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Hospital information system: PULSE (implementing IT in health-care)

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 Hospital information system: PULSE Hospital
information
[implementing IT in health-care] system
Ashwani .K. Ramani
King Faisal University, Al-Ahsa, Saudi Arabia
Khushboo Ramani, N.Uikey, Gaurav Pandey, Pranav Bahutra, Saurabh Wable, Chinmayee
Lakkad, Shifali Upadhyay & Deepika Gupta
Devi Ahilya University, Khandwa Rd., Indore, IIndia

Keywords Health Information System, IT Projects, Cost, Government, Quality, Success rates.

Abstract IT has become an important tool for improving the efficiency of business and government organizations. How-
ever, IT projects for business and government bodies have not shown high success rates. Among many reasons attributed
towards failures, cost factor is an important reason. The Indian software industry have been leveraging on this factor
1
for software exports, however, because of high cost of IT, local industries and governments have not been able to reap
the benefits of IT. To cut the cost and to develop a pilot application for local small business person will remain the chal-
lenge. In this paper, we present the development of an application, piloted for a medium size medical organization, suc-
cessfully developed to benefit the hospital administration and staff for better decision making process, resulting in better
patient care as well as better business. The project was successfully developed by a large team of graduating students of
Devi Ahilya University, Indore, India with minimal sponsorship cost, while working at CMM-2 quality level. The project
was considerably appreciated and several organizations including Government Hospital (M.Y. Hospital), Civil Hospital,
Indore have shown interest for using I.T. as a necessary tool in medical organizations.

Introduction
Hospital information systems are turning to be a new need for medical organizations to survive in
throat cut business struggles. Also, changing face of technology has enabled medical organizations
to prove themselves committed for better healthcare solutions with improved services. There are
many issues in realizing such projects. Shortage of capital and lack of common data dictionary have
been a problem. Also, hand-written and dictated physicians’ notes without common structure of
format and variability among different hospitals make every implementation different from others.
Beside above the project implementation issues like, huge project size, peoples’ perception about IT
and such implementation etc make the project in lengthy cycle and monotonous.

The aim of any Hospital Information System (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, satisfying the functional requirements of all the stakeholders. It also helps as a
decision support system for the hospital authorities for developing comprehensive health care poli-
cies, with cost effectiveness and efficiency.

We target to provide services of I.T. in healthcare so that our clients can stand on the top position
among the healthcare organizations. Without a proper Management Information System, a hospital
can be regarded as “Paper machine which could suffer drastic loss which cannot be reviewed or
observed so easily”. We help our clients for decision-making process so that they can take accurate
decisions to improve the quality of their organization supporting better patient care and better busi-
ness, eliminating the chances of data loss, and improve the accuracy of information.

The Client is a small/medium size hospital, which has yet to benefit from IT, however unable to
afford the cost aspect, however willing to move with IT. We plan to associate students with such
organization to enable them face challenges of real-life large size project development, and derive
useful learning out of this experience. Such projects are win-win for both parties, enabling to cut
the cost and experiment successfully (Kofi Annan, 2003). The major challenges of the project are
its management due to large size, inexperience clients, and design & implementation of the overall
system and users interfaces.

PULSE, the short name of the HIS system, is completely an integrated system, automates the entire
work flow of the hospital, by incorporating the modules for all the departments of the Hospital. The
rest of the paper is organized as follows: the architectural aspects are discussed in the next section.
Section-3 presents the development methodology, followed by details about several modules of the
system, and discussions and conclusion of the project in the last section. 18th National
Computer
Conference 2006
System Architecture: The Hospital Information System architecture requires a scalable approach © Saudi Computer
in hardware as well as software design. The upgradability in system functionality will be essential, Society
 development methodology, followed by details about several modules of the system,
and discussions and conclusion of the project in the last section.

System Architecture: The Hospital Information System architecture requires a

scalable approach in hardware as well as software design. The upgradability in system
functionality will be essential, as awareness to use I.T. increases. The features like, data
warehousing & data-mining may be called for the future applications like,
telemedicine,as e-consulting,
awareness to usedigital
I.T. increases.
storageThe of features like, data
radiological warehousing
reports etc. The& data-mining
present may be called
for the future applications like, telemedicine, e-consulting, digital storage of radiological reports etc.
requirementsThearepresent
to provide automation
requirements for patient
are to provide automationregistration, bed allocation,
for patient registration, bed allocation, pathol-
pathology, I.C.U., medical
ogy, I.C.U., record,
medical stores
record, storesetc.
etc.for
forsmooth and error
smooth and errorfree
freeflow
flow of data
of data across the organiza-
tion.
across the organization.

Web user

ISP Server hosting CHL web site

2
End user

Figure 1.
The System Application Server
Architecture End user
Database Server

End user
The proposed hardware
Fig. 1. The System Architecturearchitecture consists of a central database server with latest technical fea-
tures for reducing data loss chances, connected to end-terminal systems with required configuration
to support front-end technology. The system architecture is shown in Fig.1.

Development Methodology: The aim of this section is to explain the information system develop-
ment approach adopted for this large size application development. Last few decades have seen the
explosion of software applications. 2 The experience with information system development has not
been very good, but instead has been a bad taste. In one of the study made it is observed that only 16
percent of the IT projects are able to meet their time, scope and cost constraints (Kathy, 2005). Many
applications required constant maintenance involving correcting faults, implementing new user
requirements, modifying the software to run on new or upgraded platforms. This poor track record
with IT projects calls for a careful attention in dealing with IT projects. Also, a study on software
projects in 1996 in the UK revealed the following (Connolly, T., C. Begg, and A. Strachan, 2002):

• 80 - 90% do not meet their performance goals.

• About 80% of systems are delivered late and over budget.
• Around 40% of developments fail or are abandoned.
• Under 40% fully address training and skills requirements.
• Less than 25% properly integrate business and technology objectives.
• Just 10 - 20% meet all their success criteria.

The Major reasons for failure of software projects could be many including incomplete requirements
specifications, lack of appropriate development methodology, poor design, and non-existence of
information architecture vision (Claudia, 2003). The approach we adopted is to first help develop the
Information Architecture for the organization and then approach for development. Information Sys-
tems Architecture lays down the Conceptual blueprint for organization’s desired information systems
structure. It relates organization mission, objectives, business processes, people, business locations,
and more importantly information related components. Typically, it consists of:
• Information subjects (e.g. Data, Enterprise Data Model)
• Business Processes – Goals, Business functions, business entities, business processes, Business
locations, data flow diagrams, process decomposition, etc.
• Data Network – Network structure
• People – people management using project management tools (PERT, Gantt charts, etc.)
• Events and points in time (when processes are performed)
• Reasons for events and rules (e.g. decision tables).
An approach like, RAD will not be useful here since prototyping of such large size software will Hospital
be highly time consuming and counter productive. The top-down methodology following SDLC information
is suggested to identify the broad IS projects to be carried out, and will be the outcome of such an
architecture development. This architecture will also be useful to align/relate the achievement of system
business objectives support from the Information systems, and also enable to study the impact of a
particular IS system over the organization (Phillips, 2002, Nicholas, 2004).

The IS architecture planning comprises of four steps: Planning, Analysis, Design, and Implementa-
tion. After complete understanding of the organization and analysis of IS needs, the important step
is to develop an Enterprise Data Model to demonstrate the organization understanding through
pictures and to create a common understanding of the business flow among all the stakeholders of
the systems. It is useful to the top management to get convinced about their business process cor-
rectness and for developers to use it for further design work. The enterprise data model is a start
point for a database developer. It is essential that the validation of EDM should be done before
proceeding further. A comprehensive EDM calls for detailed decomposition of each business pro-
cess, like, patient admission, patient billing etc. An enterprise data model is constructed by using 3
high level entities identified in previous steps and their relationship among themselves through the
business process.

The Information systems envisaged to be built with SDLC approach will be employing mainly the
entities identified in high level analysis. Since it may be possible that the same entities are used
by more than one information systems, it will be necessary to see the inter-relationship of differ-
ent IS modules, which is performed by planning matrixes method. In this method many different
matrixes are prepared showing interrelationship of involved parameters. For example, one may
prepare a matrix between Data Entities and Business functions. This matrix can clearly bring out
the use of same entity in different Information systems. Similarly, this matrix can also bring out the
complexity of various business functions showing which business functions uses important enti-
ties and needs to be prioritized for development. There could be matrix like, location-to-function,
Unit-to-function, Information system-to-objectives etc. Similarly, these matrixes can also enable to
identify any hidden or missing entity in any business function. The activities steps for developing
the architecture, and analysis, design and implementation issues are discussed further.
Strategic Planning Factors: The purpose of these factors is to develop the planning context and to
link information system, plans to the strategic business plans. The goals identified for the purpose
are: develop a preliminary understanding of the business situation; document existing business
functions; analyze the functions involved in the running of the hospital and their database needs;
and demonstrate (through an application that the information processing is feasible), and extends
the traditional system.

Critical Success Factors: The factors identified after study are: ease of operation; the user interface
provided should apart from being functional also be aesthetic and easy to use and understand, with
all necessary help and documentation provided online with minimal need of training. There should
be requiring minimal need for intervention: The system developed should be automated to the
level which should also allow for user discretion in using as many features desirable (i.e., some fea-
tures may be used later after competencies are developed). Further, availability of updated records
i.e., the status of the database should be current in nature and should not reflect any outdated data. In
the last, the management support, the hospital management must be willing to set up such a system
and actively support its proper design and implementation.

Problem Areas: Because of complex and huge size of the envisaged software, the system should
be able to provide fast response in real time as the user cannot be kept waiting for the processing of
the system since the availability of the information may be urgent in some cases. Security is another
issue, the system should be able to have a reasonable level of security to unauthorized operations.
The size of the data would increase at an exponential rate and may have to be managed separately
using data archiving for storage for historical purposes.

Corporate Planning Objects: These objects defines the business scope, and the scope limits the
subsequent systems analysis and where information system changes can occur. The CHL Apollo
Hospitals, Indore has 23 different departments, like the Registration, Accounts, IPD, OP|D, ICU,
Radiology, Pathology, Stores, Pharmacy etc. The system will be implemented in all the departments
of the organization. Physically the hospital is located in one building with four stories, however, in
future may expand to near by locations, and call for interlinking, web support and even linking to
customers (doctors who directs their patients for treatment) and suppliers.
 The high level requirements classified the hospital services into areas like, Admissions, Diagnostics,
Patient Care, Surgery, Ward management, Stores, Accounts and billing etc. The hospital functionality
is spread over 23 modules obtained from SRS document, which took 2 months of time, understand-
ing the functionality of entire organization. However, in discussion with the management, few mod-
ules are identified as apriory. These modules are designed across Oracle-9i & VB.Net technologies.
It needs to be taken care that throughout the development of the project and software, user interaction
and management support are the two essential aspects of successful software implementation (Kathy,
2005). The EDM for different departments is worked out to assist development of E-R system for the
respective departments. The SDLC approach & CMM-2 level quality assurance policy is followed
to minimize risk of failures. In next section, some of the modules of PULSE are described with their
features and facilities.

HIS Sample Modules: There are 15 modules initiated for development in the first phase. Some of
these modules are presented here to limit the length of the paper, as their approach for development
4 remains same, and the diagnostic module development is described in detail.
Registration module: Registration of the patients is the foremost activity in the overall Hospital
Information System. Every patient who approaches a hospital has to get registered prior to get-
ting any consultation, treatment, and investigations done from the hospital. Registration of patients
involves accepting certain general and demographic information about the patient. The patient is
given a unique central registration number.

The Patient is also given a patient identification card, known as Registration Card. Normal Staff
Emergency VIP/Senior Citizen Normal registrations are done in the routine OPD timings. Emer-
gency Registration is done for the patients who require immediate medical attention. The patients
getting registered under this category are basically out-patients whose unit is closed on that day,
Medico-Legal Cases where patients requiring immediate medical attention, and patients coming after
the OPD hours, are registered as Emergency Patients. Staff Registration takes care of the registra-
tions related to all the staff members of the hospital. Some of the functions of the process in input/
output are as below:

Capturing Demographic Details: The Registration module captures the demographic details of the
patient. A patient is assigned a unique 12 digit Central Identification Number.
Visit Creation for the Old Patients: Every time a patient visits the hospital after registering, the visit
gets stamped.

Change of Department: This facility is provided to record the change of the department, in which
the patient is registered.
Duplicate Card Printing: Since the OPD card tends to get filled there is a facility to reprint this card.
Modification Request: There is a provision to handle subsequent modification requests in registration
data.

Reports/Graphical Output: Printing of Normal OPD registration card Printing of OPD register
department wise Printing a report on number of registrations department wise Printing a report on
number of total emergency registrations Printing a report on number of registrations User wise Cash
collection department-wise on a daily basis Cash collection user-wise on a daily basis.
Billing module: Billing module is one of the most supportive module for admitting a patient from the
very beginning up to its discharge. It supports several features such as transfer of a patient in wards
multiple times ( as existing software supports only 3 transfer’s ), collection of advance payment at
counter and it is adjusted automatically during payment at the discharge time in billing. Also patient
is privileged with facility of chosen discount under several categories such as senior citizen, medical
insurance case etc.

The main feature of billing module is generation of final bill with perfect accuracy. If any test
requested could not be performed than it’s charge is automatically excluded from final bill. Every
facility such as drugs, room services are charged automatically if request is made in the respective
module. Facility to pay via cheque, ATM card and draft is also provided. Reports concerned to bill-
ing department are helpful to staff in order to update the daily transactional matters within very short
time. Featured reports are: tariff-wise, department-wise, inpatient or Outpatient wise collections and
also generates reports up to the trial balance stage.

Diagnostics module: In the routine functioning of a hospital, various types of investigations are
carried out. Carrying out number of investigation tests and making the results available promptly is
 � Sending samples to laboratories
� Entry of test results
� Validation and Printing of Test Reports.
The Result Entry facility allows result to be entered in different formats like Single
Parameter, Multi-Parameter, and Tests with parameters having Sub-parameters, Textual
very crucial for assessing the patient’s medical status and deciding on the further course of action. Hospital
results
The and
EDM so on. out
derived The Validation
of the Informationfacility ensures
Architecture is shownthat the2, test
in Fig. whichresults
has beenare
usedcorrect and
to information
develop the ER model further shown in Fig. 3.
ready for Printing/transmission. The Diagnostics Module interacts with the Registration system
Module
There to
are fetch
6 majorbasic patient
departments underdetails. The
diagnostics Billing
namely, Module
Pathology, stores
Radiology, all the Urol-
Cardiology, investigation
ogy, Neurology and CT-Scan. Salient features of this module are:
payment details.
• Accepting Its salient
investigation features are:
requisitions
• Sending samples to laboratories
Integration
�• Entry of test resultsof all departments of diagnostic unit
• Validation and Printing of Test Reports.
� Report generation for about 500 investigations
�The Result Entry
Facility to facility
suspend allows result toan
/resume beinvestigation
entered in different formats like Single Parameter,
Multi-Parameter, and Tests with parameters having Sub-parameters, Textual results and so on. The
Adding
�Validation new
facility investigations
ensures at a mouse
that the test results are correctclick in a for
and ready simplified way
Printing/transmission. The
Diagnostics Module interacts with the Registration Module to fetch basic patient details. The Bill-
Adding
�ing Module andallupdating
stores of normal
the investigation paymentvalues
details. Its salient features are: 5
• Integration
Form
�• Report of all departments
generation at runtime of diagnostic unit
generation for about 500 investigations
Facility
�• Facility for sample
to suspend /resume an entry – in case of pathology.
investigation
• Adding new investigations at a mouse click in a simplified way
Facility
�• Adding to addofthe
and updating master
normal valuesentries for a new investigation in a simplified way.
• Form generation
Facility
�• Facility at runtime
to add the alias name for an investigation.
for sample entry – in case of pathology.
EasytoValidation
�• Facility add the masterand updating
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investigation in a simplified way.
• Facility to add the alias name for an investigation.
�• EasyFacility
Validationto and
print multiple
updating of testreports
results. on a single page according to the tests selected
(pathology).
• Facility to print multiple reports on a single page according to the tests selected (pathology).
• Facility to view comparative values of an investigation for a single patient for future referencing.
Facility to view comparative values of an investigation for a single patient for
�(Pathology).
• Generation of various MIS reports for administrative purpose
future referencing.
• Integration of the department (Pathology).
with Registration, Stores and Billing.
� Generation of various MIS reports for administrative purpose
The flow diagram is depicted below in Fig.2, while ER model made out from the study of this
Integration
�department is shownof in the
Fig.3.department with Registration, Stores and Billing.
The flow diagram is depicted below in Fig.2, while ER model made out from the
study of this department is shown in Fig.3.

Figure 2.
Data Flow
Diagram for
Diagnostic
System

Fig. 2. Data Flow Diagram for Diagnostic System

7
 Connector

Clearance
6 Slip

CATEGORY_
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Pathology_Master RADIOLOGY_M
ASTER
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Pathology_ Neurology_ radiology_tran

transaction transaction saction

Figure 3.
E-R Diagram
for Diagnostics CARDIOLOGY Urology_tr
System _transaction
ansaction

CTcan_tr
ansaction

Fig.3. E-R Diagram for Diagnostics System

Patient Management: This module is also fairly complex and integrates in-patient and
out-patient related information services integration, and each one is described below:
The In-patient module commences when the patient is being allotted a bed in the ward.
Patient Management: This module is also fairly complex and integrates in-patient and out-patient Hospital
related information services integration, and each one is described below: information
The In-patient module commences when the patient is being allotted a bed in the ward. It deals system
with the complete treatment of the patient during his/her stay in the hospital. This module interacts
with the OPD, Billing, Investigation, OT and pharmacy modules. This module depends on the OPD
module for admission details, and is integrated with the following modules:
• Pharmacy module for requisition of drugs and consumables.
• Investigation module for requisitions and report viewing.
• Operation Theatre Module for requisitioning operations.
• Billing module for admission advance and discharge settlements. It mainly includes the room
charges, charges made during medical investigations.

Its salient features are:

Bed Allotment: This sub-module can be invoked from the OPD module and keeps track of avail-
able beds in the wards .The module also deals to avoid clashes made during allocation of beds. It 7
shows number of beds which are empty as per their category like private, deluxe, general etc. It also
helps maintain record made at counter during bed allocation. It blocks a bed for a given patient. If
payment for that bed is not made, the same module can be used to de-allocate the bed.

Inter-departmental Consultation: It sends request to other departments for comments on the patient’s
specific problems Keeps track of the status of each request (whether sent, received, accepted or
rejected). Basically this feature is useful for requesting any test from one side and receiving it at
appropriate place as laboratories and departments. A doctor is able to review the treatment at any
system or the result of tests requested.

Transfer of patient between wards and beds: In case an inter-department consultation is sent and the
consulting department feels that the patient needs to be transferred to their department, then using
this module, the patient’s details are transferred to the new department. This module can also be
used to transfer the patient to a new bed in the same department. It helps to calculate room charges
as well at the same time too.

Raising investigations and report viewing: An investigation requisition is raised for patients admit-
ted in the ward. Sample collection and assignment of unique sample numbers is also facilitated
through this module. Viewing and printing of reports for tests whose results have been entered is
done through this module. Also pending investigations, previous investigations made and medical
record of patients are accessible through this.

Maintenance of billing sheets for patients: Automatic maintenance of all expenses incurred by the
patient. Automatic scrutiny of the credit limit available to the patient in the hospital accounts. In
case the amount is not sufficient, the module provides tools to ask for more amounts to be deposited
in the patient account. Printing of account statement showing each deposit and expense is one of the
basic features. Also hospital administration can use facilities like fine made on a patient, discount
given or in case of insurance at the time of final billing.
Discharge of patients: Main use is for preparation of discharge summary, checking of patient
accounts and conveyance of request for additional payment to billing counter if required. Sending
a request for refund to the billing counter if the patient’s account shows a credit balance. Reallo-
cations of bed. Sending patient records to the Medical Archives. Reports like Ward Census, bed
occupancy and others can be printed Printing the complete discharge summary. Report on the total
number of discharges, death and the number of days spent by the patient in the hospital.

The out-patient module deals with recording the basic medical treatment details required for the
patient. It consists of the following parts:

Bay Management: This module depends on the Registration module for the patient’s demographic
data. This module includes the following sub-modules:
• Appointment module for scheduling of patient and test appointments.
• Investigation module for requisition of investigations and report viewing.
• In-patient module for bed allotment.

Its salient features are given below:

• Paging and Checking of patients in the bay.
• Appointment scheduling of patients (normal and investigations).
 • Printing of investigation requisition forms.

Patient Visit Creation and Maintenance: The patient wise record is one of the most necessary tools for
decision support system. It also helps staff to supervise the patient as access to information is made
easier. The patient visit module deals with following key objectives :
• Creation of sessions and recording of complaints and history.
• Creation of visit and recording of clinical summary, provisional diagnosis, drugs, diets and Prob-
lem Oriented Medical Records.
• Raising Investigation requisition.
• Viewing of reports of tests for which results have been entered.
• Printing of reports (visit record, investigation reports etc.).
• Allotment of beds for patients to be admitted.
• Appointment Scheduling (normal and investigations).
• Losing of treatment session and recording of final diagnosis.
8 • Making OPD summary and printing it.
• Printing all pending investigation reports for a patient till date.
• Facility to print duplicate investigation reports.
• Printing a report on the total number of old patients handled during a period.

Project Deployment: To make software usable and yield desired information, it has been tested on
more than 20,000 data during black box testing period. Deployment of PULSE includes following
hardware and software support:
• LAN installation to connect user terminals to main EDP server as central database storage access.
• A dedicated server, which will act as central server and will store the entire data of the hospital.
• licensed oracle software with strong back up system. The memory should be sufficient so that
system is not slow.
• PC Systems with P4, 256 MB RAM and 20 GB hard disk at end-terminals in departments.
• VB.Net licensed version
• Windows-XP licensed Version

Discussions and Conclusions

After the design of database & software, PULSE has been tested on more than 20,000 data during
black box testing. Also, the errors faced & featured requirements were edited. As a result, high reli-
ability & chances of data loss or corruption were reduced. On site, training was provided to more
than 20 staff members & users feedback helped to develop better interfaces & logics.

The system grew from initial 130 entities & needed performance tuning. The number of reports close
to 400 were successfully implemented and tested. Some of the crucial logics were development of
patient billing with multiple changes in wards, efficient handling of pathological reports, billing
mechanism to suit individual patient needs etc. The salient learning’s from the project are ample, and
some of the problems faced are listed below:
• Not clear statement of Requirements
• Change of Requirements from time to time
• Non cooperative people in the organization
• Reluctant attitude of the hospital towards IT
• Inadequate time
• Inexperienced people in the team
• No experience in Healthcare Industry
• Very complex working of the hospital
• Form generation at runtime
• Coordination of such a large team
• Problems in use of latest Technology

The project gave ample learning to handle such large projects and some of the best practices are listed
below:
• Identify interdependencies.
• Identify and track critical milestones.
• Participate in project phase reviews.
• Secure needed resources.
• Manage the change control process.
• Report project status

The important lessons learnt from the project are:

• Try as many channels of communications.
• Make sure the prototype is installed on the sponsor’s.
 • Pressure sponsor for prompt decisions and feedbacks. Hospital
• Knowledge about systematic development of a project. information
• Team orientation and skills to work together.
• Enhancing programming skills and creativity. system
• Commit to what the user wants.
• Avoid Scope Creep.
• Provided good and adequate User Training
• Retrieving clear statement of requirements.
• Proper delegation of jobs to the members.
• Time management.
• Proper handling of change of requirements.

Although doctors showed great interest but to use data as an asset for better patient care & decision
making is still a bigger challenge. The future work involves data mining issues in Hospital Informa-
tion Systems. Finally it is concluded that this project development successfully provided a strong
experience to management its staff & project team so that in future they can successfully integrate 9
I.T. application.

References
Nicholas J.M., 2004, “Project Management For Business and Technology: Principles and Practice”, Second edition, Prentice Hall of
India, India.
Phillips Joseph (2002) ,“Information Technology Project Management”, First edition, Tata McGraw Hill, India.
Kathy Schwalbe, (2005) “Information Technology Project Management”, Fourth edition, Course Technology, USA.
Kofi Annan, (Feb. 2003), “IT challenge to Silicon valley”, The Intosai IT Journal, issue 17, pp. 3-4.
Claudia Imhoff and Jonathan G. Geiger (Jan. 2003), “Data Management Why Your Organization Must Understand and Achieve It”,
Available http://www.dataflux.com/resources.
Connolly, T., C. Begg, and A. Strachan, (2002), “ Database systems: a practical approach to design, implementation and management”,
. 3 ed. 2002: Addison-Wesley.

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