CLINICAL TRANSFORMATION BY EHR IMPLEMENTATION

1. CLINICAL TRANSFORMATION BY EHR IMPLEMENTATION Submitted by DINESH JHAWAR (HealthIT) 2011 Submitted to Professor- INDRAJEET BHATTACHARYA

2. LAYOUT OF MY STUDY • PROFILE OF THE HOSPITAL. • CLINICAL TRANSFORMATION.( Intro). • OBJECTIVE OF THE STUDY. • METHODOLOGY. • OVERVIEW OF HIS and VISTA. • CHANGE IN WORKFLOW AFTER EHR IMPLEMENTATION. • SURVEY and TRAINING. • ROLE OF CHANGE MANAGEMENT. • FINDINGS. • CONCLUSIONS. • RECOMMENDATIONS. • LIMITATIONS OF MY STUDY. • CASE STUDY

3. Founded in 1985, Max India Ltd. is a Public Limited company listed on the NSE and BSE of India with over 30,000 shareholders. Max India Limited is a multi-business corporate entity driven by the spirit of enterprise with a focus on people and service oriented businesses. 

4. MAX OVERVIEW • Max Super Specialty Hospital (MSSH) is a multi-specialty hospital, owned and operated by Max Healthcare Institute Limited (MHIL). • Infrastructure - Max Super Specialty Hospital, Saket is ideally located in South Delhi, approximately 10 kilometers from the airport. It is easily accessible from all the satellite townships of Delhi, NCR. • Services & Facilities - The hospital is designed to provide highest levels of professional expertise and world class care in all major medical disciplines and support specialties. • With over 930 Beds and 8 hospitals in Delhi, over 1500 physicians and 3500 support staff Max Healthcare is one of leading chain of hospitals in India. The state of the art infrastructure is one of the best in Delhi, over 275 ICU beds & most advanced technologies makes it one of the best hospitals in India.

5. Max Overview……… BRANCHES DEPARTMENT Max Heart & Vascular Institute Max Cancer Centre Max Institute of Minimal Access, Metabolic & Bariatric Surgery Max Institute of Neurosciences Max Institute of Orthopedics & Joint Replacement Surgery Max Institute of Obstetrics and Gynecology Max Institute of Pediatrics Max Institute of Aesthetic & Reconstructive Surgery Max Eye Care Max Dental Care Department of Endocrinology, Diabetes and Obesity Department of ENT Department of Mental Health & Behavioral Sciences . Department of Physiotherapy & Rehabilitation Department of Nuclear Medicine Department of Lab Medicine and Transfusion Services Allied Specialties • Max Super Specialty Hospital (A unit of Devki Devi Foundation), Saket • Max Super Specialty Hospital, Saket • Max Super Specialty Hospital, Patparganj • Max Hospital - Pitampura • Max Hospital - Noida • Max Med centre - Panchsheel Park • Max Specialty Centre - Panchsheel Park • Max Hospital - Gurgaon

6. CLINICAL TRANSFORMATION (Introduction) • The healthcare industry is in the process of transforming itself using technology. • These transformation efforts focus on moving from manual processes, often based on historical practices, to technology‐enabled or even automated processes. • The overall effort involved in such a transformation creates a tremendous amount of disruption to all aspects of the organization,

7. OBJECTIVE OF THE STUDY • TO Study the effect of ongoing EHR implementation on the people and workflow processes. • Training. • Role of Change Management in adapting changes.

8. METHODOLOGY • Study Design: The study is a before –and-after, Prospective in nature which includes collection of primary and secondary data. The primary data was collected from survey and interviewing (patients, clinicians and nurses).Convenient sampling method was applied for Clinicians whereas Quota and Purposive sampling technique was applied for Nurses. Whereas Secondary data was collected by participating in training sessions, databases provided by the organization, various books, articles and websites.

9. METHODOLOGY………

10. DATA and METHODS

11. HIS HOME PAGE

12. ABOUT HIS • Hospital Information software is developed by Max Healthcare primarily for billing, material management, Patient registration and bed management. • It also helps in ordering Lab tests, radiology tests and pharmacy orders, acknowledging/issuing drugs and consumables, thereby stock management and billing. It also helps in result generation. • HIS is robust enough for changing healthcare needs scalable (i.e., same software can be implemented if new branches are opened).

13. ABOUT HIS……… • FEATURES: Since its home-grown software, it fulfills the business need of max healthcare and user friendly, well accepted by different group of users. • LIMITATIONS: It doesn’t create a complete comprehensive patient record since healthcare is dynamic and complex and also to make it a world-class, development in HIS was far more difficult than adopting time-tested medical record software (EHR) which is scalable, accepted by healthcare user, medical and Para-medical staff

14. VISTA

15. ABOUT VISTA EHR • FEATURES: It’s a public domain software available through the freedom of info act directly from the VA website or through growing network of distributors. The vista software alliance is a new profit trade organization that promote the wide spread adoption of versions of vista for a variety of provider environment. It’s a collection of about 100 integrated software modules. Some of the modules included in vista which enables the users with number of advantages are: • World vista EHR features include core vista function such as: • Patient registration. • Clinical reminders for chronic disease management. • Clinical order entry. • Progress notes template. • Results reporting

16. VISTA…….. Now, vista which is being implemented in MAX healthcare needs to be integrated to the following three for smooth functioning. • Max home HIS. • Lab Analyzers. •  PACS (by G.E) • The middleware platform which is being used for the integration of VistA with the existing Max HIS is MIRTH.(An integration engine software which moves data between two information systems. • This process involves the transportation of data between messaging standards and requires support for multiple transmission protocols

17. AESSIS

18. GAP ANALYSIS • Following are the problem areas observed in the existing workflow of the client’s hospital: • High degree of patient’s documentation involved. • Duplication of work at different levels. • Patient documents handled by a number of individuals. • A lot of manual operation involve. • Orders sent manually.

19. FUTURE STAT WORKFLOW

20. FEW CHANGES

21. BENEFIT REALIZATION AFTER EHR IMPLEMENTATION: • Indirect patient care would be at a much faster rate. • Manual steps would be reduced. • Computerized patient info will now be available across the max healthcare facilities for physicians, specialists and surgeons. • Patient records will be accessible in their entirety from any max healthcare location where you have access to computer. • Patient record will be comprehensive and current. • Avg. length of stay for a patient in a hospital would decrease or patient care would be at a faster rate or improvement in patient care. • TPA claim denials would reduce.(with improved documentation) • Improved patient experiences in hospitals. • Increased Nursing efficiency. • Work duplication wouldn’t occur. • Confidentiality of patient record would be maintained. • Reduced medication errors.(alerts for doctors which is inbuilt in vista)

22. TRAINING OF CLINICIANS AND NURSES • Trainers were identified from among the department, a mix of clinicians, technical and non technical staffs were identified based on their interest. • Training skill development workshops followed by evaluation was done by the Max Learning and development team to create a team of capable trainer. • Role based training curriculum is prepared. • Training rooms with computer Labs is made available with all required infrastructure . • Training calendar is prepared without disrupting daily operation. • New process orientation sessions are conducted by the Clinical Transformation team for Trainers. • Training supervisors are made available during each training session for supervision and support during end user training.

23. METHODS OF DATA COLLECTION • Out of the 50-60 doctors trained, survey was conducted or sample was taken as 21 and for Nurses the sample size was 25. • The Questionnaire was divided into two parts- General Questions (Yes-No Type and on Likert Scale). • The Questions were based on their General Understanding of the EHR and its various aspects like their enthusiasm . • No. of Questions for Clinicians - 38. • No.of Questions for Nurses - 32. • Deliberately, Slightly Technical Questions were not included for the nurses.

25. WORKFLOW PROCESS

26. TECHNOLOGY EVALUATION

27. TRAINING/SUPPORT

28. BUSSINESS GOALS

29. COMMUNICATION/PERCEPTION FOR EHR

30. PATIENT ORIENTATION

31. SURVEY ANALYSIS • The survey was completed in nearly 15-20 days. It included designing of Questionnaire, Interviewing Nurses and Physicians, Distributing Questionnaires and Finally Analyzing and interpreting results by using SPSS software. • The results were thoroughly analyzed and interpreted and the results for the EHR implementation were positive and encouraging. • The medical and nursing staffs were mostly willing and enthusiastic about the EHR implementation. They understand, how it can bring overall improvement in patient-care by process redesign. Hence, the successful implementation of the new system can help the organization to achieve its long term goals. • There were initially hiccups regarding few features, of using the new system in place but the problems are being identified and no stone is left unturned or steps are being taken from the organization to make it more customized and user friendly.

32. CHNGE MNGEMNT • Change Management Is an Integral Part of a Clinical Transformation Initiative • (It comprises 80% of the project time and remaining 20% only for technical). • Successful transformation initiatives integrate change management techniques throughout the lifecycle of the initiative. • Change management is not something that the organization does as an afterthought; it is as important as system testing and training. • Change-management activities are directed at identifying and mitigating "people" risks associated with clinical and operational personnel's acceptance of new systems and their ability to use the new processes and technology. In the end when this occurs, clinical transformation is deemed successful. • Change Management Never Ceases

33. COMPONENTS OF C.M

34. ROLE OF CHANGE MANAGEMENT AT MAX • Weekly Change manager meeting. • Workout plan from different department. • Scheduling department activity. • Process gap identification.

35. GENERAL FINDINGS OR CHALLENGES FACED BY MAX • Doctors were willing an enthusiastic about the EHR but they wanted it to be more user friendly. According to them it takes more time to fill the templates. • Since huge number of people were to be trained, there were no sufficient rooms . They had to temporary arrange in Day-Care centre. • People mostly failed to turn-up for training on the scheduled time and date. • They complained that they generally tends to forget, so repeated number of training sessions were sometimes burden of resources.

36. CONCLUSIONS AND DISCUSSIONS • The planning and implementation of new clinical systems has a significant impact on the entire organization – not only from a technology standpoint, but from patient, staff, and process perspectives as well. So in order to create the synergies among people, processes, and technologies to drive the transformation required to advance healthcare goals. • Following needs to be done: • Integrate key transformation enablers: employ a holistic approach. • Identify the drivers: understand the environment. • Realizing maximum effectiveness: execute the transformation.

37. RECOMMENDATIONS • Making templates more user friendly by customizing it. • Video-recording of training should be done. (Availability training at Asynchronous mode or training on demand) • FAQ/Q&A sessions on the weekly meetings. • Hands -on –practice and also provide them with web-based portal (LMS). • Communicate benefit realizations to the end users. • Dedicated IT support.

38. LIMITATIONS OF MY STUDY • Rights to use HIS and VistA not granted due to the policies of the organization. • Some people involved with the project were not approachable. ( might be due to their busy schedule). • Doctors on large-scale couldn’t be involved in the survey, since many were yet to undergo training. • Time duration of the study wasn’t sufficient.

39. CASE STUDY INTERNATIONAL PATIENT SERVICES

40. INTRODUCTION • Medical tourism in India is a rapidly growing opportunity for people to recover themselves as well as discover the rich heritage of India. • Medical Tourism is defined as a ‘cost effective’ personal healthcare treatment with the association of the tourism industry for patients needing surgical as well as other specialized treatments. This concept is being developed both by the corporate sector involved in healthcare and the tourism industry.

41. METHODOLOGY: It’s an observational study based on analysis of secondary data, interviewing IPS team and FGD’s with foreign patients. • OBJECTIVE: International Patient Services is the major source of business and revenue for corporate hospitals like Max. So, need was felt to study the overall functioning of the department.

42. OBSERVATION • Max Healthcare has a department dedicated to international patient services which takes care of all healthcare and related requirements of patients and their attendants travelling to India. Max’s Services include: • Travel arrangements • Accommodation arrangements. • Single window of contact. • Interpreter services. • Query Resolution (including tele -consultation). • Value Added Services.

43. OVERVIEW OF THE DEPARTMENT • This department comprises of dedicated team of 8-9 members- Head of the department, Manager, Assistant Manager, Interpreters and other team members. • Their role is in day-today Operations and Marketing. • Marketing: • Consultants and facilitators abroad. • Tie-ups with Ministries of countries. • Tie-ups with Medical Tourism companies • Tie-up with International Insurance companies • Up gradation of Website • Organizing Medical camps and CMEs in overseas

44. CONTD…. • Operations: • Care of the patient from admission to discharge. • Arrangement of Medical Visas. • Priority given 24*7 to them through their operation executives and team member. • Interpreter services. • Co-ordination with doctors, staff nurse, front office, billing and other departments of the hospital • To respond to patient queries received through website, Healthcare facilitators and Medical Tourism Companies. • To provide assistance in searching accommodation for patients and their companion

45. INTERNATIONAL PATIENTS • Patient’s categories   • Referred by Medical Tourism Companies. • Referred by International Insurance Companies. • Through local Healthcare facilitators. • Through website. • Direct patients. • Walk-in s. • If Patient comes through agent or government sponsored of that country, then he sends his all details online which is checked, scheduling and appointment is fixed and then on arrival, he is guided appropriately and the treatment starts.

46. INTERNATIONAL PATIENTS

47. SPECIALITY WISE CLASSIFICATION of FOREIGN PATIENTS:

48. FINDINGS • The interpretation and analysis of secondary data shows that: • Patients are primarily from SAARC and Middle East countries for Cardiac, Oncology followed by orthopedic surgery are most common among others. • On Interviewing, few International patients, it was also found that they have preferred Max Hospital due to affordable Cost ,quality of care and the hospitality of the organization.

49. RECOMMENDATIONS • Elimination of India’s poor image among the patients of developed countries. • To increase doctor-patient ratio. • Max Healthcare should establish in house currency exchange. • Assist them in extension of Visas in case they have to stay longer. • To focus towards, developed countries also by proper marketing and establishing tie-ups with local healthcare providers and government.

50. REFERENCES • BOOKS and JOURNALS: • Cusack CM: Electronic health records and electronic prescribing: promise and pitfalls. Obstetric Gynecol Clin North Am. 2008 Mar;35(1):63-79, ix. Review.PMID: 18319129 • Implementing an Electronic Health Record System (Health Informatics) by James M. Walker, Eric J. Bieber, Frank Richards, and Sandra Buckley (Paperback - June 28, 2006) • Electronic Health Records, Second Edition by Jerome Carter (Paperback - Mar. 15, 2008) • Smith M, Dang D, Lee J: E-prescribing: clinical implications for patients with diabetes. J Diabetes Sci Technol. 2009 Sep 1;3(5):1215-8.PMID: 20144439 [Pub Med - indexed for MEDLINE].  • EHR Implementation: A Step-by-Step Guide for the Medical Practice (American Medical Association) by Carolyn P. Hartley, Edward D. Jones III, and Newt Gingrich (Paperback - Feb. 28, 2005)