Kazan Inter-regional Center makes its choice

Technocracy is usually considered to be inhuman. However, if we remember all our experiences with medical facilities, we would often catch ourselves thinking that it could be reasonably good to entrust some work to heartless equipment. In that case there is a possibility we wouldn’t have to look for our registration card in an outpatient hospital for half an hour, or retell the background of our disease and passed treatment courses to every doctor, or remind about our allergic reactions on certain medications, etc. No doubt, doctors wish the same as they have to do too much inefficient routine work to the prejudice of their main duties. Medicine in Russia has been financed on leftovers for a long time already. When there is not enough money for necessities, information technologies are the last thing to be mentioned. But at present the country has finances and medical facilities are receiving more and more funding. The question is what is the best way to use the allocated money? If we think about using IT, impersonal stories about implementation of information technologies in different medical facilities could be quite useful.

One of such institutions is the Inter-regional Clinical-Diagnostic Center (ICDC) in Kazan. It is the only healthcare facility in the Republic of Tatarstan where advanced information technologies have been extensively implemented in daily clinical practice. It specializes in cardiovascular diseases, performing surgeries, which include cardiological and neurosurgical operations. 27,641 people underwent diagnostics and in-patient treatment there, 3,717 surgeries, including 1,257 heart and vessel operations and 262 brain and spinal cord operations, were performed in 2007. The ICDC staff consists of about 1,200 employees, which include not only doctors and medical personnel, but also staff of the financial service, nutrition service, pharmacy, administrative office, and vehicle fleet. All these auxiliary services and departments which perform the primary functions are managed by an integrated corporative system, which this article will focus on.

A hospital is quite a special enterprise, but an enterprise anyway. As any other enterprise, it has certain financial, physical and human resources, diagnostic, therapeutic, operating, reanimation and other equipment, which is a kind of an analogue of production machinery. All these resources need to be planned and registered. Nevertheless, it is quite obvious that planning methods used at a manufacturing venture won’t do in this case. As opposed to industrial products, all people are different; even upon availability of standard treatment methods (certain analogues of business processes) each patient requires an individual approach.

That’s why industrial ERP-systems, that most readers are familiar with, cannot be used at medical facilities without having undergone considerable modification. That was the ICDC management’s view on the issue at the time when they had to choose a management system. It turned out that among industrial ERP-systems there were no solutions which cover all the specifics of a medical facility quite fully. High prices of foreign products also were a constraining factor at that time. On the other hand, ordering a unique development which takes into account all requests of a client is quite an expensive move. Finally, the management opted for a special purpose medical information system which was developed by CIR company.

When making such a responsible decision, the customer must take into account a whole lot of factors and assess many risks. Along with scalability, convenient interface and availability of full and up-to-date references, issues concerning a life cycle of the implemented system must be taken into consideration. It happens that it might not accomplish the tasks as thoroughly as expected, or it might get out of date in ethical terms. Then the system has to be replaced. But there are also cases of some kind of voluntarism when a new executive comes to an institution and starts changing everything, including the hospital information system (HIS). As financing comes from the government budget, there are considerably less natural constraints which are typical for the commercial field. Such approach doesn’t guarantee efficient use of budget funds. In this context popular and well-circulating ERP-systems has one advantage – several successful implementations in the field can be demonstrated to an extremely fastidious executive to prove that the issue is not about the software product drawbacks. That’s why, as it seems, introducing examples of the HIS successful exploitation could be useful for the whole field of healthcare.

Developing the HIS in the ICDC started in 2000. Usually the financial outline is automated in the first place during implementation of traditional ERP-systems. In the case of the HIS the first stage was creating a subsystem of an electronic record of patients. It is one of the HIS front office block key elements. It stores patients’ biographical data, and also information about the blood type, the medications which are not recommended to this patient, history of diagnoses, registered symptoms, confirmed and unconfirmed diagnoses, conceptions of taken treatments, prescribed procedures and medications, data of laboratory tests and many other things. All these information is patient-specific and needs protection. At present the CIR system provides it by access control. Encryption technologies haven’t been facilitated yet, but they will be used in course of time.

The data collected in a patient’s medical record is also used in the back office block, which helps to manage work of a medical facility on the whole: to monitor dynamics of disease and patients’ recovery efficiently, analyze the so-called “narrow spots”, maintain sufficient supply of essential medications without exceeding the standard overplus amount and expiration dates, control the working hours and schedules of specialists, and optimize the medical facility’s work.

The important factor which significantly reduces effectiveness of investments in medicine is lack of a complex approach to technical re-equipment of medical facilities. Quite often the most up-to-date diagnostic and laboratory equipment is purchased, but due to the fact that the HIS is not well-integrated with it, doctors spend plenty of time on contacting relevant subdivisions and requesting test results. Naturally, the next stage of the ICDC automation was installation of a single purpose electronic archive General Electric Medical Systems, connecting medical diagnostic equipment to it, and organizing immediate access for diagnosticians. Visual images of printed documents created by different medical devices (ECG, chemotherapy, blood pressure monitors, respiratory function) and images generated by diagnostic equipment are stored in the archive. There are departments of roentgen, X-ray, ultrasound, radiologic diagnostics in the ICDC; tomography, angiography, and endoscopy equipment is used. As it supports the international DICOM (Digital Imaging and Communications in Medicine) standard, bilateral interoperation of the HIS and diagnostic equipment was realized (equipment receive lists of scheduled examinations and transfer diagnostic images to computer workstations of doctors). This is how tomographic scanners, ultrasound, angiography, X-ray devices, and a gamma-camera are connected.
Analogue devices of ultrasound, endoscopy, ophthalmoscopy, a thermovision camera are connected via a digitalization module and a DICOM-converter. The hospital also uses laboratory equipment which was integrated in collaboration with Altei company.

The archive of diagnostic examinations results is stored in the file system on the central server; all of them are directly attached to patients’ medical records. The ICDC local area network consists of approximately 500 personal computers, which are set up, for instance, at working places of doctors, who can access an electronic medical record and see an X-ray image, cardiogram, and other materials of this kind at any time. Development of the electronic archive began in 2001 and finished in 2002.

Implementation of financial accounting systems (based on 1C products), the vehicle fleet and the nutrition unit management systems was carried out after that. The ICDC is a public medical facility under the jurisdiction of the Republic of Tatarstan Healthcare Ministry. It offers most its services free of charge, but they are financed from different resources (the state budget, the fund of compulsory health insurance (CHI)). Some services are offered for a fee both from a patient’s own finances and on the basis of voluntary health insurance (VHI). All these impose certain requirements to the HIS system. The financing resource is specified for each service (state budget, CHI, extra-budgetary funds, VHI), the fact of service fulfillment and, when necessary, the fact of payment are registered. This gives the institution management and regulatory agencies an opportunity to receive all information on rendered services in terms of financial resources promptly. The cost of charged services must be specified; it is calculated based on a price list and discounts (for example, the second consultation with the same specialist costs twice cheaper if held within 10 days after the first one).

The subsystems of charged services records, and also pharmacy, personnel document flow and workflow management were implemented during the following three years. The specific character of medical workflow is determined both by availability of many regulatory enactments, mandatory forms and types of documents, and also strict requirements to executing documents of reporting, including sick-leave certificates. In the CIR system the document flow is carried out in electronic format which considerably simplifies daily life of the medical personnel. Nevertheless, due to well-known reasons, electronic documents are not legally valid in our country (at least in public-sector organizations) all legally relevant documents are executed on paper, endorsed and approved according to the standard procedure.

The CIR medical information system consists of two large subsystems – “Out-patient hospital” and “In-patient hospital”. They can be used both simultaneously in one medical facility and separately. The ICDC has both these subdivisions and CIR functionality is being facilitated in its full extent. CIR company has been this medical institution’s general contractor on implementing and developing the HIS since 2000.

According to words of the company’s vice-director Yekaterina Murga, so far over 80% of functionality of the information system, which has been implemented at the ICDC, has been realized on the basis of the CIR product. Some projects were realized in cooperation with other companies or were given to subcontractors. The following subsystems were implemented in the recent two years: subsystems which automate an integrated dispatch service, information desk, statistics management and reporting (in cooperation with the Republican Medical Informational-Analytical Center), budgeting (with ICL KME-CS company). A dispatch center for planning and maintenance of patient hospitalization is to be commissioned this year; it will constantly exchange information with other out-patient and in-patient hospitals of Kazan.

A significant part of the last project is integration of the ICDC system with HIS of external organizations. It’s not the first time CIR specialists face integration tasks: a medical facility cannot avoid using software products of different vendors; the ICDC only proves this statement. Integration tasks were tackled conjointly by specialists of CIR and the company which is involved in implementation of a certain product. From Yekaterina Murga’s point of view, such kind of works at the ICDC were accomplished quite fast and successfully thanks to availability of open software interfaces in the CIR system.

The ICDC automatic system of management, the main consultant of the hospital in IT questions, maintains technical support and contacts CIR company’s specialists when necessary. Besides, it supports the central robotized archive of diagnostic images General Electric Medical Systems. It is quite obvious that the better the system users are trained, the simpler the maintenance is. But CIR is convinced that along with staff training it is necessary to pay attention to improving accompanying documents and the interactive help system. Such approach benefits the whole medical facility: under the conditions of personnel turnover expenses on staff training may become a burden.

The example of the ICDC informatization demonstrates that the HIS market is quite promising at present. Development of the system began eight years ago and it is operating successfully; its functions are extended year by year. Positive results if implementing IT in such organizations as the ICDC will certainly become a landmark for majority of Russian medical facilities.


Published in PC Week Doctor №1 (1), March 2008