IT 'Clicks' Healthcare - Express Healthcare

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Focus

IT 'Clicks' Healthcare

Indian healthcare is witnessing a metamorphosis, with the onset of newer, better IT

applications as well as a broadening focus and increased investment in technology by
hospitals. Sonal Shukla and Priti Pathak explore

Technology is gradually but surely penetrating Indian healthcare

industry. Along with newer technological trends appearing on
the Indian scene, several positive developments in the last
couple of years have driven the adoption of IT in healthcare
delivery. Today the hospital industry is lapping up better
technology and is gradually moving on to leverage the benefits
of outsourcing their non-core functions. The US based research
firm Datamonitor estimates Indian healthcare IT market to be
the fastest growing in Asia, with around 22 per cent annual
growth, followed by China and Vietnam. In India, it estimates
that IT spent on healthcare will reach $315 million (Rs 1,260 crore) by 2011. Healthcare
sector is always criticised as a laggard when compared to other sectors in accepting IT.
However the scenario is changing as more and more hospitals are realising the
advantages of IT enabling their hospital.

Driving Factors

The current IT spending estimates are below $ 8,000 (Rs 3.2 lakh) per hospital in India,
as per Datamonitor. With a maturing private healthcare sector, large private hospital
chains have become the primary consumers of HIT (healthcare IT). Not content at that,
IT companies have also started pushing boundaries aggressively to bring large
government hospitals into their fold. "In the recent past, HIT spent used to be less than
one per cent of the operating budget, even for large corporate hospitals. However, this
has changed and the scene looks much lucrative for IT players now, with HIT spend
touching as much as six to seven per cent of operating budgets," shares Anthony
Basumatary, Managing Consultant, Datamonitor, India. This change has been driven in
part by the growth of private medical insurance and in part by the surge in medical
tourism in India.

Agrees Anurag Dubey, Programme Manager, Healthcare Practice - South Asia and Middle
East, Frost & Sullivan, “The fact that IT adoption is currently limited to large, private
hospitals in tier-I cities in India leaves a lot of untapped market to focus on for the IT
players. However, the penetration rate in India of such IT solutions is still very small
compared to the matured markets in the West. Says Kapil Khandelwal, Head, Health and

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life Sciences Vertical, Asia Pacific and Emerging Markets, Cisco Systems, Inc, "It is
higher in the private and corporate hospitals segment at around 80 per cent." However,
in the public sector (Government hospitals) segment it is around 25 per cent. We are
seeing an increasing interest from both public and private sector. Many Governments are
planning on e- health initiatives and have plans to implement health records."

Needs

Worldwide, IT applications in healthcare today are seen in two broad categories. One is
care delivery which contains aspects like patient access management and evidence
based medicine. The second category is of business infrastructure which includes supply
chain management, payroll and benefits administration, finance and accounts,
infrastructure and security, regulatory and standards compliance, patient education and
e-portals.

In a hospital there are basic four areas that benefit from computerisation. The first is
related to patient management activities like admissions, billing and discharge.
Computerisation of these allows faster processing of patient related activities leading to
better patient satisfaction. It also allows more effective utilisation of hospital staff,
leading to reduced manpower costs. The second area relates to inventory management
in a hospital. Enterprise wide automation greatly streamlines inventory control and leads
to tremendous cost saving and according to industry experts this is probably the most
tangible part of returns on investment. The third is related to implementation of EHR.
"For medical staff this is the most important part of computerisation since it allows a
continuity of medical records across various visits to the hospital by the patient and
allows them to provide better medical care," opines Dr BK Rao, Chairman and CEO, Sir
Ganga Ram Hospital, New Delhi. Lastly, like any other industry, hospitals also benefit
from computerisation of back office functionalities like accounts, human resources and
payroll.

Setbacks
Policy: There are no clearly articulated/ communicated
government policy on IT adoption in public hospitals. Government
funding for HIT is nearly non-existent.

Computer literacy: Limited computer literacy of staff.

Infrastructure:Infrastructure to support HIT adoption is

underdeveloped.

Co-ordination: Coordination between public and private sector is

yet to emerge.

Legacy systems: Patient health records are paper based in most

hospitals (except for large, private hospitals).

Standards: HIT systems developed locally do not follow

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standards for information representation and exchange. This is

complicated further by the multitude of languages used across
the country.

Privacy: Confidentiality of patient health information is still being

debated and the apex court is yet to come out with an opinion on
this.

(Source: Datamonitor)

Hospital Perspective

"The 'connectors' will Technology is now seen as a differentiator by hospitals

be the next big thing to set them apart in the competition. Today, all hospital
in healthcare as HIS, chains have leveraged IT to their advantage in
EMR, PACS will need
to interact in real- streamlining their operations and providing a better
time with each other" experience to their patients. Hospitals like Sri Sathya Sai
Institute of Higher Medical Sciences, Christian Medical
College Vellore, Amrita Institute of Medical Sciences,
- Dr Seema Gupta Fortis Healthcare, Kovai Medical Center, Coimbatore;
Domain Consultant Max Hospitals, Apollo Hospitals, Manipal Hospital,
Wipro HCIT
Sankara Nethralaya and Aravind Eye Hospital are said to
"The newer trends be the forerunners in adopting IT in India.
emerging in
healthcare
technology today are Says Dr Rao, "A good business model is always the key
about collaboration, driver to any industry. Fortunately a good business
visualisation and
convergence" model is available for healthcare IT solutions. One of the
key drivers will be corporate hospitals who set up a
chain of hospitals in different parts of the country. For
them to maintain uniformity in their different branches,
- Kapil Khandelwal
Head, Health and life Sciences Vertical as well as provide continuity of EHRs across their
Asia Pacific and Emerging Markets branches, an enterprise wide computerisation is a must.
Cisco Systems, Inc. Smaller solution providers will find enough mid-sized
"Our choice has been hospitals who will ensure that they remain financially
more towards buying viable."
all our solutions from
the same vendor
since we consider Apollo Hospitals plans to integrate their information
inter-operability systems across their network of 42 hospitals. It will also
critical to a successful
implementation" introduce HIPAA standards in its systems for EHR
implementations. (HIPAA is the Health Insurance
- Dr BK Rao Portability and Accountability Act, USA, 1996. This
Chairman and CEO addresses, among others, privacy concerns in healthcare
Sir Ganga Ram Hospital, New Delhi information). The IT team at Apollo has a core group of
30 people. The growing IT budget at Apollo constitutes
around 4.5 per cent of its operational expenses.

Pune based (RHC) Ruby Hall Clinic was relying more on paper and verbal inputs to

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manage business. The prevailing business situation led to leakage in revenue, lack of
information flow, and since there was no IT integrated system, time was wasted in doing
routine repetitive tasks. The management also needed to lower the costs of completing
administrative and clinical transactions. Many times, this directly affected patient care.
In 1999, RHC started revamping the IT infrastructure of the hospital and decided to go
with best-of-class solutions available in terms of hardware, enterprise application
software and networking. HIS, RIS, PACS, EMR, ERP and telemedicine solution'are some
of the IT solutions adopted by RHC over a period of eight years. PACS enabled it to
improve patient care by streamlining clinical processes and creating a seamless flow of
information. Its HIS system consists of a unique medical record number to identify a
patient, so while a patient is being admitted, an intimation is sent to the concerned
doctor on his mobile informing him about this. Telemedicine technology allows to extend
the distance at which patient consultation occur. EMR when integrated allowed greater
protection for medical information and improve data sharing without any threat to
patient privacy. Today, activities related to patient billing, consulting charges, payments
to be made to vendors are all recorded electronically. "The major challenge was the
resistance from human resource at operational level", says Anand Patil, Manager-IT,
Ruby Hall Clinic. This is a direct outcome for focused implementation of responsibility
matrix coupled with the authority decentralisation. The buy-in by senior management is
a very critical point in this activity. However at RHC the senior management was not
only behind the effort but also led with examples. Today the Hospital is working on the
final blueprint for implementing CDSS, clinical pathways and clinical research. "After the
implementation of RIS / PACS, the patient volumes have significantly increased. With
critical patient information like lab results, radiology images, medications available on-
line, there has been a significant reduction of file movements and has helped the doctors
to take decisions on time. It enables them to provide single window service for all
patient related activities. They are able to get morbidity / mortality information which
are just a matter of few clicks,"says Patil.

Another corporate bigwig, Fortis Healthcare is building a mobile-cum-wireless

communication framework on IP enabled PBX to connect the nurses, doctors and
patients. With this kind of networking system, nurses can use handheld devices to input
patient data within the hospital's network, removing the process of taking handwritten
notes and then inputting the data by hand. With this implementation, on the other hand
patients can also communicate easily with the doctors and nurses faster. The other
initiatives taken by the Hospital includes the 'web based interface' and 'database
shadowing' for performing data check-in/check-out operations. The 'web-based interface'
basically connects the people ie the hospital staff including the doctors and the
information/data through web. This system is accessible to the doctors and the other
hospital staff and enables easy data sharing faster. The web interface allows access to
internet, while the database shadowing reduces recovery time by staging the database
restore and roll-forward process, enabling recovery within hours and allows online
archival and thus doesn't need any separate solution. Database shadowing is a data
backup technique in which an identical copy of the hospital's database is maintained on
the computer systems. The primary database and its shadow are linked via cable,
telephone line or wireless that any change in the primary database is immediately
reflected on the shadow.

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However, usage of papers and manual work was such that it became challenging to get
the staff accustomed to working on the web-based database. "Perhaps one reason for
resistance amongst the front office staff was that after the new system, they would be
more accountable. Because, earlier the front office staff used to redirect the patient to
the billing clerk for any query, but now they themselves would be answerable to the
patient's queries," says JS Puri, VP-IT, Fortis Healthcare, Delhi. Earlier when the doctor
ordered to discharge the patient, it took time for the nurses to prepare the documents
for the patient discharge and thus the patient had to wait and then further it followed
with the billing procedures. A long time was consumed in this entire process since
everything was carried out manually. Whereas now when the doctor orders for
discharging the patient the entire process is carried out through the web-based hospital
system interfaced with the patient's medical records which makes it faster and saves
time. Time to admit a patient and indent a drug has reduced by 30 per cent and that too
at its initial stage and it will further reduce when data is cleaned further.

Trends and Technology

CDSS

According to experts, while IT has been doing a lot in patient billing, CDSS
(Clinical Decision Support System) is the most important tool that any
healthcare organisation should have. Agrees Pradeep Saha, Head-IT, Max
Healthcare, "The benefits of CDSS are immediate minimisation of medical
errors and availability of clinical analytics." According to a landmark study
published by Institute of Medicine in 1999, annually, medical errors in
healthcare industry results in loss of more than 100,000 lives in North
America alone. The WHO also cites that one in seven patients admitted to
hospitals in developing countries are affected by medical errors. CDSS are
interactive computer programmes which are designed to assist physicians
and other health professionals with decision making tasks. "CDSS link
health observations like patient data with health knowledge like estabilished
clinical protocols to help doctors take right decisions for improved
healthcare. However, it is yet to reach the Indian healthcare industry," says
Dr S Manivannan, Executive Director, Kavery Medical Centre And Hospital,
Trichy, Tamilnadu. CDSS are present to a variable extent in most
implementations. "One of the very useful CDSS in our system warns a care
provider if a drug to drug interaction exists while prescribing a drug for a
patient. Another warns if the patient is allergic to a drug being prescribed.
More advanced CDSS exist which help the doctor in reaching a diagnosis.
Even though they are not currently implemented in India, they will play a
great role in the future in reducing medical diagnostic errors which take a
toll on any hospital," opines Dr BK Rao, Chairman, Sir Ganga Ram Hospital,
Delhi.

CPOE

Computerised Physician Order Entry (CPOE), a process of electronic entry

of doctor's instructions for the treatment of patients under his or her care.
These orders are communicated over a computer network to the staff
(nurses, pharmacists) or to the departments (pharmacy, laboratory or
radiology) responsible for fulfilling the order. CPOE decreases delay in order
completion, reduces errors related to handwriting and simplifies inventory
and posting of charges. "It reduces the movement of the staff, which helps
in effective utilisation of clinical staff. At Kavery Medical Centre and

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Hospital, we have 120 systems networked. We have started using CPOE in

the past year and have found that it has improved efficiency of clinical care
delivery. It also limited manual records entry and helped to reduce
movement of staff from one department to another," explains Dr
Manivannan.

E-learning

3-D training is an alternative to actual training which is done in a virtual

environment, with no possibility of causing harm to a patient during the
training period. With the advent of laparoscopic and robotic surgery, this
offers a great potential of training future surgeons. Advanced virtual
training is also available today for simpler procedures like vascular access.

Indian Association of Medical Informatics, an association that provides IT

solutions has been utilising the concept of e-Learning to its fullest to train
and educate medical students as well as professionals. "We use a host of e
learning solutions as well as simulation techniques which are important for
medical graduates, post- graduate students as well as practitioners as
newer techniques are coming up in all fields and we cannot experiment on
the patient. Conferences and meetings are now possible online with
eLearning," states SB Gogia, President, IAMI.

e-Learning is also used for the capability development purposes in the

hospital set-up. "Training systems are vital to excellence. Fortis has a
hugely successful capability development initiative called Fortis Institute of
Enhanced Leadership Development (FIELD) that drives e-Learning in
multiple formats. "We are developing 3D animated and multimedia enabled
learning tracks for the same," says JS Puri, Vice President-IT, Fortis
Helathcare.

Digitising Health

Apart from PHR which is typically a health record that is initiated and
maintained by an individual, the other upcoming technological trend is said
to be Personal Health Application (PHA ), a next generation health
information which includes PHR and wellness data too. "PHA is a collection
of applications that are personalised for a person's use. PHA is said to be a
consumer-centric information system that can incorporate sick-care data
currently found in EHRs and PHRs.

They can give a view of a person's physiological and psychological risk

factors, current health, health trends and projected health status. They can
further reveal the interventions that are effective for an individual by
integrating and analysing a lifetime of data about health statues and quality
of life, Conventional and Complementary and Alternative medicine (CAM)
treatment received and the clinical outcomes of that care. "Whereas today's
PHRs present narrow views of a person's general health information, PHAs
would provide clear, comprehensive views of the environment- showing risk
factors, current health status, health trends, and projected future health
status. Revealing such trends and predicting one's health condition under
different scenarios can be powerful motivators for health living, as well as
offering important clinical insights for healthcare providers," opines Dr
Rahul Shetty, Founder-President, Mezocore Technologies, Canada.
According to experts only PACS and EMR are currently available in India,
although not widely adopted, and PHA tools are still in infancy world-wide

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and it will be while before it is available in India. Further, with presence of

tools like digital stethoscopes, monitors and ECG machines, problems can
be diagnosed by experts who are not physically present.

Preferring End-to-End

As newer healthcare delivery models rely on integration of services between multiple

service providers (outsourced, in-house fulltime and part time, contract etc), their
competitive edge, in terms of quality and cost, will be determined by a good IT end-to-
end solution provider. In a significant 'IT in Healthcare' study done in the west, the
single most important finding is that healthcare providers that invest and utilise IT only
in the billing or clerical areas inadequately utilise the investment in IT hardware and
software. However, hospitals that fully utilise HIS for both clinical and operational
functioning, with complementary networks and devices, reap the benefits of improved
care and costs. Today, more and more hospitals prefer end-to-end IT solutions.
However, both options have advantages as well as disadvantages. "India is a volumes
market and has to be played like one. Models that work in the west would in most cases
fail here," opines Ajay Chanam, AGM-WW Communications, Sobha Renaissance
Information Technology.

Purchasing different solutions from the same vendor allows better integration between
the various components, something that is critical in today's complex environments. On
the other hand, purchasing different solutions from different vendors allows one to have
the 'best of breed.' Gangaram Hospital chose to stick to one vendor to accentuate inter-
operability. "Our choice has been more towards buying all our solutions from the same
vendor since we consider inter-operability critical to a successful implementation," avers
Dr Rao.

Benefits Galore

To improve quality of care, reduce costs and plus increase access to healthcare is driving
IT adoption in the healthcare industry. Healthcare technology, if implemented properly,
prevents medication errors. A physician ordering a medication electronically will know
immediately if the medication he/ she is prescribing counter reacts with a prescription
that the patient is already on or if the wrong dosage was mistakenly prescribed.
According to experts, the greatest benefit of IT lies in chronic disease management,
where costs are typically high. Delta checks built-in at key decision clinical transactions
reduce errors in diagnosis, medication and critical test reporting. Secondly, the
instantaneous availability of clinical data like imaging, lab reports, and second opinion
shortens the time taken for diagnosis and initiation of treatment. There has been some
research that has shown that healthcare IT does improve clinical outcomes. However,
there has also been some research that has found IT decreasing clinical outcomes. "Part
of this decrease may be due to end-users needing time to learn the new system.
Additionally, much of the clinical benefits are not realised immediately. Rather, they will
be realised in five to ten years (or even later for preventive health measures). Given
that, decreased re-hospitalisation rates and decreased medication errors are often cited
as an indicator of IT improving clinical outcomes," states Christine Chang, Associate

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Analyst, Datamonitor. Care pathways and treatment plans are already being
incorporated in the healthcare IT at hospitals in the western world and have yielded rich
returns. Says Dr Gupta, "Sentara in the US, with 90 ICU beds distributed over four
hospitals, leveraged IT to reduce their ICU ALOS (Average Length Of Stay) by 17 per
cent and patient mortality by 20 per cent as far back as in 2000." Improved clinical
outcomes also bought the cost for each ICU patient down by $ 2,150 per patient giving
them a Return on Investment (ROI) of 155 per cent. The benefit of this is enormous with
an immediate benefit of minimisation of medical errors and availability of clinical
analytics.

Although the official healthcare expenditure for healthcare in India is around five per
cent of GDP, in rural families it can go up to 15 per cent because of such hidden costs
like travel and time of work. "Everyone knows that there are peripheral costs involved in
healthcare like travel and stay. They sometimes can amount up to 40-60 per cent of a
person's entire healthcare costs. Technologies like tele-medicine can totally negate this
cost for all non-invasive treatments (which amount for the majority)," shares Ajay
Chanam, AGM WW Communications, Sobha Renaissance Information Technology (SRIT)
and GM - Head Private Sector and SME, iHCX. Telemedicine can dramatically decrease
the travel costs which although a hidden cost of healthcare (and not measured) is a very
significant help.

Connected Healthcare

The concept of connected healthcare is said to have captured the imagination of

healthcare industry today and includes network infrastructure, information access and
remote service delivery for seamless provision of healthcare. Dr Seema Gupta, Domain
Consultant, Wipro HCIT feels that the 'connectors' will be the next big thing in healthcare
as HIS, EMR, PACS will need to interact in real-time with each other and with patient
monitoring gadgets at the hospitals, consulting rooms, homes and workplace. The
connectors would be V SAT, internet, mobile and anything which connects the available
information to all the service providers ranging from insurance companies, doctors,
home care providers as well as vendors. Dr Gupta cites Israel's example where the
hospitals have used normal landline connections to transmit health related data. "For
example, when you monitor heart patterns, they are monitored in real time and
transmitted over the normal phone wire. To a substantial limit even the hospitals in
Australia have utilised the concept of connectors," states Dr Gupta. Khandelwal believes
that the newer trends emerging in healthcare technology today are about collaboration,
visualisation and convergence. "Healthcare technologies need to unite patients,
caregivers, administration and families across the care continuum through the innovative
use of data, voice and video so people can communicate wherever they are, using any
device whether wired or wireless," states Khandelwal.

Even though the mobile phone is omnipresent today, it is still not used for health as
patient and doctor still desire a human interaction. However, mobile use in reminders
and emergency and clinical alerts is growing. "At Fortis, our doctors use clinical software
on mobiles. I envisage a 'mobile health' SIM card that will also store health information
securely. With 3G and enterprise level bandwidths on mobile, I expect video consults on

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mobile with doctors," says Puri.

Mobile computing is going to play a major role feels Murthy Rayaprolu, Head- Delivery,
VBU-Healthcare Provider, Satyam Computer Services Limited. "We do not have a
bedside computer today. That is also because desktop at every bedside is not
economically viable. It can interfere with some of the medical systems which could be
there in emergency rooms. However, there are devices coming up in the market which
looks like a tablet and can be carried anywhere in the hospital and has limited
interference with the electronic equipment. The doctors carrying this device can locate
the patients wherever he is in the hospital. These kind of devices are coming into the
market but it is not fully implemented anywhere," shares Rayaprolu.

Furthermore, traditional data, voice and video technologies in a hospital are quickly
getting redundant and expensive to sustain. Newer technologies based on IP- platforms
are leading towards a digital transformation and are cheaper to maintain. Healthcare is
witnessing a convergence of data, voice and video over wire/ wireless IP-based networks
in a hospital and according to experts these technologies are scalable (build as you
grow) and easier to operate and maintain in a hospital. Experts predict that wireless
technology is going to be a turning point - through which doctors, nurses and patients
can communicate seamlessly on Wireless Local Area Network (WLAN) and eventually
WiMax. "At Fortis, we are building a mobile-cum-wireless communication framework on
IP enabled PBX that will really connect these users. If patients can find and talk to the
care provider fast, half the battle is won," opines Puri. Trichy based Kaveri Medical
Centre and Hospital has implemented a SMS software which is used in applications like,
informing consultants about patient admission, informing referral physician about their
patient details, informing patients about latest news in hospitals, informing patients
when their lab reports are ready, intimating patient about health check-up dates as well
as informing HOD about new job orders and pending orders. "Overall it is a good CRM
module. When railways and airlines can use SMS CRM why not healthcare? We have
scanned all the old medical records, which clinicians can access from their desktop. This
is used to review old case sheets when the patient come for review and used for clinical
research," states Dr S Manivannan, Executive Director, Kavery Medical Centre and
Hospital, Trichy. Also, the reality in healthcare technology is that there are no
standardised applications across healthcare industry. In order to improve patient care
through rapid access to information means that applications need to follow industry
guidelines and workflows. "Technologies that can increase access to information,
anytime, anywhere and reduce the Total Cost of Ownership (TCO), lead us in the
direction towards visualisation of different layers of technology architecture," adds
Khandelwal.

Sir Ganga Ram Hospital, New Delhi

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Delhi based Sir Ganga Ram Hospital has invested funds for the
implementation of a PACS system which will allow images from radiology,
CT, MRI to be available on all computers within the organisation. The
Hospital is planning a RFID tagging system for its fixed asset management
system. Later this year the Hospital would also introduce PACS for
enterprise-wide imaging. This 'enterprise-wide PACS' enables imaging
specialists to do their primary interpretation work within their own
departments and to store the images and reports in a central,
multidisciplinary archive where the information can be accessed by partner
institutions, as well as by primary care physicians, using a custom-designed
web browser and desktop computers running windows. Every system is
integrated with HIS leading to easy availability of data that helps the
hospital management make better and informed decisions.

Challenges

One of the major challenges faced were the change in workflows in various
departments of the Hospital because of enterprise-wide computerisation.
People took time to adapt to these. Previously, computerisation did not
involve medical and paramedical staff functions but now it did. Many of
them found it difficult to adapt to the new environment. "Our laboratories
had gone paperless and this was a double edged sword. Doctors were used
to seeing reports on the move, going through paper records while
examining a patient. Now, it necessitated them to view the reports on a
computer," explains Dr B K Rao, Chairman. Medical care workers are
mobile while computers are not and this clashes. Therefore, the Hospital is
planning to implement laptops to overcome this problem. Another problem
is related to training of the users to operate in a fully computerised
environment. Healthcare workers often find it difficult to spare time from
their daily activities to undergo training. Today, training has become a
continuous process in the Hospital with new staff joining regularly.

Key Concerns

Healthcare sector is always said to be less open as compared to other sectors when it
comes to adopting newer IT trends. Indian hospitals have indeed been late in realising
the advantages of IT. Lack of awareness, resistance to change, the low priority given to
financing IT-related investments, lack of suitable solutions, as well as the absence of
professional decision making has led to low penetration of HIS in this high-potential
market. Hence, there are not many hospitals in India which have successfully automated
all their core functions like administrative areas, clinical areas and back office. "Most
hospitals that have already embraced technology, have automated their operations in
parts and therefore most of them are not deriving the full benefits of information
technology," states Khandelwal. Hence, there are not too many examples (reference
sites) that other hospitals in India can follow. Moreover, the full benefits of IT will be
apparent only when the core clinical operations are automated, which is still a few years
away in India. Some of the other problems that are unique to India are lack of enough
trained professional medical/ healthcare informatics personnel in the industry. "All the
innovations available in the west are available in India, and very often at competitive
costs. However, currently, the limiting factor is lack of the domain knowledge and
overview to utilise these innovations to deliver the most effective and efficient solution,"
opines Dr Gupta. Also, the lack of integrated information across the enterprise (lack of

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data sharing across departments and applications and lack of collaboration across
various stakeholders in healthcare are few main intimidating issues present in the Indian
healthcare today. "The other big challenge has been to design an EMR system that can
have unlimited sub-modules as per the specialties and super specialties ranging from
general medicine to paediatrics, to cardiology, to neurology and urology," believes
Dinesh Samudra, CEO- SEED Healthcare Solutions Private Limited.

Vendor Watch
Just as hospitals vary in their size, so will their
demand for the size and scalability of the IT solutions.
The requirements of large hospital are met mostly by
international vendors or reputed Indian vendors,
whereas small hospitals are likely to adopt smaller
solutions, which are readily available in the Indian
market. The Indian market for such products has not
yet matured. Applications available in the market
range from HIS, including EHR and back office
functionalities to PACS. Adjunct solutions are available
for attendance systems and RF tagging. Some IT healthcare companies had
ventured into the Indian market as tie-ups with local solution providers.
This enabled them have to have a readymade support base with minimal
investment. For example, TrakHealth from Australia (now InterSystems,
USA) has tied up with MTech of Delhi to implement and support its
solutions. However, more and more international vendors are entering the
Indian market directly with their own brands, for example, Siemens, GE,
and iSoft. Industry giants like Cerner, Vista are also close to entering the
Indian market. According to experts, for the IT vendors, large part of the
opportunity lies in the replacement of outdated first-generation HIS with
newer, more powerful HIS applications at large hospitals with complex and
sophisticated operations. "There are an estimated 25,000 hospitals in India,
excluding the private clinics and nursing homes. This factor should be
enough to drive the HIS market in India," opines Dinesh Samudra, CEO -
SEED Healthcare Solutions Private Limited. Currently, the HIS market in
India is still in the early growth stage. It is a small market dominated by in-
house implementations and customised solutions developed by small local
software developers. In terms of technology adoption, the Indian market is
far behind its Asia Pacific counterparts such as Australia, Japan, South
Korea, Singapore and Malaysia.

Also, the newer technologies require very high initial investment and the ROI takes
many years. All these factors make adoption of newer technologies difficult for any
hospital. Hence a cautious and patient approach is said to be required before any viable
results could be obtained.

Apart from this, cost incurred on maintenance of systems can be a major factor for
hospitals when deciding to invest in technology. And this is especially true with systems
that are built on obsolete technology. As technologies change rapidly over few years,
hospitals need to adapt to the changing environment. Proprietary technologies will make
certain IT solutions adoption in healthcare industry expensive. "As healthcare is already
expensive, implementation of an expensive IT infrastructure in any hospital will be a
major deterrent," agrees Dr Rahul Shetty, Founder-President, Mezocore Technologies,
Canada. However, according to Dr Gupta, hospitals are traditionally very familiar with

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maintenance costs as they buy expensive machinery and often run a large maintenance
department, therefore IT maintenance costs are both -understandable and acceptable-
to them.

"Unfortunately, initial implementation is more than just installing the hardware and
software. The costs of change management (ie. implementing the change from manual
to digital) are never included or negotiated in any contract which allows vendors the
convenience of calling that maintenance. So, most projects fail (the failure rate is
officially 60-70 per cent though unofficially it goes up to 95 per cent at least as partial
failures) and that is a deterrent," avers SB Gogia, Indian Association of Medical
Informatics (IAMI).

Another reason is lack of common standards in healthcare which makes it even more
difficult for hospitals to adopt newer technology. "HIPPA is widely used in North America,
yet in India there are no common standards. Many hospitals adopt a very conservative
and cautious approach to adoption of IT in healthcare," opines Dr Shetty. Further, fear of
loss of privacy and confidentiality of health data hamper the IT penetration.

Max Healthcare
Max Healthcare's hospitals are spread across eight locations within the
boundaries of Delhi. So the main purpose for opting IT solution was to get
all these hospitals at various locations connected to each other with a
centralised system making it convenient for both the hospital and the
patients. They felt a need of having such a system which could make the
health analytic to understand the disease trend and decide the medicine,
required treatment to be provided to the patient, thus reducing the
occurrences of medication error.

IT implementations

The 'lease line connectivity' is a service through which all the hospitals can
remain connected to the data server. This service is implemented since
2006. Leased lines are dedicated data circuits between two locations via a
private line used to transmit data at a constant speed. This is integrated
with the HIS, so whatever information relevant to the hospital or the
patient that is entered in the HIS gets recorded in the server through lease
line. 'Bharti' is the lease line connectivity service provider for Max. The
speed of the connectivity was upgraded from 512 kbps to 4 mbps since the
last two years. 'PACS' is incorporated from the past six months and the cost
investment for this was round about Rs 60 lakh. Laboratory Information
System (LIS) is another solution adopted by Max to keep a track of all the
laboratory records. The LIS software integrated with HIS stores the entire
lab information. Two months ago the HIS got updated with a 'blood bank
module' and 'diet module.' The updated HIS with the blood bank and diet
module acts like a guide and helps in patient care. Earlier the blood bank
and diet module used to run manually but now there is a 'system
parameter control team' to make an entry on the blood bank module which
is known as a master entry. Likewise the diet module enables to make the
diet record for each patient.

Future

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In this quality driven healthcare industry, it is no news that the healthcare IT market will
continue to grow, particularly in countries like India. Hospitals moving towards quality
certification and accreditation leading to standard operating procedures are driving the
demand for standard based applications. "We are moving towards an integrated
healthcare scenario - where various healthcare entities will get connected on a common
platform to allow information exchange between standard based applications and thus
improving efficiency of systems," feels Dubey.

"Implementing IT at the inception stage is much easier rather than trying to install it in
the older ones. Thus, as new healthcare organisations are built in India, they should be
built with the use of healthcare IT the mind right from the beginning," says Chang.
Today more and more hospitals are realising the advantages to implementing IT
solutions. India has a large number of hospitals and in terms of sheer numbers of
implementations possible, the potential is huge. The Indian vendors are also improving
on the quality of solutions they provide and it is hoped that they will soon be able to
meet the challenge provided by the international players since India has highly skilled IT
manpower resources. In the private sector, hospitals are looking at IT mainly from a
commercial application perspective. Experts feel that these hospitals should now go
beyond the ADT and billing processes to apply IT in clinical applications like CDSS, EMR
and clinical research. There is surely a lot to be done in terms of applying IT from the
patient care perspective.

As Dr Gupta concludes, "The complexity and variability of healthcare delivery- both in

terms of business models and clinical demands a deep insider 'worm-view' and an
informed IT 'bird-view' from its IT solution. Only an intelligent solution that provides this
integration can succeed in healthcare. The good news is we are getting there, may be
slower than the other sectors but still getting there."

sonal.shukla@expressindia.com
priti.pathak@expressindia.com

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