With a network of 22 hospitals and more than 2,500 beds, Fortis Healthcare is one of India’s leading chains of private hospitals. In July, the company reported its first time net profit of Rs 94 lakh for the quarter ended June 30, 2008.

The profits may look meager at the moment, but the scale of operations that the company is fortifying itself for is humongous: Forty is the number of hospitals that Fortis is targeting by the end of 2010.

In a scenario where healthcare is getting better and competitive, the role that technology plays cannot be overplayed. “One of the first things that my boss asked me was, ‘How will you cut the paperwork?’” says CIO Manish Gupta, who has been putting together several IT initiatives at Fortis’s sprawl of hospitals in order to take the entire organization to the next level of operational efficiency and success.

So the first thing Gupta did was to analyze the processes in different departments of the organization. “We found that there was a lot of unnecessary paperwork associated with routine procedures such as moving a patient to another room,” he says. Gupta suggested several changes to shorten or smoothen various procedures associated with patient care as well as internal operations of the company. He also put in place a print management system through which printing rights were prioritized or reserved only for those with the most pressing needs – such as for legal and compliance purposes.

Taking a cue from print management, the next step perhaps would be to put in place a document management system. However, Gupta is in favor of taking a cautious approach. Says he, “It may be easy to just go ahead and implement a DLM (document lifecycle management) solution but you have to figure out why you need a DLM.”

Such an analytical approach is critical to examining processes and implementing change in an organization that has grown through stitching together several mergers and acquisitions. Citing just one example of merging Escorts and Fortis systems, Gupta says, “Technically, the Escorts system and the Fortis system were on the same platform, but the teams were different, the culture was different and the behavior of people was different.”

An initiative that Gupta has undertaken in earnest is the integration of two separate Hospital Management Systems (HMSs) which, he says, “are fundamentally different.” One is a home-grown administrative system to ensure that the patients are properly admitted and discharged and the other is a world-class third-party clinical system called MedTrak (from TrakHealth, a subsidiary of Australia-based InterSystems Corp.). Apart from administration, clinical information such as blood pressure, temperature, type of allergy, etc. is also captured – what in healthcare parlance is called EPR or electronic patient record.

“All our new hospitals are running on MedTrak while the rest run the in-house Hospital Information System (HIS). One of the experiments we did last year was to migrate the HIS at one of our oldest hospitals, in Mohali, to MedTrak – including everyone from doctors and nurses to pharmacist,” says Gupta. The success of that experiment? “We are realizing that our hospitals are ready for world-class software.”

Putting the pieces together
A key change that Gupta has brought about is centralization of IT. “Unlike many other healthcare providers that have their software teams sitting at individual locations, we have a centralized team. So any change in software is seen and approved by the central team,” says Gupta.

As a hospital, we have to collect and keep all the information we get regarding the patients, says Gupta. Part of this information is in paper form, which goes to the medical records department, and part of it is fed into the computers. Fortis is trying to get all the paper-based information online. “The challenge is that there’s relatively much less information in our HIS than what exists on paper.”

There are several ways in which Gupta and his team are trying to increase the collection and conversion of information into the digital format. “One is I’m trying to sell the Tablet PC to our doctors. I’ve gone to them a few times, showing them how it works and how they can enter information into it conveniently and they are quite enthusiastic about it. Fortunately, doctors are a different kind of breed – they like to play with toys!” says Gupta. So he’s hoping some of the senior doctors will catch on with the Tablet PCs and then the younger ones will follow.

Another thing that IT is doing is that the moment new doctors join, it “catches them right there” – preventing them from getting into the paper culture. “So I ask my medical operations group team to expose them to HIS as soon as they join,” says Gupta.

“The third thing we are doing is putting data entry operators to digitize patient records,” says Gupta. After key entry, these records are verified by a doctor who’s specifically assigned for this task so that the final records are accurate. Gupta has also enlisted nurses as active participants in many of his initiatives, as they are IT’s biggest users and are directly responsible for administering the care to patients most of the time. Naturally, they have the best knowledge of patient needs and preferences.

Another challenge Fortis faces is that even though all the imaging data – generated through scores of X-Ray machines, MRI scanners, dopplers, etc. – is available in a digital format and gets recorded in a database, these machines do not talk to each other as they are from different manufacturers. “What we want to do is make all images on a patient available to the doctor in an integrated format,” says Gupta.

There’s a specialized solution called PACS or Picture Archival and Communication Server at Fortis hospitals, which pulls out images from all the machines, connects them to the patient and stores and retrieves them whenever the doctor wants. While bigger machines have their own database embedded, for X-ray machines there’s an in-house database application. What PACS does is aggregate images from this database as well as other machines’ databases. This is an off-the-shelf package and can be customized but the challenge, says Gupta, is to implement it in the right way. For instance, you need to look at the best way to make the huge bank of images available to doctors within the same hospital against sending out the images to others posted in different locations.

Until the complete centralization happens, what Fortis is doing is storing the images in local hospitals for about five to seven days or during the hospitalization of the patient – and then sending those images to a central location for storage, archival and later retrieval.

Managing complexity

So how does one manage complexity at a ragtag bunch of hospitals? One way, as Gupta has discovered, is to standardize the software and the development process. “Over the past one year, I’ve created a software change control team. Any hospital that requires a change in their software will have to go through this central team,” says Gupta. The advantage is that IT takes inputs from hospitals other than the ones that have requested a change. If most hospitals concur, then the team implements the change centrally across all hospitals. At the same time, if only one or two hospitals want to change, say, the check-out time for applying room rents, IT can do that as well. “Such a centralized mode of operation keeps our workload minimized and our tasks streamlined,” says Gupta.

Regarding the data center, Fortis has a small data center where it houses its mail server and some other applications, but the hospital systems are not yet centralized – they are still running in pockets. “So there’s a need for us to centralize our applications,” says Gupta. Currently, there’s a database at each hospital that pulls information in batch mode from various applications such as patient information and other high-level data.

Fortis is currently evaluating SAP as an enterprise-wide software. “Why we felt the need for an SAP is that we realized that each hospital was running its own set of financial and inventory software, and the existence of multiple software – many of which were old and outdated – was impeding our ability to centralize operations,” says Gupta.

“The business problem we face is how to match SAP’s inventory controls with the way we administer medicines using our HIS,” says Gupta. SAP is a very tightly controlled system: it will not allow the issue of an item from the inventory without completing all the validations (like batch number, rack number, location, etc). “However, in a real hospital environment, I cannot have so many controls because sometimes the system will not allow a medicine to be issued if some validation condition is not met; as a result, the patient may suffer,” says Gupta.

While SAP may work in a factory environment, there can be certain issues with how things work in a hospital setting. For instance, the pharmacist will give the medicine and think about the [SAP] system later. Thus, matching the exigencies of the HIS with the intricacies of ERP is a challenge that must be met if the whole system is to work smoothly.

Platform for knowledge-sharing

“Another initiative we are undertaking is to roll out our intranet using Microsoft SharePoint. The portal will have company-wide information for employees – information like medical records, paperless processes like leave and clearance forms, new hires and induction,” says Gupta. The company is also planning to have knowledge management through SharePoint, in which employee discussions can happen on the portal. “When I interacted with doctors I found that everybody is looking for recognition and research – for instance, publish their papers in journals. So the challenge is how do we do that, and are they [doctors] willing to share knowledge with each other?” says Gupta.

Having a creative bent of mind, Gupta is turned on rather than put off by challenges. Says he: “Healthcare is an emergency industry when it comes to facing patients and doctors. So you cannot drive a lot of things by systems here – it’s not a factory environment. You have to make things easy for people, for instance, by ensuring that the screens we give them are very user friendly and we are able to take care of their usage issues even through mobile calls.”

Another challenge before Fortis in its attempt to further rationalize cost and optimize resources is the way accounting and costing is done in the healthcare business. “In healthcare, it is very difficult to ensure accounting and costing,” says Gupta. “Unlike in, say, manufacturing, where there’s a defined assembly line procedure and I know that there are some components going into it, there’s electricity going into it...in our case when a patient comes in, there are two or three doctors and four-five nurses working on it, there’s room facilities, there are labs and other things involved…so it becomes difficult to assess and analyze our cost structure for different patients and different services we offer to them.”

In the midst of multiple challenges, Gupta is thinking ahead on what he’s going to do next. Among the things on the anvil at Fortis are an MPLS network; biometric authentication of patients; RFID implementation in select applications; and e-learning tools for doctors undergoing training.

Surely, as Fortis blazes the trail toward its ambitious goals in healthcare, Gupta will have a lot on his Tablet.

So how does one manage complexity at a ragtag bunch of hospitals? One way, as Gupta has discovered, is to standardize the software and the development process. “Over the past one year, I’ve created a software change control team. Any hospital that requires a change in their software will have to go through this central team,” says Gupta. The advantage is that IT takes inputs from hospitals other than the ones that have requested a change. If most hospitals concur, then the team implements the change centrally across all hospitals. At the same time, if only one or two hospitals want to change, say, the check-out time for applying room rents, IT can do that as well. “Such a centralized mode of operation keeps our workload minimized and our tasks streamlined,” says Gupta. “Another initiative we are undertaking is to roll out our intranet using Microsoft SharePoint. The portal will have company-wide information for employees – information like medical records, paperless processes like leave and clearance forms, new hires and induction,” says Gupta.

The company is also planning to have knowledge management through SharePoint, in which employee discussions can happen on the portal. “When I interacted with doctors I found that everybody is looking for recognition and research – for instance, publish their papers in journals. So the challenge is how do we do that, and are they [doctors] willing to share knowledge with each other?” says Gupta.