Summer Placement In

HiSPindia

(April 4 - May 30, 2011)

IMPLEMENTATION OF HOSPITAL INFORMATION SYSTEM IN DEEN DAYAL UPADHAYAY HOSPITAL, SHIMLA

Chahat Narula PG/10/010

Post-graduate Programme in Hospital & Health Management, New Delhi 2010-12

International Institute of Health Management Research, New Delhi 2011

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ACKNOWLEDGEMENT

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

I hereby express my deep gratitude towards Ms. Arunima S Mukherjee, Project-Lead Coordinator, HiSPindia, and Ms. Rashi Banta, Project-Lead Coordinator, HiSPindia, for their valuable guidance, support, interest, involvement, encouragement and advice. They inspired us greatly to work on this project.

My sincere acknowledgement goes to Prof Indrajit Bhattacharya and Prof Anandhi Ramachandran for their kind assistance and support throughout our summer training.

Finally, an honorable mention goes to my family and friends for their understanding and support in completing this project.

Thank You

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ABBREVIATIONS
1. AIDS- Acquired Immuno-deficiency Syndrome 2. API- Application Programming Interface 3. BPL- Below Poverty Line 4. DDU- Deen Dayal Upadhayay 5. DHIS- District Health Information System 6. DOTS- Directly observed treatment short-course 7. HIS- Hospital Information System 8. HISP- Health Informatics Systems Programme 9. HIV- Human Immuno-deficiency Virus 10. ICTC- Integrated Counselling and Testing Centre 11. IPD- In-patient Department 12. MLC- Medico-legal Cases 13. MRS- Medical Record System 14. MS- Medical Superintendent 15. OPD- Out-patient Department 16. RKS- Rogi Kalyan Samiti 17. RSBY- Rashtriya Suraksha Bima Yogna 18. SMO- Senior Medical Officer 19. TAT- Turn Around Time

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TABLE OF CONTENTS
1. HiSPindia Profile««««««««««««««««««««7 2. Introduction«««««««««««««««««««.««....9 3. Operational Plan««««««««««««««««««....«.11 3.1 Need Assessment for HIS««««««««««««.««..11 3.2 Initiating the Process«««««««««««««««.«.12 3.2 (a) Demo of OpenMRS (HIS) in Hospital 3.2 (b) Review of Existing Process 3.2 (c) Requirements Based on Review of Existing System 3.2 (d) Meeting on HIS implementation 3.2 (e) Action Plan for HIS implementation 3.3 Procurement of Software/Hardware Support«««««««....23 3.4 Module Implementing«................................................................24 3.5 Training Session/Capacity Building for the End User«.««....46 3.5(a) Training Objective«««««««««««««.....«46 3.5(b) Identification and Assessment of Training Need«««...46 3.5(c) Basic Requirements««««««««««««««....46 3.5 (d) Training Plan««««««««««««««««.....47 3.6 Dry Run«««««««««««««««««««««........ 49 3.6 (a) Testing the Application for 10-15 days«««................«.49 3.6 (b) Hands on with End Users (nurses and doctors)................«50 3.7 Going Live Process«««««««««««««««««««50 4. Conclusion«««««««««««««««««««««««...«51 5. Case study«««««««««««««««««««««««...«.53 6. References«««««««««««««««««««««««...«.58 7. Annexure««««««««««««««««««««««..............59
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ABSTRACT
Introduction Innovation in Healthcare Information Technology (IT) has fueled unprecedented gains in improving the medical field over the last 30 years. Today, IT companies with their healthcare verticals are an important engine to drive growth for hospitals getting automated. A Hospital Information System (HIS) is an integrated information system designed to manage the administrative, financial and clinical aspects of a hospital. HIS is vital tool in decision-making and plays a vital role in the success of any organization. Computerization and automation of the medical records and their documentation has resulted in efficient data management and exchange of information for the users. With the help of HIS, managers, clinicians and other healthcare workers can access the information without any delays or errors.

Aim The primary aim is to establish an approach for implementing HIS (Hospital Information System) in Dean Dayal Upadhyay Hospital (Ripon), Shimla, which is already an established and functional government hospital. The approach should be such that it aligns to support the mission, vision, goals, objectives, and strategies of DDU.

Objective Articulating and communicating the right vision and mission for HIS implementation project, committed involvement of the top management of a hospital and persistent training of the actual end users.

Methodology The following practices, grouped into management processes, helps in the implementation of HIS in Hospitals:(1) Assessing the complete requirements of the Hospital and the end-users (2) Designing an existing flow and analyzing the gaps (3)Optimizing the workflow (4)Preparing the users by imparting high level training and capacity building 5|Page

(5)Transforming the system with live implementation, (6)Sustaining and providing support.

Conclusion The implementation of HIS in DDU would result in the following (1) Reduced cost (2) Improve quality (3) Standardize Workflow (4) Better Management Control

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1. HiSPindia PROFILE

HiSPindia is a not-for-profit NGO specializing since more than a decade in designing and implementing solutions in health informatics for the public health sector in Indian states, and also recently in Bangladesh and Sri Lanka. It is not a solely technology focused organization, but a multi-disciplinary organization concentrating on the domains of public health and informatics. The organization has a strong commitment to free and open source technologies, and works with a global perspective of the Health Information Systems Programmes (HISP) network, coordinated by the University of Oslo, Norway, and is active in more than 20 countries in Africa and Asia. HiSPindia has a registered and head office in New Delhi, and project offices in Kerala, Himachal Pradesh, and Punjab. The team members are intensively travelling to different parts of the country to provide technical support services. 1.1 VISION ³To enable and coordinate a network of excellence in public health informatics, specializing in integrated health information architectures, with a geographical focus on South-East Asia.´ 1.2 HISTORY In 1999, an informal group of idealists got together to start a project in a primary health centre in the remote villages of Kuppam, Chittoor district in Andhra Pradesh. These efforts were supported by the University of Oslo, Norway, and had initial partnerships with IIM Bangalore and ASCI Hyderabad. During the first five years, it remained focused on Andhra Pradesh and carried out implementations of the first version of the DHIS software application. From 2005, it started to work in the State of Kerala first in one facility and by 2008 all the facilities were reporting data in the DHIS2. The DHIS2, which is a global standard today for facility reporting, took birth in a clinic in Kerala in 2006. The achievements in Kerala prompted the state of Gujarat 7|Page

first, and then Jharkhand and Madhya Pradesh to initiate DHIS2 implementations. This led to collaboration in 2008 at the national level with National Health Systems Resource Centre (NHSRC) to provide technical support on DHIS2 nationally. About 25 states took up DHIS2 in 2008. Today, HISP has gained international recognition, and has also been invited to provide technical support in Bangladesh, Sri Lanka, Rwanda, and Philippines. 1.3 GEOGRAPHICAL COVERAGE With a 30 team members, HISP has a strong national and global coverage of work. In India, it has worked in at least 90% of the states, and currently has a presence in about 20 states. Internationally, HiSPindia has worked in Bangladesh and Sri Lanka, and on an individual basis, experts have contributed to Global HISP activities in various countries including Vietnam, Tanzania, Zanzibar, Ethiopia, Mozambique, South Africa, and those in West Africa.

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2. INTRODUCTION
Over the last few decades, medical sciences have significant progress leading to improvements in the modes of investigations, therapeutic activities and surgical procedures. This has enhanced the need to have authentic and accurate medical records of the patients. Health Information System (HIS) is one of the most promising applications of Information Technology (IT) in the Health Care Sector. The aim of HIS is to use a network of computers to collect, process and retrieve patient care and administrative information from various departments for all hospital activities. It also helps in decision-making for developing comprehensive health care policies.

2.1 CONTEXT AND CONCEPT The HIS comprises of an electronic patient record which forms the core of the system and links it to all other departments in the hospital where every department can be viewed baas an information-processing agency. Present health Information system reveals that the existing system at DDU Hospital requires up-gradation to meet the requirements of the managers and the clinicians. The management at DDU feels HIS assists in decision making, and medical audit. It is also felt that the existing HIS resulted in longer time for OPD consultation and delay in investigation results.

2.2 ADVANTAGES OF HOSPITAL INFORMATION SYSTEM y HIS is based on the exemplar of a centralized information system designed for quick delivery of operational and administrative information. y The administration can actively use HIS for monitoring and controlling the quality of patient care. y Helps in providing improved clinical outcomes and better diagnosis and care to the patients. y The administrative and supply chain modules improve productivity and efficiency, driving down costs and waste.

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y

Assesses the performance of the medical staff; in keeping track on how hospital¶s resources are being put to use.

y y y

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

y

Improved monitoring of drug usage, and study of effectiveness.

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3. OPERATIONAL PLAN
The implementation of HIS can succeed if the following two conditions are met y y A consistent organization of people and processes A clear choice for the establishment of infrastructure (hardware & software) backed up by financial investment. DDU¶s hospital management is informed, thorough and methodical. Within this hospital, implementation of HIS is based on computerization of care processes as well as support processes like registration, billing, logistics etc. to ensure coherence of clinical and business activities of the hospital.

The implementation of a HIS is a complex procedure. It requires being operationalized step-wise with optimum support to enable the users a confident approach towards using the system thereafter. HIS implementation cannot be done at once for the entire hospital as it might become complicated. Hence a module-wise approach was taken for implementation depending on the priority of modules as mentioned by the hospital authorities.

Following steps were undertaken for HIS implementation -

3.1 NEED ASSESSMENT FOR HIS
Assessment is the first component of the HIS implementation framework. This step gives the organization the opportunity to carefully examine its current state, actual needs and the readiness to accept a cultural and organizational change. This process engages the clinicians, physicians, paramedical staff, and support workers directly or indirectly linked with the hospital. The main important needs of DDU for HIS realized werey y To create Electronic Patient Medical Records. Allow monitoring of the health care services provided by the hospital to the patients registered in DDU. A data warehouse of such records can be utilized for statistical requirements and for research. 11 | P a g e

y y y

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

y

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

y y y

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

3.2 INITIATING THE PROCESS
HiSPindia followed 5 major steps in the initiation of the implementation of HIS in DDU hospital in Shimla. These steps include-

3.2(a) DEMO OF OpenMRS IN HOSPITAL About OpenMRS OpenMRS was created in 2004 as an open source medical record system platform for developing countries. OpenMRS is a multi-institution, non-profit collaborative led by Regenstrief Institute, a world-renowned leader in medical informatics research, and Partners in Health, a Boston-based philanthropic organization with a focus on improving the lives of underprivileged people worldwide through health care service. OpenMRS is now in use around the world including South Africa, Kenya, Rwanda, Lesotho, Zimbabwe, Mozambique, Uganda, Tanzania, Haiti, India, China, United States, Pakistan, the Philippines, and many other places.

It is community developed software which enables to design customized medical records without any programming knowledge, only medical and systems analysis knowledge is required. It uses minimal free text and maximum coded information making it easier to summarize and analyze. Its core is a Concept Dictionary which stores all diagnosis, tests, procedures, drugs and other general questions and their potential answers. 12 | P a g e

In a meeting with the hospital authorities and end users of the software, a detailed demonstration of OpenMRS was given in order to acquaint them with the software, how it looks and works like, together with its linked benefits to the hospital. The following features were shown:
y

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

y y y

Security: User authentication Privilege-based access: User roles and permission system Patient repository: Creation and maintenance of patient data, including demographics, clinical observations, encounter data, orders, etc.

y

Unique identifiers per patient: A single patient will have a unique identifier which will be used across the system to search that particular patient.

y

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

y

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

y

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

y

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

y y

Patient merging: Merging duplicate patients Reporting tools: Flexible reporting tools

3.2(b) REVIEW OF EXISTING PROCESS In order to develop HIS for DDU, first there was a need to understand the hospital in different spheres which enables one to magnify the horizon of growth and invention required. It is only after reviewing the current functionalities and existing process that the hospital¶s layout can be determined to be placed in future virtually.

While doing so, following were the observations13 | P a g e

Registration In DDU, computerized registration was done and there was only one counter for registration bearing a daily patient load of around 1000 to 1500 patients per day. The screen shot of registration slip (prior to HIS implementation) wasName: Age: F/M ±H-C/O Name: Gender: Department: Unit: Category: District: State: Old patient: (General/ IRDP/ Poor free/ BPL/ RSBY/ Senior citizen/ Others) Area: (Himachal/ others) (-, yes) (male/ female/ male child/ female child/ unknown) *(department with room no.) Registration no: (Years/ Months/ Weeks/ Days)

There are 16 departments in the hospital and the list of department is as follows: Department Physiotherapy Ortho OPD X-Ray Gynae OPD Children OPD General OPD Medicine OPD Eye OPD Surgical OPD Room No. 4 7 8 11 12 24 25 27 28 14 | P a g e

ENT OPD Dental OPD ECG Casualty T.B clinic Leprosy clinic Skin OPD/ STD

29 30 31 33 34 35 38

The operation time for the registration is 8.45am to 3.45pm and maximum hourly load is 200. Computers Printers Ups HR- data entry operators 1 1 1 1

Reports prepared for registration were: y Male Age wise OPD Report: Female Male Child Female Child Male citizen Sr. Female Sr. citizen

y S. no

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

Billing The hospital had a centralized billing process before the implementation of HIS, where billing for all services is done at counter number 2. y Existing process of billing services through OPD- A patient after having gone to a respective out-patient department, when advised certain tests or investigations by the doctor, goes to the billing counter and pays for the investigations to be conducted. The billing clerk generates a computerized bill and stamps it after the patient has paid. The 15 | P a g e

bill along with the OPD slip will then be taken to the respective department where the investigation has to be conducted.

Patient registers and goes to OPD; doctor advices for tests/ investigations

Patient goes to billing counter and a bill is raised for the tests/ investigations to be conducted

Patient pays and the billing clerk stamps the bill

Patient goes and gets the x-ray done

The BPL and poor patients are provided all services free of cost. The laboratories of all the national programmes (ICTC, RNTCP/DOTS, NLEP, Family planning, IDSP) conduct the tests free of cost for all patients i.e. the investigations conducted by these labs are not billed for.
y

Existing process for billing services through IPD: A patient admitted in the IPD is billed only for procedures and investigations. All other services of the IPD ± bed, diet etc are free of cost. For any investigations and procedures to be conducted, the patient goes and pays for the service at the billing counter, after which the test or procedure is conducted. At the time of discharge, a discharge summary is prepared by the respective department, where the patient has been admitted and sent to the billing counter. The patient goes there to clear any dues after which he/she is given the discharge.

Patient is admitted in the IPD, advised tests/ procedures by the doctor

Patient goes to the billing counter, gets the services billed for and pays for them

Patient goes to the billing counter, gets the services billed for and pays for them

The discharge summary is sent by the IPD to counter no 2; any balance dues are cleared by the patient

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y

Current/ Existing process for medical examinations: The hospital conducts medical examinations on people for various purposes (it may be for getting a government job, for driving license, as a part of the routine process for any organization etc.). For administrative and billing convenience, the medical examinations are divided mainly into 2 categories:  Medical examinations ± Gazetted: This is for government employees, who are sent by their respective departments for medical examinations. The person first has to deposit the medical examination fee (Rs 200) at the billing counter, after which he/she goes to Room no 21, where the patient is given 3 copies of the medical examination form. At the end of the examination, one copy is retained by the hospital, one is given to the patient and one is sent directly by the hospital to the department from which the patient has come. Behind each form, a stamp containing the details of the departments to be visited, along with the room numbers is put: Eye (Complete Checkup) ««««««..27 Blood & urine testing«««««««««.37 Chest X-ray«««««««««««««««08 Blood grouping««««««««««««..32 ENT checkup««««««««««««««.29 Ortho unit«««««««««««««««..07 Gynae unit (only for females)««««11 Medical unit«««««««««««««24/25 Surgical unit««««««««««««««.28

The patient then visits each of these departments and the doctor at each department writes his/her observations either in the place provided in the form, or against the department name on the stamp. After having visited all the departments, all the 3 copies of the forms come to the S.M.O, who then certifies the patient, based on the observations of the various departments. 

Medical examinations - Non-Gazetted: The only difference between the gazette and non-gazetted is that, for non-gazetted, the patients bring their own forms, 17 | P a g e

from their respective organizations, and the stamp is put on their form. The charges are Rs. 100.

Inventory The Inventory/General store is the main store at DDU. All Receipts come to the Main store and from here items are dispensed to sub-stores on the basis of the indent order raised by them. Laboratory There are mainly five types of tests that are conducted in the lab. These are biochemistry, hematology, serology, cytology and urine examination.

Patient registers and goes to OPD; doctor advices for tests/ investigations

Patient goes to Room no 31 where the bill is raised

Patient goes to billing counter where the dues are paid and the clerk stamps the bill

Patient goes to the lab and gets the tests done

There are two receipts handed over to the patient at billing counter, one receipt has to be handed over to the lab technician and the other is retained by the patient. The patient then goes back to the lab where his sample is collected and entered in the registers of the lab.

IPD In DDU hospital there are 4 nursing stations catering to 14 wards, the patient flow in IPD will start with OPD from there the doctor will advice to patient for admission. Patient will be referred to the particular ward where the details of patient (demographics, bed number, provisional diagnosis and income) are entered in the admission register. In the ward, dispatch register is

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

Registration

OPD-doctor advises admission

Ward-patient is entered in admission register and admission no is issued

Treatment begins

Pharmacy In DDU hospital pharmacy is working with one counter. There are 51 drugs in their stock and the patient gets these drugs for free. Patients come to the pharmacy to receive the medicines prescribed by the doctors. If the medicine/drug is available in the pharmacy, the patient is given the advised dosage. The stock in the pharmacy comes from the hospital inventory. The Pharmacist performs the tasks of raising indents, receiving transfers from Main store and Issuing drugs to patients. He enters the details of patient and issued drugs details to particular patient in register.

Blood bank Blood bank at DDU is a unit which functions independently from the hospital, under the Himachal Pradesh state AIDS control society (HPSACS) and the blood bank society of the state, chaired by the DC. Issue of blood is done either by replacement or by payment of Rs. 45 per unit for government hospitals and Rs. 750 per unit for private hospitals. The blood bank issues blood when they receive request from DDU or any other hospital. The blood is issued in the following manner:

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Request for blood- form filled by doctor at DDU

Bllod bankchecks for availability

Patient pays for the blood/blood is replaced by donation

Cross matching details are written C.M is issued

Blood issued

3.2(c) REQUIREMENTS BASED ON REVIEW OF EXISTING SYSTEM After understanding the existing patterns of DDU hospital in regard to patient flow, hospital workflow, clinician¶s requirement, the next step is to find out the specific requirements in context of the HIS to be developed for the hospital. These are known by discussing with the hospital authorities and also by self observation of the existing processes done earlier. A comprehensive understanding and documentation of these features are the keys to success in this phase.

The requirements can be either functional (comprising of business/ end users) or non-functional (comprising of technology). There are several ways to gather information-

y

Interviewing- It includes asking the potential end users (doctors, nurses, technicians etc ) of the software a set of questions to analyze their need and attitude towards the transformation from the conventional way to the modernized version. Personal interviewing helps in judging the level of computer literacy among different users and thereby helps to determine the depth of training required accordingly.

y

Focus group discussion- The methodology lies in getting together the people of same background ( like doctors in a group or nurses in another) to commonly discuss their requirements as well as give suggestions. 20 | P a g e

y

Surveys- It is a way to observe the system workflow by enetering the workflow as a consumer/patient in order to understand the requirements from the patient point of view. its principle underlies the study of time and motion in a hospital so as to create a system to complement the existing processes.

y

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

SHADOWING

SURVEYS

WAYS TO GATHER INFORMATION

INERVIEWIN G

FOCUS GROUP

There are several sources of informationy

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

y

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

y

System- Existing application and its functionalities.

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PEOPLE

SOURCES OF INFORMATION

SYSTEM

MANUAL

The next step is Documentation. It is the process of compiling and aggregating the observations. It is a kind of conclusion that the fact or statement is true, done with a purpose to support a tool or a process. It is a kind of written information, a prototype of the existing system, requirements and information in the form of text, photos and physical evidence.

3.2(d) MEETING ON HIS IMPLEMENTATION Once the lists of requirements were compiled based on hospital¶s input and our own observations, a meeting was held with the hospital authorities. Based on these observations, a proposal was compiled by the HISP team comprising of the requirements that the system would bear, the functionalities of system as well as other generated records that would be provided. The proposal was to be studied by the hospital team thoroughly. A round of discussion, cross questioning and explanation were held to clarify and put across the real picture of the proposal to the hospital team. Also their suggestions were put into consideration. With mutual agreement,

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

3.2(e) ACTION PLAN FOR HIS IMPLEMENTATION After having a consigned agreement with the hospital for customized development of HIS, the next step undertaken was to convey the entire requirements to the developers¶ team and thus develop a plan of action regarding the same. It is the most crucial step, where the information gained was translated to the developers in order to enable them to customize and develop the software exactly the way it was desired by the hospital. The developers work on different modules that would be working in the hospital. They modify each module and specific fields and functionalities, such that the software becomes most suited and easy to use for the hospital users. Thus, this the developing stage of the software in terms of customization.

3.3 PROCUREMENT OF SOFTWARE AND HARDWARE SUPPORT
Installation and configuration of server: In DDU there are currently 26 computers that are networked to a server running Linux Ubuntu 10.10. It is being shared on 10/100mbps LAN connection. DDU has new branded HCL computers and HP LaserJet Printers. Their network is also wiring all CAT6 in organized way and connect to switch¶s via patch panel in racks. The hardware that connects to the network arey y y y Servers Workstation Print Servers Printers / Copiers

In order to install the server, first Tomcat Servlet was installed. Apache tomcat is an open source servlet container. Tomcat implements java servlet and extracts the war file. war file will come with application (openMRS). After installing the servlet, database with mysql is created. mysql is a open source database which connects the application(openMRS)to database. OpenMRS default modules will be diverted and the customized modules will be installed manually.

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3.4 MODULE IMPLEMENTING
In DDU, modules were implemented in phases to avoid various problems in the transition of old system to new system. as in doing so the problems which are faced during the implementation are rectified then and there only by making appropriate changes. During the process of rectification of new system, old system can be utilized to run without any hang up in the system. The various modules in DDU were implemented in two phases y Phase I- In the first phase of implementation the following modules were implemented  Registration  Billing  Laboratory

Registration module The module involves capturing and recording patient demographics and visits at the point-ofcare. Registration data will be displayed consistently and automatically on screens in the clinical system. The system generates a unique registration number for each patient (CR. no.), this is an auto generated 16-digit number comprising district, name of hospital, date, time and serial number that will appear on the OPD slip issued to the patient and will serves as µidentifier¶. All referral Patients under National Health Programme including TB Leprosy, Except HIV will be directed through this central registration.

Currently in DDU, there is one registration counter from where online OPD registration is done. There are two computers and two data entry operators. Registration is done from the registration counter in the routine OPD timings and emergency registration is done from the casualty department for the patients who require immediate medical care.

The registration clerk logs in to the system by entering the billing clerk-name and password in the home page and then selects the find/create patient from the navigation menu. After clicking on the find/create patient option, following registration page will be displayed.

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The registration clerk then adds the details of the patient in the various fields of registration. y y Patient name Demographics- age and gender. The age of the patient falls under the following categories. 
  

0-12 yrs-Child 13-19 yrs-Adolescent 20-59- yrs Adult 60+ yrs-Senior Citizen

y

Relative¶s name ± The registration clerk would have to enter either the father¶s name, or the husband¶s name.

y

Referral information- The registration clerk would have to select the appropriate option for µreferred from¶ from the drop-down list which includes PHC, CHC, SDC, SC, other district hospitals and private institutions. The registration clerk would then have to select the appropriate option for µreferral type¶ from the drop-down list.

y

Patient identifier - An auto generated 16 digits ID Number would be generated by the system, which would appear on the registration page. This number would be unique to this particular patient for life.

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y

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

y

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

y

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

After having filled all the above fields, the registration clerk would have to select the µSave¶ option. Following which the system would generate the OPD slip, as shown in the screen-shot below. The registration clerk can then select the µprint¶ option to print the OPD slip generated.

In-case multiple patients with the same name exist, µadvance search¶ option helps to filter the patient by gender, age, date of registration and relative¶s name and thus the search would be refined. Billing module The Billing module deals in collection of money for services availed by a patient at OPD, IPD and other services other services like Ambulances, tenders, blood bank, fee for medical examinations.

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The billing clerk logs in to the system by entering the billing clerk-name and password. To generate a bill for a patient, the billing clerk would have to select the µbilling¶ option from the navigation menu. On selecting the µbilling¶ option, a screen as below will be displayed.

The billing clerk would be able to bill for 4 main services of the hospital: y Patient services ± Patients are billed for various investigations/ tests are prescribed by the doctors in the OPD¶s. The patient to be billed for is searched and selected through patient name or identifier. A screen will be displayed showing the billing history of the patient and a new bill is raised by selecting the µadd a new bill¶ option. On selecting µadd new bill¶ option, 9 major categories which are further divided into sub categories of the services provided by the hospital are displayed. These are blood bank, dental department, general laboratory, hospital charges, national programme laboratories, physiotherapy department, radiology, radiography and cardiology. From the appropriate category the desired test to be billed is selected. Multiple services from different categories can be selected. After having selected all the services the bill is saved and the dateails of the current bill are displayed. An option to print the bill and the billing history of the patient is displayed. y Ambulance services Money for each trip is paid by the patient to the driver of the respective ambulance who then deposits the money collected at the billing counter at the end of the day. To bill for ambulance services, the billing clerk would first have to select the µbilling ambulance¶ option, on the main billing screen and then search for the driver in µsearch driver¶ field and select the appropriate driver for whom a bill has to be raised. 27 | P a g e

A new driver can also added, using the add driver functionality ± on selecting the µAdd new driver¶ option. To add a new bill for the selected account, the billing clerk selects the µadd new bill¶ option. On selecting the required service, the price assigned for that service would be populated in the table at bottom. y Tenders - The tender fees or the amount to be paid to be able to bid for the tender) is deposited by the company bidding for the tender at the billing counter. To bill for a tender, the billing clerk first selects the µbilling tender¶ option, on the main billing screen and then search for the company name in the account name field. To bill the company for a tender, the billing clerk selects the µAdd new bill¶ option. To add a new company name µadd new company¶ option is selected and details of that company is entered and saved. The billing clerk then selects the tender to be billed for and appropriate tender is selected and the price assigned for that tender is populated. y Miscellaneous services ± other services that are not covered in the above 3 categories e.g. student internship fees. To bill for µmiscellaneous services¶, the billing clerk would have to select the µbilling miscellaneous service¶ option from the main billing interface and then click on add miscellaneous service bill option. The billing clerk would then have to select the appropriate service for which the bill has to be generated. Once the service has been selected, the billing clerk would have to enter the name of the person, for whom the bill has to be generated. Then the bill is saved and printed.

Laboratory module In DDU online Laboratory Module operates for Laboratory services. All lab orders are directly routed through the billing module. The laboratory technician first logs in to the system by entering the username and password in the home page. To go to the lab entry, the µLab Entry¶ icon is selected. Here the laboratory technician can select 4 main functions: y y y y Lab Entry System Work List Enter Result Print Patient Report 28 | P a g e

Lab Entry System This is a display of all the investigations for all patients that are rooted from the Billing module. Laboratory investigations can be accepted or rescheduled within this function. To be able to identify a given patient, the laboratory technician first finds the patient on the system and identifies the investigation(s) to be carried out. This can be done by using the filters available on the top of the page-date, patient name/ID and Lab sub divisions. After having selected the filters, the lab technician selects the µGet Patient list¶ option. (Selecting µGet Patient List¶ without choosing any filters would display the entire list of lab orders received by the laboratory.)

Then after the list of patients along with the tests to be performed appears. On identifying, lab technician accepts the request or to reschedule the request for another day. Accepting the test changes the background to green and a Sample ID is generated as shown below. Choosing to µReschedule¶ option prompts the lab technician to enter a date to reschedule to.

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Work List The work-list facilitates the finding and printing of a list of accepted investigation for each subdivision of the laboratory. This list is printed out as hard copies. The Printed worklist also provide a space to report on the various investigations conducted.

Enter Result It facilitates the entering of test results into the system. To achieve this lab technician has to select date and select lab in which to enter result then click on µGet Work List¶. This displays the Work List¶s along with displaying an additional filter to select test. On selecting test the displayed list allow provide an option to µEnter Result µin the work list. Clicking on entering result displays a screen on which individual results for the test can be entered. After the lab technician enters the result date of result entry has to be entered then only will the results be saved on clicking the save button. There is an option to cancel result entry for a particular patient. If the test could not be performed on the sample and sampling has to be reordered the lab technician has the option to reorder sample. This is done by checking the reorder test check box. Activating the check box prompts the lab technician to selecting a date and clicking the save button transfers the lab order to the selected date.

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Print Patient Report Provides the option to print test results for various investigation conducted for a given patient on a given day. On selecting the µPrint Patient Report¶ option the system prompts the lab technician to enter name of patient and date for test to be printed. Entering these details and clicking µGet Patient Report¶ displays, patient details and the results of all the test reported on that day along with known normal ranges for the tests. The bottom left corner of the page displays an option to µPrint¶ the test report of the patient.

y

Phase II- In the first phase of implementation the following modules were implemented  OPD  IPD 31 | P a g e 

Inventory  Pharmacy  Blood Bank

OPD module The OPD module forms the heart of the system that maintains the electronic medical record for each patient reviewed by the doctor. The OPD module in DDU is made functional in 10 OPD¶s. Each OPD has a computer set-up to be operated by the respective doctors. The module screen consists of two major parts- the patient queue and patient dashboard. Once the patient is registered in the registration counter, his/her name appears in the patient queue of the OPD he/she is registered for. On reviewing the patient, the doctor clicks on the identifier of the patient. The screen that appears here is the patient dashboard. The patient¶s diagnosis, procedure can be entered. Through this dashboard, the clinical summary/medical history, results of all investigations and in-patient record can be viewed across the hospital. On entering the username and password, a screen as shown below appears. The doctor will have to select the respective OPD from the drop-down list.

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On the main OPD interface screen, the doctor would be able to view 3 main options ± y Patient queue ± This is a queue of patients who have been registered for a particular OPD on that day . y Search patient in queue ±This is a functionality to search for a patient in the queue ± the patient can be searched by his/her name or identifier y Search patient in system ± If the patient has not visited the registration, he/she will not be visible in the patient queue. The doctor would then have to search for the patient in the system by either name or identifier.

Details of the patient ID, Name of the patient, Age and Gender of the patient are displayed in the queue. Also the details of referral type i.e. if the patient is a new patient, a revisit patient or has been referred from some other OPD. E.g. in the screenshot as ahown below, patient µRam¶ has been searched for, a list of all the patients with name µRam¶ will be displayed. The doctor then select the appropriate patient by matching the age and the identifier.

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Now the next step is to make entry for each patient, or to view the previous clinical summary/medical history. The doctor would have to click on the name/identifier of the particular patient in the list. On clicking the patient dashboard appears. The dashboad is an entry review screen, in which medical information regarding patient can be entered and reviewd by the doctor. Following is the screen shot of the patient dashboard as it appears.

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It has the following features y OPD Entry ± This has been designed keeping in mind the long patient queues and minimal time per patient for each doctor, and hence caters to minimal data entry. It has two mandatory data entry fields ± provisional diagnosis and concluding a visit. A list of diagnosis has already been provided in the system. On having selected the appropriate diagnosis, it will be moved to the box on the right. This would indicate that the diagnosis has been selected. In-case the doctor would want to add any specific details, there is a provision to add a note. y Clinical summary ± Here the doctor would be able to view all the entries that have been previously made for each patient. y Investigation report ± The doctor is able to view the results of all the investigations that have been conducted on the patient as prescribed. y IPD record ± The doctor is able to view the admission and discharge details of the patient. The doctor could also refer a patient internally within the hospital to any other OPD. The doctor would have to choose the appropriate OPD to which the patient has to be referred to from the dropdown The doctor then concludes the visit by selecting either of the folllowing options ± y y y y y Follow up and selecting a follow up date Cured Died Reviewed Admit. On selecting the µadmit¶ option, the doctor would have to select the appropriate ward to which the patient has to be admitted.

IPD module The end-user log in to the system by entering the username and password in the OpenMRS home page. The end-user selects the µIPD¶ option from the navigation menu. Once the IPD option is selected, the end-user would be able to see a following main IPD interface screen:

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Here the end-user would be able to view 2 main options y Patients for admission: This a queue of patients who have been refered to a particular IPD by the doctors in OPD. . Details of the patient ID, Name of the patient, Age, Gender, ward to which the patient has been admitted (E.g.: Female medical, male medical) and name of the OPD doctor, who made the admission would be visible to the end-user. y Admitted patient index: This a list of patients who have already been admitted to the various IPD wards. The end-user has the choice to filter the list (in both the tabs ± patients for admission and admitted patient index) using multiple criteria ± By patient ID, IPD ward, tereating doctor, and date of admission. In the list of µpatients for admission¶, against each patient on the list, the end-user would have the following three options:

y

Admit- The end-user would have to enter the details of caste, monthly income, basic pay and bed number and then select the µsubmit¶ option, after which the patient will now be transferred to the µadmitted patient index¶ and an admission slip will be generated. A print out of the same can be taken. 36 | P a g e

y

Remove- If a patient does not show up in the ward, the patient¶s name can be removed by selecting this option.

y

No bed- In-case of unavailability of beds, the end-use selects the µno bed¶ option; to remove the patient from the queue.

In the µAdmitted patient index¶, the end-user can see the patients who have been admitted in different wards of the in-patient department. The end-user will be able to see the details of admission date, patient ID, name, age, gender, and the particular ward where patient has been admitted and admission by which OPD doctor.

Here the end-user can perform 3 operations for each admission ± y Transfer- The end-user uses the µtransfer¶ option, in-case of transferring of a patient from one ward to another, internally within the hospital. y Discharge- The end-user uses the µdischarge¶ option to discharge a patient from the hospital. The end-user would first have to select a µdiagnosis¶ for the patient. This is a mandatory field. The end-user would then select the discharge outcome of the patient from the drop-down and select the µsubmit¶ option. y Print

Inventory module The Inventory is the main-store at DDU. All Receipts come to this Main store and from here items are dispensed to sub-stores on the basis of the indent raised by the sub store. Inventory consists of the Main Inventory Store and 28 Sub stores which indent from the Main Inventory store. Categorization of Inventory Items in the Main Inventory Store 37 | P a g e

Vital

Drugs

Essential

Desired Inventory Linen, Electric spares, Medical consumales, office supplies Furniture, Electric Equipment and Medical Equipment

Consumables Other inventory items Dead stock

Online Inventory module will operate for Hospital Main store. Online Inventory module will be based on all stock items listed in the Main Store Stock Registers. Each Department/Sub store will raise an indent for transfer of stock after the approval from the Medical Superintendent. General Store/Inventory will transfer stock to respective sub stores. In case the Main store is out off stock and needs to purchase some items, a purchase Indent/order needs to be raised by the Inventory Manager. On receipt of the items , the same will be entered under a receipt no. by the Inventory manager into the stock list at the main store before transferring them to the substore that had indented those items. The Inventory manager logs into his system with username and password. The screen that appears displays a list of operations that the Inventory manager can perform for both Drugs and Inventory Items.

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The lists of operations are: y View Stock Balance for General Store- This functionality enables a user to View the current stock in terms of Name of Item, Sub Category that it belongs to, Available Qty and Reorder Point. y View Stock Balance Expiry- An inbuilt alert mechanism has been built in, whenever a drugs approaches its expiry (3 month advance) it will shown an alert message. The drugs will turn red. y Receipts to the general Store- This functionality enables the user to add receipts to the general store. The Inventory manager receives items that have been purchased. He then enters that stock as Receipts to the general store. Every Receipt that has been entered has a name/Description which is distinct and contains a list of all items that have been received under that Receipt. A print out of this receipt can also be taken. y Tranfer to Sub Store- This functionality enables the Inventory Manger to tranfer the items to Substores example ³Transfer from General Store´ . Press on the Tranfer From General Store Tab and the following window appears. This process is separately done For Items (It displays balance of all stock items available in the inventory on that particular date viz Name, Sub Category, Specification , Available/Current Qty, Reorder Point.) and For Drugs (It displays balance of all stock items available in the inventory

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

Status: Once the indent has been received by the general store with due authorization the following three status are encounteredy The status Done refers to a condition when indented items have been transferred to the Sub store by the main store and has been accepted by the Sub store manager y The status Sub Store Refuse refers to the condition when the indented items that have been transferred to the Sub store but have been refused by the Sub store manager. y The status Wait Process refers to a condition when the indented items have been transferred to the Sub store by the main store but has not yet been processed at the Main store. Administration Functionalities y y Manage Store- This functionality enables the Inventory manager to create new Stores. Manage Item- This functionality enables the Inventory Manager to index a new item. By clicking on Manage Item the following screen appears with list of operations- Manage Category, Manage Unit, Manage Subcategory, Manage Specification and Manage Item.

y

Manage Drugs- The functionality enables the inventory manager to either add or view drugs. The functionality enables the inventory manager to either add or view drugs with list of operations- Manage Category, Manage Unit, Manage Formulation and Manage Specification.

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Pharmacy Module It enables the Pharmacist to perform the tasks of raising indents to main store , receiving transfers from Main store and Issuing drugs to patients. Patient comes to Pharmacy with prescription and the medicine /drug (if available) is given in advised dosage and an online entry is done. The stock gets automatically updated. The pharmacy is also here linked with Main Store and through the system only the Indents are sent and processed. The drugs in Pharmacy are classified asy y y Essential Vital Desirable

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

y View Stock Balance- shows the current stock list of drugs available in the Pharmacy in terms of opening balance, balance at hand and the unit price. A search Function based on category of a drug and by the Name of drug is available to dill down to a particular drug is there. It also shows, drug been received or issued, Opening balance, stock transferred/issued and closing balance date of transaction y View Stock Balance Expiry y Indent for Drugs- To add a new indent pharmacist Clicks on the add indent Slip and the following window appears

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After selecting different drugs, by selecting from their respective categories, and required quantity, each is added to the indent slip and the final slip is saved and µsent¶ to the µMain Store¶. As per the reply from Main store, the status of indent can be either µProcess Indent¶ ( replied from main store need to be processed in pharmacy i.e to accept or refuse), µSent¶ (sent by pharmacy, not yet processed by main store), µReceipt¶ (accepted and received by pharmacy),¶ Main Store Refuse¶ or µ Sub Store Refuse¶.

y Issues Drugs to patient ±patient from OPD comes with the prescription. The pharmacist, finds the drug by selecting the category and formulation, the drugs are displayed with the Date of Manufacture, Date of Expiry, Company name, Batch No. and Quantity available. The drug is added to the µindent slip¶ by µadd to indent slip¶ option, then he µfinds patient¶ by entering his unique code/name. after selecting the patient, his name appears over the indent slip, and its printout is handed over to the patient.

Search functionality is available to search a patient. By typing the name/Identifier of the patient (alone) or along with the period (Start date/End date) will search a patient to whom Drugs have been issued.

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

Blood Bank Hospital Blood Bank under online Blood Bank module will be based on availability of blood of various blood groups in the blood bank stock. Each donor will be first registered and then his blood sample will be tested. Only if all the tests administered on his sample are negative, his blood will enter the blood stock else it will be outright rejected. The blood is categorized under different blood groups and the donor¶s secrecy is maintained. The blood issued to the recipient will be mapped against the donor and after each disbursement the stock gets updated. The module enables the technician to add stock of blood in the inventory after administering lab tests and issuing to respective patients after cross matching.

y

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

After saving the information, click on the edit button. A questionnaire pops up which is to be filled for very patient which is the Patient Registration Slip.

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y

Administer Lab tests for Donors Blood Sample ± after clicking on the Lab Tab and the following window appears. As seen here the donor¶s name and id appear whose registration and questionnaire was filled in the previous screen shots. To add the test results of the donor click on the add test data and the following window appears.

Only if all the blood tests are negative, only then this blood enters the stock else it is outright rejected and doesn¶t enter the blood bank stock. y View Stock and Issue blood after cross matching - . The stock of blood is categorized under various blood group categories. To issue blood to a particular patient the blood group of the patient and donor are matched and press the Issue icon. against a particular the donor , the recipient patient details are added and the blood is issued to the respective recipient

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The blood bank in DDU functions under the National AIDS control program hence a vertical system of management and reporting is followed, in concern to which the functioning of Blood Bank Module is withheld till the time concerned authorities grant permission.

Diagram showing module interconnectivity

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3.5 TRAINING SESSION/ CAPACITY BUILDING FOR THE END USER
The most important part of implementing HIS is to train the end users in using the modules. The end users in DDU basically comprises of Doctors, nurses, laboratory technicians, pharmacist, paramedical staff and other clerical staff. It was essentially taken into consideration to plan training in a proper and feasible manner to ensure satisfactory results. At HISP, the training needs of different end users were assessed and planned accordingly.

3.5(a) TRAINING OBJECTIVE Training is required in order to prepare the end users to be compatible and comfortable in using the product developed in the most effective way so that it is accessible by the staff in the full fledged way. Important issues can be discovered to help improve the overall acceptance of the system and usability. It involves delivering learning in regard to product usage and management depending upon the need of different kinds of users.

3.5(b) IDENTIFICATION AND ASSESSMENT OF TRAINING NEEDS y y y y Identify and document the skills required for each job description. Address overall current skill specific training issues Perform a gap analysis to determine where training is needed Identify people who have high potential and provide them specialized training opportunities. y Ensure that resources are allocated and timelines are decided

3.5(c) BASIC REQUIREMENTS All DDU staff that needs to be trained for different modules should havey y y y Basic computing skills Working knowledge of English language Approval from DDU administration for this training To get the information of shift timings of all the users according to that training sessions should be designed 46 | P a g e

3.5(d) TRAINING PLAN y y Training practices for both the clinical and nonclinical staff were planned out Training programme documentation was reviewed to provide training in a standard format y The organization reviewed and commented on the training format and necessary changes were made. Duration of training DAYS 15-20days 45days 20days 10-15days 45days DEPARTMENTS Registration and billing OPD(for doctors) Lab Inventory and pharmacy IPD(for nurses)

Training schedule At HISP, following was the schedule for hands on training in DDU hospital ± y Phase I - Training on computer Basics  Presentation teaching- The first step taken was to provide a classroom teaching session to nurses. Lessons on Introduction to computers and Basics of computers were taught via PowerPoint presentations.  Training for MS word- Introduction to Microsoft Word and commonly used functions like cut, copy and paste was given. Individual training for each nurse was designed in a way to provide thorough knowledge of MS word.  Training for MS Excel- Introduction to Microsoft Excel and commonly used functions like additions, subtractions, drawing charts, making tables etc were taught.  Training for MS Power Point- Introduction to Microsoft power point and commonly used functions were taught.

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y

Phase II - Training about modules  Nurses ± the training schedule was made flexible for nurses as per their work timings. It was arranged in two different shifts ± morning and evening. The total number of nurses in DDU is 54, and all of them were covered in the training schedule. The modules which were taught in the session were inventory, IPD, OPD and Registration module for 1 hour everyday (with a break up of 30mins for inventory module, for IPD 20mins and for registration and OPD module 10mins). The schedule for training is shown in TABLE-1 in ANNEXURE ±1. 

Doctors - the modules which are covered in doctors training programme were OPD, Registration and IPD module. According to each module, duration of training was decided and timelines were set (like 20mins for OPD and 10mins for registration and IPD module). Our major concern was to enable doctor to register patient and make OPD. By doing so, doctors can daily calculate the total number of patients in OPD. The schedule for training is shown in TABLE-2 in ANNEXURE ±1. 

Pharmacist ± DDU has 4 pharmacists. There prime function is to manage the overall supply of drugs, maintain stocks, to make and process indents and to maintain all the records. Thus the training schedule was planned such that to cover the pharmacy module and inventory module. The duration for Pharmacy module was set for 25mins and inventory module for 5mins. The schedule for training is shown in TABLE-3 in ANNEXURE ±1. 

Inventory staff and inventory manager ± in view of functioning of sub-store and main store, training schedule for the inventor staff (30mins) and inventory manager (60mins) were planned. The schedule for training is shoiwn in TABLE-4&5 in ANNEXURE ±1.

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The HISP team then developed various Competency Tests for different users in order to analyze the level of learning imparted and regained by the end users. These were designed differently for different user as per their requirements. Furthermore, these tests were analyzed to track the persons requiring re-training and also to identify those who have best understood the system and so can motivate and help others. The competency tests are presented in ANNEXURE ±2.

3.6 DRY RUN
Dry run is a process where the software developer does a mental run of the program to examine the source code one step at a time in order to determine what the code would do when it would run. In software development, dry run is also known as Static Testing. Here the actual program or application is not used. It is generally done to ensure the apt performance and stability of a program/ product before making it available. It is a process to intentionally mitigate the effects of a possible failure.

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

Once the modules were developed in accordance with the hospital requirement, each of it was put on rigorous testing by the developers. The modules were run offline and checked for every possible error. Each bug was reported with its specifications and details, the level of priority mentioned along with the reporting person¶s name. There forth every bug/error reported was tested to find out the missing link and the problem occurred was sorted unless the bug gets removed from the concerned field. Same process was followed by the team till the time the application becomes mature enough to be carried to the working site and is flawless, hence ready to be used. The practice was continued for a period of 15 days to ensure the smooth working of every module. Every specific field was checked in the registration, OPD, IPD, billing, laboratory, inventory and pharmacy module. The testing is a means of building a strong flawless product so that no interference is seen when the product goes online.

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

Once the schematic testing is conducted the systems were installed in the hospital. Various modules were run in concerned departments. The next step was to train the users, that is, the doctors in OPD, nurses in IPD, staff at registration, the pharmacist and the inventory manager. Hands-on training allows a person not only to hear what tasks need to be completed, but also provides an opportunity to perform the task right then and there. In an ideal situation, a trainer is available with the trainee and provides guidance rather than leaving the trainee on his own to figure out what needs to be done. Hence, under the trainer¶s supervision user performs the assigned tasks. This is how the hands on training were given to the doctors and nurses in order to acquaint them with the system and its functionalities. It helped in coming across with the problems faced by users while operating the system which were solved then and there by the trainer. Thus, the skills are most likely to be stuck with the users. This method was use to get the users comfortable with the system and understand its functioning and also to realize the need and value of such a transformation in the premises.

During hands on training, the feedback from users is taken- any more additions they need, any field which they felt is not required, any more customization, or any bugs confronted by them are noted. They are to be dealt with by presenting them to the developing team which them makes necessary changes to update the existing system.

3.7 GOING LIVE PROCESS
Once all the modules are tested rigoursly and necessary updates done, the system now is mature to GO LIVE. The show stoppers are fixed and permission is taken by the hospital authorities to make system go online. Here, all the system functionalities become operational and the workflow is now done online through the HIS.

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4. CONCLUSION
CHALLENGES y Behavioural reluctance from end users is a big challenge to overcome due to habituation to conventional method of working. Reluctance in the sense that they felt that using computer is just an additional work and not their primary responsibility. y Training of entire staff was a problem due to vast manpower and different work timings especially of nurses. y Enormous patient load in public hospital like DDU causes difficulty in acceptance of the system by users due to work overload keeping them busy. y Acceptance and appreciation of computerization by medical, paramedical and other healthcare specialist as a compliment and not a supplement. y Maintaining patience among users in initial phase when both old and new systems were Underestimation of the complexity of routine clinical and managerial processes. y It was a challenge to bring all the staff with varied levels of computer literacy to the same level of competency. y DDU has an old heritage building, the infrastructure thus posed a threat while creating and installing an intranet in the premises. y y y y y 24*7 assistance to the users could not be provided. Known shortage of materials and operating infrastructure. The Open Source software often lack well designed and well developed user manual. Lack of clean Power supply and backup interfered in the smooth working. Release and development of new and stable version of modules.

RECOMMENDATIONS y Implementation of HIS in hospital is not merely computerization and automation of the existing paper trail but a practice to improve the efficiency and effectivity of the hospital. This fact should be well delivered and conceived by the users.

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y

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

y

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

y

Setting up of a local centralized IT department within the hospital to take care of HIS working.

LEARNINGS y It is not unrealistic to believe in the feasibility of HIS in a public hospital provided motivated infusion of understanding and hardwork is there. y The economic argument no longer holds since there are Open Source tools adjustable at a low cost by local teams. y It was realized how important is to make the hospital decision makers in aware of the efficient of role of HIS. y A consistency in approach with a clear vision and pre defined guideline can ensure acceptance even among the most reluctant users. y HIS is a source of high quality medical information giving DDU a new brand image.

Our work is mostly focused on implementing HIS which is economically and locally acceptable to the users of DDU, where we took the project. Our study showed that public hospitals in Himachal show a brand new and wide open area of hospital information computerization.

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5. CASE STUDY
COMPUTER LITERACY AMONG THE DOCTORS OF REGIONAL HOSPITAL, SOLAN

ABSTRACT The field of medicine and medical practice requires the use of computers for support in information processing, decision making and records keeping. The success of information and communications technology applications in health is dependent on the level of computer use by health professionals especially doctors. This questionnaire-based study assessed the level of computer and internet usage by doctors in Regional Hospital, Solan as well as their perception of the medical recording system in their place of practice.

INTRODUCTION The computer as a tool has transformed information and data handling in all fields of endeavour. Computers have been used to manage patients at a distance (telemedicine), to manage hospitals and their patients¶ records and to search and retrieve information for research and assist in clinical decision making. In general, clinical practice has been tremendously improved by the technological interventions and a new and rapidly growing field of applications called health (or medical) informatics has emerged. In most of the developing world, computer use and literacy, though rising, is still very low. The success of any health informatics program will depend on the skill level and the perception of those who will run it.

RATIONALE FOR THE STUDY This case study highlights the level to which doctors apply computers to tasks at their places of work highlighting the level of their knowledge and utilization. The study determines the accessibility of the internet to doctors, the view of doctors regarding the computerization of the medical records and the problems associated with the present paper-based medical recording system. It would also highlight the level of their knowledge and utilization.

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METHODOLOGY The survey was conducted at Regional Hospital, Solan prior to the implementation of HIS. The study population consists of 30 doctors working full-time at Regional Hospital. The

questionnaire contained questions regarding the socio-demographic details of the respondents, attitudes towards usage of computer and their view regarding the computerization of records Data were entered into the computer and analysis was done using Microsoft Excel.

RESULTS Demographic profile Out of the 30 respondents (doctors), 18 were males while 12 were females.

Personal Skills/Competencies The personal skills and information-handling competencies of the respondents were asked in the next section. Out of the 30 doctors, 20 doctors could use word processing software. Only 9 of them could make their own slides for presentation. Large number (24) surf the net for various purposes. 3 of them referred Pubmed out of which 2 had published a paper as well.

25

20 15 10 5

0 Word Pocessing Making slides for presenattion Surfing the internet Pubmed Ever published a paper

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Access to the internet/personal computer Almost all respondents had access to the internet. 20 of the doctors have a PC at home. They were generally young and middle-aged doctors. It was noted that the younger respondents tended to have multiple access (like work, cybercafé) to the internet than the older respondents. 18 out of the 30 respondents accessed internet used internet <1 hour for checking important mails.

20 15 10 5 0 Home/PCs Work Mobile Cyber café

Medical Recording System The medical recording system at DDU is paper-base. A large number (21 doctors) think that the computer-based system will be a better system. 7 respondents thought otherwise while 2 were undecided.

30 20 10 0 yes No Cant say

The major reason given by the respondents on why the computer-based system was better was better accessibility of records to doctors. Other popular reasons were that it would be timesaving, saves space/portable. Doctors agreed that easy tracking of the data could be done. The 55 | P a g e

data is more presentable and durable. Some of them also agreed that it would be cheaper on the long run.
30 25 20 15 10 5 0

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

DISCUSSION & RECOMMENDATION One central factor is, however, the ownership of a personal computer. The ownership of a computer is associated with favorable perception of the computer-based record system. Also, the people who could use Microsoft Word, PowerPoint and excel were more males than femalessuggesting a gender-based digital gap.

The older doctors specifically among the age group 45-60 are so used to the traditional paperwork. 4 among this group think computer-based records are of no use, they believe in their recording system. 2 among this group are not sure if at all the system will work or not. Nevertheless, they are aware of the advantages of the computer-based record system. It is mandatory to enable and assist doctors in their acquiring of computer literacy for personal as well as use in the hospital. The training modules should be planned according to the literacy level of the doctor, their willingness to learn and the patient load else computer will become an 56 | P a g e

additional burden. Female doctors of this government hospital are low in computer literacy; they should be encouraged and assisted in their skills. This test was conducted on a very preliminary level. Thus, more research is needed to understand the factors that influence computer and internet use among doctors in Solan.

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6. REFERENCES
a. b. c. d. e. www.hisp.org www.hispindia.org www.opemrs.org http://en.wikipedia.org/wiki/OpenMRS HIS- OpenMRS-DDU manual by HISP

f. A study on µDetermination of the success of a hospital's information system implementation¶ by J.C. Sarivougioukas and A. Th. Vagelatos. g. J. Van Bemmel, M. Musen, "Handbook of Medical Informatics", Springer, 1997. h. Cusack CM: Electronic health records and electronic prescribing: promise and pitfalls. Obstet Gynecol Clin North Am. 2008 Mar; 35(1):63-79, ix. Review. PMID: 18319129 [PubMed - indexed for MEDLINE. i. Implementing an Electronic Health Record System (Health Informatics) by James M. Walker, Eric J. Bieber, Frank Richards, and Sandra Buckley (Paperback - June 28, 2006) j. Electronic Health Records, Second Edition by Jerome Carter (Paperback - Mar. 15, 2008) k. EHR Implementation: A Step-by-Step Guide for the Medical Practice (American Medical Association) by Carolyn P. Hartley, Edward D. Jones III, and Newt Gingrich (Paperback - Feb. 28, 2005) l. D. Protti, V. Peel, "Critical Success Factors for Evolving a Hospital Toward an Electronic Patient Record System", The Journal of the Healthcare Information and Management Systems Society, vol 12- 4, 1998.

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7. ANNEXURES
ANNEXURE 1: TRAINING SCHEDULE

Table 1: TRAINING OF NURSES Training session: 1 hour MODULE TIME ASPECTS TO BE COVERED Viewing stock balance How to raise and process indents y WHAT THE NURSES SHOULD KNOW BY THE END OF THE SESSION y Should be able to view stock balance for items and drugs Should be able to raise indents for both items and drugs ± o Search for items/drugs from different subcategories, o Enter the required specification/formulations, o Add the required quantity and o Save and send the indent y Inventory module (Theoretical and hands-on) 30 min Issuing drugs to patients y Should be able to process indents, once stock has been received from the main-store (accept & refuse) Should be able to issue drugs to patients o Should be able to select the required drug from the required category; select the required formulation; enter the required quantity o Should be able to search a patient and then add to an issue slip and finish How to show consumption i.e. issue to account y Should be able to make an issue to an account for the items that they have consumed during the week o Should be able to select the required item from the required category; select the required specification; enter the required 59 | P a g e

quantity o Should be able to create an account and add to an issue slip and finish Using the filters y Should be able to use the different filters in ± view stock balance, indents, issue to account, issue to patients How to admit a patient y y IPD module (Theoretical and hands-on) How to 20 min discharge and transfer a patient Using the filters y y y y Should be able to admit a patient to the required ward Should be able to remove a patient from the list Should be able to declare a condition of no-beds Should be able to transfer a patient from one ward to another Should be able to discharge a patient Should be able to filter the patient list by ward, attending doctor and date y How to register a patient Registration/OPD overview Overview of 10 min OPD and how to admit Viewing patient dashboard Should be able to search for a patient by name and identifier y Should know the overall flow from registration to OPD and IPD; How a patient is admitted in a ward and how the doctor would be able to view the clinical summary of a patient

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Table 2: TRAINING OF DOCTORS Training session: Half hour MODULE TIME ASPECTS TO WHAT THE DOCTORS SHOULD KNOW BY THE BE COVERED Making an OPD entry y y Should be aware of the patient queue, how it works and select the required patient from the queue Should be able to search for a patient from the queue (in-case the queue is long) y Should be able to search for a patient from the system (should be able to use advance search) y Should be able to make an OPD entry for a patient o Should be able to search for and add the required diagnosis o Should be aware of the need of and be able to add a note OPD (Theoretical and hands-on) 20 min o Should be able to search and add the required procedure o Should be able to refer a patient (internal and external) o Should be aware of and be able to fill up the minimum (mandatory) fields before concluding a visit o Should be aware the different ways to conclude a visit for a patient y y Viewing the patient Should be able to admit a patient Should be able to customize their own list for diagnosis and procedures y Should be aware of the different tabs of the patient dashboard and their use END OF THE SESSION

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dashboard

y

Should be able to view the clinical summary of a patient

y

Should be able to view the different investigation results of a patient o Should be able to use the filter to see just the required investigations

y How to register y a patient Registration and IPD module overview 10 min Overview of how the IPD module functions y y

Should be able to view the IPD record for a patient Should know how to registration module works and how to register a patient Should know the overall flow from registration to OPD and IPD Should know overall how the IPD module works (so they can review the work of the nursing staff)

Table 3: TRAINING OF PHARMACIST Training session: Half Hour MODULE TIME ASPECTS TO BE COVERED WHAT THE PHARMACY STAFF SHOULD KNOW BY THE END OF THE SESSION Should be able to view stock balance of the drugs Should be able to view stock balance of expired drugs Pharmacy module (Theoretical and handson) y 25 min Raising and processing of indents y Should be able to raise indents for drugs ± o Search for drugs from different subcategories, o Enter the required formulation, o Add the required quantity and o Save and send the indent Should be able to process indents, once stock has been received from the main-store (accept & refuse)

Viewing stock balance y y

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Issuing drugs to patients

y

Should be able to issue drugs to patients o Should be able to select the required drug from the required category; select the required formulation; enter the required quantity o Should be able to search a patient and then add to an issue slip and finish

Issuing drugs to account

y

Should be able to make an issue to an account for the items that they have consumed during the week o Should be able to select the required drug from the required category; select the required formulation; enter the required quantity o Should be able to create an account and add to an issue slip and finish

Using the filters

y

Should be able to use the different filters in ± view stock balance, indents, issue to account, issue to patients

Inventory overview

Brief overview of 5 min working of the inventory module

y

A brief on how the inventory module works and how the indents sent from pharmacy are processed at the main store

Table 4: TRAINING OF INVENTORY STAFF Training session: Half Hour

MODULE

TIME ASPECTS TO BE COVERED

WHAT THE INVENTORY STAFF SHOULD KNOW BY THE END OF THE SESSION Should be able to view stock balance of the drugs and items y Should be able to view stock balance of expired

Inventory module (Theoretical

25 min

Viewing stock balance y

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and handson) Receiving items in the main-store y y

drugs Should know the significance of a receipt Should be able to make receipts for drugs and items ± o Search for drugs/items from different subcategories, o Select the required formulation/specification, o Add the required quantity, unit price, VAT, Company name, Date of manufacturing and expiry o Finishing the receipt Making transfers to sub-stores Using the filters y y Should be able to process an indent and transfer the required quantity of each item/ refuse an indent Should be able to use the different filters in ± view stock balance, receipts to general store and transfers from general store 5 min Overview of how the sub-stores work y An overview of how the sub-store indent to the main-store and how the stock calculation works

Table 5: TRAINING TO INVENTORY MANAGER Training session: 1 hour MODULE TIME ASPECTS TO BE COVERED WHAT THE INVENTORY MANAGER SHOULD KNOW BY THE END OF THE SESSION Inventory module ± (Theoretical and hands-on) ± COMPLETE 30 min Receiving items in y Should be able to view stock balance of expired drugs y Should know the significance of a receipt 64 | P a g e Viewing stock balance y Should be able to view stock balance of the drugs and items

FUNCTIONING OF THE MAIN STORE AND SUB STORES

the main-store

y

Should be able to make receipts for drugs and items ± o Search for drugs/items from different subcategories, o Select the required formulation/specification, o Add the required quantity, unit price, VAT, Company name, Date of manufacturing and expiry o Finishing the receipt

Making transfers to sub-stores

y

Should be able to process an indent and transfer the required quantity of each item/ refuse an indent

How to raise and process indents

y

Should be able to raise indents for both items and drugs o Search for items/drugs from different subcategories, o Enter the required specification/formulations, o Add the required quantity and o Save and send the indent

y

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

Issuing drugs to patients

y

Should be able to issue drugs to patients o Should be able to select the required drug from the required category; select the required formulation; enter the required quantity o Should be able to search a patient and

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then add to an issue slip and finish How to show consumption i.e. issue to account y Should be able to make an issue to an account for the items that they have consumed during the week o Should be able to select the required item from the required category; select the required specification; enter the required quantity o Should be able to create an account and add to an issue slip and finish Using the filters y Should be able to use the different filters in ± view stock balance, receipts to general store and transfers from general store, indents, issue to accounts, issue to patients Manage store y Should be able to create a store, assign a parent and role to the store Manage Item y Should be able to create/delete a ± category, subcategory, unit, specification y Inventory admin functions 30 min Manage drugs y Should be able to add an item and define all the necessary parameters ± category, sub-category, unit, specification, attribute Should be able to create/delete a ± category, unit, formulation y Should be able to add an item and define all the necessary parameters ± category, unit, formulation, attribute

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ANNEXURE 2: COMPETENCY TESTS (post-training)
Table 1: SELF EVALUATION FOR DOCTORS Name: SI. NO EVALUATION PARAMETER OPD: CONFIDEN T/ UNDERST CAN DO/ UNDERSTA ND WITH CANNOT DO/ DO NOT UNDERS TAND 1 2 Can you Turn on and off the computer? Can you log-into the application? OPD module 3 Do you understand the concept of the patient queue and how it works? 4 Are you aware of/understand the different ways to look for/search a patient to make an entry? 5 Are you aware of/ understand the various options to conclude a visit for a patient? 6 Are you aware of/understand the flow of a patient (electronically) from OPD to IPD? 7 Do you understand the concept of customizing the list of diagnosis for a particular OPD? 8 Can you search for a patient from the queue, in-case it is long? 9 Can you search for a patient in-case he/she come to you with an old OPD slip and is not in the queue? 10 11 Can you enter/add a diagnosis for a patient? Can you search and add a diagnosis to your list, if not available? 12 Can you add a note; enter a procedure for a patient (if

AND WELL DOUBTS

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required)? 13 14 15 Can you refer a patient internally to another OPD? Can you conclude a visit for a patient? Can you admit a patient to the required ward? Patient dashboard 16 Are you aware of / understand the patient dashboard and the various options it provides? 17 18 Can you view the clinical summary of a patient? Can you view the various investigation results of patient¶? 19 Can you select the specific category of investigations for which you want to see the results? 20 Can you view the IPD/admission records of a patient?

Table 2: SELF EVALUATION FOR NURSES Name: SI. NO EVALUATION PARAMETER Ward: CONFIDEN T/ CAN DO/ UNDERS CANNOT DO/ DO NOT UNDERS TAND

UNDERSTA TAND ND WELL WITH DOUBTS

1 2

Can you Turn on and off the computer? Can you log-into the application? Inventory module

3

Do you understand the whole processing of indenting and how it works electronically?

4

Do you understand the terms sub-category, specification, formulation?

5

Do you understand the concept of making an issue to

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account/patients to show consumption of drugs/items? 6 Do you understand the concept of accepting and refusing indents and how they affect the stock? 7 8 9 Can you view stock balance for items and drugs? Can you raise indents for both items and drugs? Are you able to search for different drugs/items from different categories? 10 11 Can you save and print indents? Can you process indents (and accept stock in your store)? 12 13 14 Can you issue drugs from your sub-store to patients? Can you issue items to account to show consumption? Can you use the filters and search for drug, item, indent etc that you want? IPD module 15 Do you understand the flow from the OPD to the IPD module and how a patient is recommended for admission? 16 Do you understand the concept of the patients for admission and admitted patient index? 17 Do you understand the concept of discharging, transferring a patient? 18 Can you admit a patient in the required ward and print the admission slip? 19 20 Can you transfer a patient from one ward to another? Can you discharge a patient from a ward? Can you filter the patient list according to wards, doctors and by date?

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Table 3: SELF EVALUATION FOR PHARMACISTS Name: SI. NO EVALUATION PARAMETER CONFIDEN T/ CAN DO/ UNDERS CANNOT DO/ DO NOT UNDERS TAND

UNDERSTA TAND ND WELL WITH DOUBTS

1 2

Can you Turn on and off the computer? Can you log-into the application? Pharmacy module

3

Do you understand the whole processing of indenting and how it works electronically?

4

Do you understand the terms category and their respective attributes (vital, essential, desired)

5

Do you understand the concept of dosage and formulation?

6

Do you understand the concept of making an issue to account to show consumption of drugs (in-case not issued to patients)?

7

Do you understand the concept of issuing a drug to a patient/ in-case of drugs with different batch numbers and expiry?

8

Do you understand the concept of accepting and refusing indents and how they affect the stock?

9 10 11 12

Can you view stock balance for drugs? Can you view stock for expired drugs? Can you raise indents for drugs? Are you able to search for different drugs from different categories?

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13 14

Can you save and print indents? Can you process indents (and accept stock in your store)?

15 16

Can you issue drugs to patients? Can you search for a patient and add drugs for the particular patient to an issue slip?

17 18 19

Can you finish and print an issue slip? Can you issue items to account to show consumption? Can you use the filters and search for drug, indent etc that you want?

20

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ANNEXURE 3: QUESTIONNAIRE
Name: Designation: Department: Tick the right option here. You may tick multiple option where ever required Gender Male Female 25-35 35-45 45-60 1-5 year >5 yrs Personal skills and competencies Word Processing Making slides for presentation Surfing the internet Pubmed Ever published a paper Location of access Home/PCs Work Mobile Cyber café <1 1-5 >5 Inaccessible to certain locations Unpredictable Time wasting Lack of durability 72 | P a g e

Age

Duration of practice

Hours of internet

Problems with the medical record

Costly/expensive Will computerbased record be better than paper

yes No Cant say

Reasons for preferring computer-based records

Better accessibility Time-saving Easy tracking Safe Presentable Saves space/portable Durable Saves cost/cheaper

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