Overall Best SME Project: Indian Spinal Injuries Center's Clinician Developed EMR

This EMR application developed with Powerbuilder & Sybase Adaptive Server Anywhere (ASA) easily replaces the manual task of picking out the appropriate fields from a 42 page Word template to provide a 4 page report. What used to take 30-90 minutes and lots of hassle in the past, is now done in less than 30 mins!

There have been many reasons for the lack of IT adoption in the healthcare segment. The blame for this is generally directed to the healthcare practitioner. However, in reality, the entire environment of the healthcare industry is the root cause.

Healthcare needs are complex, and so far no good application exists that can answer specific needs of different healthcare practitioners. Also, the practitioners generally want tried and tested systems, and are not willing to pay for upcoming innovative solutions, in which a certain level of trial and error would be involved. Let's not forget that the core competency of doctors are diagnosis and treatment, not data entry, which is necessary to maintain records of the patients. Hence understandably, doctors are not so inclined to learn how data is entered in an EMR that is complex in nature. Instead, they would prefer a system that makes their work easier and faster.

The basic problem for developers to come up with useful applications for the healthcare industry is the difficulty in understanding, because of the lack of a medical background, how the healthcare system works. For instance, there is a whole world of difference between an application that is useful for a doctor versus an application that is useful for the administration of the clinic/hospital. No wonder, the only healthcare applications that exist and are successful are those that are meant for administrative needs. The need of the hour though is a detailed patient diagnosis record keeping and retrieval system for the doctors.

The Story Behind

Prof. A N Malaviya, a senior Rheumatologist had since long been providing a meticulously prepared and detailed printed prescription to all his patients. This prescription was created by his trained secretary, who had to open a 42 page Word template (containing all possible information pertaining patients), and pick out the appropriate fields to provide a report of around 4 pages citing the case history, examinations and investigation reports, which were recorded separately -again using disease specific templates. Thus, each case sheet and report would take a minimum of 30 minutes if it was a patient revisiting; and this task would take upto 90 minutes if it was the patient's first visit.

All patients were extremely satisfied with the clinical results after visiting the doctor. What was proving to be a nightmare to the doctor and the staff though was tracing the case history of patients when they revisited or necessary information retrieval for publishing of papers. This resulted into a huge wait list of patients. As a policy, if an appointment for a patient exceeded three months, because of the lack of a robust medical record system, the patient was referred to some other clinic.

It is conceived and developed by a clinician and hence follows the exact workflow. When we had tried to ask other IT companies to develop such an application, their lack of a medical background made it difficult for us to make them understand the processes. Moreover, this self-developed application is comparatively inexpensive. Even now, any change that takes place worldwide on disease management standards are immediately available through the software. For instance, DAS28 (Disease Activity Scoring using 28 joints ) is calculated on every visit through the software, which immediately provides us the status of the disease and provides a direction on whether any treatment change is required. For instance, a recent change by an international group changed the reference points which decided whether a disease is “high activity” or “in remission”, etc are different from what was used in the past.

Secondly, since for us, the development and support of this application is not our main earning activity and more of a hobby, we are charging far lower than anyone else. This makes the application relatively affordable.

How many clinics are actually using this product?

The base product, Medic Aid has had around 150 sales over the last 10 years or so, with 40-50 % of users still using it. Rheum Aid —the version for Rheumatology is being used in five clinics —two of these are run by Prof Malaviya —one is a private clinic and other at Indian Spinal Injuries Centre, Delhi

How were you inspired to go for this project?

The initial inspiration for the software came to Prof Malaviya when he was in Kuwait, where the entire health system was computerized, even in the late 90s. After coming back to India, an elaborate system of using MS Word templates for keeping the patient records was initiated. This was similar to writing long clinical notes, a practice that is still prevalent in many hospitals including AIIMS. They scored in providing neat and detailed prescriptions.

Even though patients were extremely satisfied with their medical treatment; for the doctors however, there were 2 problems. One, long time taken for the tedious laborious data entry would limit the doctor to attend only about 6 patients per day. This meant a long waiting list, that could span to over 3 months for appointments. Dr Malaviya started seeing only very few specific patients and refusing the rest. Two, even after doing such detailed entries, getting the case history back for research output and further medical diagnosis called for manually scanning a huge load of text files.

When I joined the clinic, I suggested shifting data entry to a database. On completion of the project, this also reduced our data entry time to one third of what it used to take earlier. Similarly, the patients seen per day jumped to 15 — but we have consciously decreased that back a little, as our clinic time has now been consciously decreased from 8 hours to 5 ½ hours. This gives us more free time as well as time for research and academics.

The IT Implementation

The objective was to develop an EMR application which would provide easily searchable and retrievable patient records, reduce the data entry time, as well as provide good looking reports. The reports should match what was already provided to the patient and there should be no duplication of effort. Prof Malaviya teamed up with Dr S B Gogia, a plastic surgeon, to develop this application. Dr Gogia, who also happens to have a hobby of software development, drove the entire development stage. The key technologies used were Powerbuilder Version 9.03 and Sybase Adaptive Server Anywhere (ASA) 9.0 for the back end. It uses many standards like ICD10 coding (International Statistical Classification of Diseases and Related Health Problems, 10th Revision), single keystroke access, automated logs, user created templates (e.g. for prescriptions, radiology reports, operation notes etc), integrated disease status indicators, multi select dropdown lists, etc.

The Result

Even though the workflow and report generated was similar to the reports generated using the MS Word template earlier, the data entry time for first visit by a patient-the patient card, clinical details and prescription came down to less than 30 minutes. In case of revisits, data entry and retrieval used to go up to 90 minutes at times. This started getting cleared in 5-10 mins post implementation of this EMR system. As a result, the number of patients being attended rose by between 80-150%, with no deterioration in patient care. Needless to mention, the revenue has also improved as much.

Looking at the benefits raked by Prof Malaviya's clinic, they decided to implement this at the Indian Spinal Injuries Center, Delhi. Soon enough, this solution was in demand by fellow doctors. The total number of installations of this application done so far is over 150 clinics. The total cost of implementing the project during the development phase was Rs 2.5 Lac and the cost of software used was Rs 1 Lac. Since this low cost solution is priced at Rs 15,000 per installation per year, the costs incurred on its development were recovered in less than 6 months.