Integration of the Regional Public Health Resources and Establishment

of the Digital Hospital

Hanping Jiang, Fulin Zhang

Shenzhen Bureau of Health
No. 5, Tianbei Road 1
Shenzhen, Guangdong 518020
P. R. of China
E-mail: jhp98@tom.com or fulinz@tom.com

Abstract exploring the advanced methods of project

It is generally accepted that digitized
hospital is of great significance in
reducing medical errors, improving the
quality of medical care and service, and
lowering the costs. In recent years, most
of the 17 thousands hospitals in China
have made arduous and continuous efforts
in establishing hospital information
systems, however, the outcome is not
promising, even in the developed
countries, the result of their practice in
such efforts is not satisfied. In this paper,
we proposed a new method for
establishment of digital hospital, with
emphasis on the integration of the regional
health resources, such as human resources,
advanced information technologies, funds,
experiences, project management, etc.
This approach is consisted of three main
points, first, sharing the regional human
resources and standardization of the
professional requirements and technical
design; second, adopting the "first
experimentation and then promotion"
strategy and efficiently utilizing public
health resources; third, researching and
management of the health information
system and sharing positive as well as
negative experiences. We believed these
suggestions among others are useful for
efficient establishment of digital hospital
in the future.
[Key words] Digital hospital
Integration of resources Regional health
plan Quality of medical care
I Significance of Establishing the
Digital Hospital
Chinese government made the
commitment that China after joining the
WTO would open up its medical and
public health market to the world. As a
result, what will be inevitable is that the
non-state funds (foreign or private capitals)
will gradually enter the relatively closed
sector of medical care. In the near future,
the development of hospitals will mainly
depend on their own standings in the
competitive market. As an important
infrastructure of contemporary hospitals,
digitalization of the hospital has many
significant implications, some of which
are stated as the following.

Proceedings of the IDEAS Workshop on Medical Information Systems: The Digital Hospital (IDEAS-DH’04)
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 1. Reducing medical error and
improving the quality of medical care
Generally speaking, the quality of
medical care should correspond to the
level of scientific and technological
development at a given time. For various
reasons, however, this is not the case
either in China or abroad. According to a
report published by the Institute of
Medicine1, approximately 522,000 cases
of serious medical error that could have
been avoided occur each year in the U.S.,
causing the death of 44,000-98,000
persons. The effectiveness of diagnosis
and treatment is further undermined
because many medical staff cannot
thoroughly understand and apply the most
advanced scientific and technological
knowledge. At present, the level of
medical treatment varies from hospital to
hospital, from doctor to doctor, and from
region to region. As King and others
pointed out, besides the conventional
measures, to establish the digital hospital
is a very effective and practical way to
improve the quality of medical treatment,
especially in the reduction of medical
error2.
2. Improving the quality of
service
Information technology including
the Internet may offer great potential for
the reconstruction of the public health
service system. Although it has been well
applied in many other areas, its
application in public health is yet to be
explored. The application of information
technology usually focuses on the
automation of the specific clinical
information of the patient. Nevertheless,
this kind of information now scatters on
papers, which makes it difficult to
organize, identify and update and almost
impossible to monitor various types of
diseases, especially for those suffering
from chronicle illness who demand
Proceedings of the IDEAS Workshop on Medical Information Systems: The Digital Hospital (IDEAS-DH’04)
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regular monitoring and assistance. If
patients were equipped to communicate
with medical staff via email, many of
them would be able to receive quicker
service at lower costs. Moreover, an
automated medicine classification system
could help reduce the number of errors in
prescription and dosage because patients
and clinical medical practitioners would
be reminded by the computer system
regarding the really needed service.
As all the information is entered
and processed electronically and papers
and films disappear from the new digital
hospital, errors of all kinds will be
reduced. Doctors with patients in the
hospital will spend less time filling out
forms, hunting medical records and
waiting for test results, cutting 15% of a
physician’s regular workday, said
neurosurgeon Swaid N, MD, the medical
director for HealthSouth medical center at
Binghamton. "Physicians do spend a lot of
time in hospitals that is not really very
productive,¡±he said, "We now have it to
spend with patients. We can see more
patients than we could before,¡±giving
doctors and the hospital an opportunity to
make more money.3
3. Lowing costs and raising
efficiency
The digital hospital will help to
dramatically reduce costs. First, it can
reduce the unnecessary manpower. For
instance, in the digital hospital, patients
can pay hospital bills through the bank
ATM or on the Internet, so the number of
billing staff can be drastically reduced.
Second, it can reduce the consumption of
paper. Hospitals consume large amount
of paper in preparing prescriptions,
medical records, registration books and
various test reports, and these can be
almost eliminated in the digital hospital.
Third, it can reduce the consumption of
medical materials. Large numbers of
 films and developing materials can be
saved as the output of the medical testing
and examination instruments will be
digitalized. Fourth, it can avoid all kinds
of wastefulness such as "skipping,
pretending, dripping and missing".
Favoritism as a problem exists in the
majority of hospitals. Another problem is
the delayed data processing. Sometimes
test results are not sent to the ward until
the patient is released, which leads to
missing payments. Bills can also not be
collected when tests and examinations
done are falsely claimed for the patient. It
is estimated that a hospital with the annual
revenue of 400 million yuan may lose
about 8 million yuan to various forms of
wastefulness. Suppose half of the
loopholes are stopped, the hospital can
save 4 million yuan per year. Fifth, it can
reduce many indirect costs. For example,
reduction of paper work would help
decrease the number of staff in writing,
organizing and managing the prescriptions,
medical records, registration books, test
reports and film reports. The
establishment of PACS can help reduce
the space, equipment and staff needed for
preserving and managing the conventional
films. Sixth, it can reduce the costs of
information sharing. For example, it
allows the reading of the digital
information of patients not to be restricted
by the given space and time, and thus save
doctors and nurses large amount of
moving around time and energy4.
II Enormous Complexity of
Establishing the Digital Hospital
Without doubt, it is imperative to
establish the digital hospital. The project,
however, will rather be a long,
challenging and complicated process, and
requires collaborative efforts with
utilization of various resources.
Proceedings of the IDEAS Workshop on Medical Information Systems: The Digital Hospital (IDEAS-DH’04)
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1. The ineffectiveness of the
digitalization of hospitals in China
As a matter of fact, more than 20 years
have passed since the establishment of the
hospital information system began in
China. Continuous exploration has been
made in China as well as abroad to
establish the digital hospital. Despite of
many positive experiences, so far not even
a single hospital has become completely
digitalized. Rao Keqin, director of the
Statistical Information Center for Public
Health of the Ministry of Health, reported5
that, by June 2001, between 30 to 35% of
the 15,000 hospitals at county (district)
level or above have establishment the
information management system. The
percentage varies from region to region.
In eastern China, nearly 80% of the
hospitals have established the information
management system, while in the
northwestern regions less than 20%
hospitals have done so. Moreover, more
than 85% of hospitals use the information
system only for finance and accounting. It
is therefore evident that although
significant efforts and massive investment
of human and material resources have
been made in establishing the digital
hospital, the results produced so far are
"not quite satisfying"6. Very few hospitals
have the information system in its real
sense. The existing ones cannot be
considered as complete management
information system and they are just used
to process financial revenues and
expenditures.
2. Difficulties in establishing
the digital hospital
First, the existing
organizational and management
methods in hospitals lack
standards and consistency. The
digitalization of hospitals can not simply
transfer the work currently done by hand
 to computer, instead, it requires the
procedures be optimized and the standards
of clinical work reconstructed. As is
known, medical care and public health are
among the more stagnant sectors During
China's recent reform and development,
and the administrative procedures and
clinical work lack standards and
consistency. Therefore, digitalization of
the hospital has to deal with the hospital
reform, which involves numerous
challenging issues regarding policy,
economy and conflict of interests.
Second, the concepts and
standards of the digital hospital
are not well developed. At present,
there lacks a shared understanding of the
digital hospital in either the academic or
technical circles. The standards are being
explored and yet to be determined. The
HL7 and other standards initiated in the
U.S. can hardly be applied in China
because of China's given conditions.
China has few professionals who are able
to handle such standards well. Some so-
called "digitalized" hospitals have not
gained acceptance among colleagues as
well as the general public. Their work, in
fact, is far limited and far from meeting
the standards of the digital hospital.
Third, the development of the
digital hospital lacks established
models or experience.
Digitalization of the hospital as a
new project has raised many questions:
what is the amount of funds needed for
investment? How should the project
management be done? What should the
qualifications of the staff engaged in the
project development be? What are their
responsibilities or obligations? How
should we proceed step by step? How
should quality of the project be controlled?
How should we handle the project
proposal, bidding, inspection, supervision
Proceedings of the IDEAS Workshop on Medical Information Systems: The Digital Hospital (IDEAS-DH’04)
0-7695-2289-0/04 $ 20.00 IEEE
and assessment? Without established
models or experience, the hospitals, public
health agencies and the information
system are confronted with numerous new
issues.
In fact, the difficulties in the
digitalization of the hospital are
worldwide experiences shared even by
many developed countries. It was pointed
out in an American IOM report that "the
challenges of applying information
technology should not be underestimated.
No doubt, medical care and public health
is one of the most complicated economic
enterprises which demands quite large
amount of investment and years of
construction. The large-scale application
of information technology also requires
adaptation of the work style of the clinical
doctors, institutions and patients. The
specialists committee of the IOM
proposes to establish a nation-wide basic
information environment which will
support the supply of health service,
public health, quality measurement and
improvement, public responsibilities,
clinical and public health research and
clinical education. It is hoped that, within
ten years, handwritten clinical data will be
mostly eliminated."
III Integration of the Regional
Public Health Resources and
Resolution of the Key Problems in
the Establishment of the Digital
Hospital
Among the many problems in the
development of the hospital information
system, a major one is that the
overwhelming majority of the hospitals in
China need experts, technology,
experience, funds and organizational skills
at varying degrees. The "independent
development" of any single hospital can
hardly bear fruit. Therefore, we believe it
 to be an effective measure to utilize and
well integrate the public health resources
of the entire region.
1. Sharing the regional human
resources and
standardization of the
professional requirements
and technical design
At present, the procedures in clinical
and administrative work in Chinese
hospitals are not standardized. The
existing information system can hardly
meet the needs of a given hospital. Each
hospital stresses "personalized"
development of the information system.
Although it is necessary, questions to be
dealt with include: "what is 'personalize'?
" "Who may advocate the 'personalized'
needs on behalf of the hospital?" and "In
what ways should they be advocated?"
Typically, a computer programmer
cooperates with clinical doctors who make
suggestions upon which the programmer
revises his/her programs. This "face-to-
face" exchange of ideas between the
software developer and the clients is
simple and direct, but it has the
disadvantage of being too direct,
personalized, and thus lacks consistency
and applicability. Since the clinical and
administrative procedures lack
consistency and standards, the opinions of
clinical doctors are subjective and varied,
and the majority of clinical doctors are
unfamiliar with the functions of
information technology, feedback
resulting from the above interaction are
often biased, incidental and subjective.
They cannot reflect the real needs.
Meanwhile, the programmer can hardly
understand such needs and thus unable to
meet them. We propose the following
measures to solve the above-described
problems:
Proceedings of the IDEAS Workshop on Medical Information Systems: The Digital Hospital (IDEAS-DH’04)
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First, the professional needs
should be confined to the
generally shared standards and be
precisely explained. Clinical staff
must present their professional needs in
writing. Professional and administrative
specialists within the region will then be
consulted. We should also make
reference to the concerned documents and
reports in China and abroad, and finalize
the "best" or well thought-out report with
the standardized professional needs
to the developer.
Second, the technical design
should be based on thorough
assessment and precise language
expression. After the standardized
professional needs are presented, the
developer should conduct in-depth
research and analysis, and formulate
realistic and scientific design and
implementation plan. He/she should
carefully select the most suitable products
or plans rather than practicing favoritism
or simply choosing the least costly ones.
Third, the client and the
developer should well
communicate with each other in
order to finalize the program.
After the above two steps, the client and
the developer should well communicate
with each other so that both can
understand and share the viewpoints and
suggestions of the other. It may require
an extensive collection of feedback as
well as written documents to ensure that
the final program shall represent the most
advanced theoretical ideas, organizational
skills and technology.
2. Adopting the "first
experimentation and then
promotion" strategy and
 efficiently utilizing public
health resources.
So far problems such as the lack of
planning, inconsistent standards and
repetition at low levels exist in the
development of the hospital information
system in China. In our opinion, it is
imperative to adopt the strategy of "first
experimentation and then promotion"
within the region, the province or the
entire country. The concentration of
various resources of the region, including
personnel, technology, funds and
management experience in one or a few
select hospitals will help explore new or
key issues and work out solutions.
Successful cases will then be replicated in
other hospitals of the same type. This
strategy has the following advantages.
First, it helps reduce repetition
at the low level and massive
wastefulness. The Establishment of
hospital information system is a new and
challenging area without any ready-made
experience or model to draw upon. In
order to avoid blindness and wastefulness,
we should proceed cautiously. We should
initially concentrate the resources in one
or a few select hospitals so that we can
reduce repetition at the low level and
massive wastefulness.
Second, it helps increase
certainty of success. The
concentration of resources helps resolve
key problems and increase the chances of
success and positive results. Countless
cases have taught us that because the
resources of each hospital are quite
limited and the digitalization of the
hospital is a rather challenging systematic
project, it is extremely difficult to achieve
success with the isolated efforts of a
single hospital. Thus, mobilization of the
resources of the health administrative
agencies and hospitals of the entire region
Proceedings of the IDEAS Workshop on Medical Information Systems: The Digital Hospital (IDEAS-DH’04)
0-7695-2289-0/04 $ 20.00 IEEE
and collaboration between these
institutions can help increase the chances
of success of developing the information
system.
Third, it helps minimize the
negative effects. There has gathered
tremendous enthusiasm for the
digitalization of the hospital.
Nevertheless, the actual application of the
information system has not been effective.
Consequently, misunderstanding and
underestimate of the functions of the
digital hospital have appeared, resulting in
the negative effects. Thus, concentration
of resources to ensure success will help
overcome the misunderstanding and gain
general support for the establishment of
the digital hospital.
Fourth, it helps fully utilize
public health information
resources. The SARS epidemic of
2003 revealed China's inadequate
investment in public health. Moreover,
health resources here are relatively scarce.
What confronts us is how to fully utilize
the limited public health resources. The
"first experimentation and then
promotion" strategy to be applied in
health digitalization will help economize
and make full use of the precious health
information resources.
3. Researching and exploring
the advanced methods of
project management of the
health information system
and sharing positive as well
as negative experiences.
A problem not to be overlooked in the
establishment of the information system is
the "closed development" in hospitals.
Despite of various forms of study, visiting
and experience sharing, the ineffective
organization and management have led
many of these activities to become a mere
formality. The actual development
 process is mostly "closed" and training staff, and mastering technical and
experiences and lessons resulting from the organizational skills. In another word,
large amount of energy invested have not the engagement of the hospital in the pilot
been shared. We thus suggest the development can well benefit itself so that
following two crucial points for it can develop "on the shoulders of the
consideration. giant", to avoid similar mistakes. On the
First, we should share positive regional level, what can be ensured is the
experiences as well as lessons. The continuous improvement of the
development of information system in a development and ultimately achieving the
hospital normally costs thousands of yuan goal of establishing the information
and involves the participation of personnel system.
at all levels. After several years' hard
work when it is finally completed, one
wonders about the results. Those who
devoted time and energy in the project
must have been confronted with numerous
difficulties, resolved a lot of new
problems, and also accumulated rich
experiences and reflections in areas such
as investment, developing, quality control,
management, division of labor
cooperation and training. Unfortunately,
hospitals are more or less competitive
with each other, and due to the lack of
effective leadership, precious experiences
and lessons have not been shared among
hospitals or other counterparts. This, in
fact, is another form of wasting health
resources. More important, as there is no
model to draw upon, the development of
one or a few digital hospitals within the
region can help ensure the quality and
high standard of the system and share the
"intangible assets" such as the developing
experiences, lessons, methods,
management and project supervision.
This will ultimately raise the level of
information system in the entire region.
Second, we should make joint
efforts toward progress. The
experimentation can also help make joint
progress and development. In the process
of assisting others, the hospital can not
only contribute to those being assisted, but
also benefit by raising its own standard,
accumulating experiences and lessons,

Proceedings of the IDEAS Workshop on Medical Information Systems: The Digital Hospital (IDEAS-DH’04)
0-7695-2289-0/04 $ 20.00 IEEE