Focus

IT 'Clicks' Healthcare

Indian healthcare is witnessing a metamorphosis, with the onset of newer, better IT applications as well as a broadening focus and increased investment in technology by hospitals. Sonal Shukla and Priti Pathak explore

Technology is gradually but surely penetrating Indian healthcare industry. Along with newer technological trends appearing on the Indian scene, several positive developments in the last couple of years have driven the adoption of IT in healthcare delivery. Today the hospital industry is lapping up better technology and is gradually moving on to leverage the benefits of outsourcing their non-core functions. The US based research firm Datamonitor estimates Indian healthcare IT market to be the fastest growing in Asia, with around 22 per cent annual growth, followed by China and Vietnam. In India, it estimates that IT spent on healthcare will reach $315 million (Rs 1,260 crore) by 2011. Healthcare sector is always criticised as a laggard when compared to other sectors in accepting IT. However the scenario is changing as more and more hospitals are realising the advantages of IT enabling their hospital.

Driving Factors

The current IT spending estimates are below $ 8,000 (Rs 3.2 lakh) per hospital in India, as per Datamonitor. With a maturing private healthcare sector, large private hospital chains have become the primary consumers of HIT (healthcare IT). Not content at that, IT companies have also started pushing boundaries aggressively to bring large government hospitals into their fold. "In the recent past, HIT spent used to be less than one per cent of the operating budget, even for large corporate hospitals. However, this has changed and the scene looks much lucrative for IT players now, with HIT spend touching as much as six to seven per cent of operating budgets," shares Anthony Basumatary, Managing Consultant, Datamonitor, India. This change has been driven in part by the growth of private medical insurance and in part by the surge in medical tourism in India.

Agrees Anurag Dubey, Programme Manager, Healthcare Practice - South Asia and Middle East, Frost & Sullivan, “The fact that IT adoption is currently limited to large, private hospitals in tier-I cities in India leaves a lot of untapped market to focus on for the IT players. However, the penetration rate in India of such IT solutions is still very small compared to the matured markets in the West. Says Kapil Khandelwal, Head, Health and life Sciences Vertical, Asia Pacific and Emerging Markets, Cisco Systems, Inc, "It is higher in the private and corporate hospitals segment at around 80 per cent." However, in the public sector (Government hospitals) segment it is around 25 per cent. We are seeing an increasing interest from both public and private sector. Many Governments are planning on e- health initiatives and have plans to implement health records."

Needs

Worldwide, IT applications in healthcare today are seen in two broad categories. One is care delivery which contains aspects like patient access management and evidence based medicine. The second category is of business infrastructure which includes supply chain management, payroll and benefits administration, finance and accounts, infrastructure and security, regulatory and standards compliance, patient education and e-portals.

In a hospital there are basic four areas that benefit from computerisation. The first is related to patient management activities like admissions, billing and discharge. Computerisation of these allows faster processing of patient related activities leading to better patient satisfaction. It also allows more effective utilisation of hospital staff, leading to reduced manpower costs. The second area relates to inventory management in a hospital. Enterprise wide automation greatly streamlines inventory control and leads to tremendous cost saving and according to industry experts this is probably the most tangible part of returns on investment. The third is related to implementation of EHR. "For medical staff this is the most important part of computerisation since it allows a continuity of medical records across various visits to the hospital by the patient and allows them to provide better medical care," opines Dr BK Rao, Chairman and CEO, Sir Ganga Ram Hospital, New Delhi. Lastly, like any other industry, hospitals also benefit from computerisation of back office functionalities like accounts, human resources and payroll.

Hospital Perspective

"The 'connectors' will be the next big thing in healthcare as HIS, EMR, PACS will need to interact in real-time with each other" - Dr Seema Gupta Domain Consultant Wipro HCIT

"The newer trends emerging in healthcare technology today are about collaboration, visualisation and convergence" - Kapil Khandelwal Head, Health and life Sciences Vertical Asia Pacific and Emerging Markets Cisco Systems, Inc.

"Our choice has been more towards buying all our solutions from the same vendor since we consider inter-operability critical to a successful implementation" - Dr BK Rao Chairman and CEO Sir Ganga Ram Hospital, New Delhi

Technology is now seen as a differentiator by hospitals to set them apart in the competition. Today, all hospital chains have leveraged IT to their advantage in streamlining their operations and providing a better experience to their patients. Hospitals like Sri Sathya Sai Institute of Higher Medical Sciences, Christian Medical College Vellore, Amrita Institute of Medical Sciences, Fortis Healthcare, Kovai Medical Center, Coimbatore; Max Hospitals, Apollo Hospitals, Manipal Hospital, Sankara Nethralaya and Aravind Eye Hospital are said to be the forerunners in adopting IT in India.

Says Dr Rao, "A good business model is always the key driver to any industry. Fortunately a good business model is available for healthcare IT solutions. One of the key drivers will be corporate hospitals who set up a chain of hospitals in different parts of the country. For them to maintain uniformity in their different branches, as well as provide continuity of EHRs across their branches, an enterprise wide computerisation is a must. Smaller solution providers will find enough mid-sized hospitals who will ensure that they remain financially viable."

Apollo Hospitals plans to integrate their information systems across their network of 42 hospitals. It will also introduce HIPAA standards in its systems for EHR implementations. (HIPAA is the Health Insurance Portability and Accountability Act, USA, 1996. This addresses, among others, privacy concerns in healthcare information). The IT team at Apollo has a core group of 30 people. The growing IT budget at Apollo constitutes around 4.5 per cent of its operational expenses.

Pune based (RHC) Ruby Hall Clinic was relying more on paper and verbal inputs to manage business. The prevailing business situation led to leakage in revenue, lack of information flow, and since there was no IT integrated system, time was wasted in doing routine repetitive tasks. The management also needed to lower the costs of completing administrative and clinical transactions. Many times, this directly affected patient care. In 1999, RHC started revamping the IT infrastructure of the hospital and decided to go with best-of-class solutions available in terms of hardware, enterprise application software and networking. HIS, RIS, PACS, EMR, ERP and telemedicine solution'are some of the IT solutions adopted by RHC over a period of eight years. PACS enabled it to improve patient care by streamlining clinical processes and creating a seamless flow of information. Its HIS system consists of a unique medical record number to identify a patient, so while a patient is being admitted, an intimation is sent to the concerned doctor on his mobile informing him about this. Telemedicine technology allows to extend the distance at which patient consultation occur. EMR when integrated allowed greater protection for medical information and improve data sharing without any threat to patient privacy. Today, activities related to patient billing, consulting charges, payments to be made to vendors are all recorded electronically. "The major challenge was the resistance from human resource at operational level", says Anand Patil, Manager-IT, Ruby Hall Clinic. This is a direct outcome for focused implementation of responsibility matrix coupled with the authority decentralisation. The buy-in by senior management is a very critical point in this activity. However at RHC the senior management was not only behind the effort but also led with examples. Today the Hospital is working on the final blueprint for implementing CDSS, clinical pathways and clinical research. "After the implementation of RIS / PACS, the patient volumes have significantly increased. With critical patient information like lab results, radiology images, medications available on-line, there has been a significant reduction of file movements and has helped the doctors to take decisions on time. It enables them to provide single window service for all patient related activities. They are able to get morbidity / mortality information which are just a matter of few clicks,"says Patil.

Another corporate bigwig, Fortis Healthcare is building a mobile-cum-wireless communication framework on IP enabled PBX to connect the nurses, doctors and patients. With this kind of networking system, nurses can use handheld devices to input patient data within the hospital's network, removing the process of taking handwritten notes and then inputting the data by hand. With this implementation, on the other hand patients can also communicate easily with the doctors and nurses faster. The other initiatives taken by the Hospital includes the 'web based interface' and 'database shadowing' for performing data check-in/check-out operations. The 'web-based interface' basically connects the people ie the hospital staff including the doctors and the information/data through web. This system is accessible to the doctors and the other hospital staff and enables easy data sharing faster. The web interface allows access to internet, while the database shadowing reduces recovery time by staging the database restore and roll-forward process, enabling recovery within hours and allows online archival and thus doesn't need any separate solution. Database shadowing is a data backup technique in which an identical copy of the hospital's database is maintained on the computer systems. The primary database and its shadow are linked via cable, telephone line or wireless that any change in the primary database is immediately reflected on the shadow.

However, usage of papers and manual work was such that it became challenging to get the staff accustomed to working on the web-based database. "Perhaps one reason for resistance amongst the front office staff was that after the new system, they would be more accountable. Because, earlier the front office staff used to redirect the patient to the billing clerk for any query, but now they themselves would be answerable to the patient's queries," says JS Puri, VP-IT, Fortis Healthcare, Delhi. Earlier when the doctor ordered to discharge the patient, it took time for the nurses to prepare the documents for the patient discharge and thus the patient had to wait and then further it followed with the billing procedures. A long time was consumed in this entire process since everything was carried out manually. Whereas now when the doctor orders for discharging the patient the entire process is carried out through the web-based hospital system interfaced with the patient's medical records which makes it faster and saves time. Time to admit a patient and indent a drug has reduced by 30 per cent and that too at its initial stage and it will further reduce when data is cleaned further.

Preferring End-to-End

As newer healthcare delivery models rely on integration of services between multiple service providers (outsourced, in-house fulltime and part time, contract etc), their competitive edge, in terms of quality and cost, will be determined by a good IT end-to-end solution provider. In a significant 'IT in Healthcare' study done in the west, the single most important finding is that healthcare providers that invest and utilise IT only in the billing or clerical areas inadequately utilise the investment in IT hardware and software. However, hospitals that fully utilise HIS for both clinical and operational functioning, with complementary networks and devices, reap the benefits of improved care and costs. Today, more and more hospitals prefer end-to-end IT solutions. However, both options have advantages as well as disadvantages. "India is a volumes market and has to be played like one. Models that work in the west would in most cases fail here," opines Ajay Chanam, AGM-WW Communications, Sobha Renaissance Information Technology.

Purchasing different solutions from the same vendor allows better integration between the various components, something that is critical in today's complex environments. On the other hand, purchasing different solutions from different vendors allows one to have the 'best of breed.' Gangaram Hospital chose to stick to one vendor to accentuate inter-operability. "Our choice has been more towards buying all our solutions from the same vendor since we consider inter-operability critical to a successful implementation," avers Dr Rao.

Benefits Galore

To improve quality of care, reduce costs and plus increase access to healthcare is driving IT adoption in the healthcare industry. Healthcare technology, if implemented properly, prevents medication errors. A physician ordering a medication electronically will know immediately if the medication he/ she is prescribing counter reacts with a prescription that the patient is already on or if the wrong dosage was mistakenly prescribed. According to experts, the greatest benefit of IT lies in chronic disease management, where costs are typically high. Delta checks built-in at key decision clinical transactions reduce errors in diagnosis, medication and critical test reporting. Secondly, the instantaneous availability of clinical data like imaging, lab reports, and second opinion shortens the time taken for diagnosis and initiation of treatment. There has been some research that has shown that healthcare IT does improve clinical outcomes. However, there has also been some research that has found IT decreasing clinical outcomes. "Part of this decrease may be due to end-users needing time to learn the new system. Additionally, much of the clinical benefits are not realised immediately. Rather, they will be realised in five to ten years (or even later for preventive health measures). Given that, decreased re-hospitalisation rates and decreased medication errors are often cited as an indicator of IT improving clinical outcomes," states Christine Chang, Associate Analyst, Datamonitor. Care pathways and treatment plans are already being incorporated in the healthcare IT at hospitals in the western world and have yielded rich returns. Says Dr Gupta, "Sentara in the US, with 90 ICU beds distributed over four hospitals, leveraged IT to reduce their ICU ALOS (Average Length Of Stay) by 17 per cent and patient mortality by 20 per cent as far back as in 2000." Improved clinical outcomes also bought the cost for each ICU patient down by $ 2,150 per patient giving them a Return on Investment (ROI) of 155 per cent. The benefit of this is enormous with an immediate benefit of minimisation of medical errors and availability of clinical analytics.

Although the official healthcare expenditure for healthcare in India is around five per cent of GDP, in rural families it can go up to 15 per cent because of such hidden costs like travel and time of work. "Everyone knows that there are peripheral costs involved in healthcare like travel and stay. They sometimes can amount up to 40-60 per cent of a person's entire healthcare costs. Technologies like tele-medicine can totally negate this cost for all non-invasive treatments (which amount for the majority)," shares Ajay Chanam, AGM WW Communications, Sobha Renaissance Information Technology (SRIT) and GM - Head Private Sector and SME, iHCX. Telemedicine can dramatically decrease the travel costs which although a hidden cost of healthcare (and not measured) is a very significant help.

Connected Healthcare

The concept of connected healthcare is said to have captured the imagination of healthcare industry today and includes network infrastructure, information access and remote service delivery for seamless provision of healthcare. Dr Seema Gupta, Domain Consultant, Wipro HCIT feels that the 'connectors' will be the next big thing in healthcare as HIS, EMR, PACS will need to interact in real-time with each other and with patient monitoring gadgets at the hospitals, consulting rooms, homes and workplace. The connectors would be V SAT, internet, mobile and anything which connects the available information to all the service providers ranging from insurance companies, doctors, home care providers as well as vendors. Dr Gupta cites Israel's example where the hospitals have used normal landline connections to transmit health related data. "For example, when you monitor heart patterns, they are monitored in real time and transmitted over the normal phone wire. To a substantial limit even the hospitals in Australia have utilised the concept of connectors," states Dr Gupta. Khandelwal believes that the newer trends emerging in healthcare technology today are about collaboration, visualisation and convergence. "Healthcare technologies need to unite patients, caregivers, administration and families across the care continuum through the innovative use of data, voice and video so people can communicate wherever they are, using any device whether wired or wireless," states Khandelwal.

Even though the mobile phone is omnipresent today, it is still not used for health as patient and doctor still desire a human interaction. However, mobile use in reminders and emergency and clinical alerts is growing. "At Fortis, our doctors use clinical software on mobiles. I envisage a 'mobile health' SIM card that will also store health information securely. With 3G and enterprise level bandwidths on mobile, I expect video consults on mobile with doctors," says Puri.

Mobile computing is going to play a major role feels Murthy Rayaprolu, Head- Delivery, VBU-Healthcare Provider, Satyam Computer Services Limited. "We do not have a bedside computer today. That is also because desktop at every bedside is not economically viable. It can interfere with some of the medical systems which could be there in emergency rooms. However, there are devices coming up in the market which looks like a tablet and can be carried anywhere in the hospital and has limited interference with the electronic equipment. The doctors carrying this device can locate the patients wherever he is in the hospital. These kind of devices are coming into the market but it is not fully implemented anywhere," shares Rayaprolu.

Furthermore, traditional data, voice and video technologies in a hospital are quickly getting redundant and expensive to sustain. Newer technologies based on IP- platforms are leading towards a digital transformation and are cheaper to maintain. Healthcare is witnessing a convergence of data, voice and video over wire/ wireless IP-based networks in a hospital and according to experts these technologies are scalable (build as you grow) and easier to operate and maintain in a hospital. Experts predict that wireless technology is going to be a turning point - through which doctors, nurses and patients can communicate seamlessly on Wireless Local Area Network (WLAN) and eventually WiMax. "At Fortis, we are building a mobile-cum-wireless communication framework on IP enabled PBX that will really connect these users. If patients can find and talk to the care provider fast, half the battle is won," opines Puri. Trichy based Kaveri Medical Centre and Hospital has implemented a SMS software which is used in applications like, informing consultants about patient admission, informing referral physician about their patient details, informing patients about latest news in hospitals, informing patients when their lab reports are ready, intimating patient about health check-up dates as well as informing HOD about new job orders and pending orders. "Overall it is a good CRM module. When railways and airlines can use SMS CRM why not healthcare? We have scanned all the old medical records, which clinicians can access from their desktop. This is used to review old case sheets when the patient come for review and used for clinical research," states Dr S Manivannan, Executive Director, Kavery Medical Centre and Hospital, Trichy. Also, the reality in healthcare technology is that there are no standardised applications across healthcare industry. In order to improve patient care through rapid access to information means that applications need to follow industry guidelines and workflows. "Technologies that can increase access to information, anytime, anywhere and reduce the Total Cost of Ownership (TCO), lead us in the direction towards visualisation of different layers of technology architecture," adds Khandelwal.

Key Concerns

Healthcare sector is always said to be less open as compared to other sectors when it comes to adopting newer IT trends. Indian hospitals have indeed been late in realising the advantages of IT. Lack of awareness, resistance to change, the low priority given to financing IT-related investments, lack of suitable solutions, as well as the absence of professional decision making has led to low penetration of HIS in this high-potential market. Hence, there are not many hospitals in India which have successfully automated all their core functions like administrative areas, clinical areas and back office. "Most hospitals that have already embraced technology, have automated their operations in parts and therefore most of them are not deriving the full benefits of information technology," states Khandelwal. Hence, there are not too many examples (reference sites) that other hospitals in India can follow. Moreover, the full benefits of IT will be apparent only when the core clinical operations are automated, which is still a few years away in India. Some of the other problems that are unique to India are lack of enough trained professional medical/ healthcare informatics personnel in the industry. "All the innovations available in the west are available in India, and very often at competitive costs. However, currently, the limiting factor is lack of the domain knowledge and overview to utilise these innovations to deliver the most effective and efficient solution," opines Dr Gupta. Also, the lack of integrated information across the enterprise (lack of data sharing across departments and applications and lack of collaboration across various stakeholders in healthcare are few main intimidating issues present in the Indian healthcare today. "The other big challenge has been to design an EMR system that can have unlimited sub-modules as per the specialties and super specialties ranging from general medicine to paediatrics, to cardiology, to neurology and urology," believes Dinesh Samudra, CEO- SEED Healthcare Solutions Private Limited.

Vendor Watch

Just as hospitals vary in their size, so will their demand for the size and scalability of the IT solutions. The requirements of large hospital are met mostly by international vendors or reputed Indian vendors, whereas small hospitals are likely to adopt smaller solutions, which are readily available in the Indian market. The Indian market for such products has not yet matured. Applications available in the market range from HIS, including EHR and back office functionalities to PACS. Adjunct solutions are available for attendance systems and RF tagging. Some IT healthcare companies had ventured into the Indian market as tie-ups with local solution providers. This enabled them have to have a readymade support base with minimal investment. For example, TrakHealth from Australia (now InterSystems, USA) has tied up with MTech of Delhi to implement and support its solutions. However, more and more international vendors are entering the Indian market directly with their own brands, for example, Siemens, GE, and iSoft. Industry giants like Cerner, Vista are also close to entering the Indian market. According to experts, for the IT vendors, large part of the opportunity lies in the replacement of outdated first-generation HIS with newer, more powerful HIS applications at large hospitals with complex and sophisticated operations. "There are an estimated 25,000 hospitals in India, excluding the private clinics and nursing homes. This factor should be enough to drive the HIS market in India," opines Dinesh Samudra, CEO - SEED Healthcare Solutions Private Limited. Currently, the HIS market in India is still in the early growth stage. It is a small market dominated by in-house implementations and customised solutions developed by small local software developers. In terms of technology adoption, the Indian market is far behind its Asia Pacific counterparts such as Australia, Japan, South Korea, Singapore and Malaysia.

Also, the newer technologies require very high initial investment and the ROI takes many years. All these factors make adoption of newer technologies difficult for any hospital. Hence a cautious and patient approach is said to be required before any viable results could be obtained.

Apart from this, cost incurred on maintenance of systems can be a major factor for hospitals when deciding to invest in technology. And this is especially true with systems that are built on obsolete technology. As technologies change rapidly over few years, hospitals need to adapt to the changing environment. Proprietary technologies will make certain IT solutions adoption in healthcare industry expensive. "As healthcare is already expensive, implementation of an expensive IT infrastructure in any hospital will be a major deterrent," agrees Dr Rahul Shetty, Founder-President, Mezocore Technologies, Canada. However, according to Dr Gupta, hospitals are traditionally very familiar with maintenance costs as they buy expensive machinery and often run a large maintenance department, therefore IT maintenance costs are both -understandable and acceptable- to them.

"Unfortunately, initial implementation is more than just installing the hardware and software. The costs of change management (ie. implementing the change from manual to digital) are never included or negotiated in any contract which allows vendors the convenience of calling that maintenance. So, most projects fail (the failure rate is officially 60-70 per cent though unofficially it goes up to 95 per cent at least as partial failures) and that is a deterrent," avers SB Gogia, Indian Association of Medical Informatics (IAMI).

Another reason is lack of common standards in healthcare which makes it even more difficult for hospitals to adopt newer technology. "HIPPA is widely used in North America, yet in India there are no common standards. Many hospitals adopt a very conservative and cautious approach to adoption of IT in healthcare," opines Dr Shetty. Further, fear of loss of privacy and confidentiality of health data hamper the IT penetration.

Future

In this quality driven healthcare industry, it is no news that the healthcare IT market will continue to grow, particularly in countries like India. Hospitals moving towards quality certification and accreditation leading to standard operating procedures are driving the demand for standard based applications. "We are moving towards an integrated healthcare scenario - where various healthcare entities will get connected on a common platform to allow information exchange between standard based applications and thus improving efficiency of systems," feels Dubey.

"Implementing IT at the inception stage is much easier rather than trying to install it in the older ones. Thus, as new healthcare organisations are built in India, they should be built with the use of healthcare IT the mind right from the beginning," says Chang. Today more and more hospitals are realising the advantages to implementing IT solutions. India has a large number of hospitals and in terms of sheer numbers of implementations possible, the potential is huge. The Indian vendors are also improving on the quality of solutions they provide and it is hoped that they will soon be able to meet the challenge provided by the international players since India has highly skilled IT manpower resources. In the private sector, hospitals are looking at IT mainly from a commercial application perspective. Experts feel that these hospitals should now go beyond the ADT and billing processes to apply IT in clinical applications like CDSS, EMR and clinical research. There is surely a lot to be done in terms of applying IT from the patient care perspective.

As Dr Gupta concludes, "The complexity and variability of healthcare delivery- both in terms of business models and clinical demands a deep insider 'worm-view' and an informed IT 'bird-view' from its IT solution. Only an intelligent solution that provides this integration can succeed in healthcare. The good news is we are getting there, may be slower than the other sectors but still getting there."

sonal.shukla@expressindia.com
priti.pathak@expressindia.com