Newer advances in IT, technology and data management have had repercussions on the healthcare industry. Today’s discerning patient is increasingly demanding efficient service delivery ï¿½ which is largely possible only through a reasonable degree of automation. The advantages of automation are numerous. First there is the advantage of speed and accuracy. Hospitals have other incentives such as lowering of turnaround time per bed, better quality control, and of late, business intelligence. The reasons why hospitals choose to automate certain processes and for which particular processes they chose to do so, we found, varies according to the size and type of facility.
Any hospital with a 100+ bed capacity has the potential to improve services through the use of information technology. However, despite being a major IT hub, India’s hospital’s still follow manual processes to a large extent. Especially in a large facility, it is difficult to retrieve data of a single patient; and when it is done, it takes a long time – eating into precious man hours of hospital staff who can be gainfully employed in the care of patients.
Southern and western India has traditionally been at the forefront of hi-tech medicine and hospitals. However, with a population of 17 million in Delhi alone, demand far exceeds supply and continues to increase in the north. Nearly 33% of the population in the National Capital Region is employed and the rapidly developing satellite towns of Gurgaon, Faridabad, NOIDA and Ghaziabad have witnessed variable but higher than average growths in per capita income over the past several years. Two of the worlds top 10 fastest growing cities, Ghaziabad and Faridabad, are situated here.
The IT@Hospitals Survey is an attempt to capture the situation and trends with respect to automation in hospitals in India. The survey is being conducted in IV stages. This edition of eHEALTH brings you the first part, covering the National Capital Territory (NCR), Chandigarh and Punjab. This region has witnessed a considerable growth in the number of large medical facilities over the past decade. Besides being home to some of India’s best hospitals, it’s proximity to New Delhi puts it in an advantageous position viz-a-viz supporting infrastructure.
A good quality education system and significant English-speaking workforce has led to the growth of IT companies in the region. Telecommunications, real estate and health are integral contributors to the economy here. Chandigarh boasts of the highest per capita income in India, and the Tricity (Chandigarh, Panchkula and Mohali) is advancing rapidly in terms of income, industries and infrastructure, especially the service sector. Its high literacy rate of 77% makes for easier implementation of automation. According to reports, it is one of the top emerging outsourcing and IT services destinations worldwide. The Rajiv Gandhi Chandigarh Technology Park (RGCTP) and Centre for Development of Advanced Computing (C-DAC) in the vicinity can provide a strong technical and infrastructural support system.
The IT heads/managers of 100+ bed hospitals in the region were contacted and familiarised with the survey, its purpose and scope. A questionnaire consisting of 12 relevant questions and other important information was then sent to them via e-mail. The responses were stored in an online database and coded on a weekly basis, then tabulated and analysed before preparing the report.
The survey threw up several challenges. We found that many hospitals, including some with over 300 beds, did not have a designated IT manager. Often a doctor in-charge of administration is assigned to oversee the IT implementation as well. At other times, a technician handles the system.
Owing to the corporate healthcare boom in recent years, the northern region has a higher number of private medical institutions as compared to mission/trust/NGO-run hospitals. Out of the cross-section of hospitals surveyed, 52.2% belong to the private sector. 43.5% are non-government mission, NGO or Trust establishments whilst the rest are government hospitals. (Figure: 1)
The other broad classification is by size as this has a direct impact on the kind of technology needed and used. The institutions are divided into those with less than 150 beds, 150-300 beds and over 300 beds. Nearly half the hospitals [47.8%] have over 300 beds. (Figure: 2)
Whilst conducting the survey, we must admit to resistance to divulging details about operations and systems by several hospitals. This was more so with government hospitals, some of which demanded authorisation documents. This is why we have (for the most part) compared private facilities with mission/trust/NGO ones.
Another thing we would like to mention is that most of the comparisons according to size compare the hospitals with <150 beds and those whose bed capacity exceeds 300, for better clarity.
Driving forces of automation:
Multiple factors are responsible for increasing automation in hospitals. It is true that most often, hospitals do not have a planned strategy for automation and implement a solution only when they find that the manual process has unacceptably high error rate or clinical and administrative processes need speeding up urgently. The single biggest factor is the need for higher service quality (in 86.96% of facilities) followed by the corporatisation of healthcare delivery [78.26%]. The significance of medical tourism appears to be increasing as a significant number of respondents [26%] cited it as a reason for automation. However, there is a marked difference in the perception of this as a driving force of automation when we look at private vs mission/trust/NGO hospitals. Approximately half the latter hospitals view medical tourism as promoting automation whilst just over 8% of private hospitals think the same.
In larger hospitals (>300 beds), corporatisation of healthcare delivery and medical tourism are more important causes of automation than in smaller facilities of less than 150 beds.
Nearly 40% of IT managers surveyed think that demand from medical and nursing staff is leading to increasing automation of facilities – a positive sign for the sector. Interestingly, none of the hospitals surveyed admitted to health insurance being a factor responsible for increasing automation. (Figure: 3)
The survey results indicate that the demand for automation is increasing from the end user ï¿½ medical staff. It is heartening to see that the enthusiasm for the same is high in the mission/trust/NGO facilities. Increasing competition between hospitals and a desire to differentiate themselves from other facilities is bound to impact the level of automation in the near future. With the development of IT solutions and both availability and choice of software on the rise, we can hope for lower costs and more accurate data management in the years to come.
Advantages of IT
From the front desk to archive management, the scope of IT in the healthcare sector is on the rise. New and innovative applications of ICT and technology are being tested. Its usage however, depends significantly on the size of the institution and the resources available at its disposal as our survey reveals.
Automation has both long term and short term advantages, though the former exceeds the latter. Given this scenario, larger hospital chains may be in a more advantageous position with respect to implementation of IT systems, due to their deeper pockets and ability to put up with longer gestation periods.
Out of the hospitals surveyed, an overwhelming majority [91.3%] said that long term strategic planning is an advantage of implementing IT systems. This is irrespective of the size of the institution. The private hospitals were unanimous in their agreement, indicating that IT implementation in these institutions is part of their long-term strategic plan and not just today’s requirement. Nearly two-thirds of the hospitals use IT to make day-to-day administrative processes easier. These are perhaps the most time consuming, but assume great importance especially in emergency/medico-legal cases. Speeding up clinical processes is another important benefit of automation as nearly 61% of hospitals agreed. The data indicates that mission/trust/NGO hospitals give automation of clinical processes greater importance.
Hospitals do not disagree too much about advantages of IT depending on their size. The larger facilities however, lay more stress on short term departmental processes. Those with <150 beds are more concerned with flexible clinical operations and strategic, long term planning. The need to increase speed is a factor irrespective of size. (Figure: 4)
Kind of software in use
We at eHEALTH wanted to look into the kind of information systems that were most commonly used. A Hospital Management System (HMS) or Hospital Information System (HIS) is the most widely used software. Some kind of HIS is used by over 95% of hospitals. The Laboratory Information System (LIS) is also installed in 73.9% of facilities.
The data shows that overall, there is not much of a difference between private and mission/trust/NGO hospitals as far as the use of software goes. HIS/HMS is the most widely implemented software. All private hospitals and 90% of mission/trust/NGO ones have an HIS system in place. Laboratory Information Systems are the next most common software with an implementation rate of 70% and 75% respectively – not a significant difference. The biggest difference we see is in the implementation of Pictures Archiving and Communication System (PACS). Whilst over 58% of private hospitals use it, only 20% of mission/trust/NGO hospitals do so. It is to be noted here that picture archiving and transfer is a capital-intensive technology which also requires high bandwidth (Figure: 5).
It is important to note here that most of the softwares were mostly adopted after 2002, hence the advantages may not yet be availed of completely. Moreover, it takes time for the end users ï¿½ doctors, nurses, other hospital staff and patients ï¿½ to use these systems most efficiently.
IT managers can choose between commercially available off the shelf software, a customised solution package or even (in case of smaller establishments with limited budgets) hosted/managed solutions. A customised package, though ideal, is the most expensive type.
More private hospitals [17%] prefer commercially available ready made software compared to 10% of mission/trust/NGO facilities. The greatest difference in choice comes when the solution is hosted/managed. At 30%, the number of those who would opt for it in the mission/trust/NGO institutions is almost double that of private institutions (approximately 16.5%) (Figure: 6).
Changing for the better
It is heartening to see that hospitals now have a choice of vendors and packages to choose from. 56.5% of hospitals surveyed admit to having changed their software package. The most common reason for this was because of technical problems with the solution [34.78%]. Other reasons for switching from one software to another are lower than expected benefits [26.1%] and poor vendor support service [17.4%]. (Figure: 7)
Presently Hospitals are driven by the need to keep track of revenues and Inventory and also by Customer relationship Management and these are the main driving forces for automation. Ideally this should change and Patient care should become the key focus area but there are large challenges before this becomes a reality.
Dr. Sumanth C Raman
Undoubtedly it is patient satisfaction which is the backbone of all IT services. The other points are security of crucial medical data, availability on time & to right person specific medical data, exchange of medical data between different hospitals enabling right treatment to patients, different as well as fast modes connectivity available for specific data exchange between insurance companies etc.
Mr. Ratnakar S.
Mission/trust/NGO hospitals appear to have much higher expectations as far as benefits go. 40% of these have changed due to this reason as opposed to just 16.7% of private hospitals. A larger number [50%] of non-government public hospitals also changed due to technical problems with the software, as compared to only half that number of private institutions.
Larger hospitals (>300 beds) appear to have more serious technical problems with the software [45.45%] than smaller facilities [37.5]. The latter (<150 beds) feel more plagued with poor vendor support [about a fourth of the hospitals] as compared to the large ones [18.18%].
Paperless – still a long way off
Though automation ensures speed, accuracy and easy retri of information, we are still a far cry from a functional paperless hospital. 86.4% of hospitals which have implemented automation, still maintain paper records. The percentage is high for both private and mission/trust/NGO facilities and also irrespective of the size of the facility. The primary reasons for this are the reluctance of staff members to use computer systems [over 26%] and legal reasons. The reluctance to use automated systems in private hospitals is more than three times that of mission/trust/NGO ones [10%]. In <150 bed hospitals, this is only marginally more than in 300+ bed ones. (Figure: 8)
Electronic document management enables greater agility and is integral to end-to-end integration of hospital systems. It assists in better organising and managing patient data and information can be retrieved easily at any time. It saves the staff precious time which they would otherwise use to manually search for documents. Warehousing space and costs are also saved. Of the hospitals surveyed, only 4.4% have EDMS ï¿½ almost all from the mission/trust/NGO category. The silver lining is that close to 70% of hospitals currently without EDMS plan to install such a system in the future. This number varies according to size and type of hospital. Private hospitals [75%] and larger facilities [73%] have plans to implement an EDMS in the near future – more than 10% mission/trust/NGO and <150 bedded institutions.
How is a vendor selected?
The eHEALTH research team decided that the answer to this question is best sought by asking the IT managers to rank various criteria. These were 9 – Cost/Pricing, Maintenance and Support, Level of R&D Investment, Inbuilt Tools to Measure Outcomes, Implementation Assistance, User Training, Vendor/Support Organisation Reputation, Flexibility/Scalability and Provision of Managed/Hosted Services.
The national consumer disputes redressal commission has made it mandatory for all medical practitioners and hospitals across the country to provide the entire medical records of a patient to himher or the authorised nominee or legal authorities concerned within 72 hours of the demand.
The primary criteria for all hospitals, we found, is the cost of the automation solution. The next factor is maintenance and support systems. Mission/trust/NGO hospitals gave a marginally higher rank to the level of R&D investment of the company and also inbuilt tools to measure outcomes. Certain criteria like user training, (predictably) flexibility/scalability, implementation assistance and reputation of the vendor are given more weightage by private players.
The size of a facility also has a bearing on the rank given to various criteria for selection of a vendor. Pricing and maintenance/support are ranked the highest irrespective of size. However, larger establishments (>300 beds) give greater weightage to the level of R&D investment of the vendor, inbuilt tools to measure outcomes, vendor’s reputation, flexibility/scalability of the solution and provision of managed/hosted solutions. This is understandable as large hospitals have deeper pockets and are also more likely to be part of a chain/growing business. (Table: 2)
Measuring the success of implementation
Once a hospital is partially or fully automated, administrators will look at the outcome of the new system. There is no doubt that the success of a particular implementation will be measured according to the intention behind the project. 82.6% of respondents said that they measure the success of implementation by the corresponding increase in service levels and customer satisfaction. Hence, it is evident that public perception of service quality is a matter of concern to most hospitals. This figure varies according to the type of hospital. In private hospitals, it is given 11% more weightage as compared to mission/trust/NGO hospitals, with 91.7% of hospitals considering this as a factor (Figure: 9).
In the table we see that the criterion to select avendor differs significantly between mission/trust NGO and private hospitals only when it comes to the user training provided and the flexibility/scalability of the solution (both have rank differences >1).
Factors like pricing, maintenance and user training receive similar rankings from facilities with <150 beds and large ones with >300 beds. However, value-addition such as inbuilt tools to measure outcomes, managed/hosted services and criteria like reputed vendors, high R&D investment which come at a higher price, are given greater weightage by large hospitals.
Better operational control was cited by both kinds of institutions with an average of 82.6% agreeing. The third measurement is by cost savings. Here we find a marked difference between private and mission/trust/NGO hospitals. Cost savings appear to be a bigger consideration amongst the latter with 70% measuring the success of a software against it. 58.3% of private institutions measure implementation success by cost savings.
To make the doctor community more open to using IT in hospitals, make Healthcare IT solutions in medical colleges a part of the curriculum.
What do hospitals see as the major advantages of using IT systems?
There are two ways to look at major advantages of Healthcare IT from the perspective by Hospitals.
All the above benefits can be quantified to work out return of investment on IT
Intangible Benefits :
Higher satisfaction levels of hospital services by patients and relatives due to correct information being available as and when it is required, more transparency, less waiting and anxiety and fewer errors in services – medicines, diets etc. provided to them.
There are some differences in measuring implementation success depending on the size of the facility. Hospitals with over 300 beds [90.91%] look at increase in service levels and customer satisfaction more than those with up to 150 beds (approximately 75%). Larger hospitals also take into account reputation (a difference of more than 10% between the two groups) and business intelligence ( 54.6% and 37.5%
respectively). Smaller hospitals are more concerned about cost savings and turnaround time per bed.
Business Intelligence (BI), i.e. the extraction, analysis, and reporting of information to improve business decision-making, is a fairly new role of hospital systems in a formal sense. 41.7% of IT managers in private hospitals surveyed said that they would factor in better business intelligence in assessing the success of a software, compared to half of the IT managers in mission/trust/NGO hospitals.
The turnaround time per bed is more of a concern in private hospitals (half of them take it into account) than mission/trust/NGO institutions (about 40% agreed).
Half of the private hospitals surveyed have an annual IT budget of more than 50 lacs. Within the mission/trust/NGO segment though, about half the hospitals spend between 5 and 20 lacs. On the whole, the majority of hospitals spend less than 15 lacs a year on IT systems. A division by size would be more accurate and indicative. As expected, over 45% of 300+ bed hospitals spend over 50 lacs per annum on IT whereas 12.5% of hospitals with less than 150 beds do the same.
While conducting the survey we realised that IT heads of hospitals are very often non-existent or technicians, and the hospital’s IT system is overseen by one of the doctors. Often, a decision has to be taken about whether a facility should go in for a complete solution from one vendor or whether different information systems should be sourced from different service providers. This is indeed a tough decision due to the limited budgets in India and scale of such projects. We observe that the majority of hospitals have limited automation with a solution that covers only a particular clinical or administrative process.
Implementing an automation solution can take anywhere from a couple of months to a few years. The bigger the project, the more important is the choice of vendor. Hospitals need to pick a solution provider who has a local presence and will provide after-implementation assistance with minimum fuss. Keeping in mind future plans of expansion, the software should be scalable enough. They should also have complete knowledge of compliance regulations and standards as hospitals administrators have to keep in mind medico-legal issues.
Medical and information technology is constantly changing, allowing for better diagnosis and greater accuracy. What is required to give the hospital IT business a boost is standardisation, keeping in mind that India and the region are key destinations for medical tourism ï¿½ touted to be a US$ 40 million industry by 2010. Strengthening of infrastructure is another issue that needs to be addressed. Higher bandwidth is required for heavy PACS transfers. Telephone and Internet connectivity in smaller towns and cities is a major issue.
Software vendors have raised the issue of inadequate manpower and training in the use of systems. In order to extract the maximum benefit from an information system, the staff using it and those who will be affected by its implementation, must be properly trained.
As the market matures, we can expect more hospitals adopting integrated information systems and, in turn, more such solutions being developed. The ‘learning by doing’ concept is sure to lead to better innovations and improvements in information systems. But that is one side of the picture. The other side ï¿½ and an equally important one ï¿½ is the implementation and servicing that a vendor provides. One of the immediate major challenges today is to get doctors to overcome their reluctance and use IT regularly. The good news on this front is that things can only get better on this front as IT is fast becoming an integral part of the life of the common man.