IMPLEMENTATION OF A HEALTHCARE INFORMATION SYSTEM: KEY PERFORMANCE INDICATORS IN KING ABDULAZIZ UNIVERSITY HOSPITAL.

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1 Page22 IMPLEMENTATION OF A HEALTHCARE INFORMATION SYSTEM: KEY PERFORMANCE INDICATORS IN KING ABDULAZIZ UNIVERSITY HOSPITAL. Submission Date:21 st Dec, 2013 Acceptance Date:30 th Dec, 2013 Revision Date: 25 th Jan, 2014 Publication Date: 28 th Jan, 2014 Kamel Khoualdi (KSA) Saud Mandurah (KSA) International Journal of Modern Business Issues of Global Market (IJMBIGM) ISSN No PP all rights reserved to IJMBIGM Full Manuscript is accessible at Current Issue and Full text manuscript is available at Keywords: Heath Care, Information Systems, Electronic Medical Record. Abstract: King Abdulaziz University Hospital (KAUH), Saudi Arabia, Jeddah caters its services to the patients coming from in and around of Jeddah and Makkah. KAUH is an eight hundred and fifty bedded hospital equipped with modern facilities and catering all specialties. Before the implementation of the computerized system, all the information relating to patients and administration was in the form of hard copies (paper work). Due to which the process of finding information was cumbersome. There was no consistency and most of the time the information was not accurate. There were many errors being recorded due to manual entry of critical clinical data. In order to improve patient safety and to achieve accuracy and reliability of clinical data King Abdulaziz University decided to implement and computerized patient care management system. Patient care management at KAUH has fully utilized the power of computers in Medicare, whereby healthcare information system maintains patient database for the hospital services in the areas of laboratory and pathology, radiology, operating room, medical research, in-patient admissions, out-patient scheduling and billing, medical stores and pharmacy. This project tries to give an insight to the Hospital Information System implemented at KAUH, which is being utilized to provide quality service. Department of Management Information Systems, King AbdulAziz University, Jeddah, Saudi Arabia Department of Business Administration, King AbdulAziz University, Jeddah, Saudi Arabia kamel_khoualdi@yahoo.com Introduction: Hospitals are very expensive to build and to operate. Administrators and professionals have to be extremely cost conscious. Effective systems and procedures need to be implemented to ensure proper utilization of limited resources toward quality health care. Healthcare is a large and growing industry that is experiencing major transformation in its information technology base. Information systems (Walsham and Sahay, 2006) confronted similar transformations in other industries and developed theories and methods that should prove useful in healthcare applications. In turn, Information systems may benefit from incorporating knowledge from health informatics, a discipline that studies information technology within medical and healthcare contexts (Wilson and Lankton, 2004).The adoption of information systems in healthcare is no less significant than in any other commercial or caring organization (Mantzana et al., 2007). Information technology has made a significant impact on the healthcare sector. The past decade has witnessed the foray of numerous information systems and their resultant products into the hospital scenario. The number of investments in computers and types of hospital systems has

2 Page23 increased. This is because paper medical records are cumbersome, bulky to use and difficult to manage. On the other hand digital records are much easier to handle and improve the workflow efficiency by integrating various tasks. The ultimate objective is to build a network of interdependent centers such as the clinical laboratory, radiology department, pharmacy, and so on in order to effectively meet the needs arising within the hospital. Despite the fact that these individual centers are autonomous, they are interdependent in terms of delivering services and to ensure effectiveness of providing care. All this can be achieved through hospital information systems (HIS) that have formed the cornerstone of today s modern hospital. A Hospital Information System (HIS) (Wager et al., 2009) can be defined as a computerized system that is designed to meet all the information needs within a hospital. This includes diverse data types such as patient information, billing, finance and accounting, staffing and scheduling, pharmacy ordering, prescription handling, supplies, inventory, maintenance and orders management, diagnostic reports related to laboratory, radiology and patient monitoring as well as providing decision support. Rationale of the Study Computerization at King AbdulAziz University Hospital During the early days at King Abdulaziz University Hospital, patient records and administrative records were maintained in hard copy files. As the hospital was growing bigger in size, the number of departments, and number of patients, staff and patient services increased. Managing the information of patients was getting difficult. The business processes slowed down due to non-availability of timely and accurate information. Critical Clinical Data was being recorded incorrectly, this could lead to fatal mistakes. During such time hospital management decided to look for solutions to improve the business process and improve the accuracy and reliability of data being recorded. It was then decided that hospital would more towards computerization. As a prelude to computerization a comprehensive requirement analysis study was conducted by a team of KAUH staff and IT staff to ascertain the various needs for computerization. Patient Care related areas were given priority in order to achieve the objectives. Objectives of the Computerized System KAUH is a large hospital which devotes considerable emphasis on Patient Care, education and Research. The short term objectives of the on-line computerized system at King Abdulaziz University Hospital are to reduce costs and improve the accuracy and timeliness of patient care, accounting and administration, record keeping, and management reporting.the long term goal are to build and maintain a patient database for analysis of data to facilitate decision making process. Scope of the System Patient Care related areas were given priority in order to achieve the objectives. Some of the Departments computerized at KAUH are:

3 Page24 Patient Registration Department. Out Patient Appointment Scheduling Department. Admissions, Discharges and Transfers (ADT) Department. Pathology Department. (Laboratory). Radiology Department. Pharmacy Department. Patient Wards. Blood Bank. Medical Stores. In order to achieve the objectives through computerization, each functional business process was studied and then questioned. Radical changes were brought about by reengineering the processes and simplifying the existing business procedures to meet the needs of computerization. FIGURE 1: BUSINESS - REENGINEERING CYCLE Study existing business / workflow process Evaluate each business / workflow process Methodology (Strategic Planning) A project team was formed for monitoring and managing the project. The Team comprised of Head of Departments, Key users consisting of doctors from various functional areas along with IT personnel. Project Manager (Medical Services) set directives and reviewed project. Technical guidance was provided by Senior IT personnel. The project execution methodology was carefully designed to incorporate almost all the essentials of comprehensive methodology for building information systems. Main emphasis was given to Joint Application Development (JAD) where approach was participative, user driven, highly interactive, stress on quality, use of productive tools, phase approach etc. Each phase end was certified by key users, Steering Committee members. Business Process Re-Engineering (BPR) Implement the new process with computerized information System Key Performance Indicators (KPI) The benefits of computerization come from better management through informed decision making. The Key Performance Indicator s showed remarkable improvements after computerization. Hardware and Software Requirements for Existing Hospital Information System Database Revalidate the business / workflow process Enhance and improve the business / workflow process The Hospital Information System uses Oracle Database Management System (Oracle 11G), which is one of the most reliable Relational Database Management Systems. The Database is installed on three servers and clustered using ORACLE RAC technology. Using RAC provides high availability of the servers.

4 Page25 The Data files reside on a (Storage Area Network) SAN storage, which has a storage capacity of 10 Terabytes. FIGURE 2: SOLITION ARCHITECTURE There is an identical set of Database servers installed at the disaster recovery site. The Disaster recovery site is located away from the hospital, In the event of failure at the Main site; The Disaster Recovery servers will be operational. The servers at the disaster recovery site ensure data availability and business process continuity. Client Machines The Hospital Information System runs on Intel based machines with minimum of 1 GB RAM. The HIS is a windows based system and runs on Win XP, Windows vista, Windows 7 or Windows Application Software The Hospital Information Software (Phoenix Hospital Information System) is a Client Server architecture based system. The Hospital Information System works on windows operating system. Backup Procedures The data from the Hospital Information System database is backed up using automated Tape Library. The backup is done through Oracle RMAN. Using RMAN ensures that no data is lost in case of any hardware failure. Solution Architecture Diagram The architecture of the system is as below Comparison of Manual Systems vs. Computerized Systems Outpatient Scheduling System Manual Outpatient Appointment System Advantages No investment and maintenance required for computer hardware and software. Disadvantages Appointments were booked at appointment clerks using Hard Copy Appointment Register. If more than one clerk booking the appointment for the same clinic was not possible. Doctors inside the clinics were not aware about the available appointments.

5 Page26 It was difficult to keep a record of the patients previous and future appointments. Manual creation of appointments was prone to errors such as wrong appointment dates and patients being booked with a wrong clinic or doctor. No backups for the Manual Appointment Register. Reporting of the statistics was a cumbersome process. Computerized Outpatient Appointment Scheduling System Outpatient Management System provides a totally paperless solution that will meet the requirements of large outpatient departments. It provides a unique five day graphical view of the booking dairy. Some of the features are: The facility to enter an approximate date to locate the earliest available appointment. A color coded calendar indicates whether the clinic is fully or partially booked. Facility to reschedule or freeze appointments. Quick display of previous / future appointments for a patient. Facility for the doctor s to view and book their patient appointments. Data is backed up on daily basis. Appointment slips printed automatically on booking. Validations restricting the number of new patients or revisit patient per each clinic. New clinics can be setup quickly and easily. Statistics for administration purposes can be extracted from the system. Some KPI s recorded after implementation of Outpatient System are illustrated below: Admissions, Transfers and Discharges Module Manual Admission, Transfers and Discharges System. Advantages No investment and maintenance required for computer hardware and software. Disadvantages Booking of the Beds for the patient was not reliable. Phone was used as a channel of communication between the Admissions office and Wards to notify regarding and admission, Discharge or Transfer. Multiple hard copy registers had to be maintained by each ward and admission office. It was not easy or accurate to find the available beds in the wards. Backup of the data for booked beds and currently occupied beds was difficult. Reporting of the statistics was a cumbersome process. Computerized Admission, Transfers and Discharges System ADT Management System provides a totally paperless solution that will meet the requirements of more than 1000 bedded hospital. It provides a graphical view of the available, occupied or booked beds. Some of the features are: Graphical bed planning screen displays the status of every bed for a 25 day period.

6 Page27 Various options available for calculating the expected length of stay (LOS). Facility to cancel, transfer and reschedule bookings. Facility to review patients who did not arrive and to monitor double booked beds. Graphical and colorful display of the discharge planning process. Automated scheduling of the pre Anesthetic appointments, Pre and Postoperative clinic appointments. Quick display of previous / future admissions or bookings for a patient Data is backed up on daily basis. Automatic printing of admission face sheet and patient wrist bands. New wards, beds and rooms setup quickly and easily. Statistics for administration purposes can be extracted from the system. FIGURE 3: COMPUTERIZED INFORMATION SYSTEM AND MANUAL SYSTEM Laboratory Information System Manual Laboratory System Disadvantages Doctors have to request laboratory tests using test request form. No specimen labeling system. No interfaces to analyzers. Manual requests and Manual Result Entry is prone to human errors. Delay in processing samples and Delay in the Turn Around time of tests. Difficult to retrieve any statistics from the manual forms. Computerized Laboratory Information System Laboratory information system currently at KAUH is focused on improving the efficiency and reducing the cost and turnaround times. Some Features of LIS are: Computerized requests for laboratory tests. Sample collection with bar code printing facilities. Automated pick list generation for the Phlebotomists. Automated recording of the specimen tracing information at each step of the process. Validation rules on the releasing of the results. Normal range check based on age,sex, analyzers etc. Delta check, panic values and impossible value checking for manual result entry. Analyzer interfaces for all analyzers.(no need for manual result entry). Online verification of the results by the consultants. Multiple levels of verification for each tests based on the system rules. Automatic reporting of critical results.

7 Page28 Point of Care testing and reporting interfaces. Results reported and available on the patients Electronic Medical Record. Results Display in various format, routine report, graphical display and tabular display. Data backed up and maintained. Various kinds of statistics reports available. Automatic Turnaround time calculation for each specimen or test. Thus, by implementation of the computerized Laboratory information system KAUH has improved the workflow, efficiency and the turnaround times were reduced significantly. Some KPI s Recorded after implementation of the Laboratory System are shown below: FIGURE 4: RADIOLOGY INFORMATION SYSTEM AND MANUAL RADIOLOGY SYSTEM No centralized system for the booking of examinations. Hand written requests were provided to the patients. Reports were either hand written of typed and maintained using word processor applications. Reporting statistics was a difficult process. Hand written reports were prone to human errors. Computerized Radiology System The major components of Phoenix Radiology Information System are the computerized appointment scheduling, reporting, dictation, transcription and report verification system. Some of the features of the existing system are: Comprehensive appointment scheduling system including facility to double-book, reschedule, cancel or freeze appointments. Requisition of radiology exams done electronically. Exams are reported and verified electronically using the RIS. Utilizes Hand writing recognition. Utilizes Dictation. Statistics available through pre-defined reports or through custom reports. Disadvantages Booking of the patients for each machine was maintained in hard copy registers. KPI s recorded before and after implementation of computerized system are illustrated below: Material Management System Manual Process at the Stores Disadvantages

8 Page29 Inventories of all the products maintained using the hard copy files and registers. Items quantity on hand calculation was almost not possible. Each sub store had their own process and record of the inventory. It was difficult to find the impress levels. Receipts of goods were done manually, which made it difficult to track the history of the goods received. Expiry Dates had to be manually checked before transferring or delivering to products to other departments. Unit of measure for each item had to be calculated manually. Maintaining multiple units of measures was not easy task. FIGURE 5: COMPUTERIZED MATERIAL MANAGEMENT SYSTEM VS MANUAL SYSTEM Products are assigned codes and multiple units of setup are possible. Products are received electronically from the supplier and the stock on hand is updated automatically when the items are received. System has ability to prioritize the near expiry products. System alerts the store in charge of the critical stock availability. Facility for the wards, clinics and other departments to request items electronically using the Material Management System. Transfer of the items is done electronically and which reduces the quantity on hand. Automatic verification of the expiry of the products. Statistical reports available for administrative purposes. Computerized Material Management System Some of the features of the existing material management system are: KPI s Measured after implementation of computerized system in Stores are shown below: Key Process Indicators Some of the following KPI s were measured before and after the implementation of the computerized system. TABLE 1: KEY PERFORMANCE INDICATORS Sr Measured KPI Outcome Waiting times for Average Booking time Outpatient for new using the manual system appointments and was 10 minutes, with the 1 follow up computerization the bookings. average booking time was 2 Time for processing a new patient admission. reduced to 2 minutes. Average time for admitting a new patient was 25 minutes, which reduced to 5 minutes

9 Page Turn Around time for laboratory tests Turn Around time for Radiology Examinations Accuracy of the Quantity on Hand for each product in the store using the computerized system. Accuracy of the system improved. Turnaround time for chemistry and hematology tests was reduced from more than 2 hours to 30 minutes for routine tests. Turnaround time for radiology report verification reduced from 3 days to 1 day. Accuracy of the Quantity on hand of the products increased from 60% to 95 %. FIGURE 6: KEY PROCESS PERFORMANCE INDICATORS accessible by multiple physicians at the same time. Furthermore, any patient related information would be either entered using the Hospital Information System or the hard copy would be scanned and viewed as a PDF file. On completion of this process the Hospital will totally be paperless. Online Access Conversion of the existing client server to web based system. The web based system will facilitate the Physicians, Students and researchers to access the system from anywhere by using the internet Manual Computerized Drug Interactions The existing system lacks the facility to provide alerts to the physicians during prescribing medicines; the hospital has planned to integrate a drug database to the existing order entry system. This integration would enable the existing system to alert the physicians regarding Dosage Range Checks. Drug to Patient conditions interactions. Drug to drug interaction. Short Messaging System (SMS) Upcoming enhancement to Information System Electronic Medical Record The implementation of Electronic Medical Record aims for a paperless solution for the patient medical record. All patient hard copy files will be converted into softcopy, by scanning files; this will make the file Short Messaging System is a recent feature; the physicians get an SMS on their mobile if their patient is in critical condition. Patients receive information regarding the appointment schedule, cancellation or re booking. Conclusion It can thus be seen that deploying Hospital Information System can help the medical

10 Page31 profession in improving its quality of service and thus automatically increasing the preparedness and defensiveness. Of course, it is of vital importance that the software must have the right type of modularity and openness so that it is manageable, maintainable and upgradable. The hardware should also be reliable, available and have the necessary performance capacity. Certainly, computers with their intrinsic power can play a major role in a hospital. Wilson E. V., Lankton, N.K. (2004). Interdisciplinary Research and Publication Opportunities in Information Systems and Healthcare. Communications of the Association for Information Systems, Volume 14, Computers can act as a communication link between departments and allows the common database to be shared by them. They can perform the complex task of matching, tabulating, calculating, retrieving, printing and securing the data as required. Well designed, integrated computer system can be a great tool in the hands of the hospital management in improving services, controlling cost, and ensuring optimal utilization of facilities. References Mantzana, V., Themistocleous, M., Irani, Z., and Morabito, V. (2007). Identifying Healthcare Actors Involved in the Adoption of Information Systems. European Journal of Information Systems, Volume 16, Wager, K. A.V., Lee, F. W., and Glaser, J. P. (2009). Health Care Information Systems: A Practical Approach for Health Care Management, Jossey-Bass, 2 edition. Walsham, V., and Sahay, S. (2006). Research on Information Systems in Developing Countries: Current Landscape and Future Prospects. Information Technology for Development, 12(1), pp