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Public Healthcare Service Takes the IT route

Information technology is here to redefine public healthcare service. K Deepalakshmi narrates the IT revolution in PHS

Whilst corporate healthcare is gearing into fast track growth and using the latest technology to provide the best of services in this era of competition, the gradually collapsing and over-burdened public healthcare system has also opened its eyes and chosen IT to better itself and improve patient care and services. Here are some of the most remarkable projects that are changing the dynamics of healthcare services in the public delivery space through technology that is spearheading better services and efficiency to the people who need it the most.

Wipro's for Delhi Municipal Corporation

Delhi Municipal Corporation (DMC), in association with Wipro, is implementing Hospital Information System (HIS) in the six hospitals managed by it. "The solution is an integrated system which allows relevant information to be readily accessed from various departments," says Dr Seema Gupta, Domain Consultant, Wipro HealthCare IT. Wipro HealthCare IT provides a HIS with 28 modules, which cater to the needs of outpatient and inpatient functionality within each hospital. This includes patient registration with demographic details, outpatient visits, doctors' appointment scheduling, Admission/Discharge/Transfer, Order Entry, Laboratory/ Radiology/ Cardiology Result Reporting, Operation Theatre Management and Pharmacy etc.

The project was started in November 2004 and the first phase was implemented at the 230-bed Swami Dayanand Hospital. Wipro HIS is currently implemented in five of the six DMC-managed hospitals. Hindu Rao Hospital is the next in line and will be going live shortly.

Automating these functions has helped DMC in handling large numbers of patients and helps them in providing better patient care. Many of the census reports required by DMC were earlier generated manually as there was no automated system in place. "This was very time consuming and needed a lot of manpower. Automation helps in generating timely census reports with accurate data," says Dr Gupta. Various other reports, which are required for the Government, can now be generated easily.

An Electronic Patient Folder with details of each visit would be available at all of these locations once the implementation is done at all six hospitals. This will enable the doctors to have ready access to past episodes and information of the patient, thus ensuring efficient patient care.

"The application will help to manage EMR, which is a module of our Hospital Management System" - Dr Sumanth Raman Advisor Lifescience & Healthcare Practice TCS

"The solution is an integrated system which allows relevant information to be readily accessed from various departments" - Dr Seema Gupta Domain Consultant Wipro HealthCare IT

TCS for Tamil Nadu

With a plan to digitise all patient records in state-run hospitals, the Tamil Nadu Government has allotted Rs 5 crore to Tata Consultancy Services (TCS) to develop a suitable solution to maintain electronic medical records (EMR). "The application will help to manage EMR, which is a module of our Hospital Management System," says Dr Sumanth Raman, Advisor, Lifescience & Healthcare Practice, TCS. The system will start functioning in all the 26 district headquarters hospitals, 162 taluka hospitals and 77 non-taluka hospitals and some of the Primary Health Centres (PHCs) managed by the Government.

This application created by TCS is web-based, wherein each patient will be allotted a unique ID. All related data will be fed into the system. The system, being centralised, can be accessed from anywhere, making the clinical history of the patients handily available. In future, if the hospitals across the state are brought under the same network, the data can be shared among hospitals. "The system will start functioning in five centres in the next three months and in 30-40 within a year. We have four years to complete the project," says Dr Raman.

TCS has also implemented HMS in Gujarat, where the project has already gone live in 10 out of 30 hospitals. The company has provided solutions to Punjab Health Corporation, Uttar Pradesh and West Bengal Governments. TCS has designed software for Tamil Nadu State AIDS Control Society (TNSACS) and major medical college hospitals in Tamil Nadu.

"IT is employed in medical college hospitals in Tamil Nadu to manage in-patient and out-patient details, medical records, office automation, lab and pharma services," says Dr TP Kalanidi, Director of Medical Education, Government of Tamil Nadu. HMS manages Madras Medical College and medical colleges in Coimbatore, Vellore, Tirunelveli, Theni, Kanyakumari, Tuticorin and Madurai. "The data has to be perfect and this can be achieved if the data flow is electronic," he adds.

21st Century's HealthNET in Goa

The Government of Goa in association with 21st Century Health Management Solutions implemented a Rs-2.5-crore Hospital Management Information System (HMIS) called HealthNET in Goa Medical College (GMC) Hospital. "The project was conceptualised almost four to five years ago in 2002-03," recalls Satish Kini, Chief Mentor and Principal Consultant, 21st Century Health Management Solutions. The project for the 1,000-bed hospital includes Patient Management Systems, Hospital Management Systems, the Laboratory Management System, Blood Bank Management System, the Advanced Imaging System (which is an advanced form of traditional PACS), Library and Academic Section Management System, and Management Information System.

The objective of the project was to improve the availability and quality of healthcare delivery process and give Goa a fully computerised healthcare system by providing good quality healthcare services to all segments of society, especially the poor in remote locations. "Our focus is to first complete this project and then showcase the entire Goa HealthNET in the next two years before we take up any other major Government projects in India," says Kini.

21st Century Health has also successfully completed the computerisation of patient registration and billing for OPD and indoor patients at Navi Mumbai Municipal Corporation Hospital and had implemented OPD registration and billing module at the Maharashtra state-run Sir JJ Hospital in Mumbai as part of the Mid Town Rotary Club's mega project of upgrading JJ Hospital's OPD lobby.

"The doctor can recall the report anytime he wishes through this solution" - K Gopinath Director Public Sector HP India

"The project commenced in Rui Hospital offers health service in areas of cardiology and ophthalmology" - Ashok Chandavarkar APAC Regional Marketing Programmes Manager Healthcare, Intel

Maharashtra Partners with HP

The Government of Maharashtra is implementing a Rs 180 crore, eight-year, networking and automation project to transform its public hospitals. The project was initiated in January 2007 and involves 19 key Government hospitals and 14 associated medical colleges across the state. The HIS, HP Healthcare Solutions, is being implemented by HP in partnership with Amrita Technologies. "HP plays the role of system integrator in this project," says K Gopinath, Director, Public Sector, HP India. HP is also training the doctors and other medical staff and will carry out the implementation of the solution.

Gopinath explains, "When a doctor wants an X-ray to be done on a patient, he can acquire the report on his desktop as soon as the X ray report is generated in the lab. The doctor can recall the report anytime he wishes through this solution." He adds, "A patient at a Government hospital anywhere in Maharashtra should be able to access medical treatment at another Government hospital in the state without having to carry his case papers along."

Since IT was used in JJ Hospital at the registration desk, HP interfaced the solution with existing solutions and software bundled with certain equipment. The project is expected to go live by next month in JJ Hospital and Grant Medical College, Mumbai. More than 30,000 in-patients and more than 5,00,000 out-patients treated every year at JJ Hospital are sure to experience a remarkable change after the implementation.

Intel's World Ahead

The World Ahead Programme is an initiative launched by Intel to provide education and healthcare service in India. In the healthcare sector, Intel has carried out tele-health projects in Baramati, Maharashtra and Tindivanam, Tamil Nadu, and child health monitoring in Chandni Chowk, Delhi.

Speaking about the Baramati project, Ashok Chandavarkar, APAC Regional Marketing Programmes Manager, Healthcare, Intel, explains, "The project commenced in Rui Hospital, a taluka hospital in Baramati, in September 2006. Tele-health service is offered in two areas, namely, cardiology and ophthalmology." Narayana Hrudayalaya, Bangalore and Aravind Eye Hospital, Madurai are providing clinical support. SN Informatics developed the software and Vidya Pratishthan Institute of Information Technology (VIIT), Baramati were the system integrators. A special digital ECG apparatus was bought from Schiller Healthcare.

The ECG test of a patient in Baramati is transmitted to the cardio-care room of Narayana Hrudayalaya. The existing tele-medicine set-up of the hospital was utilised for this purpose. A cardiologist examines the test results and reports the abnormalities, if any, round the clock through this procedure. The average response time is less than 10 minutes. "The patient is referred to the district hospital, Pune for further treatment, because of the proximity," says Chandavarkar. Not all cases are referred to Narayana Hrudayalaya. Only the cases where the local doctors require guidance are reported via tele-medicine." Last year about 430 patients were referred to Narayana Hrudayalaya.

A slit lamp captures the inner image of the eye and the data is transferred to Aravind Eye Clinic. "Ophthalmic diagnosis, not being critical care, is responded within 30 minutes and operates during the designated OPD working hours," he says. The operating cost is as low as Rs 10 and is given free of cost in the hospital.

Under this scheme named 'Aarogya Jaal', most of the outpatients required assistance in cardiology and ophthalmology, but the hospital had only general practitioners. Dr Amol Goje, Director, VIIT, explains, "We carried out this project in the Rui Hospital, since the hospital had the necessary infrastructure." The project is working well for nearly one and a half years. "We are planning to include 13 hospitals in Pune district in the next three to four months," adds Dr Goje.

Encouraged by the working of the Baramati project, Intel has expanded the tele-health scheme to a 100-bed hospital in Tindivanam. The need for paper was eliminated by adopting a web-based system. The test results are uploaded in the web-health portal, webhealthcenter.com and can be viewed from anywhere. The project is carried out in two centres, Tindivanam Taluka Hospital and a block hospital in Mailam, near Tindivanam. The clinical support comes from Narayana Hrudayalaya and Sankara Nethralaya, Chennai. The front-end platform is provided by TCS.

Intel also provided a school health monitoring system, developed by TCS, in St Philomena Girls' Higher Secondary School, Tindivanam. The web-based solution introduces schoolchildren and faculty to benefits such as digitised health records and health camps with participatory and action-based health learning.

The child health monitoring system was also implemented in Chandni Chowk, Delhi. "We selected Chandni Chowk to prove the necessity of access to healthcare to the poor and needy in the urban areas," says Chandavarkar. TCS had developed the system according to the guidelines of World Health Organisation. The system calculates the maturity index with the height, weight and mid arm circumference data keyed in. The system enables to check and intervene in cases of malnutrition and frequent illness. Intel has carried out such healthcare projects in Mexico, Brazil, China and South Africa.

Benefits for Patients

Since earlier records and case history are available readily, it results in better follow-up and accurate diagnosis. Others point out that as the results can be accessed across the hospital, there is no replication of tests at various departments. This lowers costs, time and suffering of the patients.

Dr Kalanidi points out that in the case of patients who have undergone multiple admissions, only a small percentage brought case sheets of previous treatment when they subsequently visited a hospital. Doctors had to go by the patient's word on previous disease history instead of analysing documentation. In case of electronic medical records, such situations are unlikely.

For Medical Staff

HIS benefits the medical staff too. The system gives all the patient-related information in a single file with an easy to sort format. Since it is centralised, the clinical details can be retrieved whenever needed.

Dr Gupta explains, "Doctors' prescriptions are on the system, and routed to the pharmacy for issuing medicines to the patient ensuring better control and tracking." Regarding lab diagnosis, she says, "Lab investigations ordered by doctors go directly to the respective labs and physicians can view the lab results online from their system. Thus the turnaround time of lab results has improved."

For the Government

"The Government can keep track of disease outbreaks as well as the status of epidemics across the state," says Gopinath. It also ensures better inventory control due to ready availability of stock status. Stock requisitions are made online with necessary approval, which increases efficiency and ensures proper control.

"Since the project is carried out in Public-Private Partnership (PPP) model, IT would take two to three per cent of the capital expenditure of the capital for a 200-bed hospital," says Gopinath. Reporting of epidemics, birth rates, mortality rates and non-communicable diseases are all just a click away with the HIS.

Convincing People

Challenges in implementing the solution come in the form of infrastructure and training. "Since it is a Government project, the government took care of providing the necessary infrastructure," says Dr Raman. "The challenge was to convert the doctors and the management to the new system," says Gopinath. Overcoming the challenge was in the form of training the staff to assimilate the new method. Dr Raman says, "In order to adopt a new system, the mindsets of the people have to be changed," However, he is hopeful that this change will happen in time.

"It is important for Government officials to view healthcare IT as a strategic tool to not only increase control, but also improve patient management processes and the productivity of scarce and expensive resources such as doctors, medical staff, operation theatres, medical equipment and life-saving drugs," says Kini.

"All existing manual paper processes had to be converted to electronic processes. This took a careful re-evaluation and re-engineering of the process taking the value-additions of each step into consideration," says Dr Gupta and adds, "Our HIS had to bring in, standardise and implement best practices from both across and beyond the chain."

Working with PHS

Experts point out that as far as the technology is concerned, there is not much difference in requirements. However, the contracting procedure is different. Dr Gupta, says, "In my experience, the Government-run healthcare system is more receptive and adopts faster to the discipline of a good HIS. This is because they already have a good framework and standard operating procedures in place." Government hospitals have to service huge volumes of patients and a good HIS helps tremendously in reducing the red tape and repetitive and wasteful labour. She even praises the enthusiasm of the staff of the hospitals to adopt the new system.

However, working with PHS is not a cakewalk for many. For instance, a leading information technology provider backed out of the HIS project implemented by Gujarat without citing reasons.

In private hospitals, where decision-making is usually by an individual or top management, the projects are implemented in far less time, in comparison with the bureaucratic functioning of the Government. Improper communication could lead to the failure of the project, when the staff is not comfortable with the new system.

Kini elaborates, "The main differences lie in the ability of the officials to take and enforce decisions. Unfortunately, the organisational structure of Government institutions and the process of decision-making (from procurement to implementation) always leave enough room for the people at all levels in the organisation to maintain status quo."

Another major difference is that rather than adopting improved ways of working (and eliminating many outdated processes and procedures) which are supported and enforced by modern ERP applications, Government users try to automate their old processes (by even customising well designed systems). "This approach and resistance to adopt new improved methodologies negates the entire objective of adopting computerisation to bring about positive change," complains Kini.

The problem with HIS implementation in India is that not enough groundwork is done before the implementation of software takes place, observe analysts. The process mapping being inadequate results in failure of software to deliver all that the hospital desires. The processes not being standardised leads to the need for customisation for each hospital, which has its own perils.

Market Potential

Government being a big buyer of IT, the IT firms look at PHS as a prospective area of business. With the Central and the State Governments committed to improve the healthcare facility even in remote areas, and the 2008 budget proposing the financial groundwork to strengthen this network of healthcare delivery, the scope of IT in PHS is clearly large.

Dr Gupta says, "The Indian Government is considering both an umbrella of universal comprehensive micro-insurance and private-public partnership, to ensure access to healthcare for every Indian. These factors will add considerable impetus to the current trend in market consolidation that is already seen in all metros and most tier II / III towns."

Experience throughout the world has shown that both market consolidation and third party payment favour standardised quality of care, transparent billing, optimised use of resources and comprehensive documentation. All of these are best implemented and facilitated by a good HIS.

Recent interest in telemedicine and HIS shown nationwide by municipal/Government hospitals proves that this worldwide experience is being replicated in India. "All of the nationwide healthcare provider networks, run by the central or state Governments, armed forces, CGHS, or municipal hospitals, are potential clients for our proven, robust and multi-locational HIS," Dr Gupta of Wipro claims.

Execution plays a major role in reaping benefit from HIS. The IT firm's work ends with providing the solution, training and extending support, when needed. The execution lies in the hands of the Government and its employees. "The solution provided by us is just a part of the programme, while the success lies in proper execution by the concerned people," says Dr Raman. The management information system of TANSACS was a success only because it is being implemented properly.

Implementing information technology in Government hospitals can make a lot of difference. In addition to the number of benefits accruing to the Government, medical fraternity and the patients, such measures could attract more people to Government hospitals.

k.deepalakshmi@expressindia.com