Understanding ‘computerisation of hospitals’
Uday Pasricha

While this would be considered a blasphemous question for IT professionals, who have written on numerous occasions about the necessity for every hospital to have the ideal patient care process based on detailed medical records; the absence of HIMS in most hospitals, and the poor usage experience in others makes this question relevant. Though the need for digitised medical records is fast becoming a ’cliché and foregone conclusion’ for many reasons such as to protect the institution from medico-legal issues, or to satisfy the reimbursing body or corporate who pays for the treatment of patients and finally for the need to improve the patient throughput and the productivity of high value equipment and human resources.

So if we accept that there is the need, then the same question must be extended to ask:

What should be the design and extent of computerisation required for our kind of hospital in India? For those who are computerising for the first time there is the need to identify in the first stage The difference between computerisation of data and the need to computerise patient care in realtime!

Complete computerisation of information does not require complete computerisation of all departments. Information/Data is usually the first need of management to have greater control on costs and improve efficiency. These needs vary according to the type and objective focus of the hospital or healthcare provider. A general hospital serving a large volume based on charitable support will require “different” data in the first phase compared to the information required by ’specialty departments’ or a highly revenue dependant department.

How much data should be digitised?
Information about a routine OPD patient in India who has come for symptomatic treatment should require a different level of digitisation compared to a patient of chronic disease. Does a laboratory or x-ray report have to be seen online if its life span is a single viewing? In most general hospitals 90 per cent of the medical data in the form of pathology test reports, x-rays, and doctor advice is for ’single viewing’.

Does all the data have to be digitised and does it have to be online in real time in the first phase of computerisation?
The first need for electronic records is to have medical records for the purpose of ’easy retrieval’ and to increase the throughput of patients within the same infrastructure and manpower. The controlling factor that could determine the ’extent’ of computerisation of medical records can be proportionate to the “frequency of visit and the extent of services rendered to the same patient within the hospital.” It may be emphasised that the final cost of computerisation and HIMS is more dependant on the extent of networking and need for real-time data viewing than the programme itself.

The difference in costs and the affordability of the HIMS can thus be oversimplified in a statement as - being dependant on the decision of management as to when the record must ’appear’ as a digitised record?”. We in India may not be able to afford to spend the same value per patient for online digitisation irrespective of the type of hospital or type of disease or treatment?

Should we emulate the developed world on this issue?
When compared with the developed economies; for every one patient seen by a doctor an Indian Doctor would have to see at least 15 to 16 patients in India. The revenue from one patient or the costs allocated even for free treatment in the developed economies has to be equated with the revenue and costs equivalent to 15 to 17 patients in India.

Between the revenue and time that is practically available per patient and the affordable number of healthcare workers; the mathematical differential is self indicative of the problem and the economics for our country. If overseas doctors are sending voice files to India for transcription with their patient numbers, then why should we assume that an Indian doctor and healthcare worker has the time to capture data during patient care?

Systems design for HIMS based on the developed world would probably have never considered ’comparing or separating the process of online data capture from batch entry post function because the high cost of digital workers would itself make it unaffordable to assume that another person could enter the records based on manual notes after the healthcare worker has seen the patient.

Perhaps we in India can afford to study and budget for the extra cost of ’data entry’ if it relieves the time of the far higher cost and scarce doctors and skilled healthcare workers. This cost saving is thus dependant on the managements decision as to when they would like to see their MIS report in the first phase? Obviously the need should be to get reports faster and better than before? The difference between getting a digital report online or on the next day could alter budgets and initial capital outlay costs by a minimum of 25 to 30 per cent. Let us however assume that every hospital must computerise all information i.e. medical records and patient information vis-à-vis services rendered and revenue receipts and costs incurred by the hospital. As mentioned this does not imply that from day one of computerisation there is need for a completely networked system with computers in each department, capturing the data in real time.

Let internal priorities determine the process and let economics define the extent for HIMS
For a hospital computerising for the first time the objectives should be insure that the process is ’self evolving based on economics and the logical need for improved patient management’. An example of this process and progression could be as under:

• To first identify the MIS reports that are required as per the management objectives and priorities specific to that hospital.
• To commence digitisation so as to maximize the inclusion of ALL services and patient information to be digitised for the purposes of easy retrieval, so as to be able to get comprehensive MIS reports exactly as required by management for all revenue and cost areas.
• Identifying where batch digitisation and reports would be acceptable in the first phase so that the compiled reports are first available in digitised form for easy retrieval based on ‘redesigned manual forms’.
• Progressive computerisation in different areas and departments should be a self indicative process that can be based on three parameters: Patient traffic, investment in specific department which requires to be monitored for productivity and finally the most important reason; the culture of the healthcare providers towards data as source of better patient care.
• If healthcare professionals within a specific department have self ascertained the benefits of online digitisation then that department must be included in the next phase of computerisation. There need for online data to be viewed in realtime must have tangible benefit to patient and economics to the hospital.
• Modular and customised digitisation is thus the correct methodology where the spread is organic and driven by the above parameters. There should also be minimal disruption in services and the functioning of the professionals and doctors within an existing and running institution.

The guideline and recommendation is therefore that in the first phase the focus must be to first digitise the data and not the process every institution must prioritize its own needs based on its healthcare infrastructure and its objectives because of the extreme variation and disparity in incomes of the consumer. The system design should ideally be modular to permit progressive digitisation based on the revenue or costs that are being allocated to each patient.

Digital products get better over time within the same budget
Finally it is important to stress that unlike other products digital and software products get better and cheaper every year. While there is the need to computerise; it is extremely prudent to insure that the budget is spent on the basis of developing a self indicative process because every healthcare institution is evolving and growing exponentially.

The fast obsolescence of technology is another deterrent but can be used to our advantage. We are usually unable to afford regular replacement of technologies as we have a slower amortisation ability due to lower consumer incomes. In some areas we have been fortunate as an example; in being able to jump straight from the mechanical typewriter to the computer or from an analog or no telephone to a wireless GSM technology. We think the healthcare industry can also save itself a lot of costs by looking closely at the emerging changes that will occur due to say; voice recognition technology, digital embedded medical hardware with intelligence, web based distributed computing, telemedicine, the sharp reduction in length of patients stay due to new medical procedures, etc.

Though most of these indicate a different and perhaps complex digital structure they infact indicate that things are going to get going to get simpler and cheaper. Let us ensure that though the process of digitisation must be taken up on a war footing the extent and process helps us we conserve our budgets and funds for the natural need to keep up with change & enable us to use new technologies that are already clearly visible. Though they may yet appear to be elusive due to the impending need to upgrade our infrastructure; we first have to develop and create the most important component of digital technology:

The work culture that uses data as an integral tool for improved professional practice and patient care.

(The author is CEO, Third Eye Consultancy Div of Intellectual Properties Intl Pvt Ltd, Mumbai)