Better IT Will Improve Health Care

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Open letter to Dr Richard Kamwi, Minister of Health and Social Services: Let me first start the purpose of my open letter by congratulating you on your marvelous achievement in obtaining a Doctorate Degree specializing in Malariology. In this letter, I want to bring certain facts to your attention regarding the use of information technology in improving the healthcare and to increase access to care for all our people. While many countries are implementing information technology to improve the healthcare of its people, it seems to me we are not making improvements and seem to fall behind some African countries like Botswana, Rwanda, and some others, who are computerising their hospitals and health facilities. We Namibians seem to boast a lot but even in areas like providing electricity other African countries are overtaking us. For instance, we have been talking about the Kudu gas project for the last twenty years but nothing has been achieved (even the concept about the Kudu gas was misplaced, for example, recoup the investment). We seem to have developed an appetite for importing products and services. But I believe the great revolution in the use of information technology in healthcare can be achieved in your ministry, and if we take the initiative and support the project described in this open letter we can surpass all the African countries including Botswana during the next four years. The purpose of this open letter is to raise awareness and encourage the Ministry of Health and the Government to implement a supporting information system to assist in providing better health care for Namibians. Today, there is a mix of manual and some automated systems (for example the health information system) in government hospitals. In areas where information systems exist, they tend to be department-based and are not interlinked, making it difficult to share information within the hospitals, and with other hospitals across the nation. Once implemented country-wide, the new integrated information system provided by the HealthONE Hospital Information System (HIS) will enable the secure sharing of pertinent patient information within and between government hospitals and health facilities. All of our 35 hospitals should be connected with the HealthONE HIS for the sharing of pertinent health information. Patients, administrators, health professionals and the public will all benefit from the information system. We have sufficient evidence to state that computer-based patient records can substantially improve patient care, outcomes, and costs. Yet to date we do not have the national commitment to assure that Namibians will reap the benefits of this technology. Because the majority of government hospitals and health facilities lack comprehensive supporting information systems, this creates great challenges in providing timely clinical information to clinicians and patients. In addition, the systems that are in place today have limited capability to share information with other health facilities, resulting in repetitive data entry, unnecessary wait times for test results, and limited reporting capabilities for administrators to base strategic decisions upon. Ultimately, the overall reason for the HealthONE HIS project is to assist in providing better health care for Namibians. Hospital Information Management System We designed, implemented, and maintain the patient and hospital information management system at the Windhoek Central Hospital. Initially, this system started as a billing system to bill in-patients and outpatients admissions to the Windhoek Central Hospital. The system has proven to be extremely reliable and has earned the hospital millions in revenue since its implementation three years ago. For instance, last November a cheque of almost four million was received from PSEMAS account holders. This week we submitted claims worth more than 2.5 million. This system, trading as HealthONE, is being continuously improved and expanded. An integrated General Ledger system has been designed and we just completed this module, and during the next three months old transactions will be migrated and posted, in order to produce the financial statements, including the Trial Balance, Income Statement, Balance Sheet, and so forth. As you can imagine, this involves a lot of work. HealthONE GL accounts contain up to 20 characters. We reviewed the GL structure of other accounting systems, including Oracle Financials, Navision, Pastel, and Sage Accounting. The stock control and materials management will also be designed and implemented before the closing of this year. The basis of the HealthONE HIS system is based on the master patient index, and comprises many modules, which integrate with the patient demographic data and with each other. Patient invoices are posted after they are printed. There is no need to go through protracted month-end processes in order to update the financial and management accounts. Once the stock control and materials management modules are completed, a pharmacist can dispense to a patient or make issues to a ward and both the stock and patient and departmental accounts are automatically updated at the time of dispensing. The system will use international coding standards (ICD10, ICPC). Procedure and diagnosis codes are maintained, and codes are linked to certain procedures and tariffs. By the second half of 2007 we shall complete ICD10 and ICPC coding. Currently, data is captured into the HealthONE HIS system from patient files. The patient file serves as the main access point to the HealthONE HIS electronic medical record (EMR). This will give medical staff instant access to all present and past medical history for both inpatient and outpatient visits. It will allow radiology, laboratory and pharmacy orders to be created and supports access to laboratory, cardiology and radiology results, pharmacy information, clinic sessions, vital signs, allergies, medical and family history and any previously scanned documents. Thus over the next three years, the HealthONE HIS system will provide comprehensive patient medical records. Medical Records Important Medical records are very important. They are written collection of information about a patient’s health care and are essential for his or her present and future care. Information contained in medical records is also used for the management and planning of health care facilities and services: for medical research and the production of health care statistics. Doctors, nurses and other health care professionals write in medical records so that they can use the information again when the patient comes back to the hospital or health care center. It is the job of medical record workers to make sure that the medical record is available for health care personnel when the patient returns to the health care facility. If the medical record is not available then the patient may suffer, due to lack of previous information, which could be vital for their continuing care. In Namibian government hospitals and health facilities (clinics, health centers) medical records are compiled in patient files, but these files are rarely consulted when the same patient revisits the health facility, resulting in some cases mis-diagnosing the patient, which leads to medical errors. The HealthONE HIS system is being designed to be robust, fast, and to fully meet the requirements of the Ministry of Health and Social Services. During the planning and design of this superior system, we impressed on the management team of the Windhoek Central Hospital that we are not holding them hostage to an inferior system, while peradventure somewhere in the world a superior system exists. HealthONE is a feature-rich and complete patient and hospital management system designed to assist with the management of hospitals and clinics. The system utilizes the Microsoft SQL Server database management system as its data store. It can handle thousands of concurrent connections over the Internet and has virtually unlimited data storage capability on appropriate hardware. On appropriate hardware the system can support all the hospitals and health facilities in the whole of Africa. The HealthONE system is designed following the latest trends in software design. We took clues from virus software and instant messaging applications to build a scalable and high performance multi-tier system that works seamlessly over the Internet. There are two models, in my opinion, to providing distributed information systems to regional offices or cost centers. One is to allow distributed systems to communicate seamlessly over the Internet using XML over HTTP. These systems require careful design and years of programming expertise otherwise performance will be compromised. The other model, as can be seen by the IFMS of the Ministry of Finance (a system that costs over 70 million and is supported by dozens of support staff) is to connect each of the regional offices to the remote server through a dedicated Telecom leased line. We eschewed the IFMS model in favour of the Virtual Private Network model provided by Internet Service Providers. We shall beat the IFMS system in terms of robustness, performance, simplicity of the architecture, ease of installation and maintenance. As computer programming is an empirical science, we do not have to argue endlessly about this. Give us time until the end of 2008 and let us conduct some empirical tests of the two systems. The IFMS system cannot claim to be more complex than our HealthONE HIS system. Hospital Information Systems are some of the most complex systems available today. Normally they contain more modules and complexity than a financial and accounting system like the IFMS system. To link a remote health facility, say in Omuthiya or Kongo, would require the facility to establish a dedicated connection to the ISP’s closest point of presence. ISPs like UUNET have points of presence in more than ten sites scattered throughout the country. When we have the financial wherewithal we need, we can install the HealthONE HIS client at the honorable Minister’s home (and selected members of Cabinet), and the Minister can verify for yourself about the performance and features of the system from the comfort of his home by logging into the HealthONE HIS central site. Implemented and Phased In The HealthONE HIS system can be implemented in a phased approach over the next four years. The system will capture patient administration and clinical information from government hospitals and other health facilities. Before the end of this year we shall complete the inventory and document imaging modules and by the second half of 2007 we shall complete the ICD10 and ICPC coding. Towards the end of 2007 the Ministry must start raising awareness, consultations, and training of doctors to start coding using ICD10 and ICPC and by the end of 2008 (or during 2009) coding using ICD10 and ICPC must become mandatory in state health facilities. During the next three to four months, the Ministry should procure a server (about 35,000 to 45,000 Namibian Dollars), upgrade the server room, procure at least 3 PCs for the admissions office at WCH and upgrade the LAN. Before the end of this year the maternity ward and Katutura State Hospital should be brought online and linked to the central site. We are working extremely hard on this project and we are competing against the best Hospital Information Systems in the world – please have no doubt that we shall deliver the best system available anywhere. Presently we are receiving N$3 500 every month for the maintenance of the system (which also includes network and database administration and user support). We had pointed out to the management of the WCH that this amount is inadequate and should be raised to at least 12,000 or 18,000 this year. We think everybody agrees with this but there is so much delay and bureaucracy to raise the maintenance fee. We are therefore requesting your assistance and support to hasten this process. To make up for the shortfall, I am driving my car as a taxi and this is taking a heavy tall on the development of the system. For example, the General Ledger that we just completed now should have been completed about six months ago. I am also requesting your assistance for the maintenance fee to be paid once per year. We need a lot of financial resources. There are a couple of components we need to acquire (imaging, document management, appointment scheduling, report writer, upgrading the Integrated Development Environment software we are using, establish a dedicated internet presence, acquire two more computers). The earlier figure I submitted of 12,000 also seems to be inadequate and I think the most suitable maintenance fee for this complex system should be 18,000, which should be paid once per year. Please help us to speedily resolve this issue. Why can’t we do certain things better than developed countries? We are convinced that we can produce a Hospital Information System that can just be as good as the best systems anywhere in the world, but at far cheaper cost, and which can outperform any system on the market. We would like the honorable Minister to verify this fact as we rapidly continue to develop the system. Finally, I am inviting organisations and companies who would like to be promoted on the HealthONE HIS system. The HealthONE User Guide is completed and contains a section “Sponsors” for organisations to place a half page containing information about the organisation, address, telephone, web site address, contact information, etc. The User Guide is an online Help file and is also available as a PDF file. It is well written and is comprehensive. Promotion of your organisation on the HealthONE HIS system will help us to develop the system. Manfredt Kavetu Founder of PlanetSoft Software Corporation of Namibia Windhoek