1

Summer Training

in

Edgeware Technologies (I) Pvt. Ltd.

(April 4 – May 30, 2011)

Cashiering Module Implementation (HIS)

at JPNATC, AIIMS

Anindam Basu

PG/10/005

Post - Graduate Diploma in Hospital & Health Management,

New Delhi

2010 - 12

International Institute of Health Management Research, New Delhi

2011

2

ACKNOWLEDGEMENT

Apart from the personal effort and steadfastness to work, constant inspiration

and encouragement given by a number of individuals served as the driving force

that enabled me to submit my summer training report in the present form.

A formal statement of acknowledgement is hardly sufficient to express my

gratitude towards the personalities who have helped me undertake this project. I

hereby convey my thankfulness and obligation to all those who have rendered

their valuable help, support and guidance to meet this end. A special thanks to

the Almighty and my parents for the completion of my project.

First of all a special gratitude to IIHMR, New Delhi, for giving us the

opportunity to work on the project during the two months summer training as a

part of course curriculum of PGDHHM. It’s an immense pleasure to thank Dr.

Maitreyi Kollegal, the Director, IIHMR, New Delhi and Dr. Rajesh Bhalla, Dean

Academic and Student Affairs for appreciating and allowing me to undertake

this two months training in Edgeware Technologies (I) Pvt. Ltd (ETIPL), New

Delhi.

A sincere token of gratitude to Prof. Indrajit Bhattacharya and Dr. Anandhi

Ramachandran for constant support in my project and case studies. Their

continuous guidance and support at crucial juncture helped me complete the

assigned project on time.

No work can be perfect, without the ample guidance. It was an immense

pleasure for me to work in ETIPL, New Delhi under the guidance of Mr. Joseph

3

Puthooran, MD, Edgeware Technologies and Mr. Satish, Project Manager,

Edgeware Technologies. I specially thanks to ETIPL for providing me all the

necessary training and encouragement to work on this challenging project.

I owe my gratitude to Dr. Deepak Agarwal, Assistant Professor, Neurosurgery

and Head of Computer Facility, JPNATC to allow me to do my project and case

studies in the Hospital. Without his ample guidance and regular support it

would be rather difficult for me to complete the project.

Last but not the least, my deepest thanks to my mentors Mr. Manoj Varghasee

and Mr. Sharfraz Haque for their regular encouragement, inspiration and

intelligence criticism. Without this it would be rather difficult for me to work in

the hospital environment. I express my sincere appreciation to Mr. Pawan, Mrs

Metilda, Mr. Sachit, Mr. Mohan, Computer facility staff members including

CATS and all other Nursing Informatics Staff for being with me and cooperating

with me in the scheduled timings. It is very difficult to mention the names of all

those persons who have been involved directly and indirectly, with this work and

I extend my gratitude to all of them.

Anindam Basu

PG/10/005

Batch C. 2011

4

Declaration from the candidate

Anindam Basu (PG/10/005)

PGDHHM, Batch C

International Institute of Health Management Research

Plot No.3, HAF Pocket, Sector 18A, Phase II, Dwarka

New Delhi – 110075

This is to certify that this summer training report on “Cashiering Module

Implementation (HIS) at JPNATC, AIIMS” completed and submitted to

IIHMR, New Delhi by Anindam Basu, is an authentic work carried out at

JPNATC, AIIMS under Edgeware Technologies (I) Pvt. Ltd., New Delhi.

The material embodied in this project report has not been submitted to any other

university or institute for the award of any degree.

Anindam Basu

5

Chapter

No.

Topic Page No.

1. Executive Summary

8

2. Acronyms/ Abbreviations

10

3. Organizational Profile

11

3.1 Edgeware Technologies (I) Pvt. Ltd.

11

3.2 Jai Prakash Narayan Apex Trauma Center, AIIMS

13

4. Introduction

15

4.1 Hospital Information System

15

4.2 VistA EHR

17

4.3 Objectives of the project

19

5. Review of the Literature

20

6. Information Technology & Workflow: JPNATC, AIIMS

23

7. Methodology

25

7.1 Client Requirement for Cashiering Module

26

8. Observations

27

8.1 Workflow analysis before and after implementation

27

8.2 Benefits of the cashiering module

30

9. Conclusion

31

9.1 SWOT Analysis: Cashiering Module

31

9.2 SWOT Analysis: JPNATC, IT Transformation

33

10. Recommendations

35

11 Case Studies

36

11.1 Queue Management of OPD in JPNATC: IT initiative

37

TABLE OF CONTENTS

6

11.2 Staff Perception over the HIS/CPRS present in JPNATC

43

12. References

49

13. Annexures

51

13.1 Price list to be put in the HIS Charge Slip Option

52

13.2 Questions asked to the departments

54

13.3 Training Schedule

55

13.4 Training Manual for cashiering Cash Counter

56

13.5 Training Manual for cashiering Radiology & Inpatient

Department

63

13.6 Back End of the Cashiering Module 69

13.7 Receipt before and after implementation of Cashiering

Module

73

13.8 JPNATC OPD Schedule 74

13.9 Questionnaire for the Case Study 11.2 76

7

S.No. Title of the table

Page No.

1.

Number of wards and their specialty 14

2. Interviews and Group Discussion done with the

department

25

3. Experience of Respondents 45

4. Time Schedule of the training 55

5. OPD Schedule 74

6. Number of patients from 2nd

May to 7th

May 2011 75

S.No. Title of the Figure

Page No.

1. Billing system implemented in Mali 20

2. Workflow before implementation of cashiering module

27

3. Workflow after implementation of cashiering module

28

4. Response for working improved after HIS/CPRS 47

5. Information Flow in the back end of the cashiering

module

69

6. Charge Slip Record (Database) Variable View 70

7. Charge Slip (Master database) Variable View 70

8. Refund Record (Database) Variable View

71

9. Refund (Master Database) Variable View 71

10. Receipt (Master Database) Variable View 72

11. Before Implementation: Manual Receipt

73

12. After Implementation: Printed Receipt

73

LIST OF TABLES AND FIGURES

8

1. Executive Summary

Introduction

The global healthcare IT market is estimated to grow to $ 53.8 billion by 2014, growing at a

CAGR (Compound Annual Growth Rate) of 16.1 percent. It is expected that the market for

general applications in Health IT will grow at overall CAGR of 13 percent from 2009 to

2014. From Hospital Information system to the Electronic Health Record of the patient, the

Health IT has grown to the expectation of the Hospitals. It can be seen by the total money

invested by the west in Health IT domain. They spend approximately 3 percent of their total

expenditure in Health IT. Health IT in India is mainly been forced by the private players. The

total spending by the Indian Players on Health IT is approx 1 percent and majority by the

private players. JPNATC being a government hospital in the capital city of the country is

proud to be the first hospital in India to implement the VistA EHR and continues to be a

global player in the field of IT in hospitals with Edgeware Technologies (I) Pvt. Ltd.

Objectives:

The primary objective behind the project is to successfully implement the Cashiering module

in the HIS of the hospital. The secondary objective behind the project is to train the staff and

change the workflow of the hospital for the success of the module in the HIS.

Methodology:

The following methodologies were followed for the successful implementation of the

cashiering module:

1) Workflow analysis of the hospital before implementation.

2) Pilot and Testing phase before the live of the module.

3) Client (Hospital) Requirement for the module.

4) Training to the staff using the cashiering module.

9

Conclusion:

The implementation of the cashiering module leads to the following benefits:

1) Reduction in human error.

2) Manual work converted into electronic work.

3) Central database (My SQL) for the patient‟s payments.

4) Records now can be accessed easily.

10

2. ABBREVIATIONS USED

AIIMS: All India Institute of Medical Sciences, Delhi

BCMA: Bar Code Medication Administration

CATS: Computerization Assistance Team & Support

CPRS: Computerized Patient Record System

CRC: Casualty Registration Counter

EHR: Electronic Health Records

ETIPL: Edgeware Technologies India Private Limited

GUI: Graphical User Interface

HIS: Hospital Information System

ICU: Intensive Care Unit

JPNATC: Jai Prakash Narayan Apex Trauma Center, AIIMS, Delhi

MLC: Medico – Legal Case

OPD / IPD: Out - Patient Department / In - Patient Department

SMS: Short Message Service

TC No. / HRN: Trauma Center Number/ Hospital Record Number

RDP: Remote Desktop Procedure

VHA: Veterans Health Administration

VistA: Veterans Health Information Systems and Technology Architecture

11

3. ORGANISATION PROFILE

3.1 Edgeware Technologies

- Cutting Edge in Healthcare Information Technology Solutions

Registered Office: Edgeware Technologies (India) Pvt. Ltd.,

E- 537 Greater Kailash – II, New Delhi – 110048

Edgeware Technologies specializes in Healthcare Information Technology, and

provides consultancy to hospitals for solutions to improve clinical quality, patient care and

operational efficiency. Edgeware Technologies promotes the use of Open Source solutions

and in particular the VistA System. They provide services to evaluate Information

Technology needs in a Hospital or healthcare system, recommend an approach to the

appropriate use of Information Technology to achieve institutional goals and support its

implementation.

HISTORY:

Two Non Resident Indian businessmen located from UK, established Panther Exports Private

Limited in 1994. A Board of Directors in India was appointed, with the Managing Director

having executive management responsibility. The present management had taken over the

company under the leadership of Mr. Joseph K. Puthooran in the year 2003-04. Mr.

Puthooran brings with him a rich pool of experience in both domestic and international

market.

Panther was later in the year 2005 renamed as Edgeware Technologies India Private Limited

(ETIPL). ETIPL focuses on providing custom software programming and application

development to the Indian Software market as well as International Market, providing clients

with the latest technology and excellent quality.

They are able to execute the full software development lifecycle, starting from the

requirements specification up to system implementation and maintenance.

12

ETIPL specializes in the development of custom software solutions for Desktop, LAN and

Internet environment. They design, build and implement applications, which are user-

friendly, cost-effective and tailored to client‟s specific requirements. ETIPL‟s team has many

years of rich experience and values its clients and strives to build mutually beneficial, long-

term relationships. They aim to support their clients in all custom software-related needs, by

innovations and acquiring new skills constantly.

Business Goal/Mission

As a professional organization in the Healthcare Information Technology domain, pioneering

and leadership in the industry is a major goal. We strive to enable our customers to achieve a

sustainable, high value, competitive advantage through the effective use of information

technology solutions in Healthcare. We have a strong social element in dealing with clients

and have provided solutions to voluntary non-profit organizations and supported them at

cost.

We believe in the power and value of open source development methodologies and our

business model is to give excellent value to all our clients and remain sustainable as an

organization leveraging the unique strengths of being based in India. Providing a reasonable

return to shareholders and also using profits to build our capabilities to higher levels of

excellence.

Present Clients:

1. Jai Prakash Narayan Apex Trauma Center, New Delhi (India)

2. Rajiv Gandhi Cancer Institute and Research Center, New Delhi (India)

3. Clinica Adelante, (Arizona)

4. CHOSN Network, (Arizona)

5. A group of community clinics in Kentucky

13

3.2 JAI PRAKASH NARAYAN APEX TRAUMA CENTER, AIIMS

Spread over an area of 20,600 sq metres and seven storeys that consist of five operation

theatres, 152 inpatient and 30 casualty beds, including 26 ICU beds to provide both pre-

hospital and emergency care, Jai Prakash Narayan Apex Trauma Centre (JPNATC) has a

chequered and long history of planning and control. First conceived in 1984 by the Delhi

Government, land was acquired at Raj Nagar on the Ring Road about two kilometers from

AIIMS. For 20 odd years nothing really happened on the ground. However, as the vision was

to provide the best possible trauma services, Delhi government decided to hand over the

project to All India Institute of Medical Sciences (AIIMS) to run. Finally India's first full-

fledged trauma centre to treat victims of road accidents became a reality in the year 2006.

While the dry run began on 27 November 2006, the centre became fully functional on 26

November, 2007 when the casualty (emergency department) was thrown open to general

public.

The total cost of constructing the centre was Rs 132 crores. The centre also acts as a referral

hospital, where patients sent by zonal public hospitals and satellite trauma centers will be

observed and treated. There are total nine departments fully functional in JPNATC. These are

as follows:

1. Anesthesia

2. Emergency Medicine

3. Forensic Medicine

4. Laboratory Medicine

5. Orthopedics

6. Neurosurgery

7. Trauma Surgery

8. Radiology

9. Computer Facility

14

There are 2 ICU‟s & 4 General Wards fully functional in JPNATC

S.NO. Name of

the ward

Specialty No. of

Beds

Division of Beds

1. TC2 Common ICU 12 10 Normal and 2 Isolated A&B

2. TC3 Neurosurgery ICU 20

3. TC4 Multispecialty (Ward) 30 12 Surgery, 12 Orthopedics, 6

Neurosurgery

4. TC5 Neurosurgery (Ward) 30

5. TC6 Surgery ( Ward) 30

6. TC7 Orthopedics (Ward) 30 15 Ortho A, 15 Ortho B

Table #1: No. of Wards and their specialty.

There are total 5 Operation Theatres in the Hospital

1. OT1: Surgery

2. OT2: Orthopedics

3. OT3 & OT4: Emergency

4. OT5: Neurosurgery

JPNATC also provide Follow-Up Out Patient Department (OPD) facility. This facility is

only for the discharged patients of JPNATC.

Implementation carried out by the Computer Facility Department at JPNATC

EHR ( VistA EHR)

PACS (Picture Archival and Communication System)

Intranet (RDP)

Access & Biometric Control

Computerized Queue System in OPD

Computerized MLC (Fully Computerized Emergency Department)

Lift Stretcher Access Control System

Internet Protocol CCTV (Closed Circuit Television) and Telemedicine.

15

4. INTRODUCTION

4.1 Hospital Information System (HIS)

A Hospital Information System (HIS) 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. It is a comprehensive, integrated information system

designed to manage administrative aspects of a hospital. According to Hassett (2002):

“A hospital information system (HIS) encompasses a wide array of applications and

information systems that are linked or interfaced. A HIS supports the provision of care to

patients and the business aspects of the healthcare organization by communicating

information.”

Benefits of HIS:

Easy Access to Patient Data to generate varied records, including classification based

on demographic, gender, age, and so on. It is especially beneficial at ambulatory (out-

patient) point, hence enhancing continuity of care. As well as, Internet-based access

improves the ability to remotely access such data.

It helps as a decision support system for the hospital authorities for developing

comprehensive health care policies.

Efficient and accurate administration of finance, diet of patient, engineering, and

distribution of medical aid.

Enhances information integrity, reduces transcription errors, and reduces duplication

of information entries.

16

It is now hard to imagine healthcare without information and communication technology

(ICT) based applications for both the accumulation and interchange of clinical information

(Ammenwerth et al. 2004). Increased efficiency, reduced cost, improved patient care and

quality of service, and safety are the factors that healthcare organizations now consider when

planning to implement new ICT-based applications (Andersen & Aydin 2005; Chismar &

Thomas 2004). The outcomes of many HIS implementations in both primary care and

hospital settings have either not met yet all the expectations or have failed in their

implementation (Rahimi et al 2009; Heeks 2006; Garde et al. 2007). Such studies as Van Der

Meijden et al. (2003) and Fullerton et al. (2006) have indicated undesired consequences.

Kucukyazici et al. (2008) estimated the failure rate for new HIS implementations in

healthcare organizations to be approximately 50%.

The implementation of HIS is therefore a major challenge in the healthcare setting.

Acknowledgement of this has led to a need for understanding the match between HIS and

existing IT infrastructure, organizational structure, and established routines. This means that

the decision-making process leading to the implementation and use of ICT-based

applications in healthcare has to improve generally. Implementing HIS successfully therefore

appears to be a difficult task (Doebbeling & Pekny 2008; Pagliari 2007). JPNATC has

implemented HIS in the year 2007 and the following modules are running under HIS:

Patient Registration System (PRS)

Appointment System

Lab Module

Post Mortem Report

Stores Indent Software

MLC Report

OT module

PACS interface

There are four sets of parameters involved in all phases of a HIS development. First, the set

of all prospective characteristics determined at the planning phase by the participating

17

parties. Such parameters are abstract and refer, ususally, to the higher administration levels in

a hospital‟s organization. Second, there is the set of all targets that have to be efficiently

satisfied by the implementation of the planned HIS. The parameters of this category

enumerate the problems that have to be faced and effectively solved by the developed

system. Third, there is the set of all obtainable goals implemented by the installed system.

The elements of this set include the functional characteristics of the delivered system. The

last, fourth, set of parameters enlists the benefits and the negative impacts from the system‟s

installation. (J.C. Sarivougioukas and A. Th. Vagelatos, 2002)

4.2 Veterans Health Information Systems and Technology Architecture

(VistA)

VistA is an enterprise-wide information system built around an Electronic Health

Record (EHR), used throughout the United States Department of Veterans Affairs (VA)

medical system, known as the Veterans Health Administration (VHA) has its roots in the late

1970‟s. It's a collection of about 100 integrated software modules. By 2003, the VHA was

the largest single medical system in the United States, providing care to over 4 million

veterans, employing 180,000 medical personnel and operating 163 hospitals, over 800

clinics, and 135 nursing homes. About a quarter of the nation's population is potentially

eligible for VA benefits and services because they are veterans, family members, or survivors

of veterans. By providing electronic health records capability, VistA is thereby one of the

most widely used EHRs in the world. Nearly half of all US hospitals that have a full

implementation of an EHR are VA hospitals using VistA.

VistA was developed using the M or MUMPS language/database. The VA currently runs a

majority of VistA systems on the proprietary InterSystems Caché version of MUMPS, but

an open source MUMPS database engine, called GT.M, for Linux and Unix computers has

also been developed. Although initially separate releases, publicly available VistA

distributions are now often bundled with the GT.M database in an integrated package. This

has considerably eased installation. In addition, the free and open source nature of GT.M

allows redundant and cost-effective failsafe database implementations, increasing reliability

for complex installations of VistA.

18

Features: VistA supports both ambulatory and inpatient care, and includes several

significant enhancements. The most significant is a Graphical User Interface (GUI) for

clinicians known as the Computerized Patient Record System (CPRS), which was released

in 1997 (K. Meldrum et al, 1999). In addition, VistA includes computerized order entry, bar

code medication administration, electronic prescribing and clinical guidelines. CPRS

provides a client–server interface that allows health care providers to review and update a

patient's electronic medical record which advances a patient centered approached to clinical

computing rather a department centered approach. This includes the ability to place orders,

including those for medications, special procedures, X-rays, nursing interventions, diets, and

laboratory tests. CPRS provides flexibility in a wide variety of settings so that a consistent,

event-driven, Windows-style interface is presented to a broad spectrum of health care

workers. CPRS installation was mandated nationally in 1999 and virtually all physicians and

medical practitioners in VA usually now use it. The VistA system is public domain software,

available through the Freedom of Information Act directly from the VA website, or through a

growing network of distributors.

Another most important that VistA has recently added to its application is Bar Code

Medical Administration (BCMA). BCMA is a bedside application that validates the

administration of medications. It was installed in VA in the time frame of 1999 – 2002

(Johnson C.L. et al, 2002). BCMA enables nursing to use a bedside computerized medication

administration record (MAR). Patient identification wristbands and nursing staff

identification cards are bar coded with unique identification numbers. Medications are

packaged in plastic containers with bar-coded content identifiers and placed on the

medication carts by the pharmacy service. To administer a medication, the nurse scans the

patient‟s wristband, the packaged medication, and the employee id card. The data are sent to

an electronic MAR. Advantages include positive verification of patient identification and

prescribed medication at the point of care, an immediate alerting capability to prevent the

wrong medication from being administered, precise medication administration

documentation noting on time, early and late dosing and automated missing dose requisition.

Presently VistA is composed of 99 packages (Brown S et al 2003). Of these, there are 16

infrastructure applications, 28 administrative and financial applications and 55 clinical

19

applications. VistA applications perform functions in common with other HIS such as

laboratory, pharmacy, radiology, scheduling and ADT.

Core VistA Infrastructure: VistA applications are built on top of a common infrastructure.

This approach serves several purposes (VistA Monograph, 2002). They are as follows:

It integrates applications at the database level; common data are not shared, not

replicated.

It makes applications consistent from the perspective of both users and developers.

It minimizes maintenance expenses. Core code is centrally updated and distributed for

use by others.

It provides a stable layer between applications and operating systems to help insulate

applications from changes.

4.3 Objectives of the project:

To implement Cashiering module in JPNATC.

To test the Cashiering Module before the go – live stage

To train the staff of JPNATC using the cashiering module.

To monitor the changes in workflow after the successful implementation of the

module.

To check all the payments done by the patient to the hospital through the HIS.

20

5. Review of the Literature

The implementation of the Hospital Information System (HIS) is key production of quality

care, adequate management of rare resources and productivity. A pilot project was done in

Mali which tells the challenges faced for using open source HIS in the region. Different

modules were implemented in the hospitals of Mali, in which one of the modules

implemented was for the billing module (Bogayoko, Dufour et al, 2009). The study was done

to see the changes occurring due to the implementation of the open source HIS in the

hospitals. The five modules fully implemented were: patient administrative and medical

records management of hospital activities, tracking of practitioner‟s activities, infrastructure

management and the billing system. The billing module was fully developed by the local

team in Mali because the one proposed by others (Mediboard) was not adapted to the realities

of the country.

Figure #1: The Billing System implemented in Mali.

21

This was a necessary part for the country as they charge the patient before the patient has

undergone any procedure and they don‟t have any health insurance for the patients. The

billing was also done in local language as it would help the patient as well as the staff making

the bill easy to understand and work.

In another study done in Washington hospital in which the hospital implemented EDIS

(Emergency Department Information System) and integrated it with the hospital‟s HIS

(Wrigh, Wiechert et al, 2007). With the implementation of the EDIS, there is an

improvement in documentation which has lead to the accurate billing for the patients. Before

the implementation of EDIS, the hospital could only charge for care that was documented in

the emergency department, even if the record was incomplete. With automated

documentation, every service is documented in EDIS and which has helped them in charging

up the patients. The captured charges which are documented in EDIS gets transferred into the

HIS billing module. There pilot study has shown an increase in ED charge capture by 20

percent from December 2004 to December 2005.

The information system used in the hospitals has been specifically designed for the use in the

patient care and for the administrative purposes. They consist of different modules, each

performing a specific set of functions. In HIS, one module is for billing and another module

is for recording clinical data. These modules however, are not independent; data from the

module that records clinical data may be used for billing (Johan van der Lei, Joop S.

Duisterhout et al, 1993). Every module present in the hospital may support the billing

module implemented in the hospital.

22

The VA‟s Hospital Information system which is written using the ANSI (American National

Standard Institute) standard M language, also uses the billing module implemented in the

Hospital where the billing data can be processed by the following two mechanisms for

transferring data to and fro(Ruth Dayoff, Garrett Kirin et al, 1994):

1) The first is the use of silent application programmer interfaces to the HIS modules.

They are the entry points in the HIS module which are called by the workstation to

access or update data.

2) The second mechanism is to use a generic interface file structure, where the HIS

module if needing the data collected on the workstation will provide the processing

software to extract the data from the generic interface file and store it in packaged

specific data structures. This has lead to the generic interface file independent of the

packages and the data can be used further by the other modules without modification

to the user interface or interface file.

Use of the same data capture process for billing assures more accurate accounting and

management information. Billing module helps in knowing the accountability of each and

every department for the patient‟s bill and therefore helps the hospital management to

work efficiently and effectively.

23

6. Information Technology and Workflow: JPNATC, AIIMS

The term „workflow‟ is a concept from Business Process Re-engineering (BPR), used to

describe the processes involved in arriving at a given objective:

“Workflow, according to those offering credible definitions, is any work process that must go

through certain steps and be handled by more than one person on its way to completion.

Workflow automation relieves people of some of these tasks. Inherent in workflow are

concepts of teamwork, request and approval, routing and tracking of documents, filling out

forms and doing things either in series or in parallel” (Essex D. The Many Layers of

Workflow Automation. Healthcare Informatics, June 2000: 128-135.)

Implementation of a medical IT system will always have an impact on the workflow in the

hospital. The scale of the impact will depend on the scope and the complexity of the IT

system itself. The greater the impact of an IT solution is likely to be, the more important it

becomes to fully understand the existing workflow, and to create a consensus of opinion

about the desired workflow among all those concerned.

Workflow analysis and modeling play an important role in medical IT projects.

Implementation of an IT system requires an understanding of the processes involved and,

depending on the scope and complexity of the system, will involve a certain amount of

process re-design. Workflow models are a useful tool for understanding the impact of an IT

solution on the clinical work processes, defining the expectations and requirements for an IT

solution, and managing the change process associated with the implementation of an IT

system. Therefore the need of studying of the workflow of JPNATC, AIIMS becomes very

important to actually know how the HIS and VistA EHR is working with each other. How

the staff is using the HIS/ CPRS for giving the best possible patient care to everyone.

Patient brought in the Casualty Area / Emergency Area. Emergency has 3 defined

areas according to the severity of the patient.

o Green Area: Minor injury; Yellow Area: Observation Area; Red Area:

Seriously injured cases.

A doctor checks the patient and starts the initial treatment.

24

Meanwhile a registration form is given to the person with the patient/ patient himself

(if conscious) and is countersigned by the doctor to declare it as a MLC/Non MLC

case.

The person with the registration form goes to the emergency registration counter

where they register the details and give the patient a computerized generated TC No.

For preparing the MLC note, the doctor opens the CPRS where MLC note template is

there. They fill the details and the detailed MLC report of the patient is been

generated whose 3 print out are taken. One for the hospital record, one for the police

records and other for the patient. There are only 2 print outs given in non MLC case.

If the patient is treated and does not require admission, then doctor provides a

discharge summary to the patient while ordering the patient to come for the follow up

OPD which is given by the call center through Appointment System Software.

If the patient has to get admitted, a face sheet or Admission & Discharge sheet has to

be filled. The face sheet contains the details of patient comprising IPN (In Patient

No.), ward no. allotted, doctor/ consultant assigned are there.

These details are entered in the putty using ADT (Admission, Discharge and

Transfer) option. After the patient is admitted to the ward and all the details of the

patient are now visible in the CPRS. Admission details is been filled by the

registration counter.

Doctors/Consultants filled all the notes for the patient i.e. the allergies, clinical

history, lab values etc in the CPRS. Nurses put all the vitals of the patients, transfer in

note in the CPRS. Discharge and Transfer in the ADT been done by the CATS from

the computer facility.

Doctor checks the patient and if needed discharge, the doctor prepares the discharge

summary with next appointment for the follow up OPD.

If the patient dies, then the death report is been prepared (manually), mortuary

department prepares Post Mortem report in the HIS.

The above workflow shows that from the patient entrance to the hospital till the discharge of

the patient and also follow up OPD of the patient, IT is been used in every step. HIS or VistA

CPRS are been used by most of the staff in the Hospital.

25

7. Methodology

Cashiering module has been divided into the following 3 stages:

1) Pilot Stage: 28th

to 30th

April 2011. The main focus of this stage was to gather the

requirements from the various departments who are going to use the cashiering

module in the HIS.

2) Testing Stage: 2nd

May to 7th

May 2011. The main focus of this stage was to train the

users of the cashiering module. During this phase the testing of the software was also

done by comparing both the manual and the electronic data.

3) Go – Live Stage: 9th

May 2011. The module went live in JPNATC on 9th

May 2011,

Monday. The back end of the cashiering module is My SQL Database and the front

end is Java.

Pilot Stage: 28th

April to 30th

April, 2011. Structured questionnaires were prepared for the

following departments. The data was collected through Group Discussion and Interviews.

(See Annexure #2).

S.No. Department No. of Individuals in the

Discussion/Interview

1. Radiology 3 (Technical Head + 2 Counter

Receptionist)

2. Inpatient 4 ( Neurosurgery Faculty + 3 NIS)

3. Accounts Department 4 (Accounts officer + Cashier = 2

Assistant Cashier)

Table #2: Interviews and Group Discussions done in the department

Implementation Stage: 2nd

May to 7th

May, 2011. It was further divided into following two

sub stages.

26

1) Training to the end users: 2nd

May to 4th

May 2011 (See Annexure #3 for the training

schedule)

2) Testing Stage: 5th

to 7th

May 2011. During this stage the manual chalan forms and

electronic charge slips were prepared by the respective departments. In the cash

counter, both the manual receipts and the electronic database receipts were saved. The

report was compared with the manual receipts so that any problems coming can be

sorted out at that moment.

Go – Live Stage: From 9th

May 2011, the cashiering module was live in the trauma center.

All the users were accessed regularly so that the cashiering module becomes a success.

7.1 Client Requirement for cashiering module

Before implementation of the cashiering module, the client requirement/ requirement

gathering is must for any successful implementation of IT systems in a healthcare

organization. The following client requirements were there which are as follows:

There should not be much of the difference in the workflow. Replication of the

existing workflow with as much as little variation in the workflow.

All the charges related to patient should be provided in the charge slip (See Annexure

#1 for details)

For radiology department, there are three receipts for the same payment. One patient

copy, other for the radiology department and third copy for the accounts department.

For hospital charges and other charges they have only two receipts. One with the

patient and the other copy with the accounts department.

Regular check about the payment paid and payment deferred of the patients so that

payments can be received if left.

27

8. Observations

8.1 Workflow Analysis before and after Implementation

Workflow analysis before implementation: Inpatient Department

1. When cash counter is open, the relative directly goes to the cash counter for payment.

2. When the counter is closed, the payment is done by the relative after admission.

3. If some refund is to be done, the relative takes the discharge summary from the IPD

and refund is done according to the stay.

*Note: First admission is for 10 days. Payment of Rs 375 (Rs 25 + Rs. 35*10).

Workflow Analysis: Radiology Department (for radiology procedure)

Figure # 2: Workflow before Implementation of the cashiering module.

CRC sends Admission

Slip for First payment

for Admission

IPD admits patient,

payment done by the

relative of the patient.

Cash Counter for receiving the

payment and deciding the

payment.*

Patient/ Relative gets the

receipt of the payment.

1.

2.

3.

OPD IPD Radiology

Department

Cash counter decides the payments after seeing the

chalan form from the above department.

Patient/Relative

gets the receipt of

the payment

1 receipt copy

given to the

dept. for

procedure.

28

Workflow Analysis after implementation: Inpatient Department.

Workflow Analysis after implementation: Radiology Department

Figure #3: Workflow after implementation of cashiering module.

CRC sends the admission slip with the patient to the ward where patient is

to be admitted.

IPD nurse makes the electronic charge slip for that patient. Also for

deferred payments, the charge slip is made by the nurse. Refund is also

been made by the nurse.

Relative goes to Cash Counter for payment or

to get the refund.

Patient/Relative gets the

receipt of the payment.

OPD IPD

Radiology Department

Cash Counter receives

the payment and gives 2

receipts.

Patient/Relative gets

the receipt of the

payment.

1 receipt copy

given to the

dept. for

procedure.

29

Changes in the working of the departments after the implementation.

Now all the charge slips are been made electronically by the nursing staff and

radiology staff which helps them to track the patient‟s payment and how much to

charge from the patient.

The patient / relative of the patient use to come directly from the IPD to the cashier

department for payment of the radiology procedures like CT or MRI. The cashier

department use to check and take charges accordingly. But sometimes they took

wrong charges. For example: Head CT charge is Rs. 200 and normal body CT charge

is Rs 750. Sometimes they use to write only CT in the chalan form, which caused the

confusion with the cashier how much to charge from the patient. This would lead to

either less / more payment respectively. Now every patient relative / patient coming

for payment from ward/ICU has to go to the radiology department for preparing the

charge slip for the procedure and then come for payment.

Before this, cashier use to have two receipt books for radiology and hospital charges

respectively. Now everything has been converted into a single receipt book number.

Until and unless the charge slip is not been prepared from either the inpatient

department or radiology department, the cashier would not entertain the patient

relative. Therefore it becomes necessary for every bed side nurse for the patient to

know how much days charge is to be taken. Same is for the radiology department.

This was previously decided by the cash counter.

30

8.2 Benefits of the Cashiering Module in JPNATC.

Being a government hospital and an interim part of AIIMS, JPNATC charges the minimal to

all the patients coming to the hospital. IT systems are always benefiting the people directly or

indirectly involved in the system. After the successful implementation of the cashiering

module in the HIS, not only the hospital‟s management but also the patients are getting the

benefit of the module.

Benefit to the Cash Counter: All the money to be taken for the patient was always

been decided by the cash counter, which sometimes led to the confusion of how much

to charge from the patient. Now after the implementation of the cashiering module,

the patient‟s relative has to go to the radiology department first. The radiology

department makes the charge slip of the payment and the cash counter checks the

amount and provides them the receipt after taking the cash. This has ended the

confusion which was created when entire decision was taken by the cash counter

about the payment. Manual calculation and reports been converted into digitalized

form.

Benefit to the Wards and Radiology department: They are the one who are

preparing the charge slip. In the charge slip they can check the patient‟s charge slip

which was prepared on that day. In the charge slip if they have paid the money and a

receipt has been generated by the cash counter, there is a status shown for the charge

slip. If the payment has been done, the status is shown P which signifies paid

otherwise U is shown which means unpaid.

Benefits to the patients: In the manual receipt, the cash counter was not writing the

details in the manual receipt. In the printed receipt, there come all the details about

the charges for what they are taking (see annexure #7). This helps the patient in

medical claims.

31

9. Conclusion

9.1 SWOT Analysis Cashiering Module

For any IT system to be appreciated by the end users, it should have maximum strengths and

opportunities with bare minimum weaknesses and threats. After the successful

implementation of the cashiering module in JPNATC, the following is the SWOT analysis

for the cashiering module in the HIS.

Strengths:

Centralized database leading to easy track of the payments done by the patient.

Manual receipts and manual records been converted to electronic records.

Charge slips prepared by IPD and radiology department now know the payment to

be taken from the patient leading to very less errors, as they know the patient stay

and the radiology procedure rather than the cash counter.

The manual receipt been converted to the printed one with the full description of the

charges taken from the patient. This has helped the patients to take the claims from

the insurance company as they don‟t have to take the description from the cash

counter again and again.

Reduction in human error in the cash counter. At the end of the day when they were

closing the cash counter, it was taking the cashier to more than one hour to finalize

the report for the day. They had to first calculate the cash and then they had to enter

every receipt details in the cash book register and tally the cash with the receipts

cash. After the implementation, the time has reduced to 15 minutes (reduction of 75

percent time) as they now calculate the cash and tally it with the cashier report at the

end.

32

Weakness:

Only for the trauma patients, other charges like donations, tender fees are still done

manually. This is so because the charge slip can be made after entering the TC

number which is generated by the Patient Registration System (PRS) in the HIS.

Opportunities:

Open doors for other modules to work which can be integrated with the HIS and the

cashiering module. For example: The hospital doesn‟t have some modules like

Radiology Information System (RIS). Now after the implementation of the cashiering

module, the integration of other modules would become a reality.

Threats:

Some of the nurses in the ward don‟t know much about the hospital charges for the

initial admission. Therefore sometimes they make charge slip for less amount.

Government hospital staffs are very much resistant to the change. If some other

charges are included in the hospital for other department, they might refuse to make

the charge slip as they think it‟s a work of the cash counter.

Lack of interest of the staff as it has increased the work of the individual who is

directly and indirectly involved with the cashiering module. For example: As nurses

in the wards have to enter data in the CPRS and also do the routine work of patient

care. Making of charge slip may lead to lack of interest from the nurses.

33

9.2 SWOT Analysis JPNATC: IT Transformation

JPNATC is currently the best integrated level I trauma centre in India and continues to set

benchmarks in patient care not only in India but also all across the globe. JPNATC also

proudly becomes the first hospital in India to implement VistA EHR. More than 3 years after

the successful implementation, there is still a lot of work to do.

Strengths:

The involvement of NIS and CATS under the dynamic and impressive leadership of

Dr. Deepak Agarwal, Head Computer Facility Department are the backbone for 24

*7 support to all the medical/non medical staff of the hospital who are using the HIS

or CPRS (e.g.: training of the staff).

24*7 support for the computer hardware and software by the Computer Facility

department with round the clock presence of network professionals and hardware

engineers.

24*7 call center for providing all types of information of the appointments for the

patients after the discharge for the follow up OPD.

4 GBps network speed with the facilities of both wired and wireless facility.

24*7 CCTV camera and Biometric Attendance/ Access for tight security (IT

initiative).

Weaknesses:

Approximately 40 percent of the hospital staff needs training / retraining about the

HIS or CPRS as they are new recruited to the hospital or the modules are

implemented for them are new (e.g.: Cashiering Module).

34

Lack of awareness among the staff about the different software. The medical staffs

don‟t know much about HIS. Similarly other staff doesn‟t know about the CPRS.

Only the NIS and CATS know about both the software (HIS and CPRS).

Lack of computer knowledge among the nurses and other staff. Some of them have a

very less knowledge about the hardware present in their department.

Opportunities:

Different Modules still to come like BCMA in CPRS leading to reduction in the

manual work of the medical and supporting staff.

Government funded organization, therefore easily available funds for the

computerization.

Threats:

Government hospital has the largest threat of their staff been resistant to the change

due to implementation of the IT systems.

Lack of interest from the staff as still the manual work is going on and also entering

the data electronically in the CPRS and HIS.

35

10. Recommendations

1) In every department some nurses should be fully trained or retraining sessions should

be there with regular assessments of the medical staff after the implementation of the

new HIS module or new templates in CPRS.

2) The Nursing Informatics Staff (NIS) started as a program named Nursing Informatics

Specialist Program under the guidance of Dr. Deepak Agarwal w.e.f. 1st February

2011 (JPNATC March – April Newsletter Issue, 2011) has initially only 7 nursing

staff working in shifts and covering every department. The number should be

increased to at least 10 so that they can cover every department efficiently and

effectively.

3) Use of desktops in place of thin clients if possible. The thin clients used in JPNATC

at every ward are rather slower than the normal desktops. Similarly they are slow in

capturing wireless network. This leads to sometime less time to open the CPRS in

there thin clients.

4) Regular updation of the templates in the CPRS is required as some of the options are

regularly used are been typed.

5) Interested nursing staff should be initiated to be a part of internal training to the

nursing staff of their departments and they should be asked to be the one using both

HIS and CPRS together. For example in cashiering module, interested nursing staff

should be provided with the authority to make the charge slip. They should be fully

trained for all the options in the HIS which would reduce the confusion about how

much to charge from the patient.

36

Case Studies

37

10.1 Case Study #1: Queue Management of OPD in JPNATC: An IT

Initiative

Observational Case Study

Abstract: The following case study deals with the queue management of the OPD patients

and reducing the waiting time of the OPD patient with the help of Information Technology.

An m – health initiative, use of the latest technology (Bar Codes) and the complete EHR of

the patient not only helps the patient but also helps the consultants to give the best possible

treatment to the patient within the provided time. With this kind of IT initiative, JPNATC is

able to give consultation to all the OPD patients in a mere time span of 3 hours.

Introduction: In the past 10 years, the facilities in the hospitals especially in a government

hospital have not increased at the same rate as the population seeking medical care. Because

of the increased rush of the people visiting hospitals for treatment, long queues of patients are

seen waiting for the medical care in almost all the hospitals, resulting in overcrowding and

long waiting times. The problem of overcrowding in hospitals is not merely because of the

shortage of doctors and other paramedical staff. The majority of the problems leading to this

phenomenon are due to management. JPNATC initiated the dreams of using mobile

technology for reducing the queues of the patients in the OPD and giving patient the utmost

satisfaction. As JPNATC is especially there for the 24*7 trauma care for the patients, the

majority of the patients who are coming for the OPD come under the following

specialization:

Orthopedics, General Surgery and Neuro Surgery.

According to the new VLR data released by TRAI (Telecom Regulatory Authority of India)

report, as on 31st January 2011 there are 771.18 million mobile subscribers in India.

Whenever a patient reaches JPNATC, the patient‟s mobile number or his / her relative‟s

mobile is been noted down in the EHR of the patient. JPNATC has an outsourced 24*7 call

center (011-40401010) which helps the hospital as they have divided some of the

administrative work to the call center. The patient appointments are been given by the call

center reducing the waiting time of the patient for taking the appointment. Also the

appointment is verified by sending an SMS to the mobile number provided in the EHR of the

38

patient. A Government hospital where people think that the patient‟s time is not the first

priority for the hospital, JPNATC has proven wrong by becoming one of the first government

hospitals in India to manage the long queues of the patients in OPD. For this IT initiative

JPNATC has been awarded with the prestigious mBillionth award South Asia 2010 in M –

Health & eIndia 2010 jury‟s choice award in m Governance.

Methodology: Observational Study.

Observational study was conducted on six working days in the OPD registration counter and

the follow up OPD itself from 2nd

May to 7th

May 2011. There are 3 consultation rooms;

Room No. 103,104 and 111 respectively where the follow up OPD consultations are

provided. The OPD is known as follow up OPD because most of the patients who are coming

are the patients who were the patients of the JPNATC and got discharged from JPNATC

after getting the full treatment.

Observations: The following observations were done in the above mentioned six working

days and the following came into picture.

1) Appointment of the OPD Patient:

The patient who enters the Trauma Center is first been registered in the Emergency

Registration counter. The mobile number of the patient or the relative‟s mobile

number is been taken in the HIS and then it gets automatically transferred to the

CPRS.

The Call Center calls that mobile number to verify the patient details after the

admission or during the first visit (in Emergency). When the patient gets discharge, in

the discharge summary (template) the next appointment is entered. CATS notify the

call center of all the discharge of the patients happened for the day.

According to the doctor‟s orders, call center gives the patient the appointment for the

doctor through the appointment system provided by Edgeware Technologies (I) Pvt.

39

Ltd. The call center SMS the Token number and Appointment details to the mobile

number provided in the EHR.

The final details of the appointments is been provided to the medical records section

via email so that they can get the files ready of the respective patients in the doctors

table. The email is sent a day before the actual OPD day i.e. if the appointment is for

the Monday Ortho A OPD, then the list is been mailed to the Medical Records

Section by Saturday (See Annexure #4 for OPD days details).

2) On the Day of the OPD:

There are 2 registration counters in the OPD. One for the New Cases and other for the

Old Cases. The OPD registration timings are from 9 am to 11 am but the registration

counter gets open at around 8 am.

The counter receptionists collect the final list of patients coming for the OPD from

the Medical Records section and paste it outside the counter in the notice board. The

list consists of the names of the patients under one consultant and which consultation

room the doctor is sitting.

The registration procedure starts around 8: 30 am till 11 am. This divides the patients

into two counters. New Cases don‟t have any OPD card so they get from one counter

where new cases get register. Patients give their discharge summary and tell the TC

number and Token Number.

For verification, the OPD registration counter checks the SMS which was sent from

the call center to the patient. The printed out token number and a printed bar code

which signifies the TC number is been pasted in the OPD card. The same is not done

for the old cases as they have OPD card ready with them previous time.

40

The patients coming for OPD are also been registered with an OPD registration

number which helps the management to take out weekly, monthly or yearly census

that how many patients turned up for OPD so that necessary actions can be taken for

providing better treatment. The OPD registration is written as follows:

NS – 11 – 529. In this NS represents Neuro Surgery Department, 11 represent year 2011

and 529 is the patient number (529th

Patient). This is all present in the appointment

system software.

3) After arrival of the Consultant:

The consultation timings are from 10 am to 1 pm. The doctors arriving in the

consultation room calls the patient one by one with the help of the token number

that was provided by the call center.

There is a display system above the entrance of every consultation room and also

in patient waiting area. The patient to be called up, the token number gets

displayed in the screen which is been controlled by the doctors with the help of an

instrument known as token counter. When the button is pressed the next token

number is displayed in the screen.

The patient arriving inside the consultation room has the OPD card. The OPD

card has the bar code signifying the TC number. This helps to reduce the human

errors which may happen if written in the OPD card. The bar code scanner present

in the consultation table scans the bar code and the number is entered in the CPRS

from where the patient history can be seen by the doctor. Also the files of the

patients are bar coded with the same TC number so that the error gets minimized.

If a patient forgets to take appointment (patient might not have any contact

number) but the patient knows that doctor has asked him/her to come on that day

41

or the patient may be a referred case (not a trauma center patient) then the patient

has to fill up a form then counter signed from the consultant that he is ready to see

that patient, then reception counter at the entrance of JPNATC provides

appointment to the patient through the appointment system.

Discussion: Being a government hospital where OPD is free for the patients and such an

initiative to reduce the queues and waiting time for the patient is really appreciable. The IT

initiative of using EHR, Appointment system, M- health and 24*7 call center is a perfect

example of meaningful usage of IT in healthcare.

The patient is been given prior appointment which has reduced the time of taking

appointments while standing in queues. The patient now gets appointment after

discharge while he/ she is sitting back home.

Also the call center notifies the patient if there is a change in the appointment

schedule due to absenteeism of consultants or due to gazetted holiday declaration

which reduces the travelling time and thus reducing the opportunity cost of the patient

especially the poor patients who work on daily wages.

Also the work starts for the OPD a day before which also reduces the waiting time for

the patient as all the files of the respective patients are kept at consultation table.

Bar codes signifying the TC number of the patient help the doctor to get the correct

TC number in the CPRS. The above initiative truly deserved the awards that they

have got in 2010.

42

Recommendations: JPNATC has one of the finest OPD management systems with the help

of Information Technology, but still many of the patients have to wait for 2 hours for their

chance to get consultation from the doctors. The registration counter is opened from 9am

(starts from 8:30 am) to 11 am. Doctor‟s consultation timings are from 10 am to 1 pm. If the

registration counter is kept open till 12 pm, then the patients who are getting the chance at

around 1pm will have to wait for 1 hour maximum as they would come at around 12 pm.

Also the registration counter reception would get ample of time to get through the discharge

summary easily and leading to smooth workflow in OPD.

Conclusion: JPNATC has set an example to the Indian Healthcare system if there is a will

there is a way. JPNATC is one of the best examples in India where we can see “The

Meaningful Use of Information Technology”. They have done tremendous job while taking

care of the patient health and waiting time. Longer queues are now not at all visible except in

Mondays and Tuesdays when the orthopedics OPD is there. When there are more number of

patients for a particular day, the consultation room number 111 also gets opened to divide the

longer queues into 3 different queues. This is according to me the perfect example set up by

any healthcare organization where management of the OPD queues is also a priority while

providing the best possible patient care to everyone.

43

11.2 Case Study #2: Staff perception over the HIS/ CPRS present in

JPNATC

Questionnaire Based Study

Abstract: The following case study deals with the JPNATC staff perception for the HIS/

CPRS software present in the hospital. No IT system is perfect in this world. Different people

using the same software have sometime different opinion for the software. The different

opinions therefore lead to regular updating of the software. The study was conducted in the

JPNATC premises with 52 JPNATC staff from different departments. The staff members were

selected by using convenience sampling. The study concluded that the major problems that

everyone (52 Staff) was facing of the computer getting hanged. The average rating given to

the VistA HIS/CPRS was 7/10 (6.8). The study also concluded that the staff members were

having very little knowledge of all the software in the hospital. Those who were using CPRS

did not know about the HIS and vice versa. 88 percent respondents say that IT is important

for Hospitals, which included medical staff also.

Introduction: Healthcare over the past 10 years, has witnessed a sudden leap of information

technology in different sectors. Albeit, with slow progress, a number of information systems

have been developed and implemented in hospitals across the globe. This is been proved by

the increase in the investments being made by hospitals across the world. India is not much

far behind in this sector. However the scenario in India is still weak as compared to the west.

For any IT system to be successful especially in a hospital, the major factor affecting the

success of the software is the perception of the users for the software. ETIPL provides the

software to JPNATC for the backbone functioning of the hospital. From patient registration

till the discharge and also for the follow up OPDs, everywhere the softwares are been

provided by ETIPL. The following are the softwares which are working in the hospital which

are been used by the medical and non medical staff of JPNATC.

1) VistA HIS (For day to day activity for the patients like registration, billing etc.)

2) CPRS (For patient medical data which is been updated by the medical staff)

3) Surgery Module (Full details about the surgery to be held in the hospital)

44

4) Appointment System (Follow up OPD and radiology appointment system)

5) Lab Module etc. (Lab entries interlinked with the CPRS for the patient)

Different software has different users also. For example the CPRS is been used by the

medical staff of the hospital consisting of the Consultants, Senior & Junior Residents and the

nurses. The other supporting staffs of JPNATC are using HIS and Appointment systems etc.

Therefore different people are having different perception for the software present in

JPNATC. Also it‟s very difficult to make an overall perception of the software package

provided in the hospital. Different staff members have different requirements and sometimes

it makes some people satisfied and others are not. The case study here describes about the

perception of the staff members which have been noted down and been tried to be taken up

from the different departments so that an overall perception of the software can be presented.

Methodology: Questionnaire Based Study

For the study a Questionnaire of 13 questions was prepared which covered the department

and the working profile etc. (Annexure #9). The questionnaire also have subjective questions

so that the staff members could write the problems they face and suggestions so that the

software can be improved in the near future for smooth functioning of the hospital. SPSS

16.0 was used for the analysis of the data collected. Total numbers of respondents were 52

from different departments through convenience sampling. The convenience sampling was

done because there were many respondents who were not willing to fill the questionnaire.

The computer knowledge and also the knowledge of the different software in the hospital

were observed.

Observations: The following analyses were concluded after the data collection through

SPSS 16.0.

Number of Respondents: 52

Departments Covered: Cash Counter, Computer Facility, Emergency Medicine,

Emergency Medicine Registration, CWG ward, Neurosurgery, Nursing (NIS),

Orthopedics, and General Surgery etc.

45

Working Profile: Assistant cashier, NIS, Staff Nurses and Sister grade II, Senior and

Junior Residents, Faculty In charge, DEO, Lab Technician /CATS etc.

Experience in the Hospital

Frequency Percent Valid Percent

Cumulative

Percent

Less than 6 months 20 38.5 38.5 38.5

6 - 12 months 3 5.8 5.8 44.2

1 - 3 years 16 30.8 30.8 75.0

More than 3 years 13 25.0 25.0 100.0

Total 52 100.0 100.0

Table #3: Experience of the respondents

All the above 52 respondents used HIS/ CPRS. Most of the respondents were using the

HIS/CPRS for less than 30 minutes (48 percent). More than 88 percent respondents say that

IT is important for smooth functioning of the hospital.

Majority of the respondents has said the following type of the improvement they have seen

after the implementation of the HIS/CPRS:

Easy accessible of the patient data.

Patient whole record in just one click. Don‟t have to check the records again and

again.

After discharge they are easily been traced if they are again coming to the hospital.

Complete information about the patient is there, which helps the medical staff to

provide better treatment to the patient.

With the implementation of PACS, the doctors are now easily diagnosing the

patient‟s images through there working station.

The majority of the works are now having fewer errors.

46

Saves time as all the data is been there with one click.

This has increased the efficiency and effectiveness of the medical and non medical

staff.

No IT enabled system is perfect in this world. If there are some positive points about the

software, so there are problems or negative aspects of the software. Therefore the

respondents were about the suggestions for the software so that it can be improved for better

functioning of the hospital.

Regular training of the staff after the implementation of the software or any module.

Complete awareness to be given to the staff so that they have knowledge what new is

going to be implemented.

The software should be fast as it takes a longer time to open.

The software should be regularly updated so that they don‟t have to write or to keep a

manual record.

More options should be there rather than writing in the text format for the patient

record.

It should be user friendly with more GUI‟s present.

The templates should be prepared after the consult of the doctor.

There are some problems also after implementation any new system in the hospital or any

organization. Some of the problems were found are as follows:

Majority of the respondents agreed about the computer gets hanged and it takes a

longer time to open.

Other than these problems the major problem they faced that till now they are now

also keeping a manual record of all the details that they are entering in the CPRS/HIS.

Proper training is not been given to the staff after the new implementation been done

in the hospital and many more.

Rating to the overall software package: The respondents were asked about the overall

rating to the software, the mean rating given to the software is 7 out of 10.

47

During the analysis it was seen that the staff working in the hospital more than 1 year has

seen a satisfactory improvement (approx 50 percent) but 4 staff members out of 52 have said

that there is a tremendous improvement in the working of the hospital after the

implementation of the HIS/ CPRS and all the 4 staff members are working in the hospital for

more than 1 year. 86.5 percent of the respondents have said about the improvement in the

hospitalization (45 out of 52)

Figure #4: Response for working improved after HIS/ CPRS (out of 52)

Discussion: Nobody wants to do extra work except to their day to day routine job. It

becomes very difficult sometimes to make the medical staff to enter the details in the

computer where they can do the work faster in manual way. After the survey conducted in

the hospital, it was found out that all the respondents are thinking IT as an important part

for the proper functioning of the hospital. Also it was seen after the survey that those who

have the experience of more than 6 months in the hospital have seen improvement in the

working of the hospital. It was also seen through the survey that the staff members using the

software more, they have seen improvement in the hospital functions as well as their working

in the hospital. The software rating of 7/10 (6.8) also shows that VistA HIS / CPRS are been

appreciated by the hospital staff but still a lot of work is required. Another major problem

that was observed that except the CATS/ NIS, all were having a lower knowledge of the

computer hardware. In JPNATC, every department is having thin clients in place of the

14%

38%

40%

8%

Improvement in the working of JPNATC

Neutral

Improved a Little

Satisfactory Improvement

Tremendously Improved

48

normal PC, which they don‟t know how to operate. Next thing observed is that the medical

personnel don‟t know about the HIS and the non medical staff doesn‟t know about the CPRS,

which shows a lack of awareness about the VistA EHR (HIS and CPRS) among the JPNATC

staff.

Recommendations & Conclusions: There are some limitations to this study. The numbers

of respondents were less, if done with more number of staffs it might have given a clearer

picture about the staff perception. The above observations and discussions has lead to a

conclusion that there is a lack of awareness among the staff members especially the medical

staff as they are least interested in the HIS system installed in the hospital. They even don‟t

know the meaning of HIS. Same is the case with the non medical staff as they don‟t know

what CPRS is. To bridge out this gap JPNATC has brought out the concept of NIS (Nursing

Informatics Staff) who are giving up the training to the medical staff and CATS who are

helping them out in their formal computer related training. But this is not enough as the staff

requires training and retraining again and again.

1) Increase the number of NIS or increase the number of training or retraining sessions

of the staff members.

2) Another problem they are facing is that the computer gets hanged. Instead of using

thin clients, they should have desktops and wired connections. Instead of using 3 thin

clients, they can use 1 Desktop and rest 2 can be thin clients in each ward as they are

using in some wards.

3) Wireless connections should be replaced with the wired connections as the HIS/CPRS

requires networking to open.

4) Regular updation of the HIS and CPRS is required.

49

12. References

1. Department of Veterans Affairs‟ computerized patient record system, in: Proceedings

of AMIA Symposium, K. Meldrum et al, 1999.

2. Determination of the success of a hospital‟s information system implementation: J.C.

Sarivougioukas & A. Th. Vagelatos, 2002.

3. Edgeware Technologies (I) Pvt. Ltd

http://vista-edge.com/index.php?option=com_content&view=article&id=1&Itemid=2

4. Electronic Health Records Overview; National Institutes of Health & National Center

for Research Resources, Virgina April 2006.

5. Essex D. The Many Layers of Workflow Automation. Healthcare Informatics, June

2000: 128-135.

6. http://en.wikipedia.org/wiki/Hospital_information_system

7. http://en.wikipedia.org/wiki/VistA

8. http://trak.in/tags/business/2011/03/08/indian-telecom-subscriber-growth-january-

2011/

9. http://www.asianhhm.com/Knowledge_bank/industryreports/hospital-information-

systems.htm

10. Implementation of Health Information Systems; Bahlol Rahimi, December 2008.

11. Integrating ED with enterprise Gaylen Wright et al January 2007.

50

12. Jai Prakash Narayan Apex Trauma Center, AIIMS website

http://www.jpnatc.com/about.asp

13. Medical Data capture and display: The Importance of clinician‟s workstation design,

Ruth Dayoff et al 1995, Department of Veterans Affairs.

14. Open source challenges for hospital information system (HIS) in developing

countries: a pilot project in Mali; Cheick – Oumar Bagayoko et al, 2009.

15. Rationalisation of working of OPD in a hospital – A Case Study, T.R. Anand & Y.P.

Gupta, 1983.

16. Study on patient satisfaction in the government allopathic health facilities of

Lucknow District, India; Ranjeeta Kumari et al 2009.

17. The introduction of computer based Patient Records in Netherlands: Johan van der

Lei et al 1993.

18. Using BCMA software to improve patient safety in Veterans Administration Medical

Centers; C.L. Johnson et al 2002.

19. VistA – U.S. Department of Veterans Affairs national – scale HIS; Steven H. Brown

et al 2003: International Journal of Medical Informatics.

20. Workflow analysis and modeling in medical IT projects, A.S. Ouvry 2002.

51

Annexure

52

Annexure #1: Price List to be put in the HIS Charge Slip Option

Inpatient Department

o Admission

S.No. Charges Description Charges (Rupees)

1. Hospital Charges ( One time during first admission) 25

2. Bed Charges (Per Day Bed Charges) 35

3. Short Admission (One Day charge for a Patient) 60( 25 +35)

o Certificates

S.No. Charges Description Charges (Rupees)

1. Medical Certificate for Leave 10

2. Medical Fitness Certificate 10

o Claims

S.No. Charges Description Charges (Rupees)

1. LIC Claim 50

Out Patient Department has the same above charges except the Admission option.

Radiology Department

o Ultrasound

S.No. Charges Description Charges (Rupees)

1. Ultrasound Routine 200

2. Ultrasound Doppler 200

o X – Ray: Every X- Ray procedure in JPNATC is of Rupees 30 each.

o CT – Scan

S.No. Charges Description Charges (Rupees)

1. Head CT 200

2. PNS CT 200

3. Neck CT 200

4. Head/PNS/Neck CT Film 100

5. Body CT (one part) 750

6. CT Angio 1000

7. CT & CT Guided Interventions 750

8. Film Charges 300

53

o MRI Charges

S.No. Charges Description Charges (Rupees)

1. MRI with film – OPD 3500

2. MRI without film – OPD 3000

3. MRI with film - Inpatient 3000

4. MRI without film - Inpatient 2500

5. MRI film charges 500

6. MRI for 2nd

Body Part 1500

7. Contrast Adult 2000

8. Contrast Child 1000

Note:

1. There are no charges for the patients who are coming to the casualty area.

2. The patients who are either OPD patients, Inpatients or referred patients from

anywhere are charged with the above charges.

3. X – Ray Charges are only for the OPD and Referred cases to trauma center.

4. Payments are kept in 3 stages: a) Payment Done; b) Payment Deferred and c)

Payment Cancelled.

5. In the case of payment deferred the payment are to be done after the procedure has

been done. For example the payment of admission is to be done afterwards if the

accounts office is closed. Same in the case of the radiology procedures.

6. Timings of the cash counter:

a) Monday to Friday: 10 AM – 1 PM & 2 PM – 3 PM

b) Saturday: 10 AM – 11:30 AM

c) Sunday: OFF.

54

Annexure #2: Questions Asked to the Departments

Radiology Department

1) What is the workflow in radiology department for providing services to the patients?

2) How do Patient‟s get treatment if the cash counter is closed?

3) What are the charges for the different radiological procedures and to whom it is

applicable?

Inpatient Department

1) What are the different charges been taken from the patient‟s after admission?

2) If the cash counter is closed, how do the nurses proceeds with the payments?

3) How do you come to know that the payments have done all the payments or not?

Cash Counter

1) How do you decide that how much money to charge the patient?

2) What are the procedures followed for giving refund to the patient against the hospital

services?

3) Are there any other payments done in the cash counter other than the patient‟s

payments?

4) How many receipts do the counter provides to the patient against the payments?

55

Annexure #3: Training Schedule

Day/ Date Session

Timings

No. of

Trainees

Training For Training Place

Monday /

2nd

May 2011

Morning

10 am to 1 pm

NIS: 3

CATS: 6

Training for Charge

Slip & Refund

Computer Facility

Monday /

2nd

May 2011

Evening

3 pm to 5 pm

Radiology

Receptionist

Training for Charge

Slip & Refund

Radiology Dept.

Counter

Tuesday /

3rd

May 2011

Morning

10 am to 1 pm

NIS: 4

CATS: 4

Training for Charge

Slip & Refund

Computer Facility

Tuesday /

3rd

May 2011

Evening

3 pm to 5 pm

Cashier: 1

Asst.

Cashier: 2

Training for receipt

option.

Cash Counter

Wednesday /

4th

May 2011

Morning &

Evening

10 am to 5 pm

Nursing

Staff of the

wards

Training for Charge

Slip & Refund

TC-2 to TC-7

All wards & ICUs

Table #4 : Time Schedule of the Training

Note: The NIS and CATS were giving training to the Nursing staff when they got their

respective training.

56

Annexure #4: Training Manual for Cashiering

Cash Counter

Logging in to the HIS:

On start up the following Login Screen will pop up.

Enter the Access Code and Verify Code and Click the ‘OK’ button to log in.

The Main Screen:

The “Main screen”, as shown below, will be visible.

This screen has various menus:

Search; Pat. Reg; Ch. Slip; Refund; Pat. Bill; Receipt etc.

57

Click on this button

for making receipt.

58

Receipt Option:

The Receipt option will pop up the following screen. Here we can create receipt for patient.

Steps to follow: Red marks are mandatory fields:

1) Enter the HRN/ TC number of the patient whose payment is to be received.

2) If the patient‟s charge is there, all the details of the charge slip comes into the screen.

3) If the payment mode is by cash then click the cash option. Otherwise there are credit

card and cheque options present. By clicking on the payment mode and clicking on

the cheque and card then all the options gets open where you can fill the text of the

card and cheque details.

4) Click on the ‘Save’ option to save the charge slip details in the given receipt number.

59

When we click on 'Save' button the following window will pop up

When we click on 'Yes' button it will generate report as shown below:

Similarly we can take print of Refund from Receipt Screen. Whenever the refund is there, it shows an

alert in the receipt screen showing refund exist in red colour.

This can be done by clicking in the receipt screen as shown in page 3. The select bill/refund

option when clicked, it would give two options of patient bill and patient refund. When

patient refund is clicked then all the refunds come in the screen. The following options occur

in the screen.

60

When we click on 'Save' button the following window will pop up

61

When we click on 'Yes' button it will generate report as shown below:

In receipt screen there is an option of search at the bottom. When we click search, the

following screen pop ups.

62

If we want to search anything according to the fields provided, just enter the field and click

select. The following screen pop ups.

When we select record from list it will pop up the following window which shows detail of Receipt.

We can also Update and Delete Receipt.

Cashier Report.

When click on the report option at the top of the HIS, it has the following options:

1) Cashier Report

2) Item Wise Report.

Clicking on the option it would lead to the open of the report for the day. Cashier report gives

the details for the day to day transaction and item wise report gives you the option to select

the options like inpatients total charges and radiology charges. Also it gives the option of TC

number, monthly wise.

63

Annexure #5: Training Manual for Cashiering Module

Radiology and Inpatient Department

Logging in to the HIS:

On start up the following Login Screen will pop up.

Enter the Access Code and Verify Code and Click the ‘OK’ button to log in.

The Main Screen:

The “Main screen”, as shown below, will be visible.

This screen has various menus:

Search; Pat. Reg; Ch. Slip; Refund; Pat. Bill; Receipt etc.

64

Click on this button

for making charge

slip.

Click on this button

for making refund for

the patient.

65

Charge Slip option

The Charge Slip option will pop up the following screen. Here we can create a charge slip for

patient.

Steps to follow: Red Marked fields are compulsory.

1) Enter the HRN/TC number of the patient. Click search.

2) The details of the admission and patient demographics come automatically.

3) Select the ordering department, provider and service department by clicking to the

respective fields.

4) Click on the Item Type followed by description. After clicking both the options, the

charge code gets automatically entered.

66

5) The rate of the service gets automatically entered. Now change the number of

quantity you want to charge. By default it gives quantity 1. It multiplies the rate with

quantity to give you the final charge.

6) If you want to give any discount, then click on the Discount (Per) and enter the

percent of discount you want to give. When you click add, the charges gets add just

below charges. You can add n number of charges for the same patient for the same

charge slip. Note: If you want 2 separate receipts then make two charge slips.

7) When you will click save the charge slip gets automatically saved.

67

Search Option:

When we click the search option at the bottom of the charge slip screen, the following screen

pop ups.

You can search the details of any charge slip by any of the above options. Just enter the

search criteria and click on the search option.

Refund Option:

The refund option will pop up the following screen, where we can give refund for the patient.

68

1) Enter the TC number for which the refund is to be made.

2) Click the search button to get the detailed list of the charge slips for the patient. If you

know the charge slip number then you can get the details of the charges directly.

3) The above screen shows the refunds and the charge slips where the refund is not

there. The one you to refund just double click on it. The screen becomes like

following.

4) The above screen shows 18 units were charged. To refund let say 10 units, enter the

actual unit value (8 in this case). Click on the button add and update it. This will

provide the refund to the above charge slip.

69

Annexure #6: Back end of the Cashiering Module

The cashiering module in the HIS is having the following features:

Back End: My SQL Database. Front End: Java.

Figure #5: Information Flow in the back end of the cashiering module

Charge Slip Screen

Java

Charge Slip Record

(Database)

Charge Slip

(Master Database)

Refund Screen

Java

Refund Record

(Database)

Refund

(Master Database)

ID

Common

ID

Common

Receipt (Master database)

Receipt Screen (Java)

HRN

70

Figure #6: Charge Slip Record (Database) Variable View

Figure #7: Charge Slip (Master database) Variable View

71

Figure #8: Refund Record (Database) Variable View

Figure #9: Refund (Master Database) Variable View

72

Figure #10: Receipt (Master Database) Variable View

73

Annexure #7. Receipt before and after implementation of Cashiering Module

Figure #11: Before Implementation: Manual Receipt

Figure #12: After Implementation: Printed Receipt

74

Annexure # 8: JPNATC OPD Schedule.

The week from Monday to Saturday (Sunday OPD off) is been divided into the following

schedule and their respective consultants.

Day of the Week Department Consultant Name

Monday Ortho A Dr. Vijay Sharma

Dr. Kamran Farooque

Tuesday Ortho B Dr. B.D. Choudhary

Dr. John R. Bera

Dr. Vivek Trikha

Wednesday Surgery Dr. Subodh Kumar

Dr. Biplab Mishra

Thursday Neuro Surgery Dr. G.D. Satyarthi

Dr. Deepak Aggarwal

Friday Neuro Surgery

Medicine

Dr. Deepak Gupta

Dr. Sumit Sinha

Dr. Sanjeev Bhoi

Saturday Surgery Dr. Amit Gupta

Dr. Sushma Sagar

Dr. Maneesh Singhal

Table #5: OPD Schedule

OPD Timings: 9 am to 11 am for registration (Starts around 8:30 am)

Consultation Timings: 10 am to 1 pm.

Sundays and Gazetted holidays OPD closed.

75

Number of Patients arrived from 2nd

May to 7th

May 2011

Follow Up OPD at JPNATC, AIIMS

Day / Date

New Cases

Old Cases

Total Cases

Monday / 2nd

May

47

89

136

Tuesday / 3rd

May

53

84

137

Wednesday / 4th

May

44

34

78

Thursday / 5th

May

23

40

63

Friday / 6th

May

37

23

60

Saturday / 7th

May

31

29

60

Grand Total

235

299

534

Table #6 Number of patients from 2nd

May to 7th

May 2011

Every week Monday & Tuesday are having the most number of cases as it is the days for

Orthopedics.

Here the new cases are those patients who are discharged from the JPNATC from the

previous week or nearby to the date of the OPD. The older cases are those who have more

than one visit to the consultant. The consultant decides if the patient requires more visit to

JPNATC.

Number of Consultation Rooms: Three. Room Number 103,104,111 respectively.

76

Annexure # 9. HIS implementation in Jai Prakash Narayan Apex Trauma Center

AIIMS.

Respected Respondent. This is a part of the case study been conducted by the Management

Student from International Institute of Health Management Research as a part of the Summer

Training. None of the information would be released to anyone without the respondent‟s

written consent. The information gathered is purely for the case study which is an integral

part of the partial fulfillment of the degree from the institute.

Case Study Questions

Q. Name: ………………………………………………………………………… (Optional)

Q. Department: …………………………………………………………………….

Q. Working Profile: …………………………………………………………………….

Q. How many years you are been working in JPNATC? (Tick √ the appropriate answer)

( ) Less than 6 Months. ( ) 6 – 12 Months

( ) 1 – 3 years ( ) More than 3 years

Q. How much do you think IT is important in carrying out hospital functions?

( ) Very important ( ) Important ( ) Moderate

( ) Less Important ( ) Not Important

Q. Do you work on HIS or CPRS which is present there in JPNATC?

( ) Yes ( ) No

Q. How do you find using HIS/ CPRS?

( ) Very Easy ( ) Easy ( ) Moderate

( ) Difficult ( ) Very difficult

Q. How much time on an average do you spend daily in HIS/ CPRS provided to you in

JPNATC? (Approximately)

( ) Less than 30 Minutes ( ) 30 Minutes to 1 Hour

( ) 1 – 3 Hours ( ) More than 3 Hours.

77

Q. How much of the working of JPNATC has improved after the implementation of HIS?

( ) Neutral. ( ) Improved a little bit

( ) Satisfactory Improvement [Has met the expectation] ( ) Tremendously Improved

Q. What type of improvement you have seen after implementation of HIS?

Q. Any kind of suggestions you want to give for better working of the software?

Q. What is the overall rating you would give to HIS provided at JPNATC?

Rate it out of 10. ……………………/10.

Q. What are the basic problem do you face (if any) after computerization

SD: Strongly Disagree; D: Disagree; N: Neutral; A: Agree; SA: Strongly Agree

SD D N A SA

a) Computer gets hang ( ) ( ) ( ) ( ) ( )

b) Takes longer time to open ( ) ( ) ( ) ( ) ( )

c) Print out doesn‟t come out ( ) ( ) ( ) ( ) ( )

d) Doesn‟t accepts the access & ( ) ( ) ( ) ( ) ( )

Verify codes

e) Others ( ) ( ) ( ) ( ) ( )

For others please specify:

Thank you