REPORT Chahat

8/6/2019 REPORT Chahat

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Summer Placement

In

HiSPindia

(April 4 - May 30, 2011)

IMPLEMENTATION OF HOSPITAL INFORMATION SYSTEMIN DEEN DAYAL UPADHAYAY HOSPITAL, SHIMLA

Chahat Narula

PG/10/010

Post-graduate Programme in Hospital & Health Management,New Delhi

2010-12

International Institute of Health Management Research, New Delhi

2011


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ACKNOWLEDGEMENT

I wish to express my deep sense of gratitude to Prof Sundeep Sahay, President, H iSPindia forgiving me great opportunity to do my Summer Training at HiSPindia, Shimla.

I hereby express my deep gratitude towards Ms. Arunima S Mukherjee, Project-Lead

Coordinator, HiSPindia, and Ms. Rashi Banta, Project-Lead Coordinator, HiSPindia, for their

valuable guidance, support, interest, involvement, encouragement and advice. They inspired us

greatly to work on this project.

My sincere acknowledgement goes to Prof Indrajit Bhattacharya and Prof Anandhi

Ramachandran for their kind assistance and support throughout our summer training.

Finally, an honorable mention goes to my family and friends for their understanding and support

in completing this project.

Thank You


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ABBREVIATIONS

1. AIDS- Acquired Immuno-deficiency Syndrome2. API- Application Programming Interface3. BPL- Below Poverty Line4. DDU- Deen Dayal Upadhayay5. DHIS- District Health Information System6. DOTS- Directly observed treatment short-course7. HIS- Hospital Information System8. HISP- Health Informatics Systems Programme9. HIV- Human Immuno-deficiency Virus10.ICTC- Integrated Counselling and Testing Centre11.IPD- In-patient Department12.MLC- Medico-legal Cases13.MRS- Medical Record System14.MS- Medical Superintendent15.OPD- Out-patient Department16.RKS- Rogi Kalyan Samiti17.RSBY- Rashtriya Suraksha Bima Yogna18.SMO- Senior Medical Officer19.TAT- Turn Around Time


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TABLE OF CONTENTS

1. HiSPindia Profile72. Introduction.....93. Operational Plan.....11

3.1 Need Assessment for HIS...11

3.2 Initiating the Process..12

3.2 (a) Demo of OpenMRS (HIS) in Hospital

3.2 (b) Review of Existing Process

3.2 (c) Requirements Based on Review of Existing System

3.2 (d) Meeting on HIS implementation

3.2 (e) Action Plan for HIS implementation

3.3 Procurement of Software/Hardware Support....23

3.4 Module Implementing................................................................24

3.5 Training Session/Capacity Building for the End User.....46

3.5(a) Training Objective.....46

3.5(b) Identification and Assessment of Training Need...46

3.5(c) Basic Requirements....46

3.5 (d) Training Plan.....47

3.6 Dry Run........ 49

3.6 (a) Testing the Application for 10-15 days.................49

3.6 (b) Hands on with End Users (nurses and doctors)................50

3.7 Going Live Process50

4. Conclusion...51

5. Case study....53

6. References....58

7. Annexure..............59


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ABSTRACT

Introduction

Innovation in Healthcare Information Technology (IT) has fueled unprecedented gains in

improving the medical field over the last 30 years. Today, IT companies with their healthcare

verticals are an important engine to drive growth for hospitals getting automated. A Hospital

Information System (HIS) is an integrated information system designed to manage the

administrative, financial and clinical aspects of a hospital. HIS is vital tool in decision-making

and plays a vital role in the success of any organization. Computerization and automation of the

medical records and their documentation has resulted in efficient data management and exchange

of information for the users. With the help of HIS, managers, clinicians and other healthcare

workers can access the information without any delays or errors.

Aim

The primary aim is to establish an approach for implementing HIS (Hospital Information

System) in Dean Dayal Upadhyay Hospital (Ripon), Shimla, which is already an established and

functional government hospital. The approach should be such that it aligns to support the

mission, vision, goals, objectives, and strategies of DDU.

Objective

Articulating and communicating the right vision and mission for HIS implementation project,

committed involvement of the top management of a hospital and persistent training of the actual

end users.

Methodology

The following practices, grouped into management processes, helps in the implementation ofHIS in Hospitals:-

(1) Assessing the complete requirements of the Hospital and the end-users

(2) Designing an existing flow and analyzing the gaps

(3)Optimizing the workflow

(4)Preparing the users by imparting high level training and capacity building


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(5)Transforming the system with live implementation,

(6)Sustaining and providing support.

Conclusion

The implementation of HIS in DDU would result in the following

(1)Reduced cost(2)Improve quality(3)Standardize Workflow(4)Better Management Control


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1.HiSPindia PROFILE

HiSPindia is a not-for-profit NGO specializing since more than a decade in designing and

implementing solutions in health informatics for the public health sector in Indian states, and

also recently in Bangladesh and Sri Lanka. It is not a solely technology focused organization, but

a multi-disciplinary organization concentrating on the domains of public health and informatics.

The organization has a strong commitment to free and open source technologies, and works witha global perspective of the Health Information Systems Programmes (HISP) network,

coordinated by the University of Oslo, Norway, and is active in more than 20 countries in Africa

and Asia. HiSPindia has a registered and head office in New Delhi, and project offices in Kerala,

Himachal Pradesh, and Punjab. The team members are intensively travelling to different parts of

the country to provide technical support services.

1.1 VISION

To enable and coordinate a network of excellence in public health informatics, specializing in

integrated health information architectures, with a geographical focus on South-East Asia.

1.2 HISTORY

In 1999, an informal group of idealists got together to start a project in a primary health centre in

the remote villages of Kuppam, Chittoor district in Andhra Pradesh. These efforts were

supported by the University of Oslo, Norway, and had initial partnerships with IIM Bangalore

and ASCI Hyderabad. During the first five years, it remained focused on Andhra Pradesh and

carried out implementations of the first version of the DHIS software application. From 2005, it

started to work in the State of Kerala first in one facility and by 2008 all the facilities were

reporting data in the DHIS2. The DHIS2, which is a global standard today for facility reporting,

took birth in a clinic in Kerala in 2006. The achievements in Kerala prompted the state of Gujarat


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first, and then Jharkhand and Madhya Pradesh to initiate DHIS2 implementations. This led to

collaboration in 2008 at the national level with National Health Systems Resource Centre

(NHSRC) to provide technical support on DHIS2 nationally. About 25 states took up DHIS2 in

2008. Today, HISP has gained international recognition, and has also been invited to provide

technical support in Bangladesh, Sri Lanka, Rwanda, and Philippines.

1.3GEOGRAPHICAL COVERAGE

With a 30 team members, HISP has a strong national and global coverage of work. In India, it

has worked in at least 90% of the states, and currently has a presence in about 20 states.

Internationally, HiSPindia has worked in Bangladesh and Sri Lanka, and on an individual basis,

experts have contributed to Global HISP activities in various countries including Vietnam,

Tanzania, Zanzibar, Ethiopia, Mozambique, South Africa, and those in West Africa.


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2.INTRODUCTIONOver the last few decades, medical sciences have significant progress leading to improvements in

the modes of investigations, therapeutic activities and surgical procedures. This has enhanced the

need to have authentic and accurate medical records of the patients. Health Information System

(HIS) is one of the most promising applications of Information Technology (IT) in the Health

Care Sector. The aim of HIS is to use a network of computers to collect, process and retrieve

patient care and administrative information from various departments for all hospital activities. It

also helps in decision-making for developing comprehensive health care policies.

2.1 CONTEXT AND CONCEPT

The HIS comprises of an electronic patient record which forms the core of the system and links it

to all other departments in the hospital where every department can be viewed baas an

information-processing agency. Present health Information system reveals that the existing

system at DDU Hospital requires up-gradation to meet the requirements of the managers and the

clinicians. The management at DDU feels HIS assists in decision making, and medical audit. It is

also felt that the existing HIS resulted in longer time for OPD consultation and delay in

investigation results.

2.2 ADVANTAGES OF HOSPITAL INFORMATION SYSTEM

y HIS is based on the exemplar of a centralized information system designed for quickdelivery of operational and administrative information.

y The administration can actively use HIS for monitoring and controlling the quality ofpatient care.

y Helps in providing improved clinical outcomes and better diagnosis and care to thepatients.

y The administrative and supply chain modules improve productivity and efficiency,driving down costs and waste.


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y Assesses the performance of the medical staff; in keeping track on how hospitalsresources are being put to use.

y Gathering data for short term and long term decisions.y Prompt and reliable information storage, querying and retrieval.y A data warehouse of such records can be utilized for statistical requirements and for

research.

y Improved monitoring of drug usage, and study of effectiveness.


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3.OPERATIONAL PLANThe implementation of HIS can succeed if the following two conditions are met

y A consistent organization of people and processesy A clear choice for the establishment of infrastructure (hardware & software) backed up

by financial investment.

DDUs hospital management is informed, thorough and methodical. Within this hospital,

implementation of HIS is based on computerization of care processes as well as support

processes like registration, billing, logistics etc. to ensure coherence of clinical and business

activities of the hospital.

The implementation of a HIS is a complex procedure. It requires being operationalized step-wise

with optimum support to enable the users a confident approach towards using the system

thereafter. HIS implementation cannot be done at once for the entire hospital as it might become

complicated. Hence a module-wise approach was taken for implementation depending on the

priority of modules as mentioned by the hospital authorities.

Followingsteps were undertaken for HIS implementation -

3.1 NEED ASSESSMENT FOR HIS

Assessment is the first component of the HIS implementation framework. This step gives the

organization the opportunity to carefully examine its current state, actual needs and the readiness

to accept a cultural and organizational change. This process engages the clinicians, physicians,

paramedical staff, and support workers directly or indirectly linked with the hospital.

The main important needs of DDU for HIS realized were-

y To create Electronic Patient Medical Records.y Allow monitoring of the health care services provided by the hospital to the patients

registered in DDU. A data warehouse of such records can be utilized for statistical

requirements and for research.


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y Comprehensive management of all services/functionalities provided by DDU.y Access to all services/functionalities under a single umbrella.y Easy access to query data to generate varied records, including classifications based on

demographic, gender, age and so on.

y Efficient and accurate administration of registration, billing, OPD, IPD, Laboratory,Blood Bank, RKS hospital maintenance, inventory and pharmacy.

y To decrease the average length of stay of in the hospital by reducing the TAT.y Streamlining patient flow and providing convenience in treatment.y Reducing paper work with more computer dependency.

3.2INITIATING THE PROCESSHiSPindia followed 5 major steps in the initiation of the implementation of HIS in DDU hospital

in Shimla. These steps include-

3.2(a) DEMO OF OpenMRS IN HOSPITAL

About OpenMRS

OpenMRS was created in 2004 as an open source medical record system platform for developing

countries. OpenMRS is a multi-institution, non-profit collaborative led by Regenstrief Institute, a

world-renowned leader in medical informatics research, and Partners in Health, a Boston-based

philanthropic organization with a focus on improving the lives of underprivileged people

worldwide through health care service. OpenMRS is now in use around the world including

South Africa, Kenya, Rwanda, Lesotho, Zimbabwe, Mozambique, Uganda, Tanzania, Haiti,

India, China, United States, Pakistan, the Philippines, and many other places.

It is community developed software which enables to design customized medical records without

any programming knowledge, only medical and systems analysis knowledge is required. It uses

minimal free text and maximum coded information making it easier to summarize and analyze.

Its core is a Concept Dictionary which stores all diagnosis, tests, procedures, drugs and other

general questions and their potential answers.


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In a meeting with the hospital authorities and end users of the software, a detailed demonstration

of OpenMRS was given in order to acquaint them with the software, how it looks and works like,

together with its linked benefits to the hospital. The following features were shown:

y Central concept dictionary: Definitions of all data (both questions and answers) aredefined in a centralized dictionary, allowing for robust, coded data

y Security: User authenticationy Privilege-based access: User roles and permission systemy Patient repository: Creation and maintenance of patient data, including demographics,

clinical observations, encounter data, orders, etc.

y Unique identifiersperpatient: A single patient will have a unique identifier which willbe used across the system to search that particular patient.

y Data export: Data can be exported into a spreadsheet format for use in other tools(Excel, Access, etc.)

y Modular architecture: An OpenMRS Module can extend and add any type offunctionality to the existing API.

y Patient workflows: An embedded patient workflow service allows patient to be put intoprograms (studies, treatment programs, etc.) and tracked through various states.

y Cohort management: The cohort builder allows you to create groups of patients for dataexports, reporting, etc.

y Patient merging: Merging duplicate patientsy Reporting tools: Flexible reporting tools

3.2(b) REVIEW OF EXISTING PROCESS

In order to develop HIS for DDU, first there was a need to understand the hospital in different

spheres which enables one to magnify the horizon of growth and invention required. It is only

after reviewing the current functionalities and existing process that the hospitals layout can be

determined to be placed in future virtually.

While doing so, following were the observations-


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Name: Registration no:

Age: (Years/ Months/ Weeks/ Days)

F/M H-C/O Name:

Gender: (male/ female/ male child/ female child/ unknown)

Department: *(department with room no.)

Unit:

Category: (General/ IRDP/ Poor free/ BPL/ RSBY/ Senior citizen/ Others)

District: Area:

State: (Himachal/ others)

Old patient: (-, yes)

Registration

In DDU, computerized registration was done and there was only one counter for registration

bearing a daily patient load of around 1000 to 1500 patients per day. The screen shot of

registration slip (prior to HIS implementation) was-

There are 16 departments in the hospital and the list of department is as follows:

Department Room No.

Physiotherapy 4

Ortho OPD 7

X-Ray 8

Gynae OPD 11

Children OPD 12

General OPD 24

Medicine OPD 25

Eye OPD 27

Surgical OPD 28


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ENT OPD 29

Dental OPD 30

ECG 31

Casualty 33

T.B clinic 34

Leprosy clinic 35

Skin OPD/ STD 38

The operation time for the registration is 8.45am to 3.45pm and maximum hourly load is 200.

Computers 1

Printers 1

Ups 1

HR- data entry operators 1

Reports prepared for registration were:

y Age wise OPD Report:Male Female Male Child Female Child Male Sr.

citizen

Female Sr. citizen

y Registration Detailed Report:S. no Reg. no. Name Sex Age Department Unit Category District

Billing

The hospital had a centralized billing process before the implementation of HIS, where billingfor all services is done at counter number 2.

y Existingprocess of billing services through OPD- A patient after having gone to arespective out-patient department, when advised certain tests or investigations by the

doctor, goes to the billing counter and pays for the investigations to be conducted. The

billing clerk generates a computerized bill and stamps it after the patient has paid. The


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bill along with the OPD slip will then be taken to the respective department where the

investigation has to be conducted.

The BPL and poor patients are provided all services free of cost. The laboratories of all the

national programmes (ICTC, RNTCP/DOTS, NLEP, Family planning, IDSP) conduct the tests

free of cost for all patients i.e. the investigations conducted by these labs are not billed for.

y Existingprocess for billing services through IPD: A patient admitted in the IPD isbilled only for procedures and investigations. All other services of the IPD bed, diet etc

are free of cost. For any investigations and procedures to be conducted, the patient goes

and pays for the service at the billing counter, after which the test or procedure is

conducted. At the time of discharge, a discharge summary is prepared by the respective

department, where the patient has been admitted and sent to the billing counter. The

patient goes there to clear any dues after which he/she is given the discharge.

Patient registers andgoes to OPD; doctor

advices for tests/investigations

Patient goes tobilling counter and abill is raised for thetests/ investigations

to be conducted

Patient pays and thebilling clerk stamps

the bill

Patient goes andgets the x-ray done

Patient is admitted

in the IPD, advisedtests/ procedures by

the doctor

Patient goes to the

billing counter, getsthe services billedfor and pays for

them

Patient goes to the

billing counter, getsthe services billedfor and pays for

them

The dischargesummary is sent by

the IPD to counterno 2; any balance

dues are cleared bythe patient


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y Current/ Existingprocess formedical examinations: The hospital conducts medicalexaminations on people for various purposes (it may be for getting a government job, for

driving license, as a part of the routine process for any organization etc.). For

administrative and billing convenience, the medical examinations are divided mainly into

2 categories:

Medical examinations Gazetted: This is for government employees, who aresent by their respective departments for medical examinations. The person first

has to deposit the medical examination fee (Rs 200) at the billing counter, after

which he/she goes to Room no 21, where the patient is given 3 copies of the

medical examination form. At the end of the examination, one copy is retained

by the hospital, one is given to the patient and one is sent directly by the

hospital to the department from which the patient has come. Behind each

form, a stamp containing the details of the departments to be visited, along

with the room numbers is put:

The patient then visits each of these departments and the doctor at each

department writes his/her observations either in the place provided in the

form, or against the department name on the stamp. After having visited all

the departments, all the 3 copies of the forms come to the S.M.O, who then

certifies the patient, based on the observations of the various departments.

Medical examinations - Non-Gazetted: The only difference between the gazetteand non-gazetted is that, for non-gazetted, the patients bring their own forms,

Eye (Complete Checkup) ..27

Blood & urine testing.37Chest X-ray08

Blood grouping..32

ENT checkup.29Ortho unit..07Gynae unit (only for females)11

Medical unit24/25

Surgical unit.28


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from their respective organizations, and the stamp is put on their form. The

charges are Rs. 100.

Inventory

The Inventory/General store is the main store at DDU. All Receipts come to the Main store and

from here items are dispensed to sub-stores on the basis of the indent order raised by them.

Laboratory

There are mainly five types of tests that are conducted in the lab. These are biochemistry,

hematology, serology, cytology and urine examination.

There are two receipts handed over to the patient at billing counter, one receipt has to be handed

over to the lab technician and the other is retained by the patient. The patient then goes back to

the lab where his sample is collected and entered in the registers of the lab.

IPD

In DDU hospital there are 4 nursing stations catering to 14 wards, the patient flow in IPD will

start with OPD from there the doctor will advice to patient for admission. Patient will be referred

to the particular ward where the details of patient (demographics, bed number, provisional

diagnosis and income) are entered in the admission register. In the ward, dispatch register is

Patient registers andgoes to OPD; doctor

advices for tests/investigations

Patient goes to Roomno 31 where the bill is

raised

Patient goes to billingcounter where the

dues are paid and theclerk stamps the bill

Patient goes to thelab and gets the tests

done


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maintained in which final diagnosis, discharge date and discharge summary of patient are

recorded.

Pharmacy

In DDU hospital pharmacy is working with one counter. There are 51 drugs in their stock and

the patient gets these drugs for free. Patients come to the pharmacy to receive the medicines

prescribed by the doctors. If the medicine/drug is available in the pharmacy, the patient is given

the advised dosage. The stock in the pharmacy comes from the hospital inventory. The

Pharmacist performs the tasks of raising indents, receiving transfers from Main store and Issuing

drugs to patients. He enters the details of patient and issued drugs details to particular patient inregister.

Blood bank

Blood bank at DDU is a unit which functions independently from the hospital, under the

Himachal Pradesh state AIDS control society (HPSACS) and the blood bank society of the state,

chaired by the DC.Issue of blood is done either by replacement or by payment of Rs. 45 per unit

for government hospitals and Rs. 750 per unit for private hospitals. The blood bank issues blood

when they receive request from DDU or any other hospital. The blood is issued in the following

manner:

RegistrationOPD-doctor advises

admission

Ward-patient isentered in admission

register andadmission no is

issued

Treatment begins


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3.2(c) REQUIREMENTS BASED ON REVIEW OF EXISTING SYSTEM

After understanding the existing patterns of DDU hospital in regard to patient flow, hospital

workflow, clinicians requirement, the next step is to find out the specific requirements in

context of the HIS to be developed for the hospital. These are known by discussing with the

hospital authorities and also by self observation of the existing processes done earlier. A

comprehensive understanding and documentation of these features are the keys to success in this

phase.

The requirements can be either functional (comprising of business/ end users) or non-functional

(comprising of technology). There are several ways to gather information-

y Interviewing- It includes asking the potential end users (doctors, nurses, technicians etc )of the software a set of questions to analyze their need and attitude towards the

transformation from the conventional way to the modernized version. Personal

interviewing helps in judging the level of computer literacy among different users and

thereby helps to determine the depth of training required accordingly.

y Focusgroup discussion- The methodology lies in getting together the people of same background ( like doctors in a group or nurses in another) to commonly discuss their

requirements as well as give suggestions.

Request forblood- form

filled by doctorat DDU

Bllod bank-checks foravailability

Patient pays forthe blood/bloodis replaced by

donation

Cross matchingdetails are

written C.M isissued

Blood issued


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y Surveys- It is a way to observe the system workflow by enetering the workflow as aconsumer/patient in order to understand the requirements from the patient point of view.

its principle underlies the study of time and motion in a hospital so as to create a system

to complement the existing processes.

y Shadowing- It includes observing the end user and understanding the manual processesto know the extent to which they can be computerized and automated successfully.

There are several sources of information-

y People- They are the primary source of information. This includes the end users likedoctors, nurses, lab technicians, paramedical and other supporting staff.

y Manuals- They are the documents/registers maintained by different departments thatgives the details of the existing system and the recordable fields.

y System- Existing application and its functionalities.

WAYS TO GATHERINFORMATION

SHADOWING

INERVIEWING

FOCUS GROUP

SURVEYS


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The next step is Documentation. It is the process of compiling and aggregating the observations.

It is a kind of conclusion that the fact or statement is true, done with a purpose to support a tool

or a process. It is a kind of written information, a prototype of the existing system, requirements

and information in the form of text, photos and physical evidence.

3.2(d) MEETING ON HIS IMPLEMENTATION

Once the lists of requirements were compiled based on hospitals input and our own

observations, a meeting was held with the hospital authorities. Based on these observations, a

proposal was compiled by the HISP team comprising of the requirements that the system would

bear, the functionalities of system as well as other generated records that would be provided. The

proposal was to be studied by the hospital team thoroughly. A round of discussion, cross

questioning and explanation were held to clarify and put across the real picture of the proposal to

the hospital team. Also their suggestions were put into consideration. With mutual agreement,

SOURCES OFINFORMATION

PEOPLE

MANUALSYSTEM


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required additions and deletions, finally the proposal was accepted by the hospital in form of a

signed document.

3.2(e)ACTION PLAN FOR HIS IMPLEMENTATION

After having a consigned agreement with the hospital for customized development of HIS, the

next step undertaken was to convey the entire requirements to the developers team and thus

develop a plan of action regarding the same. It is the most crucial step, where the information

gained was translated to the developers in order to enable them to customize and develop the

software exactly the way it was desired by the hospital. The developers work on different

modules that would be working in the hospital. They modify each module and specific fields and

functionalities, such that the software becomes most suited and easy to use for the hospital users.

Thus, this the developing stage of the software in terms of customization.

3.3 PROCUREMENT OF SOFTWARE AND HARDWARE SUPPORT

Installation and configuration of server: In DDU there are currently 26 computers that are

networked to a server running Linux Ubuntu 10.10. It is being shared on 10/100mbps LAN

connection. DDU has new branded HCL computers and HP LaserJet Printers. Their network is

also wiring all CAT6 in organized way and connect to switchs via patch panel in racks.

The hardware that connects to the network are-

y Serversy Workstationy Print Serversy Printers / Copiers

In order to install the server, first Tomcat Servlet was installed. Apache tomcat is an open source

servlet container. Tomcat implements java servlet and extracts the war file. war file will come

with application (openMRS). After installing the servlet, database with mysql is created. mysql is

a open source database which connects the application(openMRS)to database. OpenMRS default

modules will be diverted and the customized modules will be installed manually.


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3.4 MODULE IMPLEMENTING

In DDU, modules were implemented in phases to avoid various problems in the transition of old

system to new system. as in doing so the problems which are faced during the implementation

are rectified then and there only by making appropriate changes. During the process of

rectification of new system, old system can be utilized to run without any hang up in the system.

The various modules in DDU were implemented in two phases

y Phase I- In the first phase of implementation the following modules were implemented Registration Billing Laboratory

Registration module

The module involves capturing and recording patient demographics and visits at the point-of-

care. Registration data will be displayed consistently and automatically on screens in the clinical

system. The system generates a unique registration number for each patient (CR. no.), this is an

auto generated 16-digit number comprising district, name of hospital, date, time and serial

number that will appear on the OPD slip issued to the patient and will serves as identifier. All

referral Patients under National Health Programme including TB Leprosy, Except HIV will be

directed through this central registration.

Currently in DDU, there is one registration counter from where online OPD registration is done.

There are two computers and two data entry operators. Registration is done from the registration

counter in the routine OPD timings and emergency registration is done from the casualty

department for the patients who require immediate medical care.

The registration clerk logs in to the system by entering the billing clerk-name and password in

the home page and then selects the find/create patient from the navigation menu. After clicking

on the find/create patient option, following registration page will be displayed.


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The registration clerk then adds the details of the patient in the various fields of registration.

y Patient namey Demographics- age and gender. The age of the patient falls under the following

categories.

0-12 yrs-Child 13-19 yrs-Adolescent

20-59- yrs Adult 60+ yrs-Senior Citizen

y Relatives name The registration clerk would have to enter either the fathers name, orthe husbands name.

y Referral information- The registration clerk would have to select the appropriate optionfor referred from from the drop-down list which includes PHC, CHC, SDC, SC, other

district hospitals and private institutions. The registration clerk would then have to select

the appropriate option for referral type from the drop-down list.

y Patient identifier- An auto generated 16 digits ID Number would be generated by thesystem, which would appear on the registration page. This number would be unique to

this particular patient for life.


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y Address - The registration clerk would then have to select the District and Thesil of thepatient.

y Patient category- The registration clerk would then have to select the appropriate patientcategory by selecting the check-box against the category of the patient.

y OPD Room to visit The registration clerk would have to select from the drop-downlist, the OPD room/ Department that the patient has to visit.

After having filled all the above fields, the registration clerk would have to select the Save

option. Following which the system would generate the OPD slip, asshown in the screen-shot

below. The registration clerk can then select the print option to print the OPD slip generated.

In-case multiple patients with the same name exist, advance search option helps to filter the

patient by gender, age, date of registration and relatives name and thus the search would be

refined.

Billingmodule

The Billing module deals in collection of money for services availed by a patient at OPD, IPD

and other services other services like Ambulances, tenders, blood bank, fee for medical

examinations.


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The billing clerk logs in to the system by entering the billing clerk-name and password. To

generate a bill for a patient, the billing clerkwould have to select the billing option from the

navigation menu.

On selecting the billing option, a screen as below will be displayed.

The billing clerk would be able to bill for 4 main services of the hospital:

y Patient services Patients are billed for various investigations/ tests are prescribed bythe doctors in the OPDs. The patient to be billed for is searched and selected through

patient name or identifier. A screen will be displayed showing the billing history of the

patient and a new bill is raised by selecting the add a new bill option. On selecting add

new bill option, 9 major categories which are further divided into sub categories of the

services provided by the hospital are displayed. These are blood bank, dental department,

general laboratory, hospital charges, national programme laboratories, physiotherapy

department, radiology, radiography and cardiology. From the appropriate category the

desired test to be billed is selected. Multiple services from different categories can be

selected. After having selected all the services the bill is saved and the dateails of the

current bill are displayed. An option to print the bill and the billing history of the patient

is displayed.

y Ambulance services Money for each trip is paid by the patient to the driver of therespective ambulance who then deposits the money collected at the billing counter at the

end of the day. To bill for ambulance services, the billing clerk would first have to select

the billing ambulance option, on the main billing screen and then search for the driver

in search driver field and select the appropriate driver for whom a bill has to be raised.


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A new driver can also added, using the add driver functionality on selecting the Add

new driver option. To add a new bill for the selected account, the billing clerk selects

the add new bill option. On selecting the required service, the price assigned for that

service would be populated in the table at bottom.

y Tenders - The tender fees or the amount to be paid to be able to bid for the tender) isdeposited by the company bidding for the tender at the billing counter. To bill for a

tender, the billing clerk first selects the billing tender option, on the main billing screen

and then search for the company name in the account name field. To bill the company

for a tender, the billing clerk selects the Add new bill option. To add a new company

name add new company option is selected and details of that company is entered and

saved. The billing clerk then selects the tender to be billed for and appropriate tender is

selected and the price assigned for that tender is populated.

y Miscellaneous services other services that are not covered in the above 3 categoriese.g. student internship fees. To bill for miscellaneous services, the billing clerk would

have to select the billingmiscellaneousservice option from the main billing interface

and then click on add miscellaneous service bill option. The billing clerk would then

have to select the appropriate service for which the bill has to be generated. Once the

service has been selected, the billing clerk would have to enter the name of the person,

for whom the bill has to be generated. Then the bill is saved and printed.

Laboratory module

In DDU online Laboratory Module operates for Laboratory services. All lab orders are directly

routed through the billing module.

The laboratory technician first logs in to the system by entering the username and password in

the home page. To go to the lab entry, the Lab Entry icon is selected. Here the laboratory

technician can select 4 main functions:

y Lab Entry Systemy WorkListy Enter Resulty Print Patient Report


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WorkList

The work-list facilitates the finding and printing of a list of accepted investigation for each

subdivision of the laboratory. This list is printed out as hard copies. The Printed worklist also

provide a space to report on the various investigations conducted.

Enter Result

It facilitates the entering of test results into the system. To achieve this lab technician has to

select date and select lab in which to enter result then click on Get Work List. This displays the

Work Lists along with displaying an additional filter to select test.

On selecting test the displayed list allow provide an option to Enter Result in the work list.

Clicking on entering result displays a screen on which individual results for the test can be

entered. After the lab technician enters the result date of result entry has to be entered then only

will the results be saved on clicking the save button. There is an option to cancel result entry for

a particular patient.

If the test could not be performed on the sample and sampling has to be reordered the lab

technician has the option to reorder sample. This is done by checking the reorder test check box.

Activating the check box prompts the lab technician to selecting a date and clicking the save

button transfers the lab order to the selected date.


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Print Patient Report

Provides the option to print test results for various investigation conducted for a given patient on

a given day. On selecting the Print Patient Report option the system prompts the lab technician

to enter name of patient and date for test to be printed. Entering these details and clicking Get

Patient Report displays, patient details and the results of all the test reported on that day along

with known normal ranges for the tests. The bottom left corner of the page displays an option to

Print the test report of the patient.

y Phase II- In the first phase of implementation the following modules were implemented OPD IPD


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Inventory Pharmacy Blood Bank

OPD module

The OPD module forms the heart of the system that maintains the electronic medical record for

each patient reviewed by the doctor. The OPD module in DDU is made functional in 10 OPDs.

Each OPD has a computer set-up to be operated by the respective doctors. The module screen

consists of two major parts- the patient queue and patient dashboard. Once the patient is

registered in the registration counter, his/her name appears in the patient queue of the OPD

he/she is registered for. On reviewing the patient, the doctor clicks on the identifier of the

patient. The screen that appears here is the patient dashboard. The patients diagnosis, procedure

can be entered. Through this dashboard, the clinical summary/medical history, results of all

investigations and in-patient record can be viewed across the hospital.

On entering the username and password, a screen as shown below appears. The doctor will have

to select the respective OPD from the drop-down list.


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On the main OPD interface screen, the doctor would be able to view 3 main options

y Patient queue This is a queue of patients who have been registered for a particularOPD on that day .

y Search patient in queue This is a functionality to search for a patient in the queue the patient can be searched by his/her name or identifier

y Search patient in system If the patient has not visited the registration, he/she will notbe visible in the patient queue. The doctor would then have to search for the patient in the

system by either name or identifier.

Details of the patient ID, Name of the patient, Age and Gender of the patient are displayed in the

queue. Also the details of referral type i.e. if the patient is a new patient, a revisit patient or has

been referred from some other OPD.

E.g. in the screenshot as ahown below, patient Ram has been searched for, a list of all the

patients with name Ram will be displayed. The doctor then select the appropriate patient by

matching the age and the identifier.


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Now the next step is to make entry for each patient, or to view the previous clinical

summary/medical history. The doctor would have to click on the name/identifier of the particular

patient in the list. On clicking the patient dashboard appears. The dashboad is an entry review

screen, in which medical information regarding patient can be entered and reviewd by the doctor.

Following is the screen shot of the patient dashboard as it appears.


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It has the following features

y OPD Entry This has been designed keeping in mind the long patient queues andminimal time per patient for each doctor, and hence caters to minimal data entry. It has

two mandatory data entry fields provisional diagnosis and concluding a visit. A list of

diagnosis has already been provided in the system. On having selected the appropriate

diagnosis, it will be moved to the box on the right. This would indicate that the diagnosis

has been selected. In-case the doctor would want to add any specific details, there is a

provision to add a note.

y Clinical summary Here the doctor would be able to view all the entries that have beenpreviously made for each patient.

y Investigation report The doctor is able to view the results of all the investigations thathave been conducted on the patient as prescribed.

y IPD record The doctor is able to view the admission and discharge details of thepatient.

The doctor could also refer a patient internally within the hospital to any other OPD. The doctor

would have to choose the appropriate OPD to which the patient has to be referred to from the

dropdown

The doctor then concludes the visit by selecting either of the folllowing options

y Follow up and selecting a follow up datey Curedy Diedy Reviewedy Admit. On selecting the admit option, the doctor would have to select the appropriate

ward to which the patient has to be admitted.

IPD module

The end-user log in to the system by entering the username and password in the OpenMRS home

page. The end-user selects the IPD option from the navigation menu. Once the IPD option is

selected, the end-user would be able to see a following main IPD interface screen:


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Here the end-user would be able to view 2 main options

y Patients for admission: This a queue of patients who have been refered to a particularIPD by the doctors in OPD. . Details of the patient ID, Name of the patient, Age, Gender,

ward to which the patient has been admitted (E.g.: Female medical, male medical) and

name of the OPD doctor, who made the admission would be visible to the end-user.

y Admitted patient index: This a list of patients who have already been admitted to thevarious IPD wards.

The end-user has the choice to filter the list (in both the tabs patients for admission and

admitted patient index) using multiple criteria By patient ID, IPD ward, tereating doctor, and

date of admission.

In the list of patients for admission, against each patient on the list, the end-user would have the

following three options:

y Admit- The end-user would have to enter the details of caste, monthly income, basic payand bed number and then select the submit option, after which the patient will now be

transferred to the admitted patient index and an admission slip will be generated. A

print out of the same can be taken.


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y Remove- If a patient does not show up in the ward, the patients name can be removed byselecting this option.

y No bed- In-case of unavailability of beds, the end-use selects the no bed option; toremove the patient from the queue.

In the Admitted patient index, the end-user can see the patients who have been admitted in

different wards of the in-patient department. The end-user will be able to see the details of

admission date, patient ID, name, age, gender, and the particular ward where patient has been

admitted and admission by which OPD doctor.

Here the end-user can perform 3 operations for each admission

y Transfer- The end-user uses the transfer option, in-case of transferring of a patientfrom one ward to another, internally within the hospital.

y Discharge- The end-user uses the discharge option to discharge a patient from thehospital. The end-user would first have to select a diagnosis for the patient. This is a

mandatory field. The end-user would then select the discharge outcome of the patient

from the drop-down and select the submit option.

y Print

Inventory module

The Inventory is the main-store at DDU. All Receipts come to this Main store and from here

items are dispensed to sub-stores on the basis of the indent raised by the sub store. Inventory

consists of the Main Inventory Store and 28 Sub stores which indent from the Main Inventory

store.

Categorization of Inventory Items in the Main Inventory Store


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Online Inventory module will operate for Hospital Main store. Online Inventory module will be

based on all stock items listed in the Main Store Stock Registers. Each Department/Sub store will

raise an indent for transfer of stock after the approval from the Medical Superintendent. General

Store/Inventory will transfer stock to respective sub stores. In case the Main store is out off stock

and needs to purchase some items, a purchase Indent/order needs to be raised by the Inventory

Manager. On receipt of the items , the same will be entered under a receipt no. by the Inventory

manager into the stock list at the main store before transferring them to the substore that had

indented those items.

The Inventory manager logs into his system with username and password. The screen that

appears displays a list of operations that the Inventory manager can perform for both Drugs and

Inventory Items.

Inventory

Drugs

Vital

Essential

Desired

Other inventory items

Consumables

Linen, Electricspares, Medical

consumales, officesupplies

Dead stockFurniture, Electric

Equipment andMedical Equipment


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The lists of operations are:

y View StockBalance for General Store- This functionality enables a user to View thecurrent stock in terms of Name of Item, Sub Category that it belongs to, Available Qty

and Reorder Point.

y View StockBalance Expiry- An inbuilt alert mechanism has been built in, whenever adrugs approaches its expiry (3 month advance) it will shown an alert message. The drugs

will turn red.

y Receipts to the general Store- This functionality enables the user to add receipts to thegeneral store. The Inventory manager receives items that have been purchased. He then

enters that stock as Receipts to the general store. Every Receipt that has been entered has

a name/Description which is distinct and contains a list of all items that have been

received under that Receipt. A print out of this receipt can also be taken.

y Tranfer to Sub Store- This functionality enables the Inventory Manger to tranfer theitems to Substores example Transfer from General Store . Press on the Tranfer From

General Store Tab and the following window appears.

This process is separately done For Items (It displays balance of all stock items available in the

inventory on that particular date viz Name, Sub Category, Specification , Available/Current Qty,

Reorder Point.) and For Drugs (It displays balance of all stock items available in the inventory


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on that particular date viz Name, Category, Formulation , Available/Current Qty, Reorder

Point).

Status: Once the indent has been received by the general store with due authorization the

following three status are encountered-

y The status Done refers to a condition when indented items have been transferred to theSub store by the main store and has been accepted by the Sub store manager

y The status Sub Store Refuse refers to the condition when the indented items that havebeen transferred to the Sub store but have been refused by the Sub store manager.

y The status Wait Process refers to a condition when the indented items have beentransferred to the Sub store by the main store but has not yet been processed at the Main

store.

Administration Functionalities

y Manage Store- This functionality enables the Inventory manager to create new Stores.y Manage Item- This functionality enables the Inventory Manager to index a new item.

By clicking on Manage Item the following screen appears with list of operations- Manage

Category, Manage Unit, Manage Subcategory, Manage Specification and Manage Item.

y Manage Drugs- The functionality enables the inventory manager to either add or viewdrugs. The functionality enables the inventory manager to either add or view drugs with

list of operations- Manage Category, Manage Unit, Manage Formulation and Manage

Specification.


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Pharmacy Module

It enables the Pharmacist to perform the tasks of raising indents to main store , receiving

transfers from Main store and Issuing drugs to patients. Patient comes to Pharmacy with

prescription and the medicine /drug (if available) is given in advised dosage and an online entry

is done. The stock gets automatically updated. The pharmacy is also here linked with Main Store

and through the system only the Indents are sent and processed.

The drugs in Pharmacy are classified as-

y Essentialy Vitaly Desirable

After login, the screen displays a list of operations that the Inventory manager can perform -

y View StockBalance- shows the current stock list of drugs available in the Pharmacy interms of opening balance, balance at hand and the unit price. A search Function based on

category of a drug and by the Name of drug is available to dill down to a particular drug

is there. It also shows, drug been received or issued, Opening balance, stock

transferred/issued and closing balance date of transaction

y View StockBalance Expiryy Indent for Drugs- To add a new indent pharmacist Clicks on the add indent Slip and the

following window appears


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After selecting different drugs, by selecting from their respective categories, and required

quantity, each is added to the indent slip and the final slip is saved and sent to the Main Store.

As per the reply from Main store, the status of indent can be either Process Indent ( replied

from main store need to be processed in pharmacy i.e to accept or refuse), Sent (sent by

pharmacy, not yet processed by main store), Receipt (accepted and received by pharmacy),

Main Store Refuse or Sub Store Refuse.

y Issues Drugs topatient patient from OPD comes with the prescription. The pharmacist,finds the drug by selecting the category and formulation, the drugs are displayed with the

Date of Manufacture, Date of Expiry, Company name, Batch No. and Quantity available.

The drug is added to the indent slip by add to indent slip option, then he finds patient

by entering his unique code/name. after selecting the patient, his name appears over the

indent slip, and its printout is handed over to the patient.

Search functionality is available to search a patient. By typing the name/Identifier of the patient

(alone) or along with the period (Start date/End date) will search a patient to whom Drugs have

been issued.


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Drug issue records can be viewed by double clicking on the Identifier and the issue slip will

appear.

Blood Bank

Hospital Blood Bank under online Blood Bank module will be based on availability of blood of

various blood groups in the blood bank stock. Each donor will be first registered and then his

blood sample will be tested. Only if all the tests administered on his sample are negative, his

blood will enter the blood stock else it will be outright rejected. The blood is categorized under

different blood groups and the donors secrecy is maintained. The blood issued to the recipient

will be mapped against the donor and after each disbursement the stock gets updated. The

module enables the technician to add stock of blood in the inventory after administering lab testsand issuing to respective patients after cross matching.

y Add a donor after clicking the add donor tab, the technician feeds in the donorinformation. A system generated Donor Id is generated for every donor.

After saving the information, click on the edit button. A questionnaire pops up which is to

be filled for very patient which is the Patient Registration Slip.


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y Administer Lab tests for DonorsBlood Sample after clicking on the Lab Tab and thefollowing window appears. As seen here the donors name and id appear whose

registration and questionnaire was filled in the previous screen shots. To add the test

results of the donor click on the add test data and the following window appears.

Only if all the blood tests are negative, only then this blood enters the stock else it is outright

rejected and doesnt enter the blood bank stock.

y View Stockand Issue blood aftercrossmatching - . The stock of blood is categorizedunder various blood group categories. To issue blood to a particular patient the blood

group of the patient and donor are matched and press the Issue icon. against a particular

the donor , the recipient patient details are added and the blood is issued to the respective

recipient


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The blood bank in DDU functions under the National AIDS control program hence a vertical

system of management and reporting is followed, in concern to which the functioning of Blood

Bank Module is withheld till the time concerned authorities grant permission.

Diagramshowingmodule interconnectivity


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3.5 TRAINING SESSION/ CAPACITY BUILDING FOR THE END USER

The most important part of implementing HIS is to train the end users in using the modules. The

end users in DDU basically comprises of Doctors, nurses, laboratory technicians, pharmacist,

paramedical staff and other clerical staff. It was essentially taken into consideration to plan

training in a proper and feasible manner to ensure satisfactory results. At HISP, the training

needs of different end users were assessed and planned accordingly.

3.5(a) TRAINING OBJECTIVE

Training is required in order to prepare the end users to be compatible and comfortable in using

the product developed in the most effective way so that it is accessible by the staff in the full

fledged way. Important issues can be discovered to help improve the overall acceptance of the

system and usability. It involves delivering learning in regard to product usage and management

depending upon the need of different kinds of users.

3.5(b) IDENTIFICATION AND ASSESSMENT OF TRAINING NEEDS

y Identify and document the skills required for each job description.y Address overall current skill specific training issuesy Perform a gap analysis to determine where training is neededy Identify people who have high potential and provide them specialized training

opportunities.

y Ensure that resources are allocated and timelines are decided

3.5(c) BASIC REQUIREMENTS

All DDU staff that needs to be trained for different modules should have-

y Basic computing skillsy Working knowledge of English languagey Approval from DDU administration for this trainingy To get the information of shift timings of all the users according to that training sessions

should be designed


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3.5(d) TRAINING PLAN

y Training practices for both the clinical and nonclinical staff were planned outy Training programme documentation was reviewed to provide training in a standard

format

y The organization reviewed and commented on the training format and necessary changeswere made.

Duration of training

Trainingschedule

At HISP, following was the schedule for hands on training in DDU hospital

y Phase I - Trainingon computerBasics Presentation teaching- The first step taken was to provide a classroom

teaching session to nurses. Lessons on Introduction to computers and Basics

of computers were taught via PowerPoint presentations.

Training for MS word- Introduction to Microsoft Word and commonly usedfunctions like cut, copy and paste was given. Individual training for each

nurse was designed in a way to provide thorough knowledge of MS word.

Training for MS Excel- Introduction to Microsoft Excel and commonly usedfunctions like additions, subtractions, drawing charts, making tables etc weretaught.

Training for MS Power Point- Introduction to Microsoft power point andcommonly used functions were taught.

DAYS DEPARTMENTS

15-20days

45days

20days

10-15days

45days

Registration and billing

OPD(for doctors)

Lab

Inventory and pharmacy

IPD(for nurses)


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y Phase II - Training about modules Nurses the training schedule was made flexible for nurses as per their work

timings. It was arranged in two different shifts morning and evening. The

total number of nurses in DDU is 54, and all of them were covered in the

training schedule. The modules which were taught in the session were

inventory, IPD, OPD and Registration module for 1 hour everyday (with a

break up of30mins for inventory module, for IPD 20mins and for registration

and OPD module 10mins). The schedule for training is shown in TABLE-1 in

ANNEXURE 1.

Doctors - the modules which are covered in doctors training programme wereOPD, Registration and IPD module. According to each module, duration of

training was decided and timelines were set (like 20mins for OPD and 10mins

for registration and IPD module). Our major concern was to enable doctor to

register patient and make OPD. By doing so, doctors can daily calculate the

total number of patients in OPD. The schedule for training is shown in

TABLE-2 in ANNEXURE 1.

Pharmacist DDU has 4 pharmacists. There prime function is to manage theoverall supply of drugs, maintain stocks, to make and process indents and to

maintain all the records. Thus the training schedule was planned such that to

cover the pharmacy module and inventory module. The duration for Pharmacy

module was set for 25mins and inventory module for 5mins. The schedule for

training is shown in TABLE-3 in ANNEXURE 1.

Inventory staff and inventory manager in view of functioning of sub-storeand main store, training schedule for the inventor staff (30mins) and inventory

manager (60mins) were planned. The schedule for training is shoiwn in

TABLE-4&5 in ANNEXURE 1.


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The HISP team then developed various Competency Tests for different users in order to analyze

the level of learning imparted and regained by the end users. These were designed differently for

different user as per their requirements. Furthermore, these tests were analyzed to track the

persons requiring re-training and also to identify those who have best understood the system and

so can motivate and help others. The competency tests are presented in ANNEXURE 2.

3.6DRY RUNDry run is a process where the software developer does a mental run of the program to examine

the source code one step at a time in order to determine what the code would do when it would

run. In software development, dry run is also known as Static Testing. Here the actual program

or application is not used. It is generally done to ensure the apt performance and stability of aprogram/ product before making it available. It is a process to intentionally mitigate the effects of

a possible failure.

3.6(a) TESTING THE APPLICATION FOR 10-15 DAYS

Once the modules were developed in accordance with the hospital requirement, each of it was

put on rigorous testing by the developers. The modules were run offline and checked for every

possible error. Each bug was reported with its specifications and details, the level of priority

mentioned along with the reporting persons name. There forth every bug/error reported was

tested to find out the missing link and the problem occurred was sorted unless the bug gets

removed from the concerned field. Same process was followed by the team till the time the

application becomes mature enough to be carried to the working site and is flawless, hence ready

to be used.

The practice was continued for a period of 15 days to ensure the smooth working of every

module. Every specific field was checked in the registration, OPD, IPD, billing, laboratory,

inventory and pharmacy module. The testing is a means of building a strong flawless product so

that no interference is seen when the product goes online.


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3.6(b) HANDS ON WITH END-USERS (NURSES AND DOCTORS)

Once the schematic testing is conducted the systems were installed in the hospital. Various

modules were run in concerned departments. The next step was to train the users, that is, the

doctors in OPD, nurses in IPD, staff at registration, the pharmacist and the inventory manager.

Hands-on training allows a person not only to hear what tasks need to be completed, but also

provides an opportunity to perform the task right then and there. In an ideal situation, a trainer is

available with the trainee and provides guidance rather than leaving the trainee on his own to

figure out what needs to be done. Hence, under the trainers supervision user performs the

assigned tasks. This is how the hands on training were given to the doctors and nurses in order to

acquaint them with the system and its functionalities. It helped in coming across with the

problems faced by users while operating the system which were solved then and there by the

trainer. Thus, the skills are most likely to be stuck with the users. This method was use to get the

users comfortable with the system and understand its functioning and also to realize the need and

value of such a transformation in the premises.

During hands on training, the feedback from users is taken- any more additions they need, any

field which they felt is not required, any more customization, or any bugs confronted by them are

noted. They are to be dealt with by presenting them to the developing team which them makes

necessary changes to update the existing system.

3.7 GOING LIVE PROCESS

Once all the modules are tested rigoursly and necessary updates done, the system now is mature

to GO LIVE. The show stoppers are fixed and permission is taken by the hospital authorities to

make system go online. Here, all the system functionalities become operational and the

workflow is now done online through the HIS.


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4.CONCLUSIONCHALLENGES

y Behavioural reluctance from end users is a big challenge to overcome due to habituationto conventional method of working. Reluctance in the sense that they felt that using

computer is just an additional work and not their primary responsibility.

y Training of entire staff was a problem due to vast manpower and different work timingsespecially of nurses.

y Enormous patient load in public hospital like DDU causes difficulty in acceptance of thesystem by users due to work overload keeping them busy.

y Acceptance and appreciation of computerization by medical, paramedical and otherhealthcare specialist as a compliment and not a supplement.

y Maintaining patience among users in initial phase when both old and new systems wereUnderestimation of the complexity of routine clinical and managerial processes.

y It was a challenge to bring all the staff with varied levels of computer literacy to the samelevel of competency.

y DDU has an old heritage building, the infrastructure thus posed a threat while creatingand installing an intranet in the premises.

y 24*7 assistance to the users could not be provided.y Known shortage of materials and operating infrastructure.y The Open Source software often lack well designed and well developed user manual.y Lack of clean Power supply and backup interfered in the smooth working.y Release and development of new and stable version of modules.

RECOMMENDATIONS

y Implementation of HIS in hospital is not merely computerization and automation of theexisting paper trail but a practice to improve the efficiency and effectivity of the hospital.

This fact should be well delivered and conceived by the users.


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y The HIS product should cover maximum functionalities and should have the flexibility ofcustomization as per the need of the hospital.

y Rigourous and continuous training, user friendly screens and hand held devices for datainput so as to make the users of HIS comfortable and motivated to work.

y Setting up of a local centralized IT department within the hospital to take care of HISworking.

LEARNINGS

y It is not unrealistic to believe in the feasibility of HIS in a public hospital providedmotivated infusion of understanding and hardwork is there.

y The economic argument no longer holds since there are Open Source tools adjustable at alow cost by local teams.

y It was realized how important is to make the hospital decision makers in aware of theefficient of role of HIS.

y A consistency in approach with a clear vision and pre defined guideline can ensureacceptance even among the most reluctant users.

y HIS is a source of high quality medical information giving DDU a new brand image.Our work is mostly focused on implementing HIS which is economically and locally acceptable

to the users of DDU, where we took the project. Our study showed that public hospitals in

Himachal show a brand new and wide open area of hospital information computerization.


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5.CASE STUDYCOMPUTER LITERACY AMONG THE DOCTORS OF REGIONAL

HOSPITAL, SOLAN

ABSTRACT

The field of medicine and medical practice requires the use of computers for support in

informationprocessing, decision making and records keeping. The success of information and

communicationstechnology applications in health is dependent on the level of computer use by

health professionals especially doctors. This questionnaire-based study assessed the level of

computer and internet usage bydoctors in Regional Hospital, Solan as well as their perception of

the medical recording system in theirplace of practice.

INTRODUCTION

The computer as a tool has transformed information and data handling in all fields of endeavour.

Computers have been used to manage patients at a distance (telemedicine), to manage hospitals

and their patients records and to search and retrieve information for research and assist in

clinical decision making. In general, clinical practice has been tremendously improved by the

technological interventions and a new and rapidly growing field of applications called health (or

medical) informatics has emerged. In most of the developing world, computer use and literacy,

though rising, is still very low. The success of any health informatics program will depend on the

skill level and the perception of those who will run it.

RATIONALE FOR THE STUDY

This case study highlights the level to which doctors apply computers to tasks at their places of

work highlighting the level of their knowledge and utilization. The study determines the

accessibility of the internet to doctors, the view of doctors regarding the computerization of the

medical records and the problems associated with the present paper-based medical recording

system. It would also highlight the level of their knowledge and utilization.


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Access to the internet/personal computer

Almost all respondents had access to the internet. 20 of the doctors have a PC at home. They

were generally young and middle-aged doctors. It was noted that the younger respondents

tended to have multipleaccess (like work, cybercaf) to the internet than the older respondents.

18 out of the 30 respondents accessed internet used internet


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data is more presentable and durable. Some of them also agreed that it would be cheaper on the

long run.

Age & gender

Only 2 out of the 12 female doctors could prepare their presentation slides while 7 out of 12 male

doctors could prepare their slides.

DISCUSSION & RECOMMENDATION

One central factor is, however, the ownership of a personal computer. The ownership of a

computer is associated with favorable perception of the computer-based record system. Also, the

people who could use Microsoft Word, PowerPoint and excel were more males than females-

suggesting a gender-based digital gap.

The older doctors specifically among the age group 45-60 are so used to the traditional paper-

work. 4 among this group think computer-based records are of no use, they believe in their

recording system. 2 among this group are not sure if at all the system will work or not.

Nevertheless, they are aware of the advantages of the computer-based record system. It is

mandatory to enable and assist doctors in their acquiring of computer literacy for personal as

well as use in the hospital. The training modules should be planned according to the literacy

level of the doctor, their willingness to learn and the patient load else computer will become an

0

5

10

15

20

25

30


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additional burden. Female doctors of this government hospital are low in computer literacy; they

should be encouraged and assisted in their skills. This test was conducted on a very preliminary

level. Thus, more research is needed to understand the factors that influence computer and

internet use among doctors in Solan.


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6.REFERENCESa. www.hisp.orgb. www.hispindia.orgc. www.opemrs.orgd. http://en.wikipedia.org/wiki/OpenMRSe. HIS- OpenMRS-DDU manual by HISPf. A study on Determination of the success of a hospital's information system

implementation by J.C. Sarivougioukas and A. Th. Vagelatos.

g. J. Van Bemmel, M. Musen, "Handbook of Medical Informatics", Springer, 1997.h. Cusack CM: Electronic health records and electronic prescribing: promise and

pitfalls. Obstet Gynecol Clin North Am. 2008 Mar; 35(1):63-79, ix. Review.

PMID: 18319129 [PubMed - indexed for MEDLINE.

i. Implementing an Electronic Health Record System (Health Informatics) byJames M. Walker, Eric J. Bieber, Frank Richards, and Sandra Buckley (Paperback

- June 28, 2006)

j. Electronic Health Records, Second Edition by Jerome Carter (Paperback - Mar.15, 2008)

k. EHR Implementation: A Step-by-Step Guide for the Medical Practice (AmericanMedical Association) by Carolyn P. Hartley, Edward D. Jones III, and Newt

Gingrich (Paperback - Feb. 28, 2005)

l. D. Protti, V. Peel, "Critical Success Factors for Evolving a Hospital Toward anElectronic Patient Record System", The Journal of the Healthcare Information and

Management Systems Society, vol 12- 4, 1998.


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7.ANNEXURESANNEXURE 1: TRAINING SCHEDULE

Table 1: TRAINING OF NURSES

Training session: 1 hour

MODULE TIME ASPECTS TO

BE COVERED

WHAT THE NURSES SHOULD KNOW BY THE

END OF THE SESSION

Inventory module

(Theoretical and

hands-on)

30 min

Viewing stock

balance

y Should be able to view stock balance for items anddrugs

How to raise and

process indents

y Should be able to raise indents for both items anddrugs

o Search for items/drugs from different sub-categories,

o Enter the required specification/formulations,o Add the required quantity ando Save and send the indent

y Should be able to process indents, once stock hasbeen received from the main-store (accept & refuse)

Issuing drugs to

patients

y Should be able to issue drugs to patientso Should be able to select the required drug

from the required category; select the

required formulation; enter the required

quantity

o Should be able to search a patient and thenadd to an issue slip and finish

How to show

consumption i.e.

issue to account

y Should be able to make an issue to an account for theitems that they have consumed during the week

o Should be able to select the required itemfrom the required category; select the

required specification; enter the required


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quantity

o Should be able to create an account and addto an issue slip and finish

Using the filters y Should be able to use the different filters in viewstock balance, indents, issue to account, issue to

patients

IPD module

(Theoretical and

hands-on)

20 min

How to admit a

patient

y Should be able to admit a patient to the requiredward

y Should be able to remove a patient from the listy Should be able to declare a condition of no-beds

How to

discharge and

transfer a patient

y Should be able to transfer a patient from one ward toanother

y Should be able to discharge a patientUsing the filters y Should be able to filter the patient list by ward,

attending doctor and date

y Should be able to search for a patient by name andidentifier

Registration/OPD

overview10 min

How to register

a patient

y Should know the overall flow from registration toOPD and IPD; How a patient is admitted in a ward

and how the doctor would be able to view the

clinical summary of a patient

Overview of

OPD and how to

admit

Viewing patient

dashboard


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dashboard y Should be able to view the clinical summary of apatient

y Should be able to view the different investigationresults of a patient

o Should be able to use the filter to see just therequired investigations

y Should be able to view the IPD record for a patient

Registration and

IPD module

overview

10 min

How to register

a patient

y Should know how to registration module works andhow to register a patient

Overview of

how the IPD

module

functions

y Should know the overall flow from registration to OPDand IPD

y Should know overall how the IPD module works (sothey can review the work of the nursing staff)

Table 3: TRAINING OF PHARMACIST

Training session: Half Hour

MODULE TIME ASPECTS TO BE

COVERED

WHAT THE PHARMACY STAFF SHOULD

KNOW BY THE END OF THE SESSION

Pharmacy

module

(Theoretical

and hands-

on)

25

min

Viewing stock balance y Should be able to view stock balance of the drugsy Should be able to view stock balance of expired

drugs

Raising and

processing of indents

y Should be able to raise indents for drugs o Search for drugs from different sub-

categories,

o Enter the required formulation,o Add the required quantity ando Save and send the indent

y Should be able to process indents, once stock hasbeen received from the main-store (accept &

refuse)


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Issuing drugs to

patients




quantity

o Should be able to search a patient and thenadd to an issue slip and finish

Issuing drugs to

account

y Should be able to make an issue to an account forthe items that they have consumed during the week

o Should be able to select the required drugfrom the required category; select the


quantity

o Should be able to create an account and addto an issue slip and finish

Using the filters y Should be able to use the different filters in viewstock balance, indents, issue to account, issue to

patients

Inventory

overview5 min

Brief overview of

working of the

inventory module

y A brief on how the inventory module works andhow the indents sent from pharmacy are processed

at the main store

Table 4: TRAINING OF INVENTORY STAFF

Training session: Half Hour


COVERED

WHAT THE INVENTORY STAFF SHOULD

KNOW BY THE END OF THE SESSION

Inventory

module

(Theoretical

25

min

Viewing stock balance y Should be able to view stock balance of the drugsand items

y Should be able to view stock balance of expired


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and hands-

on)

drugs

Receiving items in the

main-store

y Should know the significance of a receipty Should be able to make receipts for drugs and items

o Search for drugs/items from different sub-categories,

o Select the requiredformulation/specification,

o Add the required quantity, unit price, VAT,Company name, Date of manufacturing and

expiry

o Finishing the receiptMaking transfers to

sub-stores

y Should be able to process an indent and transfer therequired quantity of each item/ refuse an indent

Using the filters y Should be able to use the different filters in viewstock balance, receipts to general store and transfers

from general store

5 min

Overview of how the

sub-stores work

y An overview of how the sub-store indent to themain-store and how the stock calculation works

Table 5: TRAINING TO INVENTORY MANAGER

Training session: 1 hour


COVERED

WHAT THE INVENTORY MANAGER

SHOULD KNOW BY THE END OF THE

SESSION

Inventory

module

(Theoretical and

hands-on)

COMPLETE

30

min

Viewing stock

balance

y Should be able to view stock balance of the drugsand items

y Should be able to view stock balance of expireddrugs

Receiving items in y Should know the significance of a receipt


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FUNCTIONING

OF THE MAIN

STORE AND

SUB STORES

the main-store y Should be able to make receipts for drugs anditems

o Search for drugs/items from different sub-categories,

o Select the requiredformulation/specification,

o Add the required quantity, unit price,VAT, Company name, Date of

manufacturing and expiry

o Finishing the receiptMaking transfers to

sub-stores

y Should be able to process an indent and transferthe required quantity of each item/ refuse an

indent

How to raise and

process indents

y Should be able to raise indents for both items anddrugs

o Search for items/drugs from different sub-categories,

o Enter the requiredspecification/formulations,

o Add the required quantity ando Save and send the indent

y Should be able to process indents, once stock hasbeen received from the main-store (accept &

refuse)

Issuing drugs to

patients




quantity

o Should be able to search a patient and


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then add to an issue slip and finish

How to show

consumption i.e.

issue to account

y Should be able to make an issue to an account forthe items that they have consumed during the

weeko Should be able to select the required item


required specification; enter the required

quantity

o Should be able to create an account andadd to an issue slip and finish

Using the filters y Should be able to use the different filters in view stock balance, receipts to general store and

transfers from general store, indents, issue to

accounts, issue to patients

Inventory admin

functions

30

min

Manage store y Should be able to create a store, assign a parentand role to the store

Manage Item y Should be able to create/delete a category, sub-category, unit, specification

y Should be able to add an item and define all thenecessary parameters category, sub-category,

unit, specification, attribute

Manage drugs y Should be able to create/delete a category, unit,formulation

y Should be able to add an item and define all thenecessary parameters category, unit,

formulation, attribute


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ANNEXURE 2: COMPETENCY TESTS (post-training)

Table 1: SELF EVALUATION FOR DOCTORS

Name:

SI.

NO

EVALUATION PARAMETER CONFIDEN

T /

UNDERST

AND WELL

CAN DO/

UNDERSTA

ND WITH

DOUBTS

CANNOT

DO/ DO

NOT

UNDERS

TAND

1 Can you Turn on and off the computer?

2 Can you log-into the application?

OPD module

3 Do you understand the concept of the patient queue and

how i

REPORT Chahat

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