyoor Country Representative (India) Deutsche Welle
PERSPECTIVE
Transforming Healthcare through Technology
“The most important beneficiary for any technology enabled process change should be the patient who visits the hospital. The second beneficiary should be the hard-pressed doctors, who have to deal with demand, which is far more than the supply.”
Dr. Vijaysingh Chauhan Lead Consultant – Clinical 21st Century Healthcare Solutions
I
f I can view my bank balance and order my bank statement sitting 5000 kilometers away from my bank online, then why do I need to personally visit the hospital a few kilometers away for the second time just to collect my blood reports. I can book a railway ticket sitting in the air conditioned comfort of my office or home but I have to trudge to the nearest hospital to get an appointment to see a doctor. In fact, it is extremely important to make things easier for a person, who requires healthcare services, by offering such solutions, as he is already hassled because of his illness. These are some of the few things
that have led me to believe that if technology has changed people’s lives in other areas, then it has the potential to bring about a paradigm shift in the delivery of healthcare in India, as well. The most important beneficiary for any technology enabled process change should be the patient who visits the hospital. The second beneficiary should be the hard-pressed doctors, who have to deal with demand, which is far more than the supply. Let us take for example a person, who while on a vacation, gets a severe bout of asthma. At the hospital he is subjected to a battery of diagnostic tests and a long history taking session because he cannot reproduce his medical records in a distant location.
If he had his own previous medical records in electronic form, it would have saved him considerable money and inconvenience of undergoing the tests and consultations by the clinicians. Currently technology permits a patient to have his important medical records in a small card, of the size of a credit card, which can be carried by him wherever he goes. Companies like Google and Microsoft provide free space on the internet for a person to store his health records safely and confidentially which be can produced by him anytime and anywhere with basic internet connectivity. These advances in technology will bring about a revolutionary change in the patient health records in the times to come. September 2009
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PERSPECTIVE
Twelve years ago when I was a fresh medical graduate I had noticed that all patients had to visit the hospital or a diagnostic centre for a second time just to collect their laboratory reports. I always found this to be very inconvenient. I thought why not have a system wherein the patient can be given an ID while collecting his sample and the freedom to view or print his report at home or at office. All that is required for this is a basic internet connection. All at 21st Century Health, the company where I am currently the Lead Consultant, passionately believe in transforming healthcare through People, Processes and Technology. Which is why I have joined the team and we have been successfully implementing web-based laboratory reporting for hospitals and chains of diagnostic centres. At some hospitals, I have also noticed the patients undergoing repeated radiological investigations because they have misplaced their original films and reports or are not carrying them on that particular occasion. Having the same on a PACS (Picture Archival and Communication System) solves their problem to a small extent, because traditional PACS only stores and reproduces certain types of images, which are DICOM in nature. At 21st Century we have gone a step further and are not only able to store non – DICOM images like 2D echocardiograms, Carm images, endoscopic procedures for example but also waveforms like ECGs with the DICOM images so the patient is not exposed to unnecessary repeated investigations including harmful radiations for want of his old investigation records. All these are then stored in patient CD with valuable patient education material made on an innovative device called 21st Century IBox. Let us see how technology would benefit the hospital in the long run. Firstly having the medical records in an electronic form would reduce their dependence on paper and make it possible for the hospital authorities
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September 2009
“Healthcare delivery institutes, which use technology to amplify their medical skills will be able to scale their operations to a higher level and provide services to larger number of patients at lower costs.”
to give the same to their patients whenever asked for. Now that the Apex Court and the MCI (Medical Council of India) have also issued directives pertaining to patient medical records, it becomes all the more important that hospitals address this issue effectively. The requirements of space to maintain conventional records are huge. These can be lost due to natural causes like floods, fire etc, or due to other causes like theft, pilferage, usage of poor quality of paper or ink. On the other hand if the patient records are in electronic format the space requirements for storing them is reduced considerably and it is no more prone to any sort of losses as backups can be stored in remote disaster plan sites. Secondly, having web-based laboratory and radiology reporting and maintaining images of patient diagnostics can result in reducing the direct and indirect costs incurred to the patients, which ultimately results in patient delight. The patients will be happy to recommend the hospital to others and thereby increase the hospital’s image and patient base leading to higher profitability. Correct and accurate MIS can help the hospitals to plan more effective patient management and marketing strategies for the future.
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I remember those days when as a medical student I used to turn the pages of my books to either confirm a diagnosis I had made for a patient or to look over for different treatment protocols that I could select for a given patient. If I had the technology that would have had helped me to either confirm a diagnosis for a patient or inform me regarding different treatment protocols for a given disease, I could have saved the precious time of the patient to decide his course of treatment. Fortunately, now this is possible in the form of evidence based medicine and clinical decision support systems. This will come as a boon to young medical students. A CDSS can now help a medical student to arrive at the most probable disease condition of a patient by entering the various symptoms. After this he is also guided with different treatment protocols, which are available to treat the disease. I wish to stress here that this evidence based approach to medicine needs to go through regular updates to keep abreast with the latest medical protocols. This approach has taken the west by a storm and it will not take long before it establishes its credibility in India. All these systems use modern IT. We need to accept the fact that those healthcare delivery institutes which use technology to amplify their medical skills will be able to scale their operations to a higher level and provide services to larger number of patients at lower costs. On the other hand, those who stick to age old practices, however well they have served them in the past, will be overtaken by those who adopt consumer oriented ICT enabled processes. While technology is not a panacea for poor medical skills, it is an invaluable innovation which can help good doctors and clinicians to reach out to remote places and serve more patients with less efforts. Hospitals need to seriously look at harnessing the effective use of technology to transform themselves into state-of-the-art 21st Century Healthcare Institutions .
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IT Directory’ - November 2009 Issue’
eHEALTH magazine is coming out with a ‘first-of-itskind’ directory of IT vendors and suppliers for hospitals, healthcare providers and doctors. The directory is aimed to create a comprehensive compilation of companies offering hardware, software, networking and communication solutions, as well as those offering specialised medical/health IT solutions including EMR, EHR, HIS, HMIS, RIS, PACS and ERP.
For advertising opportunities in this issue, please contact: Arpan Dasgupta, arpan@ehealthonline.org, 9818644022; Bharat Kumar Jaiswal, bharat@ehealthonline.org, 9396423085