INTRODUCING THE COMPUTER AIDED INFORMATION TECHNOLOGY –AN ADMINISTRATIVE EXPERIENCE IN GOVERNMENT TERTIARY CARE HOSPITAL (AN INNOVATION FOR EFFECTIVE, EFFICIENT AND HEALTHY PRACTICES BY E-GOVERNANCE)

*, Dr. Rakesh Pandey **, Mr. A. K. Sarkar * **, Dr. Sita Naik **** Dr. Rakesh Aggarwal **** *

ABSTRACT:

Traditional ways of dissemination of information in any direction in a hospital set up is now becoming out dated gradually as it has many shortcomings and new technology is being introduced. Introduction of electronic communication media in health care sector set up of the government is still an un common phenomenon due to many constraints such as non availability of funds, unwilling to introduce, resistance by the employees and least importance given to decision making process. Information based on analyzed data is an essential requirement for the decision making process. In any organization the out put/out come is also measured by the effectiveness and efficiency. To achieve these, computer in any organization has been proved a well-established tool, may it be in hospital. On introduction of new technology of effectiveness and the efficiency developing the resistance by the employees specially in the government set up is an usual phenomenon, mainly due to the apprehension of likely withdrawal of the jobs. The Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow faced the similar situation on introduction of computerized HIS. But due to dedicated and coordinated efforts made by hospital administration, faculty and other health care providers is finally achieved the implementation in 2000 and became the first public sector tertiary care hospital of India which fully runs with computerized HIS. The system was developed after a detailed study for feasibility (SWOT analysis) viability and implemented later on in phased manner. The administrative/technical difficulties/limitations were identified gradually by utilizing the services and simultaneously remedial actions were taken to overcome these. This was an effort and innovation for developing effective, efficient and healthy practices in hospital by e-governance. Any software is not perfect unless it is tested for sometimes in hospital. Users (administration, faculty & other health care providers) are important resources for software development.

INTRODUCTION:

The Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) Lucknow, a tertiary care hospital is pioneer in the field of medical advancement in the state of U.P. It conceived the idea of introducing the computerized HIS in 1994 but some how could not show the progress till 1996. Finally after having carried out the study for feasibility (SWOT analysis) and the viability of the system, it was introduced in 1998. To implement the computerized HIS, the administration and the users faced many problems but ultimately after setting coordinated efforts, the SGPGI could succeed the same and became the first fully computerized government tertiary care hospital in India. The implementation was in phased manner after doing the pilot study for selected area. Initially the administration faced some resistance from the employees mainly due to the apprehension of likely withdrawal of the employee from the regular job but gradually they were put on job with an assurance that there will be no ill effect but this is going to increase the effectiveness and efficiency. Ultimately every body was motivated and came forward and finally the computerized HIS was introduced.

The administrative and clinical problems faced by the hospital due to traditional ways of information dissemination before computerized HIS was introduce were:

1. Non-availability of some of the patient’s case sheet for admitted and OPD follow up patients, was a common feature. The institute being a research organization preserves case sheets of all patients for a limited period.
   
2. Non-availability of investigation report due to misplacement by the medical record or misplaced during transit was also a routine phenomenon.
   
3. Bad debts due to non-payment of medical facility or inability to recover the charges from the patient by the administration was a real problem. The hospital is a fully paid hospital for all but under certain circumstances such as death, abscond, left again medical advice or government owned reimbursed bill, it recovery of the medical bills was very difficult.
   
4. Misuse of lab investigation facility by the hospital staff posted in indoor area was very common. The ward staff used to get the investigation done of their near and dear (non-dependents) by using the registration of the admitted patient, which was billed for the patient.
   
5. Similarly there were many problems faced by the administration during the process of development and implementation of computerized HIS.
   

Based on the experience gathered before and during the development and implementation of computerized HIS, this article is being written to expose the health care providers about the administrative and technical difficulties faced by the administration and the user and efforts made by the administration to over come these problems. Ultimately innovation in hospital information system by computerization was achieved for e-governance. It is very much pertinent to mention here that the system was developed and implemented in adverse situation as prevailed due to on going indiscipline by the government employees in certain states including U.P. However the computerized HIS was introduced in the hospital with following objectives.

OBJECTIVES

1. To innovate the hospital information technology and develop the healthy & best practices through e-governance.
2. To switch over gradually the present manual system of information generation, storing, analyzing and retrieving into the computerized HIS system for effectiveness and efficiency.
3. To reduce the bulk of paper work used in medical care.
4. To reduce or minimize certain administrative and clinical problems, like bad debt, misuse of the hospital facility, non-availability of patient case sheet etc. etc.
5. To develop the equity concept for financing of health care.

METHODOLOGY:

Documents related to conception, decision-making and finally introducing the computerized HIS were studied in detail.

Information about expenditure involved in the project (capital and recurring) was collected from finance department and the members core committee involved in the development.

Circular, Office order, Inter office memo related to development and implementation were studied.

Core committee members and the users were interviewed for acceptance, resistance, practical problem faced and measures adopted by the administration to over come the problems.

Physical inspection of infrastructure and lay out was carried out to have the information about the total network.

Other information to meet the objectives like to reduce the bulk of paper work, to minimize bad debts, non-availability of case sheets and investigation reports etc. were collected by personal efforts and by observation as the authors are the members of the core committee for coordination and implementation of the project.

OBSERVATIONS

1. ABOUT THE SANJAY GANDHI POST GRADUATE INSTITUTE OF MEDICAL SCIENCES (SGPGIMS)

The concept of establishing a super-specialty Medical Institute at Lucknow was conceived in early 1980s. His Excellency Shri Neelam Sanjeeva Reddy, the then President of India laid the Foundation stone of the Institute on December 14, 1981; the Institute is celebrating the Day as Foundation Day year after year.

The State Government set up a team of experts to advice the Government on establishing a new Institute beginning from scratch with the hope to create an apex referral center for tertiary medical care, education and research which could be a stepping stone for 21 st century.

The basic concept of the Institute was to provide State of the art medical care to the people of State and super-specialty medical education and training so as to create medical manpower of the highest quality to take care of super-specialty medical care needs. With this motto, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow was established as an autonomous body under the Act of State Legislature in 1983. The Act was unique in providing for H.E. The Governor of UP as the Visitor and the Chief Secretary to the Government of UP as the President so as to ensure true autonomy to the Institute.

The Institute believes that “research enhances vitality of teaching” and the “teaching uplifts the standard of services”. Therefore, the Institute adopted teaching, training, patient-care and research as its motto, we derive strength from these three pillars, which are so well depicted in Institute emblem. The Institute also believed that to run the hospital services, the only alternative is the system approach and application of management techniques as a tool. The Institute is the only hospital in the whole UP & Uttaranchal, which is run by qualified, experienced and skilled administrator.

The Institute was planned to develop in three phases. The first phase included the specialties of Cardiology, Cardio Vascular Thoracic Surgery, Endocrinology and Endocrine Surgery, Gastroenterology, Surgical Gastroenterology, Medical Genetics, Clinical Immunology, Nephrology, Urology and Neuro-Surgery supported by specialties of Pathology, Microbiology, Radio diagnosis, Nuclear Medicine, Radiotherapy, Anesthesiology and Transfusion Medicine. Since research was an identified goal of the Institute, the department of Biostatistics was also included in the first phase. Recently, a new department of Critical Care Medicine has also been established and the Institute is also establishing a department of Hematology.

During formative years of this Institute, the Government of Japan through its International Cooperation Agency came forward to assist us with a generous grant-in-aid of 3.32 bil Y (Rs. 33 Crores approximately) for medical equipment. This provided a boost to rapid growth and development of high technology medical care at this Institute. Subsequently, during the years 1997-98-99, the Institute received French grant-in-aid to the tune of 33 mil FF (Rs. 26 Crore approx.) for up gradation of equipment.

The Institute has centrally air-conditioned 600 bedded hospital with 16 intensive care beds and 13 OTs. It has a committed and dedicated faculty of 150 supported by about 300 resident doctors, 600 nurses, 150 technicians along with about 800 officers and employees. The hospital services are provided at reasonable and subsidized rates.

Being a tertiary care medical center, the Institute functions a referral hospital. As a State University, the Institute offers DM, M.C.h., MD, Ph.D, Post Doctorate Certificate courses and Post-Doctorate fellowships in various specialties. All such courses have been duly approved by Medical Council of India. During a short span of 15 years the Institute has achieved an unique distinction of successfully training more than 300 medial super specialists and 40 Ph.D. scholars who are well placed in academic institutions, corporate hospitals and professional practice both at home and abroad. It shall be pertinent to mention that the Institute true reflects an All India Character as more than 50% of our students are drawn from outside the state of UP through All India selections. Besides structured teaching courses we also offer training and observer ship facilities to doctors from government and corporate hospitals. The Institute is also very active in organizing CME and other scientific meets for wide dissemination of knowledge. The Institute is also committed for excellence in research in areas of national importance. The fact that the Institute faculty has so far published more than two thousand research papers in various national and international journals of high repute reflects the commitment and dedication of faculty in sustaining high level research so as to keep pace with the time.

The Institute attends to more than 35,000 new out patients and 130,000 old out patients every year and 20,000 patients are admitted to various specialties of the Institute; about 6,000 major surgical procedures including Renal Transplantation, Liver Transplantation and Bone Marrow Transplantation are performed annually. More than 1,000,000 laboratory investigations are also performed. From hospital activities, the Institute generates approximately Rs. 18 crores every year.

To derive the best out of faculty and the officers Institute had been wise enough to encourage the participation of the faculty and officer in National and International conferences, so that they keep abreast with the latest developments in the field. Not only this, the close interaction of the faculty with the experts helps in generating new concepts and collaborations resulting in improved quality of research and patient-care.

Each specialty is being developed as a comprehensive center combining medical surgical and basic sciences disciplines. In addition, there are departments of Pathology, Microbiology, Radiodiagnosis, Nuclear Medicine, Radiotherapy and Anesthesiology, Transfusion Medicine to provide necessary support to all the specialties.

The cardiac investigative facilities are cath lab 2 D colour Doppler, ECHO, Tread mill and holter monitoring equipment. Likewise, the clinical pathology services are equipped with Technicians 24 channel autoanalyser, 8 parameter blood cell analyzer and RIA facilities. The Institute also has installed Electron, Microscopy equipment. Specialized laboratory investigations in the field of Endocrinology, Genetics and Immunology are being provided by respective specialty departments. Department of Radiotherapy is having cobalt plant and linear accelerator. The Institute is providing extensive investigative facilities. Its department of Radiodiognosis is equipped with MRI, Whole Body CT Scan, computerized Radiography, DSA & Automatic positioning GI table, besides routine and mobile X-ray equipments and ultrasounds. The department o Nuclear Medicine is having SPECT and mobile Gamma Camera. The Institute is offering Ph.D., M.Ch., DM and MD degrees in respective fields. The Institute is having equipped ultramodern CSSD, Laundry and Kitchen Services. With in short period of 10 years service, the medical & education map of the country.

A tertiary care hospital with followings superspecialities in first phase

Hospital Statistics- 2000 – June 2004

1. ABOUT THE COMPUTERIZED HIS -

(A). DEVELOPMENT OF HIS PROJECT:

The SGPGI is the first and only public sector tertiary care hospital in India, which fully runs with computerized HIS. The main functions of HIS are -

Based on above-mentioned statistics, it is obvious that the institute is generating lots of data everyday. Therefore it was evident that the SGPGI was in need of computerized HIS for the effectiveness & efficiency. In addition to above there have been many administrative and clinical problems which the hospital wanted to over come as these were polluting the hospital environment.

i. Study for feasibility of computerized HIS was conducted during -1993-94 and found the situation feasible. The component of the study were e as follow:

Aspects - Purpose of study

2. Situational (SWOT) Analysis - The SWOT analysis was carried out to establish the viability of computerized HIS and to take the decision.

Strength (S)

Weakness (W)

Opportunity (O)

Threat (T)

The institute had many strengths and the opportunities but at the same time had many weakness and threats. In view to minimize the weaknesses and the threats in future as these weakness were basically concerned with human resource, the decision was taken to go for computerized HIS. A strategy focusing the motivation and change in behaviour of employees was adopted to minimize these weaknesses and the threats.

Advance features of HIS software – The HIS software was developed by center for Development of Advanced Computing (CDAC), Pune. Followings are the advance features of HIS software developed.

Network Structure

Expenditure incurred

(a) Capital:

(b) Recurring expenditure on maintenance - Rs. 25 lacs/year

Various Modules – developed in the first phase are:

DATA SOURCE AND LINKAGE

CENTRALIZED DATA BASE

DATA SOURCE AND LINKAGES - Flow Chart

B- IMPLEMENTATION OF THE HIS PROJECT

In view to minimize the weaknesses and the threats, it was decided to develop the module gradually and implement the project in the phased manner. The other advantage of phased manner was to monitor the system closely, observe the functioning and the difficulties, and rectify them later on.

Implementation of main module (activities) in chronological order

With the help of coordinated activities, the HIS was implemented in whole hospital in phased manner. However many considerations were still kept in mind at the time of development of the HIS but still administration and the users faced many difficulties while using the system. These difficulties were basically of two types; Administrative and Technical. The remedial actions were taken simultaneously to overcome the difficulties as and when these arised. Some of the examples of major difficulties faced and remedial action taken are illustrated as below:

DIFFICULTIES FACED AND REMIDIAL ACTIONS TAKEN DURING IMPLEMENTATION:

A: Administrative

(B) TECHNICAL DIFFICULTIES:

Note - Some of the problems are still unsolved in the first phase of HIS development. They will be solved in second phase of development.

Advantages of present computerized HIS:

In addition to achieve the objectives of the system, the system proved advantageous in many directions, such as :

LIMITATIONS OF THE SYSTEM:

There is a provision of specialty wise bed allotment in the HIS. Therefore vacant beds con not be allotted to other specialty.

Sometimes the patients reporting the emergency cannot be given full treatment (in absence of admission) as no bed is available in HIS for that speciality.

No change in information can be made after discharge of the patient.

Complete range of hospital statistics is not available.

Note – They will be improved in second phase of computerization development.

FUTURE PATH:

The future path is to add upon more and more functions specially as mentioned in above and also develop the Internet based HIS (not LAN). The advantage of this will be Interhospital connectivity and on line registration, investigation report etc.

CONCLUSION:

No doubt that computerized HIS is effective & efficient but difficult to implement in hospitals specially in government owned. It requires much awareness and motivation among the HCP, dedicated effort, strong coordination, assurance to HCP about job security. Programme once made is not a final format forever. The advancement/ addition in software is required continuously and newer requirements/problems keep on cropping up with the experience. Therefore periodical upgradation of HIS is required. The system should be developed and implemented after having carried out a situational analysis (SWOT) of the organization, as it required much input too. The computerized HIS at SGPGI hospital was really an example of innovation for effective, efficient and the healthy by practices e-governance.

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* Medical Superintendent, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, (U.P.)

** Prof., Deptt. Of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, (U.P.)

*** System Analyst, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, (U.P.)

**** Prof., Deptt. Of Immunology & Chairperson, Computerization Committee, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, (U.P.)