October 2008

The Other Side of Health IT Solutions : Devesh Rajadhyax, Director and Solution Architect, 21st Century Health Management Solutions

An insightful look into the real challenges IT Admins face after implementing IT systems in healthcare institutions.

What is the other side?

We live in exciting times. Every hospital worth its salt is either implementing a new IT system or thinking of it for the next year. Each moment somewhere, one or the other software is being uated. The side of software that we all see is of course the functionality. Debates arise over small points in functionality of software. But the side that is seldom seen, and one which hides the key to how successful the system will be are the implicit qualities of the software (and hardware) that you are going to acquire, such as performance, manageability, interoperability and so on. I will in this article discuss this, with very little or no technical details.

This article is for

If you are the CIO/CTO of a hospital, this article is for you. You must be familiar with the ideas discussed here, but there are some interesting points related to ‘Healthcare’ IT.

You are not the CIO, but your hospital is planning to implement new IT systems or to change existing IT systems, and you are the informed decision maker, who likes to know things yourself, then this article is for you.

You have been (miraculously) identified as the person who is supposed to advise on the new IT systems of your hospital, and you want to know where to begin, you would like to read this stuff.

And lastly, if you are planning to make a new Healthcare IT system (my best wishes), you would like to consider the issues highlighted in this article.


I am going to discuss many problems and issues, which are specific to the healthcare industry. Speaking about India (and other such countries), we work with several limitations. It is often difficult to put together a good IT team. Many IT professionals do not consider a hospital as their long-term destination. The team changes very often. Many hospitals have to do with IT staff who are upgraded from the rank, rather than certified professionals. Some of the points that I write about have to be seen with this in mind.

India is going through a phase where earlier basic systems are being replaced by new generation systems. But the IT infrastructure, especially the desktops and network is not always revamped. This also poses certain challenges that are discussed here.

Another effect of this transient phase is that a hospital has some systems that are sophisticated and some older systems that continue because they are not easily replaceable. Issues of interoperability usually revolve around this situation.

With this background in mind, let me turn to the other side of IT systems.


Just like the Black Holes, Near Death Experiences and Team Spirit, Performance is always talked about but rarely experienced. Every system that you have bought was supposed to be high performance, but users have always complained that the system is SLOW.

Performance, almost as a rule, is measured as Time. It may be the time to make one patient bill, the time to show one x-ray image or it may be the time to start the reporting system. There is no benchmark for the right performance. It depends entirely on the use of the system. On the registration desk, where patients are waiting, you will need a quick response from the system; whereas while preparing the monthly bill of your corporate client, a more unhurried response can be tolerated.

Of course, you would like to have a nanosecond response everywhere, but as you would have guessed, there is compromise involved here. Generally, if you are looking for more facilities for the user, it will have a lower performance, than the systems which are bang on target and do very specific things. This is the reason why your old B & W Nokia phones may be much faster than the new PDAs. Also, better response sadly means more investment in state-of-the-art hardware.

The next important thing is, the response depends upon the infrastructure that you have. Some software are designed to work with lower system configurations, whereas some assume availability of high end infrastructure. Both approaches have pros and cons, but you have to decide which is the right system for you. If you have a legacy 1990’s network which is difficult to change, you should make sure that the new Imaging Systems / PACS you are buying takes this into consideration.

Now, what is regularly ignored about performance is that performance goes down with time. As the system takes in more and more data, it slows down. Many of you must have seen that the billing system, which was once blazing fast, is no longer winning the 100 m sprint now. It is especially the custom-made systems that suffer from this syndrome, as they are made, put in place and accepted because their performance seems very good. Older, established software products normally go through this in their first few implementations and so are more reliable.


Remember what I mentioned in the Background? It is often difficult to find competent Hospital IT Administrator. Most IT Administrators who have seen the system from childhood-that is, from implementation-are familiar with the whims and fancies of the system. In fact, many veteran Admins know more about the system than the techies in the company that made the system! But, when the IT administration changes hands, it is hell all over again.

The systems that are manageable, behave like an old and docile dog. Configuring such a system means something as routine and unchallenging as this:

  • read the administrators manual
  • open the system and find the SAME screen as in manual
  • change the setting
  • sit back and see that the change is effective

Some systems do not allow others to master them so easily. To change something, the admin may have to:

  • Speak to someone old and senior in the system provider organisation
  • Open database
  • Change, delete, create files
  • Restart various computers
  • And so on�

Such systems are not manageable.

Manageable systems are well documented. The documentation corresponds to the software deployed, and when software is updated, the documentation is updated too!

Manageable systems are possible to manage mostly from one place, and sometimes even from a remote place. The systems that require you to ‘come down and see for yourself’ do not fall in the ‘Ten Most Liked Systems’ of the sys admins.


IT systems are like families. They remain in good shape in the same way, but each one breaks down in its own fashion (to modify slightly what Leo Tolstoy said in Anna Karenina). The trouble is that, it becomes impossible to say whether something has gone wrong or it has not happened. For example, take your mail system. If you do not get a mail, there may not be any mail, or there is some trouble with your mailbox. Traceable systems alert the admins quickly when some part of the system is not working properly.

Take another example, the OPD clerk prepares a pharmacy request, but for some reasons it does not get stored. Now the pharmacy cannot see the request, but the pharmacist is not going to suspect anything, since s/he does not KNOW that there is a request! The system should detect such events and notify the admin that the system is behaving badly.

Traceability also means that it should be possible to find out where things are going wrong. Traceable systems allow the admin to put the system in troubleshooting mode, so that various logs are generated, which help in tracking down the problem.


A health institution goes on acquiring IT systems as it grows. Usually the billing and account systems are the first, then come the administrative systems such as HIS and RIS; later the clinical systems like PACS and EMR are installed. To make some sense out of this maze, the systems need to talk to each other. Healthcare has been blessed with many standards such as HL7 and DICOM, and it is the job of experts to understand and apply these standards. But what really matters is whether careful consideration has been given to exchanging data with other systems when the system is designed.

Interestingly, when two or more systems are interfaced, the importance of Traceability increases many times. Something may go wrong in one system, while the other system carries on as if nothing were wrong. With sound traceable systems, such disasters can be detected in time and corrected.

In closing

I hope that this article gives you a new angle to look at the IT systems being planned for your hospital. A little attention paid to these details during planning can go a long way towards ensuring many years of smooth functioning of the systems.

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