Summer Training in Edgeware Technologies (I) Pvt. Ltd.

(April 4 May 30, 2011)

Cashiering Module Implementation (HIS) at JPNATC, AIIMS

Anindam Basu PG/10/005

Post - Graduate Diploma in Hospital & Health Management, New Delhi 2010 - 12

International Institute of Health Management Research, New Delhi 2011

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ACKNOWLEDGEMENT
Apart from the personal effort and steadfastness to work, constant inspiration and encouragement given by a number of individuals served as the driving force that enabled me to submit my summer training report in the present form.

A formal statement of acknowledgement is hardly sufficient to express my gratitude towards the personalities who have helped me undertake this project. I hereby convey my thankfulness and obligation to all those who have rendered their valuable help, support and guidance to meet this end. A special thanks to the Almighty and my parents for the completion of my project.

First of all a special gratitude to IIHMR, New Delhi, for giving us the opportunity to work on the project during the two months summer training as a part of course curriculum of PGDHHM. Its an immense pleasure to thank Dr. Maitreyi Kollegal, the Director, IIHMR, New Delhi and Dr. Rajesh Bhalla, Dean Academic and Student Affairs for appreciating and allowing me to undertake this two months training in Edgeware Technologies (I) Pvt. Ltd (ETIPL), New Delhi.

A sincere token of gratitude to Prof. Indrajit Bhattacharya and Dr. Anandhi Ramachandran for constant support in my project and case studies. Their continuous guidance and support at crucial juncture helped me complete the assigned project on time.

No work can be perfect, without the ample guidance. It was an immense pleasure for me to work in ETIPL, New Delhi under the guidance of Mr. Joseph

Puthooran, MD, Edgeware Technologies and Mr. Satish, Project Manager, Edgeware Technologies. I specially thanks to ETIPL for providing me all the necessary training and encouragement to work on this challenging project. I owe my gratitude to Dr. Deepak Agarwal, Assistant Professor, Neurosurgery and Head of Computer Facility, JPNATC to allow me to do my project and case studies in the Hospital. Without his ample guidance and regular support it would be rather difficult for me to complete the project.

Last but not the least, my deepest thanks to my mentors Mr. Manoj Varghasee and Mr. Sharfraz Haque for their regular encouragement, inspiration and intelligence criticism. Without this it would be rather difficult for me to work in the hospital environment. I express my sincere appreciation to Mr. Pawan, Mrs Metilda, Mr. Sachit, Mr. Mohan, Computer facility staff members including CATS and all other Nursing Informatics Staff for being with me and cooperating with me in the scheduled timings. It is very difficult to mention the names of all those persons who have been involved directly and indirectly, with this work and I extend my gratitude to all of them.

Anindam Basu PG/10/005 Batch C. 2011

Declaration from the candidate

Anindam Basu (PG/10/005) PGDHHM, Batch C

International Institute of Health Management Research Plot No.3, HAF Pocket, Sector 18A, Phase II, Dwarka New Delhi 110075

This is to certify that this summer training report on Cashiering Module Implementation (HIS) at JPNATC, AIIMS completed and submitted to IIHMR, New Delhi by Anindam Basu, is an authentic work carried out at JPNATC, AIIMS under Edgeware Technologies (I) Pvt. Ltd., New Delhi.

The material embodied in this project report has not been submitted to any other university or institute for the award of any degree.

Anindam Basu

TABLE OF CONTENTS
Chapter No. 1. Executive Summary 2. 3. 3.1 3.2 4. 4.1 4.2 4.3 5. 6. 7. 7.1 8. 8.1 8.2 9. 9.1 9.2 10. 11 11.1 Acronyms/ Abbreviations Organizational Profile Edgeware Technologies (I) Pvt. Ltd. Jai Prakash Narayan Apex Trauma Center, AIIMS Introduction Hospital Information System VistA EHR Objectives of the project Review of the Literature Information Technology & Workflow: JPNATC, AIIMS Methodology Client Requirement for Cashiering Module Observations Workflow analysis before and after implementation Benefits of the cashiering module Conclusion SWOT Analysis: Cashiering Module SWOT Analysis: JPNATC, IT Transformation Recommendations Case Studies Queue Management of OPD in JPNATC: IT initiative
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Topic

Page No. 8 10 11 11 13 15 15 17 19 20 23 25 26 27 27 30 31 31 33 35 36 37

11.2 12. 13. 13.1 13.2 13.3 13.4 13.5

Staff Perception over the HIS/CPRS present in JPNATC References Annexures Price list to be put in the HIS Charge Slip Option Questions asked to the departments Training Schedule Training Manual for cashiering Cash Counter Training Manual for cashiering Radiology & Inpatient Department Back End of the Cashiering Module Receipt before and after implementation of Cashiering Module JPNATC OPD Schedule Questionnaire for the Case Study 11.2

43 49 51 52 54 55 56 63

13.6 13.7

69 73

13.8 13.9

74 76

LIST OF TABLES AND FIGURES S.No. 1. 2. Title of the table Number of wards and their specialty Interviews and Group Discussion done with the department Experience of Respondents Time Schedule of the training OPD Schedule Number of patients from 2nd May to 7th May 2011 Page No. 14 25

3. 4. 5. 6.

45 55 74 75

S.No. 1. 2. 3. 4. 5.

Title of the Figure Billing system implemented in Mali Workflow before implementation of cashiering module Workflow after implementation of cashiering module Response for working improved after HIS/CPRS Information Flow in the back end of the cashiering module Charge Slip Record (Database) Variable View Charge Slip (Master database) Variable View Refund Record (Database) Variable View Refund (Master Database) Variable View Receipt (Master Database) Variable View Before Implementation: Manual Receipt After Implementation: Printed Receipt

Page No. 20 27 28 47 69

6. 7. 8. 9. 10. 11. 12.

70 70 71 71 72 73 73

1. Executive Summary
Introduction The global healthcare IT market is estimated to grow to $ 53.8 billion by 2014, growing at a CAGR (Compound Annual Growth Rate) of 16.1 percent. It is expected that the market for general applications in Health IT will grow at overall CAGR of 13 percent from 2009 to 2014. From Hospital Information system to the Electronic Health Record of the patient, the Health IT has grown to the expectation of the Hospitals. It can be seen by the total money invested by the west in Health IT domain. They spend approximately 3 percent of their total expenditure in Health IT. Health IT in India is mainly been forced by the private players. The total spending by the Indian Players on Health IT is approx 1 percent and majority by the private players. JPNATC being a government hospital in the capital city of the country is proud to be the first hospital in India to implement the VistA EHR and continues to be a global player in the field of IT in hospitals with Edgeware Technologies (I) Pvt. Ltd. Objectives: The primary objective behind the project is to successfully implement the Cashiering module in the HIS of the hospital. The secondary objective behind the project is to train the staff and change the workflow of the hospital for the success of the module in the HIS. Methodology: The following methodologies were followed for the successful implementation of the cashiering module: 1) Workflow analysis of the hospital before implementation.

2) Pilot and Testing phase before the live of the module. 3) Client (Hospital) Requirement for the module.

4) Training to the staff using the cashiering module.

Conclusion: The implementation of the cashiering module leads to the following benefits: 1) Reduction in human error.

2) Manual work converted into electronic work. 3) Central database (My SQL) for the patients payments. 4) Records now can be accessed easily.

2. ABBREVIATIONS USED

AIIMS: All India Institute of Medical Sciences, Delhi BCMA: Bar Code Medication Administration CATS: Computerization Assistance Team & Support CPRS: Computerized Patient Record System CRC: Casualty Registration Counter EHR: Electronic Health Records ETIPL: Edgeware Technologies India Private Limited GUI: Graphical User Interface HIS: Hospital Information System ICU: Intensive Care Unit JPNATC: Jai Prakash Narayan Apex Trauma Center, AIIMS, Delhi MLC: Medico Legal Case OPD / IPD: Out - Patient Department / In - Patient Department SMS: Short Message Service TC No. / HRN: Trauma Center Number/ Hospital Record Number RDP: Remote Desktop Procedure VHA: Veterans Health Administration VistA: Veterans Health Information Systems and Technology Architecture

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3. ORGANISATION PROFILE
3.1

Edgeware Technologies

- Cutting Edge in Healthcare Information Technology Solutions

Registered Office: Edgeware Technologies (India) Pvt. Ltd., E- 537 Greater Kailash II, New Delhi 110048 Edgeware Technologies specializes in Healthcare Information Technology, and

provides consultancy to hospitals for solutions to improve clinical quality, patient care and operational efficiency. Edgeware Technologies promotes the use of Open Source solutions and in particular the VistA System. They provide services to evaluate Information Technology needs in a Hospital or healthcare system, recommend an approach to the appropriate use of Information Technology to achieve institutional goals and support its implementation.

HISTORY:
Two Non Resident Indian businessmen located from UK, established Panther Exports Private Limited in 1994. A Board of Directors in India was appointed, with the Managing Director having executive management responsibility. The present management had taken over the company under the leadership of Mr. Joseph K. Puthooran in the year 2003-04. Mr. Puthooran brings with him a rich pool of experience in both domestic and international market. Panther was later in the year 2005 renamed as Edgeware Technologies India Private Limited (ETIPL). ETIPL focuses on providing custom software programming and application development to the Indian Software market as well as International Market, providing clients with the latest technology and excellent quality.

They are able to execute the full software development lifecycle, starting from the requirements specification up to system implementation and maintenance.

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ETIPL specializes in the development of custom software solutions for Desktop, LAN and Internet environment. They design, build and implement applications, which are userfriendly, cost-effective and tailored to clients specific requirements. ETIPLs team has many years of rich experience and values its clients and strives to build mutually beneficial, longterm relationships. They aim to support their clients in all custom software-related needs, by innovations and acquiring new skills constantly.

Business Goal/Mission
As a professional organization in the Healthcare Information Technology domain, pioneering and leadership in the industry is a major goal. We strive to enable our customers to achieve a sustainable, high value, competitive advantage through the effective use of information technology solutions in Healthcare. We have a strong social element in dealing with clients and have provided solutions to voluntary non-profit organizations and supported them at cost.

We believe in the power and value of open source development methodologies and our business model is to give excellent value to all our clients and remain sustainable as an organization leveraging the unique strengths of being based in India. Providing a reasonable return to shareholders and also using profits to build our capabilities to higher levels of excellence.

Present Clients:
1. Jai Prakash Narayan Apex Trauma Center, New Delhi (India) 2. Rajiv Gandhi Cancer Institute and Research Center, New Delhi (India) 3. Clinica Adelante, (Arizona) 4. CHOSN Network, (Arizona) 5. A group of community clinics in Kentucky

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3.2 JAI PRAKASH NARAYAN APEX TRAUMA CENTER, AIIMS

Spread over an area of 20,600 sq metres and seven storeys that consist of five operation theatres, 152 inpatient and 30 casualty beds, including 26 ICU beds to provide both prehospital and emergency care, Jai Prakash Narayan Apex Trauma Centre (JPNATC) has a chequered and long history of planning and control. First conceived in 1984 by the Delhi Government, land was acquired at Raj Nagar on the Ring Road about two kilometers from AIIMS. For 20 odd years nothing really happened on the ground. However, as the vision was to provide the best possible trauma services, Delhi government decided to hand over the project to All India Institute of Medical Sciences (AIIMS) to run. Finally India's first fullfledged trauma centre to treat victims of road accidents became a reality in the year 2006. While the dry run began on 27 November 2006, the centre became fully functional on 26 November, 2007 when the casualty (emergency department) was thrown open to general public. The total cost of constructing the centre was Rs 132 crores. The centre also acts as a referral hospital, where patients sent by zonal public hospitals and satellite trauma centers will be observed and treated. There are total nine departments fully functional in JPNATC. These are as follows: 1. Anesthesia 2. Emergency Medicine 3. Forensic Medicine 4. Laboratory Medicine 5. Orthopedics 6. Neurosurgery 7. Trauma Surgery 8. Radiology 9. Computer Facility

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There are 2 ICUs & 4 General Wards fully functional in JPNATC S.NO. Name the ward 1. 2. 3. TC2 TC3 TC4 Common ICU Neurosurgery ICU Multispecialty (Ward) of Specialty No. Beds 12 20 30 12 Surgery, 12 Orthopedics, 6 Neurosurgery 4. 5. 6. TC5 TC6 TC7 Neurosurgery (Ward) Surgery ( Ward) Orthopedics (Ward) 30 30 30 15 Ortho A, 15 Ortho B 10 Normal and 2 Isolated A&B of Division of Beds

Table #1: No. of Wards and their specialty. There are total 5 Operation Theatres in the Hospital 1. OT1: Surgery 2. OT2: Orthopedics 3. OT3 & OT4: Emergency 4. OT5: Neurosurgery JPNATC also provide Follow-Up Out Patient Department (OPD) facility. This facility is only for the discharged patients of JPNATC. Implementation carried out by the Computer Facility Department at JPNATC EHR ( VistA EHR) PACS (Picture Archival and Communication System) Intranet (RDP) Access & Biometric Control Computerized Queue System in OPD Computerized MLC (Fully Computerized Emergency Department) Lift Stretcher Access Control System Internet Protocol CCTV (Closed Circuit Television) and Telemedicine.

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4. INTRODUCTION 4.1 Hospital Information System (HIS)

A Hospital Information System (HIS) can be defined as a computerized system that is designed to meet all the information needs within a hospital. This includes diverse data types such as patient information, billing, finance and accounting, staffing and scheduling, pharmacy ordering, prescription handling, supplies, inventory, maintenance and orders management, diagnostic reports related to laboratory, radiology and patient monitoring as well as providing decision support. It is a comprehensive, integrated information system designed to manage administrative aspects of a hospital. According to Hassett (2002): A hospital information system (HIS) encompasses a wide array of applications and information systems that are linked or interfaced. A HIS supports the provision of care to patients and the business aspects of the healthcare organization by communicating information. Benefits of HIS: Easy Access to Patient Data to generate varied records, including classification based on demographic, gender, age, and so on. It is especially beneficial at ambulatory (outpatient) point, hence enhancing continuity of care. As well as, Internet-based access improves the ability to remotely access such data. It helps as a decision support system for the hospital authorities for developing comprehensive health care policies. Efficient and accurate administration of finance, diet of patient, engineering, and distribution of medical aid. Enhances information integrity, reduces transcription errors, and reduces duplication of information entries.

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It is now hard to imagine healthcare without information and communication technology (ICT) based applications for both the accumulation and interchange of clinical information (Ammenwerth et al. 2004). Increased efficiency, reduced cost, improved patient care and quality of service, and safety are the factors that healthcare organizations now consider when planning to implement new ICT-based applications (Andersen & Aydin 2005; Chismar & Thomas 2004). The outcomes of many HIS implementations in both primary care and hospital settings have either not met yet all the expectations or have failed in their implementation (Rahimi et al 2009; Heeks 2006; Garde et al. 2007). Such studies as Van Der Meijden et al. (2003) and Fullerton et al. (2006) have indicated undesired consequences. Kucukyazici et al. (2008) estimated the failure rate for new HIS implementations in healthcare organizations to be approximately 50%.

The implementation of HIS is therefore a major challenge in the healthcare setting. Acknowledgement of this has led to a need for understanding the match between HIS and existing IT infrastructure, organizational structure, and established routines. This means that the decision-making process leading to the implementation and use of ICT-based applications in healthcare has to improve generally. Implementing HIS successfully therefore appears to be a difficult task (Doebbeling & Pekny 2008; Pagliari 2007). JPNATC has implemented HIS in the year 2007 and the following modules are running under HIS: Patient Registration System (PRS) Appointment System Lab Module Post Mortem Report Stores Indent Software MLC Report OT module PACS interface

There are four sets of parameters involved in all phases of a HIS development. First, the set of all prospective characteristics determined at the planning phase by the participating

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parties. Such parameters are abstract and refer, ususally, to the higher administration levels in a hospitals organization. Second, there is the set of all targets that have to be efficiently satisfied by the implementation of the planned HIS. The parameters of this category enumerate the problems that have to be faced and effectively solved by the developed system. Third, there is the set of all obtainable goals implemented by the installed system. The elements of this set include the functional characteristics of the delivered system. The last, fourth, set of parameters enlists the benefits and the negative impacts from the systems installation. (J.C. Sarivougioukas and A. Th. Vagelatos, 2002)

4.2 Veterans Health Information Systems and Technology Architecture (VistA)

VistA is an enterprise-wide information system built around an Electronic Health Record (EHR), used throughout the United States Department of Veterans Affairs (VA) medical system, known as the Veterans Health Administration (VHA) has its roots in the late 1970s. It's a collection of about 100 integrated software modules. By 2003, the VHA was the largest single medical system in the United States, providing care to over 4 million veterans, employing 180,000 medical personnel and operating 163 hospitals, over 800 clinics, and 135 nursing homes. About a quarter of the nation's population is potentially eligible for VA benefits and services because they are veterans, family members, or survivors of veterans. By providing electronic health records capability, VistA is thereby one of the most widely used EHRs in the world. Nearly half of all US hospitals that have a full implementation of an EHR are VA hospitals using VistA. VistA was developed using the M or MUMPS language/database. The VA currently runs a majority of VistA systems on the proprietary InterSystems Cach version of MUMPS, but an open source MUMPS database engine, called GT.M, for Linux and Unix computers has also been developed. Although initially separate releases, publicly available VistA distributions are now often bundled with the GT.M database in an integrated package. This has considerably eased installation. In addition, the free and open source nature of GT.M allows redundant and cost-effective failsafe database implementations, increasing reliability for complex installations of VistA.

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Features: VistA supports both ambulatory and inpatient care, and includes several significant enhancements. The most significant is a Graphical User Interface (GUI) for clinicians known as the Computerized Patient Record System (CPRS), which was released in 1997 (K. Meldrum et al, 1999). In addition, VistA includes computerized order entry, bar code medication administration, electronic prescribing and clinical guidelines. CPRS provides a clientserver interface that allows health care providers to review and update a patient's electronic medical record which advances a patient centered approached to clinical computing rather a department centered approach. This includes the ability to place orders, including those for medications, special procedures, X-rays, nursing interventions, diets, and laboratory tests. CPRS provides flexibility in a wide variety of settings so that a consistent, event-driven, Windows-style interface is presented to a broad spectrum of health care workers. CPRS installation was mandated nationally in 1999 and virtually all physicians and medical practitioners in VA usually now use it. The VistA system is public domain software, available through the Freedom of Information Act directly from the VA website, or through a growing network of distributors. Another most important that VistA has recently added to its application is Bar Code Medical Administration (BCMA). BCMA is a bedside application that validates the administration of medications. It was installed in VA in the time frame of 1999 2002 (Johnson C.L. et al, 2002). BCMA enables nursing to use a bedside computerized medication administration record (MAR). Patient identification wristbands and nursing staff identification cards are bar coded with unique identification numbers. Medications are packaged in plastic containers with bar-coded content identifiers and placed on the medication carts by the pharmacy service. To administer a medication, the nurse scans the patients wristband, the packaged medication, and the employee id card. The data are sent to an electronic MAR. Advantages include positive verification of patient identification and prescribed medication at the point of care, an immediate alerting capability to prevent the wrong medication from being administered, precise medication administration

documentation noting on time, early and late dosing and automated missing dose requisition.

Presently VistA is composed of 99 packages (Brown S et al 2003). Of these, there are 16 infrastructure applications, 28 administrative and financial applications and 55 clinical

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applications. VistA applications perform functions in common with other HIS such as laboratory, pharmacy, radiology, scheduling and ADT.

Core VistA Infrastructure: VistA applications are built on top of a common infrastructure. This approach serves several purposes (VistA Monograph, 2002). They are as follows: It integrates applications at the database level; common data are not shared, not replicated. It makes applications consistent from the perspective of both users and developers. It minimizes maintenance expenses. Core code is centrally updated and distributed for use by others. It provides a stable layer between applications and operating systems to help insulate applications from changes.

4.3 Objectives of the project: To implement Cashiering module in JPNATC. To test the Cashiering Module before the go live stage To train the staff of JPNATC using the cashiering module. To monitor the changes in workflow after the successful implementation of the module. To check all the payments done by the patient to the hospital through the HIS.

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5. Review of the Literature The implementation of the Hospital Information System (HIS) is key production of quality care, adequate management of rare resources and productivity. A pilot project was done in Mali which tells the challenges faced for using open source HIS in the region. Different modules were implemented in the hospitals of Mali, in which one of the modules implemented was for the billing module (Bogayoko, Dufour et al, 2009). The study was done to see the changes occurring due to the implementation of the open source HIS in the hospitals. The five modules fully implemented were: patient administrative and medical records management of hospital activities, tracking of practitioners activities, infrastructure management and the billing system. The billing module was fully developed by the local team in Mali because the one proposed by others (Mediboard) was not adapted to the realities of the country.

Figure #1: The Billing System implemented in Mali.

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This was a necessary part for the country as they charge the patient before the patient has undergone any procedure and they dont have any health insurance for the patients. The billing was also done in local language as it would help the patient as well as the staff making the bill easy to understand and work.

In another study done in Washington hospital in which the hospital implemented EDIS (Emergency Department Information System) and integrated it with the hospitals HIS (Wrigh, Wiechert et al, 2007). With the implementation of the EDIS, there is an improvement in documentation which has lead to the accurate billing for the patients. Before the implementation of EDIS, the hospital could only charge for care that was documented in the emergency department, even if the record was incomplete. With automated documentation, every service is documented in EDIS and which has helped them in charging up the patients. The captured charges which are documented in EDIS gets transferred into the HIS billing module. There pilot study has shown an increase in ED charge capture by 20 percent from December 2004 to December 2005.

The information system used in the hospitals has been specifically designed for the use in the patient care and for the administrative purposes. They consist of different modules, each performing a specific set of functions. In HIS, one module is for billing and another module is for recording clinical data. These modules however, are not independent; data from the module that records clinical data may be used for billing (Johan van der Lei, Joop S. Duisterhout et al, 1993). Every module present in the hospital may support the billing module implemented in the hospital.

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The VAs Hospital Information system which is written using the ANSI (American National Standard Institute) standard M language, also uses the billing module implemented in the Hospital where the billing data can be processed by the following two mechanisms for transferring data to and fro(Ruth Dayoff, Garrett Kirin et al, 1994):

1) The first is the use of silent application programmer interfaces to the HIS modules. They are the entry points in the HIS module which are called by the workstation to access or update data.

2) The second mechanism is to use a generic interface file structure, where the HIS module if needing the data collected on the workstation will provide the processing software to extract the data from the generic interface file and store it in packaged specific data structures. This has lead to the generic interface file independent of the packages and the data can be used further by the other modules without modification to the user interface or interface file.

Use of the same data capture process for billing assures more accurate accounting and management information. Billing module helps in knowing the accountability of each and every department for the patients bill and therefore helps the hospital management to work efficiently and effectively.

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6. Information Technology and Workflow: JPNATC, AIIMS

The term workflow is a concept from Business Process Re-engineering (BPR), used to describe the processes involved in arriving at a given objective: Workflow, according to those offering credible definitions, is any work process that must go through certain steps and be handled by more than one person on its way to completion. Workflow automation relieves people of some of these tasks. Inherent in workflow are concepts of teamwork, request and approval, routing and tracking of documents, filling out forms and doing things either in series or in parallel (Essex D. The Many Layers of Workflow Automation. Healthcare Informatics, June 2000: 128-135.) Implementation of a medical IT system will always have an impact on the workflow in the hospital. The scale of the impact will depend on the scope and the complexity of the IT system itself. The greater the impact of an IT solution is likely to be, the more important it becomes to fully understand the existing workflow, and to create a consensus of opinion about the desired workflow among all those concerned. Workflow analysis and modeling play an important role in medical IT projects. Implementation of an IT system requires an understanding of the processes involved and, depending on the scope and complexity of the system, will involve a certain amount of process re-design. Workflow models are a useful tool for understanding the impact of an IT solution on the clinical work processes, defining the expectations and requirements for an IT solution, and managing the change process associated with the implementation of an IT system. Therefore the need of studying of the workflow of JPNATC, AIIMS becomes very important to actually know how the HIS and VistA EHR is working with each other. How the staff is using the HIS/ CPRS for giving the best possible patient care to everyone. Patient brought in the Casualty Area / Emergency Area. Emergency has 3 defined areas according to the severity of the patient. o Green Area: Minor injury; Yellow Area: Observation Area; Red Area: Seriously injured cases. A doctor checks the patient and starts the initial treatment.

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 Meanwhile a registration form is given to the person with the patient/ patient himself (if conscious) and is countersigned by the doctor to declare it as a MLC/Non MLC case. The person with the registration form goes to the emergency registration counter where they register the details and give the patient a computerized generated TC No. For preparing the MLC note, the doctor opens the CPRS where MLC note template is there. They fill the details and the detailed MLC report of the patient is been generated whose 3 print out are taken. One for the hospital record, one for the police records and other for the patient. There are only 2 print outs given in non MLC case. If the patient is treated and does not require admission, then doctor provides a discharge summary to the patient while ordering the patient to come for the follow up OPD which is given by the call center through Appointment System Software. If the patient has to get admitted, a face sheet or Admission & Discharge sheet has to be filled. The face sheet contains the details of patient comprising IPN (In Patient No.), ward no. allotted, doctor/ consultant assigned are there. These details are entered in the putty using ADT (Admission, Discharge and Transfer) option. After the patient is admitted to the ward and all the details of the patient are now visible in the CPRS. Admission details is been filled by the registration counter. Doctors/Consultants filled all the notes for the patient i.e. the allergies, clinical history, lab values etc in the CPRS. Nurses put all the vitals of the patients, transfer in note in the CPRS. Discharge and Transfer in the ADT been done by the CATS from the computer facility. Doctor checks the patient and if needed discharge, the doctor prepares the discharge summary with next appointment for the follow up OPD. If the patient dies, then the death report is been prepared (manually), mortuary department prepares Post Mortem report in the HIS.

The above workflow shows that from the patient entrance to the hospital till the discharge of the patient and also follow up OPD of the patient, IT is been used in every step. HIS or VistA CPRS are been used by most of the staff in the Hospital.

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7. Methodology

Cashiering module has been divided into the following 3 stages: 1) Pilot Stage: 28th to 30th April 2011. The main focus of this stage was to gather the requirements from the various departments who are going to use the cashiering module in the HIS. 2) Testing Stage: 2nd May to 7th May 2011. The main focus of this stage was to train the users of the cashiering module. During this phase the testing of the software was also done by comparing both the manual and the electronic data. 3) Go Live Stage: 9th May 2011. The module went live in JPNATC on 9th May 2011, Monday. The back end of the cashiering module is My SQL Database and the front end is Java. Pilot Stage: 28th April to 30th April, 2011. Structured questionnaires were prepared for the following departments. The data was collected through Group Discussion and Interviews. (See Annexure #2). S.No. Department No. of Individuals in the

Discussion/Interview 1. Radiology 3 (Technical Head + 2 Counter

Receptionist) 2. 3. Inpatient Accounts Department 4 ( Neurosurgery Faculty + 3 NIS) 4 (Accounts officer + Cashier = 2 Assistant Cashier) Table #2: Interviews and Group Discussions done in the department Implementation Stage: 2nd May to 7th May, 2011. It was further divided into following two sub stages.

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1) Training to the end users: 2nd May to 4th May 2011 (See Annexure #3 for the training schedule) 2) Testing Stage: 5th to 7th May 2011. During this stage the manual chalan forms and electronic charge slips were prepared by the respective departments. In the cash counter, both the manual receipts and the electronic database receipts were saved. The report was compared with the manual receipts so that any problems coming can be sorted out at that moment. Go Live Stage: From 9th May 2011, the cashiering module was live in the trauma center. All the users were accessed regularly so that the cashiering module becomes a success.

7.1 Client Requirement for cashiering module

Before implementation of the cashiering module, the client requirement/ requirement gathering is must for any successful implementation of IT systems in a healthcare organization. The following client requirements were there which are as follows: There should not be much of the difference in the workflow. Replication of the existing workflow with as much as little variation in the workflow. All the charges related to patient should be provided in the charge slip (See Annexure #1 for details) For radiology department, there are three receipts for the same payment. One patient copy, other for the radiology department and third copy for the accounts department. For hospital charges and other charges they have only two receipts. One with the patient and the other copy with the accounts department. Regular check about the payment paid and payment deferred of the patients so that payments can be received if left.

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8. Observations 8.1 Workflow Analysis before and after Implementation

Workflow analysis before implementation: Inpatient Department CRC sends Admission Slip for First payment for Admission 1. 2. IPD admits patient, payment done by the relative of the patient. 3. Cash Counter for receiving the payment and deciding the payment.* Patient/ Relative gets the receipt of the payment.

1. When cash counter is open, the relative directly goes to the cash counter for payment. 2. When the counter is closed, the payment is done by the relative after admission. 3. If some refund is to be done, the relative takes the discharge summary from the IPD and refund is done according to the stay. *Note: First admission is for 10 days. Payment of Rs 375 (Rs 25 + Rs. 35*10).

Workflow Analysis: Radiology Department (for radiology procedure) OPD IPD Radiology Department

1 receipt copy given to the dept. for procedure. Patient/Relative gets the receipt of the payment

Cash counter decides the payments after seeing the chalan form from the above department.

Figure # 2: Workflow before Implementation of the cashiering module.

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Workflow Analysis after implementation: Inpatient Department. CRC sends the admission slip with the patient to the ward where patient is to be admitted.

IPD nurse makes the electronic charge slip for that patient. Also for deferred payments, the charge slip is made by the nurse. Refund is also been made by the nurse.

Relative goes to Cash Counter for payment or to get the refund.

Patient/Relative gets the receipt of the payment.

Workflow Analysis after implementation: Radiology Department OPD IPD

Radiology Department

1 receipt copy given to the dept. for procedure.

Cash Counter receives the payment and gives 2 receipts.

Patient/Relative gets the receipt of the payment.

Figure #3: Workflow after implementation of cashiering module.

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Changes in the working of the departments after the implementation. Now all the charge slips are been made electronically by the nursing staff and radiology staff which helps them to track the patients payment and how much to charge from the patient. The patient / relative of the patient use to come directly from the IPD to the cashier department for payment of the radiology procedures like CT or MRI. The cashier department use to check and take charges accordingly. But sometimes they took wrong charges. For example: Head CT charge is Rs. 200 and normal body CT charge is Rs 750. Sometimes they use to write only CT in the chalan form, which caused the confusion with the cashier how much to charge from the patient. This would lead to either less / more payment respectively. Now every patient relative / patient coming for payment from ward/ICU has to go to the radiology department for preparing the charge slip for the procedure and then come for payment. Before this, cashier use to have two receipt books for radiology and hospital charges respectively. Now everything has been converted into a single receipt book number. Until and unless the charge slip is not been prepared from either the inpatient department or radiology department, the cashier would not entertain the patient relative. Therefore it becomes necessary for every bed side nurse for the patient to know how much days charge is to be taken. Same is for the radiology department. This was previously decided by the cash counter.

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8.2 Benefits of the Cashiering Module in JPNATC.

Being a government hospital and an interim part of AIIMS, JPNATC charges the minimal to all the patients coming to the hospital. IT systems are always benefiting the people directly or indirectly involved in the system. After the successful implementation of the cashiering module in the HIS, not only the hospitals management but also the patients are getting the benefit of the module. Benefit to the Cash Counter: All the money to be taken for the patient was always been decided by the cash counter, which sometimes led to the confusion of how much to charge from the patient. Now after the implementation of the cashiering module, the patients relative has to go to the radiology department first. The radiology department makes the charge slip of the payment and the cash counter checks the amount and provides them the receipt after taking the cash. This has ended the confusion which was created when entire decision was taken by the cash counter about the payment. Manual calculation and reports been converted into digitalized form. Benefit to the Wards and Radiology department: They are the one who are preparing the charge slip. In the charge slip they can check the patients charge slip which was prepared on that day. In the charge slip if they have paid the money and a receipt has been generated by the cash counter, there is a status shown for the charge slip. If the payment has been done, the status is shown P which signifies paid otherwise U is shown which means unpaid.

Benefits to the patients: In the manual receipt, the cash counter was not writing the details in the manual receipt. In the printed receipt, there come all the details about the charges for what they are taking (see annexure #7). This helps the patient in medical claims.

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9. Conclusion 9.1 SWOT Analysis Cashiering Module

For any IT system to be appreciated by the end users, it should have maximum strengths and opportunities with bare minimum weaknesses and threats. After the successful implementation of the cashiering module in JPNATC, the following is the SWOT analysis for the cashiering module in the HIS. Strengths: Centralized database leading to easy track of the payments done by the patient. Manual receipts and manual records been converted to electronic records. Charge slips prepared by IPD and radiology department now know the payment to be taken from the patient leading to very less errors, as they know the patient stay and the radiology procedure rather than the cash counter. The manual receipt been converted to the printed one with the full description of the charges taken from the patient. This has helped the patients to take the claims from the insurance company as they dont have to take the description from the cash counter again and again. Reduction in human error in the cash counter. At the end of the day when they were closing the cash counter, it was taking the cashier to more than one hour to finalize the report for the day. They had to first calculate the cash and then they had to enter every receipt details in the cash book register and tally the cash with the receipts cash. After the implementation, the time has reduced to 15 minutes (reduction of 75 percent time) as they now calculate the cash and tally it with the cashier report at the end.

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Weakness: Only for the trauma patients, other charges like donations, tender fees are still done manually. This is so because the charge slip can be made after entering the TC number which is generated by the Patient Registration System (PRS) in the HIS. Opportunities: Open doors for other modules to work which can be integrated with the HIS and the cashiering module. For example: The hospital doesnt have some modules like Radiology Information System (RIS). Now after the implementation of the cashiering module, the integration of other modules would become a reality. Threats: Some of the nurses in the ward dont know much about the hospital charges for the initial admission. Therefore sometimes they make charge slip for less amount. Government hospital staffs are very much resistant to the change. If some other charges are included in the hospital for other department, they might refuse to make the charge slip as they think its a work of the cash counter. Lack of interest of the staff as it has increased the work of the individual who is directly and indirectly involved with the cashiering module. For example: As nurses in the wards have to enter data in the CPRS and also do the routine work of patient care. Making of charge slip may lead to lack of interest from the nurses.

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9.2 SWOT Analysis JPNATC: IT Transformation

JPNATC is currently the best integrated level I trauma centre in India and continues to set benchmarks in patient care not only in India but also all across the globe. JPNATC also proudly becomes the first hospital in India to implement VistA EHR. More than 3 years after the successful implementation, there is still a lot of work to do. Strengths: The involvement of NIS and CATS under the dynamic and impressive leadership of Dr. Deepak Agarwal, Head Computer Facility Department are the backbone for 24 *7 support to all the medical/non medical staff of the hospital who are using the HIS or CPRS (e.g.: training of the staff). 24*7 support for the computer hardware and software by the Computer Facility department with round the clock presence of network professionals and hardware engineers. 24*7 call center for providing all types of information of the appointments for the patients after the discharge for the follow up OPD. 4 GBps network speed with the facilities of both wired and wireless facility. 24*7 CCTV camera and Biometric Attendance/ Access for tight security (IT initiative). Weaknesses: Approximately 40 percent of the hospital staff needs training / retraining about the HIS or CPRS as they are new recruited to the hospital or the modules are implemented for them are new (e.g.: Cashiering Module).

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 Lack of awareness among the staff about the different software. The medical staffs dont know much about HIS. Similarly other staff doesnt know about the CPRS. Only the NIS and CATS know about both the software (HIS and CPRS). Lack of computer knowledge among the nurses and other staff. Some of them have a very less knowledge about the hardware present in their department. Opportunities: Different Modules still to come like BCMA in CPRS leading to reduction in the manual work of the medical and supporting staff. Government funded organization, therefore easily available funds for the computerization. Threats: Government hospital has the largest threat of their staff been resistant to the change due to implementation of the IT systems. Lack of interest from the staff as still the manual work is going on and also entering the data electronically in the CPRS and HIS.

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10. Recommendations
1) In every department some nurses should be fully trained or retraining sessions should be there with regular assessments of the medical staff after the implementation of the new HIS module or new templates in CPRS.

2) The Nursing Informatics Staff (NIS) started as a program named Nursing Informatics Specialist Program under the guidance of Dr. Deepak Agarwal w.e.f. 1st February 2011 (JPNATC March April Newsletter Issue, 2011) has initially only 7 nursing staff working in shifts and covering every department. The number should be increased to at least 10 so that they can cover every department efficiently and effectively. 3) Use of desktops in place of thin clients if possible. The thin clients used in JPNATC at every ward are rather slower than the normal desktops. Similarly they are slow in capturing wireless network. This leads to sometime less time to open the CPRS in there thin clients. 4) Regular updation of the templates in the CPRS is required as some of the options are regularly used are been typed. 5) Interested nursing staff should be initiated to be a part of internal training to the nursing staff of their departments and they should be asked to be the one using both HIS and CPRS together. For example in cashiering module, interested nursing staff should be provided with the authority to make the charge slip. They should be fully trained for all the options in the HIS which would reduce the confusion about how much to charge from the patient.

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Case Studies

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10.1 Case Study #1: Queue Management of OPD in JPNATC: An IT Initiative Observational Case Study
Abstract: The following case study deals with the queue management of the OPD patients and reducing the waiting time of the OPD patient with the help of Information Technology. An m health initiative, use of the latest technology (Bar Codes) and the complete EHR of the patient not only helps the patient but also helps the consultants to give the best possible treatment to the patient within the provided time. With this kind of IT initiative, JPNATC is able to give consultation to all the OPD patients in a mere time span of 3 hours. Introduction: In the past 10 years, the facilities in the hospitals especially in a government hospital have not increased at the same rate as the population seeking medical care. Because of the increased rush of the people visiting hospitals for treatment, long queues of patients are seen waiting for the medical care in almost all the hospitals, resulting in overcrowding and long waiting times. The problem of overcrowding in hospitals is not merely because of the shortage of doctors and other paramedical staff. The majority of the problems leading to this phenomenon are due to management. JPNATC initiated the dreams of using mobile technology for reducing the queues of the patients in the OPD and giving patient the utmost satisfaction. As JPNATC is especially there for the 24*7 trauma care for the patients, the majority of the patients who are coming for the OPD come under the following specialization: Orthopedics, General Surgery and Neuro Surgery. According to the new VLR data released by TRAI (Telecom Regulatory Authority of India) report, as on 31st January 2011 there are 771.18 million mobile subscribers in India. Whenever a patient reaches JPNATC, the patients mobile number or his / her relatives mobile is been noted down in the EHR of the patient. JPNATC has an outsourced 24*7 call center (011-40401010) which helps the hospital as they have divided some of the administrative work to the call center. The patient appointments are been given by the call center reducing the waiting time of the patient for taking the appointment. Also the appointment is verified by sending an SMS to the mobile number provided in the EHR of the

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patient. A Government hospital where people think that the patients time is not the first priority for the hospital, JPNATC has proven wrong by becoming one of the first government hospitals in India to manage the long queues of the patients in OPD. For this IT initiative JPNATC has been awarded with the prestigious mBillionth award South Asia 2010 in M Health & eIndia 2010 jurys choice award in m Governance. Methodology: Observational Study. Observational study was conducted on six working days in the OPD registration counter and the follow up OPD itself from 2nd May to 7th May 2011. There are 3 consultation rooms; Room No. 103,104 and 111 respectively where the follow up OPD consultations are provided. The OPD is known as follow up OPD because most of the patients who are coming are the patients who were the patients of the JPNATC and got discharged from JPNATC after getting the full treatment. Observations: The following observations were done in the above mentioned six working days and the following came into picture. 1) Appointment of the OPD Patient: The patient who enters the Trauma Center is first been registered in the Emergency Registration counter. The mobile number of the patient or the relatives mobile number is been taken in the HIS and then it gets automatically transferred to the CPRS. The Call Center calls that mobile number to verify the patient details after the admission or during the first visit (in Emergency). When the patient gets discharge, in the discharge summary (template) the next appointment is entered. CATS notify the call center of all the discharge of the patients happened for the day.

According to the doctors orders, call center gives the patient the appointment for the doctor through the appointment system provided by Edgeware Technologies (I) Pvt.

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Ltd. The call center SMS the Token number and Appointment details to the mobile number provided in the EHR. The final details of the appointments is been provided to the medical records section via email so that they can get the files ready of the respective patients in the doctors table. The email is sent a day before the actual OPD day i.e. if the appointment is for the Monday Ortho A OPD, then the list is been mailed to the Medical Records Section by Saturday (See Annexure #4 for OPD days details).

2) On the Day of the OPD: There are 2 registration counters in the OPD. One for the New Cases and other for the Old Cases. The OPD registration timings are from 9 am to 11 am but the registration counter gets open at around 8 am. The counter receptionists collect the final list of patients coming for the OPD from the Medical Records section and paste it outside the counter in the notice board. The list consists of the names of the patients under one consultant and which consultation room the doctor is sitting. The registration procedure starts around 8: 30 am till 11 am. This divides the patients into two counters. New Cases dont have any OPD card so they get from one counter where new cases get register. Patients give their discharge summary and tell the TC number and Token Number. For verification, the OPD registration counter checks the SMS which was sent from the call center to the patient. The printed out token number and a printed bar code which signifies the TC number is been pasted in the OPD card. The same is not done for the old cases as they have OPD card ready with them previous time.

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 The patients coming for OPD are also been registered with an OPD registration number which helps the management to take out weekly, monthly or yearly census that how many patients turned up for OPD so that necessary actions can be taken for providing better treatment. The OPD registration is written as follows: NS 11 529. In this NS represents Neuro Surgery Department, 11 represent year 2011 and 529 is the patient number (529th Patient). This is all present in the appointment system software.

3) After arrival of the Consultant: The consultation timings are from 10 am to 1 pm. The doctors arriving in the consultation room calls the patient one by one with the help of the token number that was provided by the call center. There is a display system above the entrance of every consultation room and also in patient waiting area. The patient to be called up, the token number gets displayed in the screen which is been controlled by the doctors with the help of an instrument known as token counter. When the button is pressed the next token number is displayed in the screen. The patient arriving inside the consultation room has the OPD card. The OPD card has the bar code signifying the TC number. This helps to reduce the human errors which may happen if written in the OPD card. The bar code scanner present in the consultation table scans the bar code and the number is entered in the CPRS from where the patient history can be seen by the doctor. Also the files of the patients are bar coded with the same TC number so that the error gets minimized.

If a patient forgets to take appointment (patient might not have any contact number) but the patient knows that doctor has asked him/her to come on that day

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or the patient may be a referred case (not a trauma center patient) then the patient has to fill up a form then counter signed from the consultant that he is ready to see that patient, then reception counter at the entrance of JPNATC provides appointment to the patient through the appointment system.

Discussion: Being a government hospital where OPD is free for the patients and such an initiative to reduce the queues and waiting time for the patient is really appreciable. The IT initiative of using EHR, Appointment system, M- health and 24*7 call center is a perfect example of meaningful usage of IT in healthcare. The patient is been given prior appointment which has reduced the time of taking appointments while standing in queues. The patient now gets appointment after discharge while he/ she is sitting back home. Also the call center notifies the patient if there is a change in the appointment schedule due to absenteeism of consultants or due to gazetted holiday declaration which reduces the travelling time and thus reducing the opportunity cost of the patient especially the poor patients who work on daily wages. Also the work starts for the OPD a day before which also reduces the waiting time for the patient as all the files of the respective patients are kept at consultation table. Bar codes signifying the TC number of the patient help the doctor to get the correct TC number in the CPRS. The above initiative truly deserved the awards that they have got in 2010.

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Recommendations: JPNATC has one of the finest OPD management systems with the help of Information Technology, but still many of the patients have to wait for 2 hours for their chance to get consultation from the doctors. The registration counter is opened from 9am (starts from 8:30 am) to 11 am. Doctors consultation timings are from 10 am to 1 pm. If the registration counter is kept open till 12 pm, then the patients who are getting the chance at around 1pm will have to wait for 1 hour maximum as they would come at around 12 pm. Also the registration counter reception would get ample of time to get through the discharge summary easily and leading to smooth workflow in OPD.

Conclusion: JPNATC has set an example to the Indian Healthcare system if there is a will there is a way. JPNATC is one of the best examples in India where we can see The Meaningful Use of Information Technology. They have done tremendous job while taking care of the patient health and waiting time. Longer queues are now not at all visible except in Mondays and Tuesdays when the orthopedics OPD is there. When there are more number of patients for a particular day, the consultation room number 111 also gets opened to divide the longer queues into 3 different queues. This is according to me the perfect example set up by any healthcare organization where management of the OPD queues is also a priority while providing the best possible patient care to everyone.

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11.2 Case Study #2: Staff perception over the HIS/ CPRS present in JPNATC Questionnaire Based Study

Abstract: The following case study deals with the JPNATC staff perception for the HIS/ CPRS software present in the hospital. No IT system is perfect in this world. Different people using the same software have sometime different opinion for the software. The different opinions therefore lead to regular updating of the software. The study was conducted in the JPNATC premises with 52 JPNATC staff from different departments. The staff members were selected by using convenience sampling. The study concluded that the major problems that everyone (52 Staff) was facing of the computer getting hanged. The average rating given to the VistA HIS/CPRS was 7/10 (6.8). The study also concluded that the staff members were having very little knowledge of all the software in the hospital. Those who were using CPRS did not know about the HIS and vice versa. 88 percent respondents say that IT is important for Hospitals, which included medical staff also. Introduction: Healthcare over the past 10 years, has witnessed a sudden leap of information technology in different sectors. Albeit, with slow progress, a number of information systems have been developed and implemented in hospitals across the globe. This is been proved by the increase in the investments being made by hospitals across the world. India is not much far behind in this sector. However the scenario in India is still weak as compared to the west. For any IT system to be successful especially in a hospital, the major factor affecting the success of the software is the perception of the users for the software. ETIPL provides the software to JPNATC for the backbone functioning of the hospital. From patient registration till the discharge and also for the follow up OPDs, everywhere the softwares are been provided by ETIPL. The following are the softwares which are working in the hospital which are been used by the medical and non medical staff of JPNATC. 1) VistA HIS (For day to day activity for the patients like registration, billing etc.) 2) CPRS (For patient medical data which is been updated by the medical staff) 3) Surgery Module (Full details about the surgery to be held in the hospital)

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4) Appointment System (Follow up OPD and radiology appointment system) 5) Lab Module etc. (Lab entries interlinked with the CPRS for the patient) Different software has different users also. For example the CPRS is been used by the medical staff of the hospital consisting of the Consultants, Senior & Junior Residents and the nurses. The other supporting staffs of JPNATC are using HIS and Appointment systems etc. Therefore different people are having different perception for the software present in JPNATC. Also its very difficult to make an overall perception of the software package provided in the hospital. Different staff members have different requirements and sometimes it makes some people satisfied and others are not. The case study here describes about the perception of the staff members which have been noted down and been tried to be taken up from the different departments so that an overall perception of the software can be presented. Methodology: Questionnaire Based Study For the study a Questionnaire of 13 questions was prepared which covered the department and the working profile etc. (Annexure #9). The questionnaire also have subjective questions so that the staff members could write the problems they face and suggestions so that the software can be improved in the near future for smooth functioning of the hospital. SPSS 16.0 was used for the analysis of the data collected. Total numbers of respondents were 52 from different departments through convenience sampling. The convenience sampling was done because there were many respondents who were not willing to fill the questionnaire. The computer knowledge and also the knowledge of the different software in the hospital were observed. Observations: The following analyses were concluded after the data collection through SPSS 16.0. Number of Respondents: 52 Departments Covered: Cash Counter, Computer Facility, Emergency Medicine, Emergency Medicine Registration, CWG ward, Neurosurgery, Nursing (NIS), Orthopedics, and General Surgery etc.

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 Working Profile: Assistant cashier, NIS, Staff Nurses and Sister grade II, Senior and Junior Residents, Faculty In charge, DEO, Lab Technician /CATS etc. Experience in the Hospital Cumulative Percent 38.5 44.2 75.0 100.0

Frequency Less than 6 months 6 - 12 months 1 - 3 years More than 3 years Total 20 3 16 13 52

Percent 38.5 5.8 30.8 25.0 100.0

Valid Percent 38.5 5.8 30.8 25.0 100.0

Table #3: Experience of the respondents All the above 52 respondents used HIS/ CPRS. Most of the respondents were using the HIS/CPRS for less than 30 minutes (48 percent). More than 88 percent respondents say that IT is important for smooth functioning of the hospital. Majority of the respondents has said the following type of the improvement they have seen after the implementation of the HIS/CPRS: Easy accessible of the patient data. Patient whole record in just one click. Dont have to check the records again and again. After discharge they are easily been traced if they are again coming to the hospital. Complete information about the patient is there, which helps the medical staff to provide better treatment to the patient. With the implementation of PACS, the doctors are now easily diagnosing the patients images through there working station. The majority of the works are now having fewer errors.

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 Saves time as all the data is been there with one click. This has increased the efficiency and effectiveness of the medical and non medical staff. No IT enabled system is perfect in this world. If there are some positive points about the software, so there are problems or negative aspects of the software. Therefore the respondents were about the suggestions for the software so that it can be improved for better functioning of the hospital. Regular training of the staff after the implementation of the software or any module. Complete awareness to be given to the staff so that they have knowledge what new is going to be implemented. The software should be fast as it takes a longer time to open. The software should be regularly updated so that they dont have to write or to keep a manual record. More options should be there rather than writing in the text format for the patient record. It should be user friendly with more GUIs present. The templates should be prepared after the consult of the doctor. There are some problems also after implementation any new system in the hospital or any organization. Some of the problems were found are as follows: Majority of the respondents agreed about the computer gets hanged and it takes a longer time to open. Other than these problems the major problem they faced that till now they are now also keeping a manual record of all the details that they are entering in the CPRS/HIS. Proper training is not been given to the staff after the new implementation been done in the hospital and many more. Rating to the overall software package: The respondents were asked about the overall rating to the software, the mean rating given to the software is 7 out of 10.

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During the analysis it was seen that the staff working in the hospital more than 1 year has seen a satisfactory improvement (approx 50 percent) but 4 staff members out of 52 have said that there is a tremendous improvement in the working of the hospital after the implementation of the HIS/ CPRS and all the 4 staff members are working in the hospital for more than 1 year. 86.5 percent of the respondents have said about the improvement in the hospitalization (45 out of 52)

Improvement in the working of JPNATC

8% 14% Neutral Improved a Little 40% 38% Satisfactory Improvement Tremendously Improved

Figure #4: Response for working improved after HIS/ CPRS (out of 52) Discussion: Nobody wants to do extra work except to their day to day routine job. It becomes very difficult sometimes to make the medical staff to enter the details in the computer where they can do the work faster in manual way. After the survey conducted in the hospital, it was found out that all the respondents are thinking IT as an important part for the proper functioning of the hospital. Also it was seen after the survey that those who have the experience of more than 6 months in the hospital have seen improvement in the working of the hospital. It was also seen through the survey that the staff members using the software more, they have seen improvement in the hospital functions as well as their working in the hospital. The software rating of 7/10 (6.8) also shows that VistA HIS / CPRS are been appreciated by the hospital staff but still a lot of work is required. Another major problem that was observed that except the CATS/ NIS, all were having a lower knowledge of the computer hardware. In JPNATC, every department is having thin clients in place of the

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normal PC, which they dont know how to operate. Next thing observed is that the medical personnel dont know about the HIS and the non medical staff doesnt know about the CPRS, which shows a lack of awareness about the VistA EHR (HIS and CPRS) among the JPNATC staff. Recommendations & Conclusions: There are some limitations to this study. The numbers of respondents were less, if done with more number of staffs it might have given a clearer picture about the staff perception. The above observations and discussions has lead to a conclusion that there is a lack of awareness among the staff members especially the medical staff as they are least interested in the HIS system installed in the hospital. They even dont know the meaning of HIS. Same is the case with the non medical staff as they dont know what CPRS is. To bridge out this gap JPNATC has brought out the concept of NIS (Nursing Informatics Staff) who are giving up the training to the medical staff and CATS who are helping them out in their formal computer related training. But this is not enough as the staff requires training and retraining again and again. 1) Increase the number of NIS or increase the number of training or retraining sessions of the staff members.

2) Another problem they are facing is that the computer gets hanged. Instead of using thin clients, they should have desktops and wired connections. Instead of using 3 thin clients, they can use 1 Desktop and rest 2 can be thin clients in each ward as they are using in some wards.

3) Wireless connections should be replaced with the wired connections as the HIS/CPRS requires networking to open. 4) Regular updation of the HIS and CPRS is required.

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12. References
1. Department of Veterans Affairs computerized patient record system, in: Proceedings of AMIA Symposium, K. Meldrum et al, 1999. 2. Determination of the success of a hospitals information system implementation: J.C. Sarivougioukas & A. Th. Vagelatos, 2002.

3. Edgeware Technologies (I) Pvt. Ltd http://vista-edge.com/index.php?option=com_content&view=article&id=1&Itemid=2

4. Electronic Health Records Overview; National Institutes of Health & National Center for Research Resources, Virgina April 2006.

5. Essex D. The Many Layers of Workflow Automation. Healthcare Informatics, June 2000: 128-135.

6. http://en.wikipedia.org/wiki/Hospital_information_system

7. http://en.wikipedia.org/wiki/VistA

8. http://trak.in/tags/business/2011/03/08/indian-telecom-subscriber-growth-january2011/

9. http://www.asianhhm.com/Knowledge_bank/industryreports/hospital-informationsystems.htm

10. Implementation of Health Information Systems; Bahlol Rahimi, December 2008.

11. Integrating ED with enterprise Gaylen Wright et al January 2007.

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12. Jai Prakash Narayan Apex Trauma Center, AIIMS website http://www.jpnatc.com/about.asp 13. Medical Data capture and display: The Importance of clinicians workstation design, Ruth Dayoff et al 1995, Department of Veterans Affairs. 14. Open source challenges for hospital information system (HIS) in developing countries: a pilot project in Mali; Cheick Oumar Bagayoko et al, 2009. 15. Rationalisation of working of OPD in a hospital A Case Study, T.R. Anand & Y.P. Gupta, 1983.

16. Study on patient satisfaction in the government allopathic health facilities of Lucknow District, India; Ranjeeta Kumari et al 2009.

17. The introduction of computer based Patient Records in Netherlands: Johan van der Lei et al 1993.

18. Using BCMA software to improve patient safety in Veterans Administration Medical Centers; C.L. Johnson et al 2002. 19. VistA U.S. Department of Veterans Affairs national scale HIS; Steven H. Brown et al 2003: International Journal of Medical Informatics.

20. Workflow analysis and modeling in medical IT projects, A.S. Ouvry 2002.

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Annexure

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Annexure #1: Price List to be put in the HIS Charge Slip Option Inpatient Department o Admission S.No. 1. 2. 3. Charges Description Hospital Charges ( One time during first admission) Bed Charges (Per Day Bed Charges) Short Admission (One Day charge for a Patient) o Certificates S.No. 1. 2. Charges Description Medical Certificate for Leave Medical Fitness Certificate o Claims S.No. 1. Charges Description LIC Claim Charges (Rupees) 50 Charges (Rupees) 10 10 Charges (Rupees) 25 35 60( 25 +35)

Out Patient Department has the same above charges except the Admission option. Radiology Department o Ultrasound S.No. 1. 2. Charges Description Ultrasound Routine Ultrasound Doppler Charges (Rupees) 200 200

o X Ray: Every X- Ray procedure in JPNATC is of Rupees 30 each. o CT Scan S.No. 1. 2. 3. 4. 5. 6. 7. 8. Charges Description Head CT PNS CT Neck CT Head/PNS/Neck CT Film Body CT (one part) CT Angio CT & CT Guided Interventions Film Charges Charges (Rupees) 200 200 200 100 750 1000 750 300

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o MRI Charges S.No. 1. 2. 3. 4. 5. 6. 7. 8. Note: 1. There are no charges for the patients who are coming to the casualty area. 2. The patients who are either OPD patients, Inpatients or referred patients from anywhere are charged with the above charges. 3. X Ray Charges are only for the OPD and Referred cases to trauma center. 4. Payments are kept in 3 stages: a) Payment Done; b) Payment Deferred and c) Payment Cancelled. 5. In the case of payment deferred the payment are to be done after the procedure has been done. For example the payment of admission is to be done afterwards if the accounts office is closed. Same in the case of the radiology procedures. 6. Timings of the cash counter: a) Monday to Friday: 10 AM 1 PM & 2 PM 3 PM b) Saturday: 10 AM 11:30 AM c) Sunday: OFF. Charges Description MRI with film OPD MRI without film OPD MRI with film - Inpatient MRI without film - Inpatient MRI film charges MRI for 2nd Body Part Contrast Adult Contrast Child Charges (Rupees) 3500 3000 3000 2500 500 1500 2000 1000

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Annexure #2: Questions Asked to the Departments

Radiology Department 1) What is the workflow in radiology department for providing services to the patients? 2) How do Patients get treatment if the cash counter is closed? 3) What are the charges for the different radiological procedures and to whom it is applicable? Inpatient Department 1) What are the different charges been taken from the patients after admission? 2) If the cash counter is closed, how do the nurses proceeds with the payments? 3) How do you come to know that the payments have done all the payments or not? Cash Counter 1) How do you decide that how much money to charge the patient? 2) What are the procedures followed for giving refund to the patient against the hospital services? 3) Are there any other payments done in the cash counter other than the patients payments? 4) How many receipts do the counter provides to the patient against the payments?

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Annexure #3: Training Schedule

Day/ Date

Session Timings

No. of Training For Trainees

Training Place

Monday / 2ndMay 2011

Morning 10 am to 1 pm

NIS: 3 CATS: 6

Training for Charge Computer Facility Slip & Refund

Monday / 2ndMay 2011

Evening 3 pm to 5 pm

Radiology Training for Charge Radiology Receptionist Slip & Refund Counter

Dept.

Tuesday / 3rd May 2011

Morning 10 am to 1 pm

NIS: 4 CATS: 4

Training for Charge Computer Facility Slip & Refund

Tuesday / 3rd May 2011

Evening 3 pm to 5 pm

Cashier: 1 Asst. Cashier: 2

Training for receipt Cash Counter option.

Wednesday / 4th May 2011

Morning & Nursing Training for Charge TC-2 to TC-7 Evening Staff of the Slip & Refund All wards & ICUs 10 am to 5 pm wards

Table #4 : Time Schedule of the Training Note: The NIS and CATS were giving training to the Nursing staff when they got their respective training.

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Annexure #4: Training Manual for Cashiering Cash Counter

Logging in to the HIS: On start up the following Login Screen will pop up. Enter the Access Code and Verify Code and Click the OK button to log in.

The Main Screen:

The Main screen, as shown below, will be visible. This screen has various menus: Search; Pat. Reg; Ch. Slip; Refund; Pat. Bill; Receipt etc.

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Click on this button for making receipt.

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Receipt Option:
The Receipt option will pop up the following screen. Here we can create receipt for patient.

Steps to follow: Red marks are mandatory fields: 1) Enter the HRN/ TC number of the patient whose payment is to be received. 2) If the patients charge is there, all the details of the charge slip comes into the screen. 3) If the payment mode is by cash then click the cash option. Otherwise there are credit card and cheque options present. By clicking on the payment mode and clicking on the cheque and card then all the options gets open where you can fill the text of the card and cheque details. 4) Click on the Save option to save the charge slip details in the given receipt number.

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When we click on 'Save' button the following window will pop up

When we click on 'Yes' button it will generate report as shown below:

Similarly we can take print of Refund from Receipt Screen. Whenever the refund is there, it shows an alert in the receipt screen showing refund exist in red colour.

This can be done by clicking in the receipt screen as shown in page 3. The select bill/refund option when clicked, it would give two options of patient bill and patient refund. When patient refund is clicked then all the refunds come in the screen. The following options occur in the screen.

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When we click on 'Save' button the following window will pop up

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When we click on 'Yes' button it will generate report as shown below:

In receipt screen there is an option of search at the bottom. When we click search, the following screen pop ups.

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If we want to search anything according to the fields provided, just enter the field and click select. The following screen pop ups.

When we select record from list it will pop up the following window which shows detail of Receipt. We can also Update and Delete Receipt. Cashier Report. When click on the report option at the top of the HIS, it has the following options: 1) Cashier Report 2) Item Wise Report.

Clicking on the option it would lead to the open of the report for the day. Cashier report gives the details for the day to day transaction and item wise report gives you the option to select the options like inpatients total charges and radiology charges. Also it gives the option of TC number, monthly wise.

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Annexure #5: Training Manual for Cashiering Module Radiology and Inpatient Department

Logging in to the HIS: On start up the following Login Screen will pop up. Enter the Access Code and Verify Code and Click the OK button to log in.

The Main Screen:

The Main screen, as shown below, will be visible. This screen has various menus: Search; Pat. Reg; Ch. Slip; Refund; Pat. Bill; Receipt etc.

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Click on this button for making charge slip.

Click on this button for making refund for the patient.

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Charge Slip option The Charge Slip option will pop up the following screen. Here we can create a charge slip for patient.

Steps to follow: Red Marked fields are compulsory.

1) Enter the HRN/TC number of the patient. Click search. 2) The details of the admission and patient demographics come automatically. 3) Select the ordering department, provider and service department by clicking to the respective fields. 4) Click on the Item Type followed by description. After clicking both the options, the charge code gets automatically entered.

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5) The rate of the service gets automatically entered. Now change the number of quantity you want to charge. By default it gives quantity 1. It multiplies the rate with quantity to give you the final charge. 6) If you want to give any discount, then click on the Discount (Per) and enter the percent of discount you want to give. When you click add, the charges gets add just below charges. You can add n number of charges for the same patient for the same charge slip. Note: If you want 2 separate receipts then make two charge slips. 7) When you will click save the charge slip gets automatically saved.

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Search Option: When we click the search option at the bottom of the charge slip screen, the following screen pop ups.

You can search the details of any charge slip by any of the above options. Just enter the search criteria and click on the search option. Refund Option: The refund option will pop up the following screen, where we can give refund for the patient.

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1) Enter the TC number for which the refund is to be made. 2) Click the search button to get the detailed list of the charge slips for the patient. If you know the charge slip number then you can get the details of the charges directly.

3) The above screen shows the refunds and the charge slips where the refund is not there. The one you to refund just double click on it. The screen becomes like following.

4) The above screen shows 18 units were charged. To refund let say 10 units, enter the actual unit value (8 in this case). Click on the button add and update it. This will provide the refund to the above charge slip.

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Annexure #6: Back end of the Cashiering Module

The cashiering module in the HIS is having the following features: Back End: My SQL Database. Front End: Java. Charge Slip Screen Java Refund Screen Java

Charge Slip Record (Database)

Refund Record (Database)

ID Common Refund (Master Database) HRN

ID Common

Charge Slip (Master Database)

Receipt (Master database)

Receipt Screen (Java)

Figure #5: Information Flow in the back end of the cashiering module

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Figure #6: Charge Slip Record (Database) Variable View

Figure #7: Charge Slip (Master database) Variable View

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Figure #8: Refund Record (Database) Variable View

Figure #9: Refund (Master Database) Variable View

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Figure #10: Receipt (Master Database) Variable View

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Annexure #7. Receipt before and after implementation of Cashiering Module

Figure #11: Before Implementation: Manual Receipt

Figure #12: After Implementation: Printed Receipt

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Annexure # 8: JPNATC OPD Schedule.

The week from Monday to Saturday (Sunday OPD off) is been divided into the following schedule and their respective consultants. Day of the Week Monday Department Ortho A Consultant Name Dr. Vijay Sharma Dr. Kamran Farooque Dr. B.D. Choudhary Dr. John R. Bera Dr. Vivek Trikha Dr. Subodh Kumar Dr. Biplab Mishra Dr. G.D. Satyarthi Dr. Deepak Aggarwal Dr. Deepak Gupta Dr. Sumit Sinha Medicine Surgery Dr. Sanjeev Bhoi Dr. Amit Gupta Dr. Sushma Sagar Dr. Maneesh Singhal Table #5: OPD Schedule OPD Timings: 9 am to 11 am for registration (Starts around 8:30 am) Consultation Timings: 10 am to 1 pm. Sundays and Gazetted holidays OPD closed.

Tuesday

Ortho B

Wednesday

Surgery

Thursday

Neuro Surgery

Friday

Neuro Surgery

Saturday

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Number of Patients arrived from 2nd May to 7th May 2011 Follow Up OPD at JPNATC, AIIMS Day / Date Monday / 2nd May Tuesday / 3rd May Wednesday / 4th May Thursday / 5th May Friday / 6th May Saturday / 7th May Grand Total New Cases 47 53 44 23 37 31 235 Old Cases 89 84 34 40 23 29 299 Total Cases 136 137 78 63 60 60 534

Table #6 Number of patients from 2nd May to 7th May 2011 Every week Monday & Tuesday are having the most number of cases as it is the days for Orthopedics. Here the new cases are those patients who are discharged from the JPNATC from the previous week or nearby to the date of the OPD. The older cases are those who have more than one visit to the consultant. The consultant decides if the patient requires more visit to JPNATC. Number of Consultation Rooms: Three. Room Number 103,104,111 respectively.

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Annexure # 9. HIS implementation in Jai Prakash Narayan Apex Trauma Center AIIMS.

Respected Respondent. This is a part of the case study been conducted by the Management Student from International Institute of Health Management Research as a part of the Summer Training. None of the information would be released to anyone without the respondents written consent. The information gathered is purely for the case study which is an integral part of the partial fulfillment of the degree from the institute. Case Study Questions Q. Name: (Optional) Q. Department: . Q. Working Profile: . Q. How many years you are been working in JPNATC? (Tick the appropriate answer) ( ) Less than 6 Months. ( ) 1 3 years ( ) 6 12 Months ( ) More than 3 years

Q. How much do you think IT is important in carrying out hospital functions? ( ) Very important ( ) Less Important ( ) Important ( ) Moderate ( ) Not Important

Q. Do you work on HIS or CPRS which is present there in JPNATC? ( ) Yes Q. How do you find using HIS/ CPRS? ( ) Very Easy ( ) Difficult ( ) Easy ( ) Moderate ( ) Very difficult ( ) No

Q. How much time on an average do you spend daily in HIS/ CPRS provided to you in JPNATC? (Approximately) ( ) Less than 30 Minutes ( ) 1 3 Hours ( ) 30 Minutes to 1 Hour ( ) More than 3 Hours.

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Q. How much of the working of JPNATC has improved after the implementation of HIS? ( ) Neutral. ( ) Improved a little bit

( ) Satisfactory Improvement [Has met the expectation] ( ) Tremendously Improved

Q. What type of improvement you have seen after implementation of HIS?

Q. Any kind of suggestions you want to give for better working of the software?

Q. What is the overall rating you would give to HIS provided at JPNATC? Rate it out of 10. /10.

Q. What are the basic problem do you face (if any) after computerization SD: Strongly Disagree; D: Disagree; N: Neutral; A: Agree; SA: Strongly Agree SD a) b) c) d) Computer gets hang Takes longer time to open Print out doesnt come out Doesnt accepts the access & Verify codes e) Others For others please specify: ( ( ( ( ( ) ) ) ) ) ( ( ( ( ( D ) ) ) ) ) N ( ( ( ( ) ) ) ) A ( ( ( ( ( ) ) ) ) ) SA ( ( ( ( ( ) ) ) ) )

( )

Thank you
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