Summer Placement In

HiSPindia

(April 4 - May 30, 2011)

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

Shruti Goel PG/10/045

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

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International Institute of Health Management Research, New Delhi 2011

ACKNOWLEDGEMENT

We wish to express our deep sense of gratitude to Prof Sundeep Sahay, President, HiSPindia for giving us great opportunity to do our Summer Training at HiSPindia, Shimla. We hereby express our 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 Professor Indrajit Bhattacharya and Professor Anandhi Ramachandran for their kind assistance and support throughout our summer training. Finally, an honorable mention goes to our family and friends for their understanding and support in completing this project. Thank You

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ABBREVIATIONS1. AIDS- Acquired Immuno-deficiency Syndrome 2. API- Application Programming Interface

3. BPL- Below Poverty Line4. DDU- Deen Dayal Upadhayay

5. DHIS- District Health Information System6. DOTS- Directly observed treatment shortcourse

7. HIS- Hospital Information System 8. HISP- Health Informatics Systems Programme9. 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 CONTENTS1. 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...12 3.2 (b) Review of Existing Process13 3.2 (c) Requirements Based on Review of Existing System.20 3.2 (d) Meeting on HIS implementation22 3.2 (e) Action Plan for HIS implementation..23 3.3 Procurement of Software/Hardware Support.23 3.4 Module Implementing24 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 Need46 3.5(c) Basic Requirements.46 3.5 (d) Training Plan..47 3.6 Dry Run49 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. References....53 4|Page

6. Case study....54 7. Annexure..60

ABSTRACTIntroduction 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 5|Page

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)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 To 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 7|Page

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 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. INTRODUCTIONOver 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 HIS is based on the exemplar of a centralized information system designed for quick delivery of operational and administrative information.

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The administration can actively use HIS for monitoring and controlling the quality of patient care. Helps in providing improved clinical outcomes and better diagnosis and care to the patients. The administrative and supply chain modules improve productivity and efficiency, driving down costs and waste. Assesses the performance of the medical staff; in keeping track on how hospitals resources are being put to use. 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.

Improved monitoring of drug usage, and study of effectiveness.

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1. OPERATIONAL PLANThe implementation of HIS can succeed if the following two conditions are met A consistent organization of people and processes A clear choice for the establishment of infrastructure (hardware & software) backed up by financial investment. DDUs 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 HIS11 | P a g e

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 were 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. 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. Efficient and accurate administration of registration, billing, OPD, IPD, Laboratory, Blood Bank, RKS hospital maintenance, inventory and pharmacy. 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 include3.2(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 12 | P a g e

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. 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: Central concept dictionary: Definitions of all data (both questions and answers) are defined in a centralized dictionary, allowing for robust, coded data 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. Unique identifiers per patient: A single patient will have a unique identifier which will be used across the system to search that particular patient. Data export: Data can be exported into a spreadsheet format for use in other tools (Excel, Access, etc.) Modular architecture: An OpenMRS Module can extend and add any type of functionality to the existing API. Patient workflows: An embedded patient workflow service allows patient to be put into programs (studies, treatment programs, etc.) and tracked through various states.

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Cohort management: The cohort builder allows you to create groups of patients for data exports, reporting, etc. 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 hospitals layout can be determined to be placed in future virtually. While doing so, following were the observationsRegistration 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) was-

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There are 16 departments in the hospital and the list of department is as follows: Department Room No. Physiotherapy 4 Ortho OPD 7 X-Ray 8 Gynae OPD 11 Name: Registration no: Children OPD 12 General OPD 24 Age: (Years/ Months/ Weeks/ Days) Medicine OPD 25 Eye OPD 27 F/M H-C/O Name: Surgical OPD 28 ENT OPD 29 Gender: (male/ female/ male child/ female child/ unknown) Dental OPD 30 ECG 31 Department: *(department with room no.) Casualty 33 T.B clinic 34 Unit: Leprosy clinic 35 Skin OPD/ STD 38 Category: (General/ IRDP/ Poor free/ BPL/ RSBY/ Senior citizen/others) District: State: Old patient: Area: (Himachal/ others) (-, yes)

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: Male Age wise OPD Report: Female Male Child Female Child Male citizen 15 | P a g e Sr. Female Sr. citizen

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

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. 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.

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 16 | P a g e

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-ray08 Blood grouping..32 ENT checkup.29 Ortho unit..07 Gynae unit (only for females)11 Medical unit24/25 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, from their respective organizations, and the stamp is put on their form. The charges are Rs. 100. 17 | P a g e

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.

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

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 18 | P a g e

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:

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, clinicians 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 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. 19 | P a g e

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.

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.

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.

There are several sources of information People- They are the primary source of information. This includes the end users like doctors, nurses, lab technicians, paramedicals and other supporting staff. Manuals- They are the documents/registers maintained by different departments that gives the details of the existing system and the recordable fields. System- Existing application and its functionalities.

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.

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3.2(d) MEETING ON HIS IMPLEMENTATION Once the lists of requirements were compiled based on hospitals 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, 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 SUPPORTInstallation 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 switchs via patch panel in racks. The hardware that connects to the network are Servers Workstation 21 | P a g e

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.

3.4 MODULE IMPLEMENTINGIn 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 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 identifier. All referral Patients under National Health Programme including TB Leprosy, Except HIV will be directed through this central registration.

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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.

The registration clerk then adds the details of the patient in the various fields of registration. 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

Relatives name The registration clerk would have to enter either the fathers name, or the husbands name. 23 | P a g e

Referral information- The registration clerk would have to select the appropriate option for referred 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 referral type from the drop-down list.

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.

Address - The registration clerk would then have to select the District and Thesil of the patient. 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. 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 Save option. Following which the system would generate the OPD slip, as shown in the screen-shot below. The registration clerk can then select the print option to print the OPD slip generated.

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In-case multiple patients with the same name exist, advance search option helps to filter the patient by gender, age, date of registration and relatives 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. 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 billing option from the navigation menu. On selecting the billing option, a screen as below will be displayed.

The billing clerk would be able to bill for 4 main services of the hospital: Patient services Patients are billed for various investigations/ tests are prescribed by the doctors in the OPDs. 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 add a new bill option. On selecting add 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 25 | P a g e

current bill are displayed. An option to print the bill and the billing history of the patient is displayed. 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 billing ambulance option, on the main billing screen and then search for the driver in search driver field and select the appropriate driver for whom a bill has to be raised. A new driver can also added, using the add driver functionality on selecting the Add new driver option. To add a new bill for the selected account, the billing clerk selects the add new bill option. On selecting the required service, the price assigned for that service would be populated in the table at bottom. 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 billing 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 Add new bill option. To add a new company name add 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. Miscellaneous services other services that are not covered in the above 3 categories e.g. student internship fees. To bill for miscellaneous services, the billing clerk would have to select the billing 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. 26 | P a g e

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 Lab Entry icon is selected. Here the laboratory technician can select 4 main functions: Lab Entry System Work List Enter Result Print Patient Report

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 Get Patient list option. (Selecting Get 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 Reschedule 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 Get Work List. This displays the Work Lists along with displaying an additional filter to select test.

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On selecting test the displayed list allow provide an option to Enter Result in 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.

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 Print 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 Get 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 Print the test report of the patient.

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Phase II- In the first phase of implementation the following modules were implemented OPD IPD 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 OPDs. 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 patients 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. 30 | P a g e

On the main OPD interface screen, the doctor would be able to view 3 main options Patient queue This is a queue of patients who have been registered for a particular OPD on that day . 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 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.

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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 Ram has been searched for, a list of all the patients with name Ram will be displayed. The doctor then select the appropriate patient by matching the age and the identifier.

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 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. Clinical summary Here the doctor would be able to view all the entries that have been previously made for each patient. Investigation report The doctor is able to view the results of all the investigations that have been conducted on the patient as prescribed. IPD record The doctor is able to view the admission and discharge details of the patient.

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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 Follow up and selecting a follow up date Cured Died Reviewed Admit. On selecting the admit 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 IPD 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:

Here the end-user would be able to view 2 main options 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. Admitted patient index: This a list of patients who have already been admitted to the various IPD wards. 34 | P a g e

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 patients for admission, against each patient on the list, the end-user would have the following three options:

Admit- The end-user would have to enter the details of caste, monthly income, basic pay and bed number and then select the submit option, after which the patient will now be transferred to the admitted patient index and an admission slip will be generated. A print out of the same can be taken.

Remove- If a patient does not show up in the ward, the patients name can be removed by selecting this option. No bed- In-case of unavailability of beds, the end-use selects the no bed option; to remove the patient from the queue.

In the Admitted 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.

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Here the end-user can perform 3 operations for each admission Transfer- The end-user uses the transfer option, in-case of transferring of a patient from one ward to another, internally within the hospital. Discharge- The end-user uses the discharge option to discharge a patient from the hospital. The end-user would first have to select a diagnosis 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 submit option. 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

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: 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. 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. 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. Tranfer to Sub Store- This functionality enables the Inventory Manger to tranfer the items to Substores example Transfer 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 37 | P a g e

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 encountered 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 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. 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 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.

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 as Essential Vital Desirable

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

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

View Stock Balance Expiry

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Indent for Drugs- To add a new indent pharmacist Clicks on the add indent Slip and the following window appears

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 sent to the Main Store. As per the reply from Main store, the status of indent can be either Process Indent ( replied from main store need to be processed in pharmacy i.e to accept or refuse), Sent (sent by pharmacy, not yet processed by main store), Receipt (accepted and received by pharmacy), Main Store Refuse or Sub Store Refuse. 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 drugs is added to the indent slip by add to indent slip option, then he finds 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 donors 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.

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.

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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. Administer Lab tests for Donors Blood Sample after clicking on the Lab Tab and the following window appears. As seen here the donors 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 doesnt enter the blood bank stock. 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 42 | P a g e

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.

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Diagram showing module interconnectivity

3.5 TRAINING SESSION/ CAPACITY BUILDING FOR THE END USERThe 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 44 | P a g e

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 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. 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 have 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 3.5(d) TRAINING PLAN Training practices for both the clinical and nonclinical staff were planned out 45 | P a g e

Training programme documentation was reviewed to provide training in a standard format 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 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.

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 46 | P a g e

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. 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

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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 persons 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.

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

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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 trainers 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 PROCESSOnce 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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CHALLENGES 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. Training of entire staff was a problem due to vast manpower and different work timings especially of nurses. Enormous patient load in public hospital like DDU causes difficulty in acceptance of the system by users due to work overload keeping them busy. Acceptance and appreciation of computerization by medical, paramedical and other healthcare specialist as a compliment and not a supplement. Maintaining patience among users in initial phase when both old and new systems were Underestimation of the complexity of routine clinical and managerial processes. It was a challenge to bring all the staff with varied levels of computer literacy to the same level of competency. DDU has an old heritage building, the infrastructure thus posed a threat while creating and installing an intranet in the premises. 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 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. The HIS product should cover maximum functionalities and should have the flexibility of customization as per the need of the hospital.

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

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

1. REFERENCES

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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 implementation by J.C. Sarivougioukas and A. Th. Vagelatos.

f. A study on Determination of the success of a hospital's information system 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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CASE STUDY 1 ASSESSMENT OF COMPUTER LITERACY STATUS AMONG THE HOSPITAL NURSING STAFF IN DEEN DAYAL UPADHYAY HOSPITAL IN SHIMLA 5.1. Introduction Computers are changing the way health care organizations do business. As the medical field becomes more progressive through technological advancements, computers are being integrated into the continuum of medical practices to provide more efficient and effective ways of delivering services. In order for any organization to be globally competitive in the market place, it is imperative that medical staff become fully computer literate in order to function effectively in their roles. Computer literacy may be defined as the understanding of computer capabilities, applications and the concept of algorithmic design. It is generally accepted that we live in a technological age. Use of computer literacy has brought a revolutionary change in education as well as in healthcare. The increased use of computers in healthcare prompts a need to increase the computer knowledge level among nurses. In recent years, hospitals and healthcare facilities have been implementing hospital information systems (HIS) as a means to streamline processes and reduce costs. Hospital automation is inevitable and Nurses being the hub of any clinical ward cannot remain untouched by this process. More importantly, they have to be active participants in the whole process to make the automation concept a success. Because nurses as a group are unsophisticated about the potentialrepresented by computers (Hebert, 1994:369), their perceived lack of computer skills is a major drawback when one is trying to meet the high-technological challenges of the professional nursing domain. The healthcare industry has been slow to embrace computers or provide sufficient funding for current computer software, hardware, technical support or staff member development. This

would have serious implications on the success of any organization's IT enablement.

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Advancement in medical technology has become more in past ten years and has challenged medical professionals to acquire and use information processing skills. Computer literacy has following three main dimensions: Understanding what the computer is and does, including basic terminology and systems capabilities; performing basic operations on a computer system to complete professional tasks and Having awareness of the impact of computers on the quality of human life. Nurses are required as part of their administrative functions to spend a large part of their day on the computer inputting data, analyzing this data and collecting and inputting statistics. This will lead to reinforce the nurses to become more effective information managers as the more effective information management relies heavily on information technology. Research has taken place regarding the computer literacy status of nurses in DDU hospital for the purpose of the study and it has been found that the attitude of nurses towards computerization vary according to age, gender, level of education, number of years in current position and past experiences with computerization and the internet usage. In DDU hospital, HIS is implemented in various departments such as registration, OPD, IPD, pharmacy, billing and laboratory. There is one computer in each of the four nursing stations for patient admission, discharge, transfer and inventory. Computer skills for the nurses are important as they are required to admit and discharge patients, for indents etc. 5.2. Methodology For the assessment of computer literacy among the hospital nursing staff, a sample survey was conducted at Deen Dayal Upadhyay hospital, Shimla and the nurses were interviewed. The questionnaire consists of questions mainly aimed at determining: -Socio- demographic details of the respondents. -basic computer operation and function -word processing skills -internet and web skills 54 | P a g e

-multimedia and e-mail skills This is a quantitative study consists of sample size of 30 nurses ranging from different departments working full time at DDU hospital. The nurses were of age group 25-59 years. The nurses were selected randomly based on their availability to answer the questions. The study was conducted in DDU, shimla after the training of nurses on the basic computer skills by the HIS team of HISP India. The study tool employed was a closed ended questionnaire was designed consisted of ten questions mainly focused on basic computer skills of nurses. The data obtained was analyzed using Microsoft excel. 5.3. Observations By analyzing the response of the respondents the following significant observation were made Demographics of the respondents Out of the 30 respondents, 16 nurses were between the age group 25-34 and 10 were between 35-44 years. Only four nurses were between the age group 45-54 and no nurse was between 55-59 years. All of the respondents were female.

Own PC Out of 30 respondents, only 23% own a PC i.e. 7 nurses own a Personal computer. Turn on/off computer Out of 30 respondents, only 30% were able to turn on/ off the computer before training while after training 80% knows it. Recognize computer parts 77% of the total respondents were able to recognize computer parts like monitor, keyboard, mouse and CPU. Prior Use of computer 27% of the 30 respondents had used computer prior to the training and implementation of HIS in their hospital. 55 | P a g e

Ability to create folders and access information Only 6% of the respondents were able to create folders and access information out of it before training while after training 25% of them were able to do it.

Use of software like MS word, excel etc Before training 30% of nurses were able to use software like MS Word, excel etc while after training around 56% of the 30 respondents were able to use it. Difficulty in using computer Around 80% of the respondents found difficulty in using computers in general.

Ability to easily read and understand information on computer Before training only 14% were able to read and understand information on computer while after training 47% of nurses were able to do it. Using e-mail facilities Before training 11% of the respondents were able to use e-mail facilities while after training around 20% were able to do it. Awareness about storage devices Before training 7% of the respondents were aware of storage devices while after training 50% of the nurses were aware about it. 5.4. Discussion The study was conducted with the aim to assess the level of computer knowledge and literacy among the nurses in DDU hospital, Shimla. This was done with a virtue to determine the need of training before it is given to nurses and the level of understanding about basic computer skills after the training. As nurses are the end users of the IPD module in HIS so they are required to possess basic computer skills in order to manage different functions on IPD module such as patient admission, discharge and raising indents. It is seen among the nurses that they were quite reluctant to use computers as most of them were unfamiliar with computers and their apprehension in transforming 56 | P a g e

from paper to computers. Thus training for basic computer skills can help in gaining self confidence by the nurses for the transformation. It is also seen that the level of computer knowledge is inversely proportional with the age of the nurses. 5.5. Limitations As the study was performed in only one hospital so the results cannot be generalized. At the time of the study, the training for basic computer skills was already given and the data before the training was collected from some other source. As the nurses were quite busy in their work so it was difficult to get proper and accurate response from them.

5.6. Recommendations Technical support systems should be provided at hospital levels which are easily accessible to all Nurses when they experience difficulty with any aspects of the computer. More training sessions for basic computer skills of nurses should be provided. There should be some proper timing for the training of nurses as they becomes reluctant and gets interrupted in their work when training is given between their working hours. 5.7. Conclusion The purpose of this study was to establish the computer literacy status of Nurses at deen dayal upadhyay hospital in shimla. The findings of the research show that there is a great need for training of basic computer skills among the nurses to be able to use HIS and a structured training program should be there to ensure same level of literacy and boosting up their self confidence. it is also believed that with adequate computer literacy, nurses will become more productive and efficient in their work.

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1.1

1. ANNEXURESANNEXURE 1: TRAINING SCHEDULETable 1: TRAINING OF NURSES Training session: 1 hour MODULE TIME ASPECTS TO WHAT THE NURSES SHOULD KNOW BY THE END OF THE SESSION Should be able to view stock balance for items and drugs Should be able to raise indents for both items and drugs Search for items/drugs from different subcategories, Enter the required specification/formulations, Add the required quantity and Save and send the indent Issuing drugs to patients 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 Should be able to select the required drug from the required category; select the required formulation; enter the required quantity Should be able to search a patient and then How to show consumption i.e. issue to account add to an issue slip and finish Should be able to make an issue to an account for the items that they have consumed during the week Should be able to select the required item from the required category; select the 58 | P a g e BE COVERED Inventory module 30 min Viewing stock (Theoretical and hands-on)

balance How to raise and process indents

required specification; enter the required quantity Should be able to create an account and add Using the filters to an issue slip and finish Should be able to use the different filters in view stock balance, indents, issue to account, issue to How to admit a patient IPD module (Theoretical and hands-on) How to 20 min discharge and transfer a patient Using the filters How to register Registration/OPD overview a patient Overview of 10 min OPD and how to admit Viewing patient dashboard patients 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 Should be able to search for a patient by name and identifier 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

Table 2: TRAINING OF DOCTORS 59 | P a g e

Training session: Half hour MODULE TIME ASPECTS TO WHAT THE DOCTORS SHOULD KNOW BY THE BE OPD (Theoretical and hands-on) COVERED 20 min Making an OPD entry END OF THE SESSION 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) Should be able to search for a patient from the system (should be able to use advance search) Should be able to make an OPD entry for a patient Should be able to search for and add the required diagnosis Should be aware of the need of and be able to add a note Should be able to search and add the required procedure Should be able to refer a patient (internal and external) Should be aware of and be able to fill up the minimum (mandatory) fields before concluding a visit Should be aware the different ways to conclude a visit for a patient Viewing the patient dashboard Should be able to admit a patient Should be able to customize their own list for diagnosis and procedures Should be aware of the different tabs of the patient dashboard and their use Should be able to view the clinical summary of a patient 60 | P a g e

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

How to register Registration and IPD module overview 10 min a patient Overview of how the IPD module functions Table 3: TRAINING OF PHARMACIST Training session: Half Hour MODULE Pharmacy module (Theoretical and handson) Raising and processing of indents TIME ASPECTS TO BE 25 min

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)

WHAT THE PHARMACY STAFF SHOULD

COVERED KNOW BY THE END OF THE SESSION Viewing stock balance Should be able to view stock balance of the drugs Should be able to view stock balance of expired drugs Should be able to raise indents for drugs Search for drugs from different subcategories, Enter the required formulation, Add the required quantity and Save and send the indent Should be able to process indents, once stock has been received from the main-store (accept & Issuing drugs to patients refuse) Should be able to issue drugs to patients Should be able to select the required drug from the required category; select the required formulation; enter the required 61 | P a g e

quantity Should be able to search a patient and then Issuing drugs to account add to an issue slip and finish Should be able to make an issue to an account for the items that they have consumed during the week Should be able to select the required drug from the required category; select the required formulation; enter the required quantity Should be able to create an account and add Using the filters to an issue slip and finish Should be able to use the different filters in view stock balance, indents, issue to account, issue to Inventory overview Brief overview of 5 min working of the inventory module patients 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 Inventory module (Theoretical and handson) Receiving items in the main-store TIME ASPECTS TO BE 25 min WHAT THE INVENTORY STAFF SHOULD

COVERED KNOW BY THE END OF THE SESSION Viewing stock balance Should be able to view stock balance of the drugs and items Should be able to view stock balance of expired drugs Should know the significance of a receipt Should be able to make receipts for drugs and items Search for drugs/items from different subcategories, 62 | P a g e

Select the required formulation/specification, Add the required quantity, unit price, VAT, Company name, Date of manufacturing and expiry Making transfers to sub-stores Using the filters Finishing the receipt 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 Overview of how the sub-stores work from general store An overview of how the sub-store indent to the main-store and how the stock calculation works

5 min

Table 5: TRAINING TO INVENTORY MANAGER Training session: 1 hour MODULE TIME ASPECTS TO BE COVERED Inventory module (Theoretical and hands-on) COMPLETE FUNCTIONIN G OF THE MAIN STORE AND SUB STORES Receiving items in the main-store 30 min Viewing stock balance WHAT THE INVENTORY MANAGER SHOULD KNOW BY THE END OF THE SESSION Should be able to view stock balance of the drugs and items Should be able to view stock balance of expired drugs Should know the significance of a receipt Should be able to make receipts for drugs and items Search for drugs/items from different subcategories, Select the required formulation/specification, Add the required quantity, unit price, VAT, Company name, Date of 63 | P a g e

manufacturing and expiry Making transfers to sub-stores How to raise and process indents Finishing the receipt Should be able to process an indent and transfer the required quantity of each item/ refuse an indent Should be able to raise indents for both items and drugs Search for items/drugs from different subcategories, Enter the required specification/formulations, Add the required quantity and Save and send the indent Should be able to process indents, once stock has been received from the main-store (accept & Issuing drugs to patients refuse) Should be able to issue drugs to patients Should be able to select the required drug from the required category; select the required formulation; enter the required quantity Should be able to search a patient and How to show consumption i.e. issue to account then add to an issue slip and finish Should be able to make an issue to an account for the items that they have consumed during the week Should be able to select the required item from the required category; select the required specification; enter the required quantity Should be able to create an account and 64 | P a g e

add to an issue slip and finish Using the filters Should be able to use the different filters in view stock balance, receipts to general store and transfers from general store, indents, issue to Manage store Manage Item Inventory admin functions 30 min Manage drugs accounts, issue to patients Should be able to create a store, assign a parent and role to the store Should be able to create/delete a category, subcategory, unit, specification 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 Should be able to add an item and define all the necessary parameters category, unit, formulation, attribute

ANNEXURE 2: COMPETENCY TESTS (post-training)Table 1: SELF EVALUATION FOR DOCTORS Name: SI. NO EVALUATION PARAMETER T/ UNDERST OPD: CONFIDEN 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? 65 | P a g e

AND WELL DOUBTS

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

OPD module Do you understand the concept of the patient queue and how it works? Are you aware of/understand the different ways to look for/search a patient to make an entry? Are you aware of/ understand the various options to conclude a visit for a patient? Are you aware of/understand the flow of a patient (electronically) from OPD to IPD? Do you understand the concept of customizing the list of diagnosis for a particular OPD? Can you search for a patient from the queue, in-case it is long? Can you search for a patient in-case he/she come to you with an old OPD slip and is not in the queue? Can you enter/add a diagnosis for a patient? Can you search and add a diagnosis to your list, if not available? Can you add a note; enter a procedure for a patient (if required)? 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 Are you aware of / understand the patient dashboard and the various options it provides? Can you view the clinical summary of a patient? Can you view the various investigation results of patient? Can you select the specific category of investigations for which you want to see the results? Can you view the IPD/admission records of a patient? Table 2: SELF EVALUATION FOR NURSES Name: Ward:

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SI. NO

EVALUATION PARAMETER

CONFIDEN T/ ND WELL

CAN DO/ UNDERS WITH DOUBTS

CANNOT DO/ DO NOT UNDERS TAND

UNDERSTA TAND

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Can you Turn on and off the computer? Can you log-into the application? Inventory module Do you understand the whole processing of indenting and how it works electronically? Do you understand the terms sub-category, specification, formulation? Do you understand the concept of making an issue to account/patients to show consumption of drugs/items? Do you understand the concept of accepting and refusing indents and how they affect the stock? 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? Can you save and print indents? Can you process indents (and accept stock in your store)? 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 Do you understand the flow from the OPD to the IPD module and how a patient is recommended for admission? Do you understand the concept of the patients for admission and admitted patient index? Do you understand the concept of discharging, transferring a patient? 67 | P a g e

15

16 17

18 19 20

Can you admit a patient in the required ward and print the admission slip? 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?

Table 3: SELF EVALUATION FOR PHARMACISTS Name: SI. NO EVALUATION PARAMETER CONFIDEN T/ ND WELL CAN DO/ UNDERS WITH DOUBTS 1 2 3 4 5 6 Can you Turn on and off the computer? Can you log-into the application? Pharmacy module Do you understand the whole processing of indenting and how it works electronically? Do you understand the terms category and their respective attributes (vital, essential, desired) Do you understand the concept of dosage and formulation? Do you understand the concept of making an issue to account to show consumption of drugs (in-case not 7 issued to patients)? Do you understand the concept of issuing a drug to a patient/ in-case of drugs with different batch numbers 8 9 10 11 and expiry? Do you understand the concept of accepting and refusing indents and how they affect the stock? Can you view stock balance for drugs? Can you view stock for expired drugs? Can you raise indents for drugs? 68 | P a g e CANNOT DO/ DO NOT UNDERS TAND

UNDERSTA TAND

12 13 14 15 16 17 18 19 20

Are you able to search for different drugs from different categories? Can you save and print indents? Can you process indents (and accept stock in your store)? Can you issue drugs to patients? Can you sea