Information is Power—this motto holds true for Mumbai-based 560-bed Tata Memorial Hospital (TMH), a reputed name in oncology. It is truly one of the first 'digital' hospitals in India as its IT story goes back to 1985 when India was not even aware of the 'alien' world of computers. Impressively, when digitisation was itself new to the healthcare industry, TMH embarked on a pioneering path to use IT for its information management with the ND550 Supermini computer and 40 dumb terminals across the hospital-wide network and thus conceptualised its own indigenous HIS. In 1997, this small indigenous project soared with an initiative to undertake a systematic review of the existing operational systems for patient care management and hospital administration in the hospital. In the process, the hospital went on to have well-integrated Electronic Medical Record (EMR) and Electronic Financial Record (EFR) systems in place. Today, the hospital is in the process of taking this initiative one step further by web enabling the entire system and fostering the concept of e-health.
Driving need
As one of the leading cancer research institutes in India, TMH has a need to retrieve patient information in a very structured manner. "The reason we created our HIS in 1985 was to computerise normal transactions in the system and retrieve them at a later stage. We were abstracting information like registration, demographic and clinical details from the patient files and putting it on the system. However, this information collection was not on a real-time basis and this HIS outlived its utility by 1996," relates Dr Narayan HKV, Medical Superintendent. The hospital felt the need for a more robust and responding integrated enterprise system that could link with all the systems in the hospital. The requirement for digitisation in the hospital was in terms of structured workflow, enhanced patient care and satisfaction, improved management tools, effective, economic, timely and manageable data processing and improved exchange of information between care givers, patients and statutory authorities. "We wanted to establish a platform and protocol for transmitting and sharing information," Dr Narayan explains.
In this context, a review was conducted with active participation of the hospital management. The scope of the review included patient care services, materials management (purchase and stores, dispensary) and financial management. "The review yielded valuable insights into inherent lacunae which kept us short of contemporary manage-ment practices. The hospital management decided to incorporate a number of recommendations into this system re-engineering process with a tight coupling to a computerised system, resulting in EMR and EFR," reveals Dr A Mahajan, Assistant Medical Superintendent. The Hospital moved into client server architecture.
Step by Step
Since 1997, the hospital has developed a variety of modules specific to an area of operations. The hospital separately implemented modules like Patient Administration System, Diagnostic Information System, PACS, Operation Theatre Module, Clinical Information System (CIS), Radiation Oncology Information System (RIOS), Medical Oncology Information System (MOIS), ICU and Inpatient Module as a part of EMR. As a part of EFR, the hospital is in the process of implementing modules like Financial Management System, Payroll system, HRD and Personal System, Stores Module, Purchase Module, Dispensary Module and Facilities Management Systems. "The integration of the EMR and EFR will enforce all the business rules of the institution and facilitate meaningful management information for timely and purposeful decision making," claims Dr Narayan.
IT@Tata
Patient Admission System: Implemented in 1999, it is said to be the pivotal system in EMR. The implementation of this system has catered for patient care activities such as registrations, appointments and travel concessions, wait listing, admissions, transfers and discharges. This system has provided key demographic and patient status information to other modules that were installed one after the other in the Hospital. "Management information such as trends in registration, waitlists, bed occupancy, lead-time analysis for treatment and re-admission rates are important outputs of this system," Dr Mahajan reveals.
Diagnostic Information System: Implemented during 2001-02, it has enabled the hospital to put in place diagnostic services like radio-diagnosis consisting of conventional radiography, CT, MR, mammography and ultrasound, bio-imaging unit consisting of PET-CT, pathology including surgical pathology, cytology, haemato-oncology, transfusion medicine including blood banking, diagnostic endoscopy and cardiology including ECG. With this implementation, in addition to placing the diagnostic reports on the clinician's desktop as soon as the investigations are reported, the turnaround time has been considerably reduced. "The problem of misplaced reports has almost been eliminated. MIS reports, both operational and executive, are a positive fallout of the system," says Dr Mahajan. On the other hand, the interfacing of analytical equipment like biomedical analysers and cell counters with the diagnostic information system has reduced the lead-time of reporting and has eliminated transcription errors.
Picture Archival & Communication System (PACS): Implementation of PACS was quite a challenge and that is why the hospital approached it in a phased manner. "First we started distributing the images on the hospital network as we had to change the views of clinicians who were used to seeing hard copies, and this was a total culture change for them," Dr Narayan recalls. An initiative was taken where the hospital first started archiving the images on the PACS system. This developed the capacity of archiving. The next step was to distribute the archived images over the web. Without curbing the clinicians' instincts of looking at the hard copy, the hospital made available the web based images. "We told the clinicians that they could not only look at the hard copy but could also go to the web and see the images. This is how the acceptability slowly came in," Dr Narayan explains.
Simultaneously, the hospital initiated soft copy reporting where all the radiologists were provided with workstations capable of post processing the images. Reporting on diagnostic workstations has enabled the hospital to move towards a filmless environment. In the last year, an advanced voice to text system has been installed in the hospital.
Operation Theatre Module: It has been functioning since 2003 with features like scheduling of procedures, pre-anaesthesia evaluation, pre-operative check lists, surgical procedure details, anaesthesia details and post-operative check list. "The OT module was among the first modules to be implemented in the hospital as OT itself is a single event for the patients. In addition, traditionally the surgery team is the most difficult team to convince in any hospital, as it is the busiest team. Therefore we wanted compliance from them first," says Dr Mahajan.
The implementation of this module streamlined the OT area in the hospital with real-time data capture of the information now possible and being available across the hospital. Today, the future refinement in the OT module is coming from the clinicians themselves as they want more information in a structured manner.
USP
Dr Narayan avers the system is integrated and not a collection of stand-alone systems. "One system should complement the other system and not work at cross purposes. If the stand-alone systems are not properly integrated, they will under-perform. Across the world there are very good stand-alone systems, but there is a need for a a totally integrated enterprise system which can address every aspect of hospital functionl," he opines.
The hospital has avoided this. The back-end server in the hospital is a single database. It is also said to be a completely customised system whereby every stakeholder knows his role and what he has to do. On the other hand, in bought systems, users have to learn about the systems and how to use them. "We took a conscious decision in 1998-99 since we didn't have a system which could really suit us; so the only alternative was to do it the hard way. We have customised this software in such a way that we are improving our existing work practices and incorporating them into this software," says Dr Narayan. The hospital has guarded itself from system failures with back-to-back servers and data replicators.
Vendor Selection
The HIS is developed by the Electronics Corporation of India Limited (ECIL), which is a sister organisation under the Department of Atomic Energy. ECIL provided the software programmes and has been continuously upgrading them. "We tell them what we require and how it must be structured. They do the coding and programming and domain logic are sourced from us," Dr Narayan says.
The hospital was opposed to vendors who propose a ready-made product which is a collage of different requirements. "They start off with a generic product and then try to fit in the requirements. We wanted a software vendor who could develop a software and maintain it as per our requirement. With ECIL, we found a worthy partner and our association has been reassuring," says Dr Narayan.
Challenges in the Path
The route to implementation of different modules has not been easy for the hospital. As Dr Mahajan puts it, "It was more difficult when we started in 1999 because people were new to the concept of real-time data entry and departments were very reluctant to share the data with each other."
The other major challenge was to get acceptance among the users. "The department of pathology was most concerned that the reports would get lost. It took a long time for them to be convinced and till recently they were maintaining a duplicate copy in the department." remembers Dr Narayan.
Systems had to be developed that could have acceptability for a broad spectrum of employees of the hospital at all levels. "We had to sell the concept of why we were implementing the different systems and what are the benefits to each of the stakeholders. We had to motivate people to use this system and bring in some sort of acceptability. It was and is a painstaking process," Dr Narayan admits.
Future plans
In the near future, the hospital aims to have web-enabled systems in place. This will include services like patient registration, appointments, admission wait list follow-up, cyber consultation, e-health initiative, investigations/ product requisitioning, access to EMR and tendering for materials managment. The application for web enabling has been completed and will be implemented in the near future. "Cancer is a disease which needs follow-up for the rest of the patient's life. Moreover, patients have a close association with us with more than 80 per cent of them coming from outside Mumbai. Web enabling will enable them to access their records online, download and archive them, which is not only more convenient but will also save them time and money. Similarly, doctors can access the patients' records from any location," Dr Mahajan points out.
The hospital is also mulling over the concept of e-health which combines aspects of medical informatics, public health and business with reference to health services and information delivered usually through the internet.
No comments:
Post a Comment