STAGES OF INFORMATION TECHNOLOGY USAGE IN A STATE HEALTH SYSTEM : A CASE FOR E-GOVERNANCE AND KNOWLEDGE MANAGEMENT IN THE HEALTH SYSTEM 

Dr. Sanjay Bedi, 
Associate Professor, 
SGRD Institute of Medical Sciences, 
Home Address 
366, Green Avenue 
Amritsar.Punjab , India Ph. 91-183-2503785, 0183-3100639(Mobile)

E-mail: sanjaybedi@vsnl.com  
website: www.drsanjaybedi.com 

Advantages of Information Technology (IT) usage in different spheres of life have been seriously felt and enormous efforts are bring made to bring up IT infrastructure. Comparatively, a very less is being contributed towards development of IT infrastructures for health systems, although powerful health systems build healthy nations. Health systems which is a foremost sector, should also go for IT usage resulting better productivity, effectiveness, efficiency and economics resulting improved health status. The present paper focuses on sustainable development of IT infrastructure (hardware, software and live-ware) in health systems with special emphasis to introduction of Virtual Private Networks to facilitaltate quick ,efficient introduction and operationalisation. It is also proposed to facilitate the utilization of CDMA telephony in the modern health system for data collection ,connectivity and educational purposes.. Five stages for IT infrastructure growth have been identified. The activities involved in these stages will be discussed at a length. 

In the stage 1, individual doctor oriented applications should be promoted as stage 1 is initial stage. So, preliminary computing facilities for selected medical personnel should be introduced to induce the computer culture.

In the second stage, record maintaining database and information systems are proposed supporting hospital level decisions. Such systems are helpful to hospital management for better administration, optimisation as well as knowing disease patterns.Virtual private networks are introduced in this stage. CDMA based telephony becomes a tool for data collection and connectivity.

In the third stage, the reports generated in the second stage should be processed and support systems like Geographical Information System should be integrated for decision making and strategic planning at civil surgeon level and epidemic alerts with control measures. Virtual Private networks help in connectivity over vastly separated hospitals.

The fourth stage is concerned with the resource, data and reports sharing over the networks supporting decision making at regional and strategic levels. 

Finally, the fifth stage incorporates intelligent systems integrated with the modern computer communication technology (INTERNET and multimedia) for seeking the rare available expert opinions from distances without delay and over the political boundaries

Some data sources for systematic processing at different stages have also been identified as tabulated below:

The paper also focuses on processes and factors involved resulting maturity in health systems. 

The such health systems mature stage by stage in a sustainable manner. Technical skills and manpower policies should be upgraded with a pace to adapt effectively in the prevalent systems The manpower policies are to be re-defined .Support systems for maintenance arrangements and software backup and recovery schemes are also to be upgraded. Possibilities of e-governance and knowledge management are explored and elaborated for the sake of efficient delivery of health services.

The cost benefit analysis of various methodologies currently available is also discussed. So far no policy or blueprint for IT infrastructure development in health systems has been noted yet and proposals for the same are provided. 

Key words: Health System , Virtual Private Networks,

1. INTRODUCTION
In spite of the fact that the computer revolution is spreading practically in every arena of human endeavor and especially in banking, railways, defense very a little impact has been noticed on the health sector. Enormous amounts of resources are being spent, but very little change on actual health status of the people has been noticed.

Further at top levels of health departments, both in public and private sectors as well as in government, there is considerable awareness of the importance and potential of Information Technology. Despite the availability of technical skills the gains from Information Technology usage have not been apparent.

Effective usage of information technology is not a purely technical issue. It has socio-technical and organisational aspects, which need to be recognized and carefully implemented. Many bureaucrats in-charge of health department's focus on installation of hardware and sometimes acquisition of software. Adequate attention to human factors and organizational issues is minimal. Such an approach would be appropriate for purely scientific and technical tasks like control software for scientific instruments or on board control systems, but rendering such systems in health departments and at hospitals level is totally ineffective.

IT applications such as computers, networking, database systems would be of little benefit if they are used to mechanize existing processes and procedures. Major benefits accrue if there is perceptible functioning of organizations, brought about in consonance with these technologies. To benefit from the potential of information technology, corresponding organizational changes should be anticipated, planned and brought about in health departments in a systematic way. The need for sustainable IT infrastructure development for optimal utilization of resources has been felt. creatively

It is therefore useful to identify types of technology required in relation to organizational changes. This would give a clearer idea of effort and strategy involved in successful implementation of IT projects in health departments.

Material and Methods
For this purpose, five stages have been identified in terms of increasing demands, sustainability, financial and organizational factors.

2. Stages in IT Infrastructure Development

IT infrastructure development stages in the in health systems are explained below as well as in diagram 1: 

i) First Stage 
The computers, because of their efficiency and accuracy are used to enhance personal productivity and in the present case that of the doctors using "stand alone" applications such as word processing ,spreadsheets, personal information systems at individual level These applications may run on stand alone or networked PCs. Capsule programs on training doctors in computer fundamentals, word processing, spreadsheets, analysis tools, presentation tools and basics of programming and networking are required to be organized for improving individual convenience. This will add quality to work and increased productivity. To improve overall quality of doctor's work, mundane/ monotonous tasks such as circulars, storage and retrieval of correspondence documents, presentations, internet access, database search, personal record keeping, time planning are popular applications to be computerised at stage one. The work involves recording personal data with the doctors which may also be related to hospital registration, accounts, case sheets in wards and OPD management, pharmacy management and maintaining reports in laboratories. The stand alone mode useful for individuals and individual departments is encouraged here. Public mailing lists can be used as a low cost option for networking these computers. Computerisation of birth records is essential to create a unique ID number for each patient.(Sanjay Bedi 1996) An immunization registry will help to get immediate return on investment. 

ii) Second Stage
This stage involves structured applications with long term periodicity. These are like batch processing applications performed on daily, weekly, monthly, or yearly basis, and may involve detection of disease patterns in hospitals, analysis of age , sex or other variables which effect occurrence of diseases, analysis of batches of case sheets of various diseases. The administrative help for payroll processing, maintaining of account ledgers and similar applications which are common in any organization can also be incorporated for increased used of IT infrastructure.

The data so generated is relevant to hospital administrative operations and also helpful in operations at civil surgeon's office level. Processing however is specific to a function at different levels. But, the results of data concern several individuals in the hospitals, district civil surgeon's office, state health authorities as well as at other levels. Planned effort is required to maintain these data files for these applications in time processing, checking validity and access so as to preserve correctness and security of the information. The applications help in better case sheet recording within a hospital. Smart cards may be issued to citizens for convenience , online access and security purposes. Wi-fi connectivity and Mobile telephone based connectivity becomes useful at this stage.

iii) Third Stage
At the third stage, applications have short periodicity and on-line processing is encouraged. Transaction processing applications like final diagnosis in Out-Patient Departments and wards should be processed promptly. Any new disease reported should activate an alarm for preventive action. For example, few malaria cases reported in a particular locality should direct fumigation of that particular locality only or viral hepatitis should suggest extensive water sampling of the concerned locality. Use of Geographical Information Systems(GIS)(Verma Harsh 1996) is required as a support tool. This will help in deciding the correct place for preventive measures. Response time interval can be greatly reduced as compared to current state of affairs. Quick performance and reliability are very important here. The cost involved in epidemic control is reduced and efficiency is enhanced. Mobile telephony especially CDMA based Internet access can help make virtual private networks eliminating the need of wires and quick deployment of network within the Hospital and outside including villages.

iv) Fourth Stage
At this stage, integrated systems are made incorporating several applications from different hospitals involving many databases in a client server mode thus forming INTRANETS and EXTRANETS within the health system involving the various allied services with Health like insurance Industry and the Pharmaceutical Industry can be implemented . This will reduce the costs of duplication of data, reduce in-consistency and timely availability during treatment. This will help in preventive medicine alerts at block, district and state levels. Also the the patient can be given a permanent index number and his medical case sheet may be available to doctors over a region or globally, where movement of patient does not come in the way of his timely diagnosis.

The integrated systems span several functional divisions and applications, and also fulfil the information requirements of the health system at strategic , management and operational levels. Though, implementation of this stage is not an easy task, however with the advent of the information super highways the dreams seems to be coming true. Special hospital information officers personnel may be needed to be appointed who can be information technology experts or drawn from within the doctors. Teamwork approach is the most ideal involving close cooperation between personnel, structures and processes in each hospital , district and ultimately the entire state level. The barriers of space and time dissolve due to networking for INTRANETS within the health system. EXTRANETS encourage the communications between different health systems and allied areas like insurance and pharmaceutical industry.

v) Fifth Stage
The fifth state of IT infrastructure is concerned with intelligent computing systems and applications, simulations and virtual reality systems.(Krishna S.1997) The resources and skills available at local, regional as well as global level are extracted to result value added diagnostics. Virtual reality systems help in performing virtual surgeries and diagnostics where risks are very high and are very useful for training purpose. The simulation systems encourage the training by reducing the costs for the actual systems and moreover speed experience based learning.

Expert systems are intelligent programs which mimic the behavior of an expert in particular a field of knowledge. Since experts are rare , non-availability of expert knowledge at places of disease incurs many problems of delay, cost ,feasibility leading to high mortality of serious patients. Expert systems are software programs which supplement/ enhance the skills of doctors in specialized topics and are highly useful here. Though these systems do not replace experts they help the lesser skilled doctor to give better decisions, and improve productivity through knowledge dissemination. Expert systems can be used in training by simulating the doctor's activities in different types of diagnostics. Expert knowledge from different sources can be put in knowledge bases which are supported by databases. Internet connectivity helps in opinion/ message/ data integration and communication.

At this stage, the health corporation should have implemented information technology projects successfully and gained valuable experience and confidence needed to reorganize its core processes in a fashion enabled by information technology. Commitment from the top management would be available to provide enough flexibility for redeployment of personnel, and restructure the methodology prevalent within the hospitals.

3. TECHNICAL SPECIFICATIONS
i) Hardware and Software 
The stage wise infrastructure development is not only based on hardware considerations but on the basis of requirements, systematic growth, hospital budget considerations, computational culture and basic IT infrastructure available at hospital, block, district and state levels. Advanced stages require advanced levels of hardware and software. However the converse relationship does not follow . A network which can implement fifth stage applications, if used only to store word processing software for use by PC clients, would be supporting a first stage application only. In many instances , database software which can support up to fourth stage of integration is used for data storage and report generation typical at second stage.

The table 1 explains the minimum hardware and software requirements at different stages:

ii) Data Management
Data integrity and security requirements are demanding and complex. Data is critical to day to day functioning and diagnostic skills. The ability to make diagnosis and deal with epidemics and diseases is dependent on the timely availability and analytical ability of the Health Systems Organization.

iii) Live Ware : 
In implementation of IT infrastructure, availability of suitable manpower plays vital role. For feasibility of systems, operational staff should be adequately trained. The table 3 shows the requirements at all five stages:

4. SYSTEM MATURITY AND PRODUCTIVITY
A health system passing through the proposed stages matures in sustainable manner where problems due to abrupt changes, technology induction and changed work culture are minimum. The ability to store large number of case sheets and process them quickly is the principal advantage provided by computers where transmission delays are eliminated by fast communication links. The orientation or focus of the organization should be on an environment where information is freely available and the ability to interpret and act on that information is the key element for efficiency.

As the result of IT induction in proposed stages, productivity improvements in the health systems follow an increasing pattern. The hospitals in the first stage experience minimal gain in productivity mainly of individuals who use requisite software effectively. In the second stage the hospital enhances its analytical ability of multiple diseases and patients thus knowing the trends and disease patterns. There is improved record keeping. However the improvements in performance are still not quantifiable . At third stage the benefits become more quantifiable and visible, like reduced inventory costs, better patient management, effective alerts and control during epidemics. This enhances the health status of the community , improvement in the parameters like infant mortality rate, maternal mortality rate etc. At fourth stage, the information becomes a resource . It can support decisions at hospital administration levels, civil surgeon levels, as well as support strategic planning at State levels . Incremental cost of new IT applications decreases and is easy to bear from time to time. At fifth stage , the potential of information technology becomes fully available shrinking the world into a global village thus making improvement in health status an ongoing process.

Financial considerations: Considering that the modern networks are developed enough the ground realities are that any Hospital can reach the 5th stage straight away or may start from intermediate stages .The Nolon's model(Nolon1999) makes an attempt of describing the stages of development in Initiation, Expansion, Formalization and Maturity. The growth indicators stages are Data Processing Era, IT era and networking era. Water tight compartments cannot be made for any Hospital and depending on the skill of the concerned doctor and other Human factors involved. 

Low cost networking can be achieved by public networks of which mailing lists are an important method which is currently finding wide appeal. Ultimately the costs will have to be shared between the patients , Hospitals and some support from the government in the form of Public networks especially networking of government hospitals . Pilot projects will have to be financed to create awareness and initial infrastructure. Teaching websites need to be created for online medical education along with leveraging the assets already available on the net

Re-engineering the Health System
Four factors influence the development in infrastructure and management for productive usage. These are management strategy, IT strategy, corporate infrastructure and IT infrastructure. Implementers can have four different approaches .In the first case work strategy drives the IT strategy where machines and tools are inducted for identified processes to accomplish in accordance to management approach. In second case IT applications strategy is driving force and infrastructure is brought up as per laid IT norms. Available corporation infrastructure becomes dominant factor in third category where re-engineering is difficult and in fourth case IT infrastructure is the driver as availability of state of art computing facility facilitates and motivates the applications. Different combinations of above factors for IT usage and implementation result in different challenges. Dominance of individuals contributing these factors determine the overall strategy stages and nature of applications. A new hospital can easily adapt state of the art approach.

In the end a brief introduction of the concept of knowledge management needs to be discussed. ."Knowledge management is a discipline that promotes a collaborative and integrated approach to the creation, capture, access and use of a health system's information assets. Through the use of electronic classroom the knowledge available in a quantifiable manner becomes more. Knowledge available is just like capital and creates health system values, by leveraging the intangible assets of knowledge, which will become the next big competitive differentiator in improvement of health systems in the Information Century. Advance Planning; change Management, cultural changes in medical teaching methodology & well-balanced approaches are essential part of knowledge management. Knowledge grows when it is shared and deteriorates when unused. One single large obstacle is changing departmental culture and doctor attitude and behavior. Fostering a knowledge sharing culture is the most important. Wiring the intangible assets of knowledge and the pathologists brains, to share useful concepts between dissimilar departments, involving staff from many levels and locations is KNOWLEDGE NETWORKING. Knowledge networking is the term for strategy to force contribution much greater than SUM of its individual knowledge of participants. The idea is to foster a spirit of RADICAL INNOVATION

Results: Being a vision paper this is only partially implemented in Punjab State using a website www.imapunjab.org and a mailing list ima-punjab@yahoogroups.com

5. CONCLUSIONS: 
An incremental and sustainable approach is necessary for computerization of the Health System. Existing setup is required to be validated according to needs . Hardware acquisition is necessary and funding is required. The telecom revolution holds the promise for an Information Technology revolution in the Health System.

Acknowledgement: I acknowledge the help given by Dr HS Saini Head of Department of Computer Sciences at Guru Nank Enginneering College Hyderabad for the help given.

Bibliography:
1) Bedi, Sanjay "Computers and Rural Health Systems" Published in CSI Communications, Sept. 1996.
2) Verma, Harsh "Internet- The potential of Global Digital Thematic Atlas" Published in CSI Communications, Dec 1996
3). Bedi, Sanjay "District Health Information Systems" Published in CSI Communication, April 1997.
4) Krishna S. " Organizational Maturity and Stages of IT Development" Published in CSI Communications, August 1 996
5) Nolan R. "Managing the crisis in data processing," Howard Business Review, March April 1999 p115 

Author's Biodata
Dr. Sanjay Bedi, a Doctor of Medicine in Pathology, is the Assistant Professor in Pathology in the Sri Guru Ram Das Institute Of Medical Sciences, Amritsar. . He is the Editor-in-Chief of Indian Journal of Medical Informatics and Secretary Computerisation of Indian Medical Association ,Punjab Branch and member core committee of Indian Society of Telemedicine. Dr Sanjay Bedi, finds his recreation in mountain climbing, reading and researching new ways to implement computerization in the medical industry. 

Dr. Sanjay Bedi may be contacted at:
sanjaybedi@vsnl.com .
Home address 366 Green Avenue , Amritsar.Punjab, India 
Website: http://www.drsanjaybedi.com