By Mark Sutton
Investment in IT in the healthcare industry has long lagged behind other sectors. Now changes in funding and better functionality in information systems are making IT managers look again at using technology to help manage the huge paper trail of hospital information and administration.
Introduction|~||~||~|It is a service industry that virtually everyone will have need of in their lifetime, regardless of where they live, their nationality or wealth. Those that work in the industry require years of technical training, and have to conform to strict government and professional regulation. Its raw materials are specialised and expensive, as is the machinery and technology it requires, but services are often provided for free, and the sector is usually seen as struggling for cash. Consequently, the healthcare industry is one of the most cost-conscious around, and despite the complexity and volumes of data that the sector has to handle, IT has played a relatively minor role in healthcare management.The reluctance of management to invest in systems is due to a number of reasons, according to Jonathan Edwards, a senior research analyst with the Gartner Group. The focus on the patient — investment centred on the primary instruments of healthcare instead of the secondary administrative structure, and the complexity of healthcare organisations are both contributing factors.“Healthcare really does lag behind other industries in the use of IT,” he said. “If you look at financial services they made IT a priority, from a long time ago. Healthcare has not. There is so much primacy in the face to face interaction between patients and doctors that people have forgotten about using IT to improve that process and make it more efficient. There is an enormous amount of paper involved in the whole process — paper medical records, paper transactions, paper accounting — there is a great opportunity to reduce costs by automating all of that.”“There is a culture of non-investment in IT in healthcare, because it is so complex,” he adds. “One business analyst was writing about different organisational structures, and said that an academic medical centre is one of the most complex organisations in the world, because of all its different component parts and fitting those together is so complicated.”But the situation is changing — rapidly. Oddly enough, it is rising costs, data complexity and the desire to provide the best care possible that is driving healthcare suppliers to focus on their IT systems. “The cost of treatment is going up all the time, due to ageing populations, advances in medical technology, the growing cost of drugs, labour and medical procedures,” said Edwards. “For all countries in the world, containing healthcare costs is an issue, and the question is can IT help contain costs or does it add additional costs?”Rising costs are having an impact, even here in the oil-rich Gulf. Chuck Grieve is consulting editor with Middle East Health Magazine. He says that cost and efficiency is currently one of the biggest issues in healthcare in the region, and an important factor in the reappraisal of IT in the region. “With the coming on-stream of the oil exports in the 1960’s, there has always been free healthcare for everybody — it is one of the great social benefits of the Gulf,” he commented. “But now you have a larger, smarter, older population, which asks for and demands a quality of healthcare that comes at a cost. The expense of providing healthcare has outstripped the balance of the budgets, so that now four out of the six GCC countries are looking very seriously at mandatory private health insurance — and that includes Saudi Arabia, so something is definitely afoot.”Grieve says that it is the growing private sector that is making the biggest investment in IT systems. “I think that it is the private hospitals that are moving more firmly into high-end IT systems, because they are the ones that are working on a profit basis. They are humanitarian businesses, but they are businesses nonetheless, so they have got to find the efficiencies that help them make the return to their investors.”||**||II|~||~||~|The focus for most hospitals is on management and information systems, particularly integrating patient data and administrative processes between different departments.Another development in the private sector that is driving efficiency, is the increasing use of managed care insurance packages. Under managed care schemes, hospitals are contracted to provide a set suite of services for a set fee (usually discounted). The system means that the insurer can offer cheaper packages to companies, but the hospital becomes obliged to provide that care for less money. This in turn has meant that hospitals have to have a better understanding of their cost centres.“We are seeing a major revolution in healthcare,” said CV Ramanamurthy, CEO of healthcare information management systems supplier Quest Middle East. “The patient is demanding quality service, the insurance companies are demanding the best value for money, so slowly, even in this region, the industry will move to managed care. To meet the challenge, most of the hospitals have to gear up their processes to be competitive. That is where healthcare systems offer a key benefit, giving information at any stage of the health provision service.”Quest’s modular healthcare software is in use in five hospitals throughout the Gulf. Integrating the different services within a healthcare organisation is the key to leverage the benefits, said Ramanamurthy. “The complexity is in the information handling, in being able to service multiple disciplines in the hospital environment,” he said. “If you look at the industry today, there are three or four systems the clients are buying from three or four vendors, which do not talk to one another. As a standalone environment they provide information; in an integrated environment they don’t. These small islands of information cause a lot of hiccups for the management.”||**||III|~||~||~|A big problem with healthcare management packages in the past has been that they promised, but could not deliver. “Healthcare organisations in the US have found they can spend an enormous amount of money, with very little to show for it,” said Edwards. “The term vapourware is becoming more and more common, and people are fed up with that, so healthcare organisations are developing metrics to hold vendors accountable for the quality and cost of their applications.”Dubai’s Welcare Hospital, a 100-bed private hospital, suffered from a management system that wasn’t suitable for the job, according to Shiraz Marzook, Welcare’s IT Manager. When he started at the hospital, the existing system had broken down so far that hospital’s accounts department had resorted to manual accounting — despite the fact that the package was mainly supposed to handle patient billing information. “They had actually computerised some of the departments like patient registration, appointments, pharmacies and certain segments for billing,” he said. “[But] the product was more billing oriented, for the doctors there was no benefit of the system, it was just catching information to bill the patient.”In order to solve the hospital’s accounting problems, Marzook prioritised the roll out of an ERP solution to handle the back office, financials and stores of the hospital, making sure that the application would be able to talk to any healthcare systems that might be put in place later. The hospital rolled out the new ERP package, Sun Financial from Sun Union, in January, and user requirements have been assessed for a hospital management system, but it will take time and effort for Marzook and his team to put it in place. “We have to face that the hospital is not willing to embark on a huge budget — the priority [of the hospital management] is on the patient side. We will need a hospital package, and that hospital package and Sun’s system should talk, so we are going to have to build up the interfaces. First we had to get the finance package, now we have to get the hospital management system, then add further systems.”||**||IV|~||~||~|Legacy systems have also been behind changes in public sector healthcare in Dubai. The Department of Health & Medical Services (DOHMS) of the Government of Dubai, launched a complete overhaul of its systems when it discovered in 1998 that the IBM mainframe that ran its patient management system was not Y2K compliant. DOHMS is responsible for four hospitals in Dubai, six community health centres and twenty clinics, handling 70,000 patient admissions and 900,000 general clinic visits every year. “The initial project was a strategic decision by DOHMS to look to the future and to invest in information technology, and to replace the non-compliant technology,” explained Sina Khoory, director of IT for DOHMS. “Then the DOHMS management had another vision, to go for a comprehensive integrated information system that will serve the strategic future needs of the department. We want the information to be a strategic tool to make smarter decisions in the future.”Considering that the system would have to serve an estimated 6000 users, the first thing to do was to establish user requirements. One of the main problems with integrated healthcare information management systems is catering for the requirements of diverse, highly specialised clinical departments. To make sure that the final tender would provide a system that would fit all of the departments, DOHMS created a series of user groups and embarked on an “extensive and lengthy” consultation process to assess requirements, said Khoory.The project faced another hurdle — convincing the users of the benefits of the system. Khoory explained: “Most of the doctors, especially the senior doctors, expressed directly to me that they were not in a position, after all these years of serving the medical sector, to go and learn about computers. These are very politically powerful individuals within our organisation, they are highly educated, and very senior in their positions and their sciences — they have to be treated differently to normal staff.”Khoory used a little psychology to win over the senior medical staff. First, IT training centres were established in each of the DOHMS hospitals, staffed by professional IT trainers. Then the staff were all offered free IT training. As the senior staff saw their juniors participating in the programme and gaining qualifications, they began to ask why they weren’t involved, until the senior staff themselves were approaching the IT department for training. Khoory then set up separate training courses for the senior management. Today he says that those who expressed doubts are now happy using the full range of office automation applications. “We created an environment where they came to us to take the training, but with their rules — and we respect their requirements,” he said.Work began with the installation of a new network in mid-1998. The existing serial links that had connected to the mainframe were replaced with a WAN and a LAN. Etisalat acts as the carrier for the WAN, with ATM fastlinks connecting the hospitals, and frame relay links to handle the traffic from the health centres and clinics. Cisco active components completed the set-up, and from the roll-out in June of 1999, 960 users have been added to the network.The contract for the integrated healthcare information system was awarded to Shared Medical Systems (SMS), operating in the region as part of the Kuwaiti Al Babtain Trading Establishment in 1999. SMS would provide the core systems and modules over a four year, three phase project. After some delays due to the Y2K problem, and the purchase of SMS by Siemens in May 2000, phase one, consisting of patient management modules, financial and ERP elements of the system was completed in January. The IBM mainframe has been replaced by four Compaq Alpha servers, one primary and one backup for the health information system, one handling the Oracle financials and another for the pharmacy system.The next phase will see the introduction of laboratory and radiology information systems, followed by theatre and nursing management in phase three. The whole project is due for completion in 2003.Future projects for DOHMS include establishing computerised patient records and a move into e-procurement. E-procurement is one of the areas where healthcare organisations are looking to make savings — with most of their materials sourced from specialist international markets, partiularly pharmaceuticals, online purchasing could provide cost benefits.The implementation of a package that integrates financials, inventory and purchasing modules with the healthcare systems puts DOHMS in a much better position to leverage accounting benefits said Khoory. “Usually organisations concentrate on the healthcare modules, but we had a broader vision that we needed to integrate the financial side also,” he explained. “In the future we will have an easy tool to do proper cost accounting, activity based accounting and so on. By setting up the Oracle financials, a fully fledged ERP we are in a good position to connect to tejari.com, to place orders electronically.”Alongside the benefits to doctors and patients provided by more efficient healthcare management, the sector, just like any other, is looking to get a return on investment from its IT.||**||V|~||~||~|The advent of the Internet has spurred a number of developments in medicine. On the consumer side, the popularity of sites such as HealthAnswers.com, WebMD.com and tashafi.com, that provide general medical information online, is creating a patient base that is more aware of medical procedures. This is both a help and a hindrance, according to Jonathan Edwards of Gartner Group.“People have far more access to medical information than they ever did in the past through the Internet. They can now be more informed on their medical condition than their doctors might be — so they are far more demanding,” he said. “Then there is the vast number of people with substandard medical care throughout the world. IT here can be of help in giving consumers medical information that hlps them prevent illnesses and manage illnesses effectively, without costly medical intervention.”Access to information is also driving initiatives in private healthcare. The Welcare Hospital in Dubai is one of several to have its own web site, and the hospital wants to extend appointment booking and other administrative capabilities to the web.Probably the most advanced use of Internet, however, is in the field of telemedicine — using web and video cameras to allow doctors to consult one another, examine patients and even perform medical procedures via the web. Surgical robots, such as the Zeus system from Computer Motion, who recently set up a regional office in Dubai, are making remote surgery a reality.Telemedicine is an area where the Gulf leads the world, according to Chuck Grieve of Middle East Health Magazine. “Saudi Arabia has been making huge strides in telemedicine, he said. “Virtually all of the major teaching hospitals in the States have telemedicine links with Saudi Arabia and the rest of the Gulf, and you have people like Apollo Telemedicine linking teaching to hospitals in India.”King Faisal Specialist Hospital in Riyadh has been recognised by the World Health Organisation (WHO) as a major telemedicine centre. In part, the growth of telemedicine in the Gulf is due to a familiar problem — skills shortages. “There is a lack of specialists,” said Grieve. “It is not a lack of expertise — relative to the rest of the world, this region is well doctored, but we have a tiny population, and the specialist specialists, the ones who are involved in breakthrough medicine are mainly stationed abroad.”However, the growth of telemedicine may well be hindered by another familiar problem — lack of infrastructure. CSS, along with Intel, Oracle and Yale University took part in a telemedicine demonstration organised by the WHO in 1997. “We expect [telemedicine] to become a key thing in future,” said NV Ravikumar, director of operations at CSS. “From a technology and integration point we are ready, but from a practical viewpoint there are other considerations in terms of the network backbone and infrastructure. The non-availability of these has not made telemedicine popular everywhere.”||**||