The IT Pill
Simple solutions to difficult problems, this is what IT promises to offer. And this comes in with economic benefits too. Nancy Singh and Nayantara Som check out the IT phenomena that is doing the rounds.
Technology is gradually permeating every aspect of healthcare in India. In a study conducted in 2004 by National Business Group on Health in the US, the average IT spending per worker in banking was $15,000, in the private industry was $8,000, while healthcare took a backseat with $3,000, which is still higher as compared to India. According to a CII-Mckinsey report, of their total revenues, hospitals in India spend around 54 per cent in enhancing infrastructure, and of this, 12-15 per cent is spent on IT, comprising mainly of desktops, printers and billing systems.
“Currently, inclusive of h/w, s/w and networking, the total market size for healthcare (hospital) IT in India is approximately over Rs 400 crore,” says Sandeep Sinha, Programme Manager, Healthcare Practice, Frost & Sullivan, South Asia and Middle East.
IT has revolutionised the delivery of healthcare, because data now is quickly available. The process of automation also brings down healthcare cost to an optimum level.
The healthcare IT market is proportional to population and therefore in India, with a population of over 1.3 billion, the market is colossal.
But IT investments in healthcare continue to remain low, mainly due to cost-restraints and initial high investment, “A mid-size hospital spends less than 1.5 per cent of their turnover on IT (new investments plus the annual maintenance) while a large hospital spends less than two percent of turnover on IT,” says Sinha.But slowly and steadily, the industry is realising the difference that technology can make in terms of operational efficiency, better revenue, lesser medical errors and a much better customer experience.
Being e-savvy has its bonuses. In 2000, US-based Senatra Hospitals integrated 90 ICU beds in four hospitals and decreased cost per patient by $2,150 giving a return of investment (RoI) of 155 per cent, reduced mortality and average length of stay (ALOS) by 20 per cent and 17 per cent respectively. Cleveland and Mayo Clinic have increased their catchments area by IT integration with outreach for diagnosis or second opinion and post intervention support.
In India too, the journey from maintaining papers to going paperless has started and few hospitals like Ruby Hall Clinic of Pune, Amrita Institute of Medical Sciences, Kochi, and Sri Sathya Sai Institute of Higher Medical Sciences at Whitefield, Bangalore are reaping in the benefits after adopting technology.
The Amrita Institute of Medical Sciences and Research Centre (AIMS), Kochi is an apt example of a healthcare institute that has experienced the wonders of information and communications technology (ICT) to become a paperless hospital.
It’s obvious, AIMS was looking at avenues like cost reduction, safety, quality and a transparency in system. Dr Prem Nair, Medical Director, AIMS, Kochi, says, “When we thought of IT, we thought it would be expensive. But we were proved wrong and we saved Rs 30-32 lakh in one year after going paperless,” says Dr Nair. Ultimately, it boiled down to the mindset of the people who earlier refused to adapt to a paperless environment. Dr Sanjeev Singh, Senior Medical Administrator, AIMS, says, “Our support staff had to be trained both in areas pertaining to the basics of their profession, and becoming IT-savvy.”
Introducing a filmless environment, with the use of PACS, the hospital saved almost a crore notwithstanding the fact that hardware was costly earlier. The hospital saved up Rs 20 lakh in hardware alone. AIMS also observed an immediate savings in pharmacy, managing to save up to Rs 40 lakh per year.
“Apart from the tangible issues, we save time in processing prescriptions, while the biggest boost is tele-education where all our four universities are connected through satellite and have video-conferencing discussion on policies,” he adds. Talking about travelling, the Lakshadweep-AIMS Telemedicine Programme needs a mention here. Savings, here, were from the patients as well as the doctors side. Around 155 patients were managed at Lakshadweep by AIMS. Drastic savings were observed in areas like travelling and transport, hotels and bookings, and cost of employment. The total savings amounted to Rs 25,11,000, and the total cost saved by providing managed care by telemedicine to Rs 16,200 per person. Also, internal and external communication through e-mails saved on paper. In addition, in the first six months itself, AIMS saw a 51 per cent decrease in transcription costs, a savings of almost Rs 3,40,000. Transcriptionists reduced from 12 in 2006 to five in 2007.
Use of bedside bar-code technology cut medication errors by 89 per cent, improved ER documentation accuracy by 85 per cent and reduced overall discrepancies in details by 71 per cent. This is not all. A 51 per cent to 80 per cent reduction in chart pulls was noticed. The cost of chart folders, dividers, and filing cabinets at Rs 150 per record amounted to a saving of Rs 23,25,000 in six months. Dr Singh says, “We are the only hospital that has an in-house HIS system. No licensing fee makes the entire system cost-effective and upgradations are done in-house.” Also, departmental integrations played an extremely important role in going paperless. AIMS also saw an increase to Rs 2 crore in a year in collections from third party payers, resulting from accurate billing and documentation.The hospital achieved a significant improvement in revenues in the first year, and expects to realise an additional Rs 5 crore in the second year.
The Candy Points
Money is where the entire phenomenon boils down to. IT ensures efficiency, both at the user and patient end with higher margin. Currently, hospitals suffer economic leakages in four prime areas: waiting area, long processing time, inventory costs and, loss and theft of data. In hospitals, IT can be used in the administrative department for patient registration, and billing or inventory management. IT improves clinical outcomes, in administration improves service measures and resource utilisation, and financially it decreases cycle times and cost. The recipient of the ‘Best IT User Award 2004’ from Nasscom, Wockhardt Hospitals Group, has implemented a Hospital Information System (HIS) with over 34 integrated modules covering patient care, billing, clinical, administrative and support services. It implemented bi-directional interface to lab equipment, bar-coding of samples, interface to plasma monitors, interface to Oracle financials, and speciality modules —for use by doctors of various specialities. All this reduced OPD billing time by more than 70 per cent, planned admission time by 35 per cent, unplanned admission time by 50 per cent, discharge time by 62.5 per cent, and increased billing accuracy by more than 12 per cent.
“HIS puts clinical and financial information at our fingertips, helping doctors and administrators in critical decision-making. The benefits of Wipro’s HIS permeate all the crucial areas from patient care to back office operations and plays an important role in providing quality medical care,” says Dr Lloyd Nazareth, Associate VP, Wockhardt Hospitals Group, Banglore.
A Government body rapidly becoming e-savvy is the Municipal Corporation of Delhi (MCD), said to be the world’s second-largest municipal body after Tokyo. MCD runs six single-speciality and multi-speciality hospitals with a heavy patient load. The hospital has 100 per cent utilisation of beds with some of the hospitals having more than 5,00,000 outpatients annually. Once all the six hospitals implement IT solutions, they will be linked to a central data centre that will hold patient demographic and clinical data required for a complete medical record. “As a public body, MCD’s objectives for HIS are slightly different from those of private hospitals,” says Dr Seema Gupta, Domain Consultant, Wipro Healthcare IT. The challenges faced are also typical to those of Government hospitals with high patient turnover and chaos in every department. “Complete computerisation of the hospitals will save time, lead to better patient care through improved management, easy access to information and better quality of documentation,” believes Dr RC Patnaik, Chief Medical Officer (Health Informatics), MCD.
Integration of HIS saw a reduction in time taken to register or discharge, as well as a patient’s medical records were available quicker with a unique identifier. Fortis Healthcare has HIS that comprises Picture Archiving and Communication Systems (PACS), Management Information Systems and patient monitors. PACS makes the quality of X-rays better, while the monitoring devices and web access enable tele-counselling. It has 20 telemedicine centres across North India alone.
If implemented and used well, PACS is a huge potential source of saving revenue for the management. Monetarily, the returns may not be immediate, but it is a one-time investment, as in the long run, films work out to be more expensive than establishing a PACS network. Sri Satya Sai Hospital, Bangalore, after implementing PACS, successfully saved Rs 80,000 on films and $1,51,800 in all annually.
To come up with an IT savvy environment is not easy. When the idea was put forward at Pune-based Ruby Hall Clinic (RHC), initial questions that arose were: Can an integrated system be established? Can there be control on revenue and expenses? Can a patient feel at ease? Can the system be made transparent?
Bomi Bhote, CEO, RHC, says, “Our initial objective of implementing IT was to integrate systems, control revenue and expenses, higher operational efficiency and being transparent.”
The HIS system at the RHC consists of a unique medical record number to identify a patient, which on admission of the patient, sends an intimation to the concerned doctor on his mobile. The system helps in international classification of disease (ICD-10), image storage in DICOM 3.0 standards, laboratory interface with workflow, various payment plans, multiple tariff application depending on patient category, insurance and service provider network interface, scheduling and appointment for doctors and resources, and electronic medical record system. The system meticulously handles direct drug indent/prescription from ward, views the history of the patient, diagnostic reports and radiology images on computer, discharge summary and instant messaging to senior staff.
Data of the entire clinical management diagnostics and laboratory, radiology, medical records, consultation rooms, operation theatre and care plans is managed electronically, along with symptoms, observation, investigation and assessment of treatment, care and medication plan. “HIS is a single window for all services, like faster discharge, accurate billing, and reduced waiting for lab reports,” says Bhote. The benefits do not stop only at patients. Doctors at RHC have also experienced manifold benefits of this system. “HIS has given them access to EMR at the press of a button, online order and booking, better referral-relationship management, scheduling of resources, and online financial management,” says Bhote. Life has become easier even for financial operations. Activities related to patient billing, consulting charges, payments to be made to vendors/partners/suppliers/employees/doctors are all electronically recorded. Going the e-way has changed the face of RHC, making data available at the click of a button.
HIS automates the functions of all departments making them paperless. AIMS is a case in point (see box on page 32). IT can enable improved customer satisfaction through efficient processes, reduced cost (purchase, inventory, billing etc.), better MIS, plugging of seepage of revenues, quicker records search, infusing transparency and ethical practices, better manpower utilisation, and thus boosting business growth.
“If used properly, HIS does help in all areas, right from registration till the mortuary,” says Dr Anil M, Senior Functional Consultant, Integrated Healthcare Group, Bangalore. Since HIS is web-enabled, it facilitates two-way communication for patient queries. Data management becomes easier. Apollo Goup, for instance, is developing a national health data network along with IBM. Called ‘Health Hiway’, the network will provide applications for the healthcare segment.
Pathology is one of the key benefeciaries of IT. It has reduced waiting time, increased resource utilisation and better patient-flow. Laboratory results are easily stored using customised software that can be easily maintained and upgraded. Organisations are now also moving towards using Internet phone, using the proven ability of wireless IT applications to bridge the communications gap, improve treatment and to support clinical decisions through instant access to records.
In addition, recent improvements in wireless infrastructure security and advanced applications, such as location-based tracking and voice over wireless-local-area-network-based (WLAN), have provided further gains in productivity and patient care.
Courtesy: Apollo Hospitals, Chennai
However, every success story has its own set of predicaments. On a visit to AIMS, Kochi, Biocon Limited’s Chairman and Managing Director, Kiran Mazumdar Shaw remarked that India is the most potential market for clinical trials due to the enormous amount of clinical data which is available. The hitch is that, this very data is never documented meticulously.
“There is no department in particular that documents all the data and this is primarily due to the fact that people are used to operating hard copies of files, charts and folders rather than soft copies,” says AIMS’s Dr Singh.
Moreover, though IT or e-health has made life easier for hospital administrators, accomplishing a paperless hospital can be near impossible because paper is used in some form, like print-outs, even if the hospital has computerised all its departments. Is this viewpoint but a reflection of the reluctance of hospitals to adapt technology or is it just a sweeping statement?
“Not at all,” clarifies Mohammad Naseem, Head, IBM’s Healthcare Practice in India, “Remember, they are all businessmen. It’s not that they do not want to, but as of now, many are not happy. Current players are not mature and tend to customise so much that in the end you cannot upgrade. So, it becomes a depreciating asset than an appreciating one.”
But experts too are divided in their opinions. “People are not IT-savvy. Maybe the younger generation are more dynamic and show more enthusiasm, but the older generation who are still used to operating from files and folders for reference and case histories, need to be more open to changes,” says Dr Singh.
Again, providing software for healthcare is not a one-time investment. Constant upgradation is necessary for streamlining internal processes and to keep pace with the changing industry. According to Sunil Kapoor, Director – Central Buying, Fortis Healthcare, New Delhi, “The biggest challenge Fortis faced was ensuring that the software deployed expanded in proportion to its growing functions. The absence of implementation guidelines for the Indian healthcare industry made this task difficult.” Aniruddha Nene, Principal Consultant, Imaging and Director, 21st Century Health Solutions, Mumbai, agrees, “Constant upgradation is a prerequisite. A simple example is upgradation of anti-virus software, as security is a major issue. Any IT system will be prone to hacking.
The question here is how competent are the system mangers to handle the security issue. Corporate hospitals have been into security measures for a long time. But they constitute a very low proportion. The remaining larger chunk of public hospitals has a lackadaisical attitude to it.
A ray of light is that newer hospitals have realised about the value-addition IT can bring, and with mature players entering the market, things are gradually changing. Talking about players, experts opine there are very few players in the market, and to top it all, hospitals can rely only on these players for end-to-end solutions. The market for e-health, they believe, is very raw.
The challenges can be many if scrutinised well. Common problems are lack of benchmarks and regulatory standards in any IT-enabled service. “Ultimately, it all boils down to the administration, as to how competent they are to adhere to standards and benchmarks. The main issue is that these system managers are not trained and guided to reach these benchmarks,” points out Nene. Another common challenge is the cost of IT projects. And, since it is a long-term investment, the RoI is not immediate.
In case of PACS, where the hospital invests over Rs 10 lakh, it cannot expect to see the benefits from the word go. Though using IT-enabled services saves time and manpower, software can be expensive.
Hence, a hospital needs to employ a customised solution, and something that is cost-effective. Even as it took banks quite a while to move from local banking to ATMs and later to internet banking, it is the same with IT in healthcare. “With the boom in infrastructure, there is a rise in IT investment and it is estimated to be $500 million by 2010,” says Naseem. The growth of IT in healthcare is expected at 15-20 per cent CAGR for the coming year, reports Frost & Sullivan.
With technology’s position translating from just being a support system to getting integrated within the main healthcare system, it is definitely a signal to the beginning of a revolution in healthcare.