An Evaluation of the Information Systems Management and Technologies in Hospitals: The Region of the Technical University of Liberec, Czech Republic

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1 An Evaluation of the Information Systems Management and Technologies in Hospitals: The Region of the Technical University of Liberec, Czech Republic (Research report of the GESITI Project) Doc. Ing. Klara Antlova, Ph.D. - Technical University of Liberec, Faculty of Economics - Dr. Antonio José Balloni - CTI

2 Content LIST OF SYMBOLS AND ABBREVIATIONS... 4 LIST OF TABLES... 6 LIST OF FIGURES... 6 INTRODUCTION... 7 DATA AND METHODOLOGY RESULTS HUMAN RESOURCES STRATEGIC MANAGEMENT OF A MEDICAL INSTITUTION RESEARCH AND DEVELOPMENT TECHNOLOGICAL INNOVATION INVESTMENTS COOPERATION FOR INNOVATION COMPETITIVENESS OF HOSPITAL & COOPERATION FOR STRATEGIC ADVANTAGE INFORMATION TECHNOLOGY AVAILABILITY IN MEDICAL INSTITUTION ACQUISITION OF EQUIPMENT AND FACILITIES APPLICATION PROGRAMS DATABASES OUTSOURCING

3 2.5.5 NETWORK, SECURITY AND TELECOMMUNICATIONS... 9 TABLE 2 NETWORK, TELECOMMUNICATION AND SECURITY IT MANAGEMENT E-COMMERCE MODULE A: GENERAL INFORMATION ABOUT COMMUNICATION AND INFORMATION TECHNOLOGIES MODULE B: USE OF THE INTERNET MODULE C: E-COMMERCE VIA THE INTERNET (E-BUSINESS) MODULE D: COSTS/EXPENDITURES OF IMPLEMENTED SYSTEM MODULE E: BARRIERS IN USE OF THE INTERNET AND IT IN GENERAL TELEMEDICINE APPROACH TO CLIENTS E-HEALTH QUICK PROTOTYPING OF HEALTH WASTE MANAGEMENT IN A HEALTH-CARE SUMMARY LITERATURE

4 List of Symbols and Abbreviations ASD Association of Suppliers of Drugs and Medical Devices AMD (Advanced Micro Devices) Processor producer B2A Business to Administration B2B Business to Business B2C Business to Consumer BI Business Intelligence BPM Business Process Management C2B Consumer to Business C2C Consumer to Consumer CIS Clinical Information System CPR Client s Patient Report CRM Customer Relation Management CSF Critical Success Factors DHE Distributed Healthcare Environment DRG Diagnosis Related Groups DWH Data Warehouse EAD Education at Distance EAM Enterprise Asset Management EEG Electroencephalogram EKG Electrocardiogram EpSOS Smart Open Services for European Patients ERP Enterprise Resource Planning eso National project Electronic Services in a Health Care EU European Union GDP Gross Domestic Product GENAS Association of Generic Producers HCP Health Consumer Powerhouse HCSA Health Care Surveillance Authority HIC health Insurance Company HIS Hospital Information System HTA Health Technology Assessment IBM (International Business Machines Corporation) American multinational technology and consulting corporation ICT Information and Communication Technologies ISO International Organization for Standardization KNIS Complex Hospital Information System KPI Key Performance Indicators LAN Local Area Network LIS Laboratory Information System MIS Medical Information System NATO North Atlantic Treaty Organization NCHI National Center for Health Information NFC Non-repayable Financial Contribution NHP National Heath Portal 4

5 OECD Organization for Economic Cooperation and Development OLAP Online Analytical Processing (a category of software tools that provides analysis of data stored in a database) OPIS Operation Program Informatization of Society PASC Picture Archiving Communication System PC Personal Computer PHA Public Health Authority R&D Research and Development RAID Redundant Array of Independent Disks RIS Radiology Information System ROI Return on Investment RTG Radioisotope Thermoelectric Generator SAN Storage Area Network SIDC State Institute for Drug Control SQL Structured Query Language SWOT Analysis (Strengths, Weaknesses, Opportunities, Threats) USG Ultrasonography VPN Virtual Private Network WAP Wireless Application Protocol WHO World Health Organization 5

6 List of tables Table Education of employees Table 2 Employees with tertiary education Table 3 Number of trained employees in the past two years Table 4 Who knows a strategic plan? Table 5 Participation in strategic planning Table 6 Important elements of a strategy creation Table 7 Importance of cooperation of analyzed hospitals Table 8 Goals of cooperation Table 9 Basic equipment of PCs and printers Table 0 Application software used within particular activities Table Databases in hospitals Table 2 Network, Telecommunication and Security Table 3IT management solutions used in hospitals Table 4Selected ICT in hospitals Table 5Use of Internet Table 6Advantages and results of Internet purchases Table 7Advantages and results of e-sales Table 8Expenditures connected with the e-commerce (in % out of 00%) Table 9Barriers of sales via Internet Table 20 Barriers of Internet utilization Table 2 Barriers of ICT utilization List of figures Figure Figure 2 6

7 Introduction Information and Communication Technologies (ICT) play an essential role in supporting daily life in today's digital society. They are used everywhere now and play and important role in the delivery of better and more efficient healthcare services. Management of medical services is currently associated with a challenge to lead an institution with a relatively large number of employees, complying with the statutory requirements of the Health Ministry and of insurance companies. Management also has to deal with significant quantities of various medical equipment, is influenced by the ethical requirements and very limited financial resources. Furthermore there are a number of other requirements and restrictions that must be observed. Therefore the hospital management depends on good information systems and information technology. The basic modules of information systems (IS) needed for health care industry are almost the same as in other business areas. They include all economic modules necessary for the operation of hospitals and therefore enable consistent economic data entry without a need to duplicate the inputs. More sophisticated information systems have advanced modules for the needs of healthcare facilities that are required for system integration and operation of medical departments. Such modules have options for editing and reading data (medical card), maintenance of medical devices, and fault reporting requirements, registration of medical devices, property records and reading bar code on drugs. Using of more sophisticated information systems enables to implement systemic approach to management in healthcare facilities. It also helps to response to the following key questions: How to improve the processes? How to assess the processes? How the processes could be more flexible? How to simulate the processes? How to be prepared for a crisis situation? ICT investment in hospitals impacts not only on the hospitals themselves but also on the wider health care system. Related issues include, firstly, the continuity of care across hospital borders and, secondly, the question whether the role of hospitals is changing with regard to relationships towards patients and the division of labour with different hospitals and other health care providers. Since healthcare is increasingly specialised and tasks are distributed across a large number of health professionals, there is a need for ensuring continuity of care across departmental and extra-mural interfaces. ICT can support structured communication among clinicians to achieve appropriate health care provision. Electronic patient records and web services are two means of improving continuity of care which are currently on the deployment agenda of many hospitals. However, there is hardly any evidence of actual implementation of comprehensive electronic health records. The role of acute care hospitals is to provide in-house, 7

8 comprehensive, specific and round-the-clock care. Some hospitals also have the role of professional and student education and academic research. In the course of increasing investment in ICT, the role of hospitals may change. European countries are supported by many programs how to increase ICT using in health sector. In May 200 the Digital agenda 2020 was established and health care creates one of the main interests. The Digital Agenda for Europe (DAE) aims to help Europe's citizens and businesses to get the most out of digital technologies. Full implementation of this updated Digital Agenda would increase European GDP by 5%, or 500 per person, over the next eight years, by increasing investment in ICT, improving eskills levels in the labour force, enabling public sector innovation, and reforming the framework conditions for the internet economy. In terms of jobs, up to one million digital jobs risk going unfilled by 205 without pan-european action while.2 million jobs could be created through infrastructure construction. This would rise to 3.8 million new jobs throughout the economy in the long term. The analysis for this report suggests that ICT impacts mainly on the relationship towards patients and the need for in-patient care. Most importantly, electronic communication between hospitals and general practitioners or the patients themselves may make a patient s visit at the hospital unnecessary. The hospitals boundaries potentially become more permeable; the role of hospitals may slowly shift from an in-house care provider to an outbound communicator. Data and methodology This research report brings results of survey which is part of big project: "An Evaluation of the Management of the Information Systems (IS) and Technologies (IT) in Hospitals" This project (http://www.cti.gov.br/projeto-gesiti.html) GESITI/Hospitals was established in the Center for Information Technology Renato Archer in Brazil by the Coordinator of the research José Antonio Balloni who is author of the questionnaire. In this project we can find the members from the whole world including European countries, Portugal, England, Czech and Slovak Republics and others). The Questionnaire (BALLONI, 20) is copyrighted of the Center for Information Technology Renato Archer (CTI), located at Campinas/SP/Br, a unit of the Ministry of Science, Technology and Innovation (MCTI) and, a Cooperation Agreement has been signed between Faculty of Economics, Technical University of Liberec. More than 200 open and closed questions are divided into several strategic areas: Human resources, Strategic management, Research and Development and Technological innovation, Competitiveness of Hospitals and their cooperation for a strategic advantage, Information technology availability, E-Business, Telemedicine, Approach to clients, Quick prototyping of health and Waste management in a Health-care. 8

9 This questionnaire has been updated since 2004 by the GESITI Project and the methodology is fully described in reference (BALLONI, 20). In Czech Republic during the year 202 the questionnaire has been distributed in three hospitals, where the managers from human recourse, IT, R&D, strategic planning and other departments fulfilled the questions. The first hospital (A) is located in smaller town (7 thousands of inhabitants), has 28 beds, 582 employees, the second hospital (B) is from bigger town (00 thousands of inhabitants), has 957 beds, 200 employees, the third one (C) is from Czech capital ( million of inhabitants), has 970 beds and 235 employees. All three hospitals are state contributory organisations. None of three hospitals operates in foreign countries. None of the hospital is private or belongs to university. 2. Results This chapter contains evaluation of collected data applying the methodology presented in Chapter. The subsections copy the structure of the questionnaire. 2. Human resources In the field of human resources, several aspects were investigated through the questionnaire. Firstly, the level of education of the employees, secondly, the possibility of training and educational courses provided by the hospital, thirdly, the other possibilities to increase the qualification of employees. And finally, it was considered important to find out if employees performance is evaluated. Hospital A B C Primary education Secondary education Tertiary Education 20% 20% 6% 60% 50% 63% 20% 30% 3% Table Education of employees 9

10 Next table represents the numbers of employees with tertiary education in different positions in analyzed hospitals. Tertiary Education Hospital A (numbers of employees) Hospital B (numbers of employees) Management Physicians System Analytics Economists Nurses Engineers 2 3 Others Table 2 Employees with tertiary education Hospital C (numbers of employees) The necessity of training is obvious in these days especially in health sector. Next table demonstrate numbers of employees trained in past two years in hospital management. Numbers of None >20% >50% employees Top management Control processes 2 0 Supervision Administration Main processes 5 Table 3 Number of trained employees in the past two years In all hospitals there are used other forms of self education: Internet, special books, magister studying courses, special courses, international conferences, journals. The monitoring of employees efficiency is realized just between the nurses and it is not systematic. 2.2 Strategic management of a medical institution Strategic Management can be defined as "the identification of the purpose of the organisation and the plans and actions to achieve the purpose. It is that set of managerial decisions and actions that determine the long term performance of a business enterprise. It involves formulating and implementing strategies that will help in aligning the organization and its environment to achieve organisational goals (Lamb 984). The only way hoe to achieve strategic plans is that all employees should know about the strategic goals. Next table indicates that the strategic plan is known just to members of management and it is not known on the operational levels. 0

11 Table 4 Who knows a strategic plan? Strategic plan is Number of hospitals known to: Director 3 Management 2 Operational level 0 It is obvious, that the strategic plan is mostly known among the top and middle managers and only these employees participate on the strategy plan. Participation on strategic Number of hospitals planning Only executive management All 0 Executive management and 2 process owners Planning group 0 Table 5 Participation in strategic planning Next table explains which elements are the important in strategy plans. Level of client importance within a process of strategy creation Level of resources importance within a process of strategy creation Low Middle High Low Middle High Number of hospitals 2 2 Table 6 Important elements of a strategy creation The Balanced Scorecard (BSC) is quite well known management and performance measurement tool (Kaplan, 2000). This tool provides executives with comprehensive frameworks that translate a company s vision and strategy into set of performance measures. These measures are organized into four perspectives: financial, customers, internal process and l

12 earning and growth. These measures could be used also in different way - to help align individual, organizational and cross departmental initiatives to achieve common goals. Therefore the elements of creating a basis for a strategy were analyzed. Within this issue, three lines can be distinguished: Importance of a mission within a strategy creation, Importance of clients satisfaction assessment, o Satisfaction as a main attribute of a process of a strategy creation, o Satisfaction as a decisive indicator in a process of creation of competitive prices, o Satisfaction as an indicator of performance measurement and management of a hospitals, o Satisfaction as a determinant of current and potential development. Importance of strategic analysis methods (SWOT analysis, scenario analysis, benchmarking). All hospitals create strategic plans for time from 2 till 24 months; all of them use SWOT analysis, benchmarking and use information about client s satisfaction. Just one hospital - the marked B uses Balanced Scorecard as tool for creating strategy. None of the analyzed hospitals have the explaining comments to strategy formulation. 2.3 Research and development Investigative activities that a organisation chooses to conduct with the intention of making a discovery that can either lead to the development of new products, processes or procedures, or to improvement of existing products, processes, or procedures. Research and development is one of the means by which organisation can experience future growth by developing new products, processes or processes to improve and expand their operations. If we look at the responses about respondents evaluation of research and development, the research and development activities have mostly been identified as "occasional" and the importance of these activities is medium important in hospitals B and C. On the other hand the R&D activities have been realized continuously in hospital marked A (clinical studies) but the importance of these activities is low. 2

13 2.3. Technological innovation investments All managers of analyzed hospitals share the same opinion. They are aware of the fact that intensive use of the information technologies increase added value of the hospitals services and their output and contribute to their competitiveness. But all hospitals declare lack of financial resources for technological innovation is concerned, they also do not see any problems connecting with implementation of any technology (a new IT solution, modernization or reconstruction) which requires an intervention into organizational units and increase in knowledge of personnel. Within the questionnaire, focus was put on the investments of hospitals into the sphere of ICT during the past three years as well as in the future. First of all, each of analyzed hospitals had included the intention to invest in innovation technologies into their strategic and business plan. Within the past three years, only one the hospital A has invested more than 2 % of revenues, two remaining hospitals invested less than % of revenues. Priorities of two hospitals A and B in the sphere of technological innovations are directed mainly towards clients databases utilization, in hospital marked C think about the cloud computing. Considering the suppliers of technological innovations all three analyzed hospitals have used small and middle-sized domestic companies. A part of questionnaire was also focused on quality standards of hospitals. International norm EN ISO 900 refers to a quality management and is applicable for any organization in sphere of production and services, including hospitals. All three analyzed hospitals use quality management system Cooperation for innovation Cooperation in hospitals can be distinguished at different levels: Intra-departmental: For example within an organisational unit of the hospital the patient s needs are met, crossing the boundaries of the organisational units is not without hindering. Exchange of patients and information between departments is sub-optimal. Inter-departmental: For example within a hospital that has is patient oriented across organisational units. In multidisciplinary sessions (gynaecology, and oncology) the patient s needs are met without the hinder of formal internal boundaries. Inter-organisational: For example in trans-mural care projects the physical boundaries of the hospital are crossed. Patient and information exchange from hospital to hospital or alms home without hindering. An important part of the questionnaire has been devoted to a cooperation of hospitals with other hospitals or other public or private institutions. 3

14 Next table bring results about the importance of cooperation in analyzed hospitals in different areas. High importance Medium Low Irrelevant importance importance Clients Suppliers 2 Other hospital Advisory companies Universities 2 and research institutions Institutes of professional capacities Table 7 Importance of cooperation of analyzed hospitals Furthermore, table 8 presents the goals of the above mentioned cooperation. R&D Technical Training Product Other assistance testing Clients Suppliers Other hospitals Advisory companies Universities and research institutions Institutes of professional capacities Table 8 Goals of cooperation The biggest problem in innovation activities all three analyzed hospitals see in financial risk, in problems with uneducated staff, problems with IT standards and insufficient information about new technologies. Next figure brings details of important factors how to increase the competitiveness, the numbers represents positive questions. 4

15 Important factors to increase the competitiveness Decrease of server costs Decrease of applications costs Decrease of IT contracts costs Decrease of data storage costs Decrease of idleness Decrease of market launch duration Increase of velocity and flexibility Use of last generation applications Benchmarking 2 Incerase of finacial sources fot the core business 2 Unlimited resources of processors and storage IT management in a centralized w ay Increase of hw independence Decrease of investment risk of new activities Increase of velocity of expected investment result Decrease of capital costs 2 Increase of data security 0 0,5,5 2 2,5 Figure Important factors how to increase competitiveness 5

16 2.4 Competitiveness of hospital & Cooperation for strategic advantage Hospitals are subject to constant impulses from the national government and insurance companies to improve efficiency and effectiveness. For example, budget restrictions by the central and local government make it necessary to improve efficiency and to reduce costs; the general need to improve patient care makes it necessary to improve effectiveness. According to the questionnaire the most important factor for efficient management in hospitals A is competitiveness and cooperation, in hospital B is minimization cost and in hospital C it is profit creation. With respect to the expectations of hospitals for the future, they were asked what the main challenge of hospitals is in the 2st century. In hospital A it is rising efficiency of processes. In hospital B and C it is efficient of strategic management and innovation. Although considering the main challenge of the 2st century, analyzed Czech hospitals do not declare the accordance of project activities with the strategy. Next question was focused on the increasing of competitiveness and on the main influencing factors. The managers from all hospitals consider the reduction of server, application, IT contracts costs. As important tool they consider benchmarking, increasing of financial resources for core business, centralisation of IT services, increasing of security and reduction of capital costs. In hospital C the using of new applications is also very important. 2.5 Information technology availability in medical institution 2.5. Acquisition of equipment and facilities Considering the results of research performed in the Czech Republic, the number of computers used in the hospitals depends on their size and structure of hospitals. Computers with Internet connection cover of all computers in hospitals (See Table 9) and also the number of computers with access to the LAN. Various devices are designed for communication of user with information system. Their construction and structure is dependable on a particular architecture of each hospital, on its mission and preferred IT applications. 6

17 A B C Average Number of PC Number of PC with access to Internet Number of PC with access to LAN Number of laser printers Number of inkjet printers Number of dot matrix printers Number of PC with multimedia Table 9 Basic equipment of PCs and printers Application programs A strong ICT strategy is pivotal to competitive survival for today s businesses. It has become a pervasive part of our working and living environments, and will continue to be an integral resource for business, government and society at large. ICT combines information, knowledge, processes, and technology to provide a foundation for driving efficiencies and fuelling innovation. It is the key to helping organizations of all sizes to connect, collaborate and compete more effectively. Analyzed hospitals use the usual office software applications. All hospitals use the package of Microsoft Office. Considering the applications used within particular activities, the following table (Table 0) displays a review of various types of software. Number of hospitals Name of software Hospital management CGM CareCenter Integrated management - Accounting 2 Navision, Amis ECO Human resources 3 VEMA PaM, Target, AVENSIO Purchases/Sales 2 Navision, AMIS ECO Inventories 3 Navision, AMIS ECO, PANAKEA Asset management 3 Navision, Profit, AMIS ECO Cost management - Other 3 Marie Pacs Table 0 Application software used within particular activities 7

18 2.5.3 Databases Information collected from all sources are used in a remarkably wide range of applications. For IS of hospitals and web application, a necessity to work with large data files is typical. In order to save and use them efficiently, it is useful to create logically interconnected structures - databases. Table brings details. Table Databases in hospitals Number of hospitals Administration 3 Financial dept. 3 Tax dept. 2 Human resources 3 Beds/Reception 3 Emergency 2 Surgery 3 Clinical lab 3 Marketing 2 Sales dept. 3 Inventories 3 Medical report 3 Outpatient dept. 3 Addtional support 3 Diagnostic 3 Other Outsourcing Outsourcing is an increasingly popular strategy that healthcare organisations can use to control the rising costs of providing services. With outsourcing, an external contractor assumes responsibility for managing one or more of a healthcare organisation s business, clinical, or hospitality services. Because the contractor specialises in providing a specific service and can achieve economies of scale, he/she may be able to provide a service more efficiently and less expensively than the healthcare organisation. Outsourcing services peripheral to the organisation s primary operations may also enable healthcare administrators and staff to concentrate more efficiently on their organisation s core business. Based on the outputs of research hospital B is using the outsourcing for security services and hospital C is using telecommunication services and Help Desk services. 8

19 Help desk E-learning - training System integration Printing media Tellecommunication services Advisory services Figure 2 Outsourcing in hospitals 0 0,5,5 2 2, Network, security and telecommunications It is important for hospitals to develop a comprehensive Security Management Program (SMP) to effectively support and maintain physical protection for patients, staff and visitors. Central to that development is the completion of a comprehensive threat assessment and an evaluation of the security protocols, policies, and procedures underlying the SMP. These vitally important elements of the SMP should be well- defined, unambiguous and reinforced with periodic staff education and training. If we focus on results of analyzed hospitals, 00 % of hospitals use antivirus programs and almost all use Firewalls. As all analyzed hospitals have been using intranet, the secured communication between intranet and Internet is essential. Next table brings results of infrastructure in analyzed hospitals. Number of hospitals LAN 3 Wireless 3 Remote Access VPN 3 DSN Routers Switches 3 Video/Tele/Web-conference VoiP VPX Security Systems 2 Firewall 2 NetSecurity System IDS Antivirus 3 Identification and Access 2 Management Software Table 2 Network, Telecommunication and Security 9

20 2.5.6 IT management Some of the implications directly affect hospital management. In order to facilitate the integration of separate information systems in hospitals, health policy makers should increase awareness about interoperability issues in health care. They should actively promote and facilitate interoperability by appropriate investments in the work of standardisation organisations and their standardisation efforts. Voluntary use of standards by hospitals and other health service providers could contribute significantly to interoperability. Enhancing ICT investment. Improvements in ICT applications in hospitals can come about only if the hospitals invest adequately in these technologies. Hospitals should carefully plan ICT spending within the near future and also develop a long-term strategic ICT plan. They should not necessarily expect quick returns of ICT investment. The hospitals lack the investment capabilities as well as human resources for a great thrust towards implementation of comprehensive ICT applications. A step-by-step investment approach however appears to be appropriate. Improving education and training in health ICT. Effective use of ICT in hospitals requires adequate education of the users, e.g. physicians, nurses, and pharmacists as well as administrative staff. Thus, policy makers should strive for providing adequate education and training opportunities for hospital managers. Hospitals need to be aware that security issues cannot be solved by purely technical means but that a broad approach needs to be applied, including a security policy and provisions such as security training. Health policy makers should thoroughly monitor the changing role of hospitals in order to drive wanted developments and to react to unwanted developments if need be. Relevant indicators to be monitored include, e.g., shifts in size classes, in different locations, and public or private ownership. The relationships of hospitals towards patients, other hospitals, and primary health service providers should also be monitored. During the last decades a lot of methodologies how to manage the IT have been developed. Also Gartner research identifies business process analysis as an important aspect and not just in manufacturing industry but also in services. The main part of hospital process management has to be focused on process maps. These maps are very important for easy viewing of the processes which are conducted in hospitals. Next table explains IT management solutions in analyzed hospitals. 20

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