PGDHHM Project-A Study On Design & Implementation of Out-Patient Module of Hospital Information System

A project on
A Study on Design & Implementation of
Out-Patient Module of Hospital Information System
Submitted by
Dr Hrishikesh Arvind Kalgaonkar
Roll No. 17200253
Under the guidance of
Dr S. S. Deepak (MD Medicine)
Submitted to
Symbiosis Centre of Health Care (SCHC), PUNE
Submitted in partial fulfilment of the requirement for the award of
Post Graduate Diploma in Hospital & Healthcare Management
Batch 2017-18
A study on design and implementation of out-patient module of hospital information system Page 1
Student Declaration
I, Dr. Hrishikesh Arvind Kalgaonkar hereby declare that this project entitled, “A study on
design & implementation of out-patient module of hospital information system” at
“Deepak Hospital, Ahmednagar” in the partial fulfilment of the requirement of the award of
the “Post Graduate Diploma in Hospital & Healthcare Management” is my original
work.
The findings in this project are based on data collected by me and I have not copied from any
other student or any other source. This report has not been submitted by me elsewhere.
Dr. Hrishikesh Arvind Kalgaonkar
Roll No 17200253
Certificate from Project Guide
This is to certify that, the project ‘A Study on Design & Implementation of Out-patient
Module of Hospital Information System’ is an academic work done by Dr. Hrishikesh
Arvind Kalgaonkar submitted in the partial fulfilment of the requirement for the award of the
“Post Graduate Diploma in Hospital & Healthcare Management” at Deepak Hospital,
Ahmednagar under my supervision & guidance.
To the best of my knowledge and belief the data & information presented by him in the
project has not been submitted earlier.
His performance during this period was satisfactory. I wish all success in his future.
Dr. Deepak S. S. (MD Medicine)
Deepak Hospital, Ahmednagar
Acknowledgements
I take this opportunity to express my gratitude to everyone who supported me for the project.
I am thankful for their aspiring guidance, invaluably constructive criticism and friendly
advice during the project work. I am sincerely grateful to Mr Anil Bhawar, Mr Shivaji
Pulate, Dr Vishakha Saamb and All staff of Deepak Hospital for sharing their truthful and
illuminating views on a number of issues related to the project.
I express my warm thanks to my guide Dr. S.S. Deepak for his constant and timely support
and guidance during my project.
Dr. Hrishikesh Arvind Kalgaonkar
Roll No 17200253
Table of Contents
Introduction ………………………………………………………………..page 7
Objectives …………………………………………………………………..page 10
Literature Review …………………………………………………………..page 11
Methodology ……………………………………………………………….page 21
Results ……………………………………………………………………..page 29
Discussion ………………………………………………………………....page 33
Summary & Conclusion …………………………………………………..page 35
Recommendations ………………………………………………………...page 37
References …………………………………………………………………page 39
Introduction:
Background:
Gone are the days when doctors were considered as a part of the extended family and they
would prescribe/order some medicines on the go and the patients would follow those orders
with their eyes closed.
Today’s fast paced world and changed scenario of the doctor-patient relationship has thrown
up many challenges. The comparatively low percentage of doctors per thousand patients in
India doesn’t help the matters either.
Need for Hospital Information System and its correct implementation
Need for documentation:
The fortunate doctors of the past were treated like God and earned respect.
Commercialization and globalization in all spheres of life have not even spared the medical
profession as well. As a result, the doctor-patients relationship has deteriorated considerably.
Since the passing of the Consumer Protection Act in 1986, litigation against doctors is on the
rise. So the need for the documentation of the each and every process in the healthcare has
become a necessity. For a busy physician, to document everything manually and maintain the
records in paper format is very difficult. Also, the law requires maintaining the records for at
least 3 years. The medical records are considered as a legal document in the court of law, so
there is no bypassing for proper documentation. A good Hospital Information System can
solve these problems with easy access and storage capability.
Huge Data Generation:
In modern medicine, tremendous amount of information is being generated. All types of

patient parameters, various lab reports, radiology images, certificates, various government
and insurance related forms etc. add to the data amount. For a simple office physician,
keeping track of this kind of data is impossible. Data management definitely impairs
physician’s clinical work. Also, requirement of space for storage of this data has added to
financial constraints of the doctors. With IT solution, such as Hospital Information System,
huge amount of data can be stored and managed easily.
Necessity of skilled office secretarial staff:
As the doctor cannot manage the clinical work and the data management work alone, the
need for the secretarial office staff has increased. This staff must be skilled in entry, filing
and retrieving the data efficiently and quickly. This has become an additional burden for the
physicians. With the help of a good Hospital Management System hospitals can save
significant amount of money on non-clinical staff.
Need for quick access to information:
Nowadays doctors as well as patients need quick access to their records. In manual records
system, many times valuable time is lost for retrieving the old records. Also it is very difficult
for the doctors to send the patient records to another doctor in paper format. With
computerised information system, doctors and patients can quickly access their data.
Privacy & Integrity management:
The patient is the owner of his/her medical records while the hospitals/doctors act as the
custodian of the medical records. In paper format, invariably now and then the privacy and
integrity of the medical records are compromised. Electronic Medical Record system can be
the answer to this problem.
Need for accuracy:
The present healthcare system generates large amount of data and documenting it manually
can lead to some human errors. For example, writing down all the lab values of all the
patients manually can unintentionally lead to typing errors. Interfacing the lab equipment to
Hospital Information System can avoid such mistakes.
Reduced TAT:
Paper based systems are time consuming. A patient needs to obtain the prescription from the
doctor, carry it physically to the pharmacy and then purchase the medicines. With Hospital
Information system, the pharmacy gets the prescription via LAN/WAN and the patient
spends less time at the counter.
Data availability for research:
Paper based records are hard to sort, manage in a structured way. For a researcher, it is very
cumbersome to go through one thick file after another and analyze it. Electronic Medical
Record in Hospital Information system provides easy and quick access to researchers.
Statement:
In Indian scenario, HIS softwares are still a novelty. Availability of HIS with all modules
and their seamless integration is very limited. Additionally their cost prevents many doctors
from implementing them.
Also just buying HIS off the shelf is not the solution but effective implementation and
adoption to the EMR-EHR concept is also important.
Objective of Study:
This study aims to analyze the design and implementation of OPD module of HIS.
Its technical features, its user friendliness, its advantages and limitations will be studied.
Also though it is an observational study, a brief comparison of its features will be done with
the other products available in the market.
The implementation of the software will be studies in terms of technical terms, viz. its
hardware requirements, number of users etc.
The end users will be questioned about their experience of the HIS.
So the design and implementation of the software, both would be studied and the findings
shall be discussed.
The capabilities and limitations of the software shall be studied.
The final recommendations shall be based on the results of the findings.
Sources of Data:
Primary data: Information obtained from the original developer of the software, responses
from the end users, i.e. doctors, lab technicians, accountants and billing clerks and employees
at the reception desk. Also input from the maintenance department was sought.
Secondary data: Information about hospital information software, its historical evolution, its
features etc. were collected from various sources e.g. world wide web, literature available in
public domain. The references are given wherever such information is used.
Literature Review:
El Camino Hospital in San Francisco Bay area implemented HIS first in the world.
A paper by then administrator of the facility in 1984 stated,
“The 15-year experience at El Camino Hospital demonstrates the viability of comprehensive

computer information systems. Furthermore, it is widely recognized that computers will play
a significant role in the labor-intensive hospital industry throughout the 1980's. Decreasing
computer costs and increasing labor costs will lead hospitals to automate many functions. The
challenge for hospitals will not be identifying these functions for computer applications. The
real issue is how well prepared is hospital management to achieve the cost-savings and
quality enhancements that are inherent with computers.”
”There are four important lessons to be learned from this experience. First, nursing
understanding and support is critical. Nursing support can be used to overcome many
physician problems. Second, physician training is difficult at best, and a hospital should use
its best imagination in designing a physician training program. Other hospitals have learned
from the El Camino experience and have done commendable jobs in obtaining physician
understanding and support. Third, the difficulty of implementing an unproven system cannot
be underestimated, particularly when there are no role-models) to call upon. Fourth, a strong
and imaginative management team (i.e., Administration and Department Heads) is needed to
implement the complex change represented by the computer system.
Adoption of EHR: Global View
According to Transparency Market Research (TMR), the industry of healthcare is in the

middle of a ample move from paper based to digital based, which in turn will up-shoot the
enhancement of the EHR by 2021 worldwide. Globally Market of electronic health records
will be placed at US$25.98 billion in the year of 2020 as per report by a CAGR.
In USA, the 2009 Health Information Technology for Economic and Clinical Health
(HITECH) Act authorized incentive payments through Medicare and Medicaid to health care
providers that use certified electronic health record (EHR) systems to achieve specified
improvements in care delivery. Eligible Medicare and Medicaid physicians may receive
incentive payments over 5 years, starting in 2011, if they demonstrate that they are using a
certified EHR system that meets 15 Stage 1 Core set objectives and 5 of 10 Menu Set
objectives.
A federally funded regional extension centre (REC) program was created to provide
physicians with assistance in purchasing and implementing EHR systems, training staff, and
addressing how they use EHR systems when they see patients. The REC program seeks to
support 100,000 primary care providers, with particular emphasis given to practices with
fewer than 10 clinicians and to clinicians who work in settings that tend to serve uninsured,
underinsured, and medically underserved populations.
Implementation of Hospital Information System: Indian Scenario
Current barriers in the use of EHR Current Barriers/ Challenges
Legacy System Most of the patient records are paper based documented
except few of well known private large scale hospitals.
It’s a difficult task to convert this paper based record to
electronic format.
Cost High cost of implementation is the foremost barrier.

Only hospitals or physicians with high IT budget can
afford these systems.
Policy To promote the implementation of EHR, there is

absence of co-ordinated policy of Government. Lack of
clarity in the existing policies of HIT.
Funding Government funding for HIT is almost non-existent.
This factor leads to reluctance to adopt the system.
Another factor is lack of well trained professional in
medical informatics.
Standards For exchange of information and representation, most of

systems don’t adhere to standards. It will be further
complicated, because of multiple local languages used
by patients and staff.
Computer Literacy Computer literacy is low among the government staff

and private hospitals’ community. System training is
required to proper use of the EHR.
Co-ordination and Lack of co-ordination and supporting infrastructure

Infrastructure (including the hardware and software) among the public
and private sectors hospitals.
Privacy Concerns Judiciary of India has not addressed any specific right
of privacy issues with respect to the patient health
record. Confidentiality of patient health record is still an
open issue.
As per Healthcare Information and Management Systems Society Asia Pacific7, there are
eight stages/levels of acceptance of EHR varying from level 0 to level 7. At Stage 0 there is
small or nil acceptance while at Stage 7, complete implementation or acceptance. Table 1 list
the various stages of model. With reference to the HIMSS analysis adoption model of EHR,
by the end of 2016, only 2.6% of hospitals were crossed the Level-6. Up to year of 2020, at
stage 7approximate 1.5% of the hospitals of India are measured completely functioning. At
stage -7 paperless work will be there to deliver and manage patient care.
Table 1. Stages of HIMMS7 EMR Adoption Model Asia Pacific
Stages Cumulative 2015 Q3 2015 Q4
Capabilities
Stage 7 Complete EMR, Data 0.4% 0.5%

Analytics to improve
care
Stage 6 Physician 3.4% 3.9%

documentation
(Templates), Full
CDSS, Closed Loop
Medication
Administration
Stage 5 Full R-PACS 8.0% 7.4%
Stage 4 CPOE, Clinical 1.7% 1.7%

Decision Support
(Clinical Protocols)
Stage 3 Nursing/Clinical 0.7% 0.6%

Documentation,
CDSS (error
checking), PACS
Available Outside
Radiology
Stage 2 CDR, Controlled 32.9% 32.7%

Medical Vocabulary,
CDS, HIE Capable
Stage 1 Ancillaries-Lab, 4.6% 4.9%

Radiology, Pharmacy-
All Installed
Stage 0 All Three Ancillaries 48.4% 48.2%
not Installed
Since 1965 El Camino Hospital has been deeply involved with a comprehensive hospital
information system. For the first 6 years this involvement was limited to systems planning
and development by the Hospital, its Medical Staff, Lockheed Corporation and later
Technicon Corporation. In 1972 the information system became operational and today El
Camino Hospital is usually regarded as the most experienced hospital in the world with
computerized information systems.
Four basic principles have endured through these periods. These principles were adopted in
1965 by Administration, Medical Staff and the Board of the Hospital, and 15 years of
experience has not required any modification whatsoever.
First, success is defined as a cost-effective system that enhances quality of care. Second, the
total understanding and commitment of the medical staff and all hospital personnel is
required to implement such a system. Third, to be successful the system must be practical for
professional and non-professional users, especially physicians and registered nurses. Fourth,
a move to a computerized information system is a long-term and permanent change in the
way nursing and medical care is provided in a hospital.
Ref: Neilson S. Buchanan, Associate Administrator, El Camino Hospital, Mountain View,

California 94040,Evolution Of A Hospital Information System.
Many studies available in the medical literature have been trying to explain the delay or
unsuccessful implementation of HIS and electronic medical records and link this problem to
the acceptance or resistance of healthcare professionals' towards these systems.
The effect of information technology knowledge, experience and skills of healthcare

professionals, current status of computerization in hospitals, and professionals' attitudes, in
terms of their positive or negative beliefs about computerized systems and electronic medical
records in the healthcare environment are considered among the major human type of barriers
to the successful implementation and use of such systems.
This is why planned training of healthcare professionals is needed to foster positive attitudes
about HIS, and build confidence in the benefits of these systems. Strategies for the successful
management of HIS development and implementation should include engaging the
physicians and other healthcare professionals and providing strong organizational support to
them before and during the implementation activities.
These two factors could eliminate major resistance and alleviate negative attitudes frequently
reported and in the same time increase level of acceptance of HIS by physicians and
healthcare professionals. This is why it is important to investigate and explore factors leading
to HIS acceptance and satisfaction among all types of users.
Ref: Hospital Information Systems (HIS) Acceptance and Satisfaction: A Case Study of a
Tertiary Care Hospital Mohamed Khalifa, MD and Osama Alswailem, MD, The 5th
International Conference on Current and Future Trends of Information and Communication
Technologies in Healthcare (ICTH 2015)
Indian EHR Market
In 2013, Electronic Health Records standards and guidelines for India has been improved and
finalized by, Government of India. To uplift the adoption of EHR, various category of
standards like Vocabulary Standards ((ICD10, ATC etc.), Content Exchange Standards (HL7,
FHIR, CCR and DICOM etc.), Clinical Standards and inter-operability (to exchange the
records between hospitals) parameters inculcated in documented polices. All these standards
are flexible and modified able.
On 2015, AIIMS-Delhi successfully implemented the cloud based EHR system to automate
the patient appointment and create repository of patient record. For unique identification of
patient this system recommended aadhar card number as primary key. It’s estimated that HIT
market will attain $1.45 billion in the year of 2018. It’s expected to three times more than the
$381.3 million crossed in 2012. There is very less diffusion of HIT in India. The total
expenditure on IT by the United State hospitals have approximately cost up to $79-80 billion
on comparison to healthcare IT spending payments up to $305 million in India. Major
barriers are lack of funding, computer literacy, scarcity of trained staff, immense initial
investments and deficiency of rigid policies.
.Ref: Meenakshi Sharma and Himanshu Aggarwal, EHR Adoption in India: Potential and the
Challenges, Indian Journal of Science and Technology, Vol 9(34), DOI:
10.17485/ijst/2016/v9i34/100211, September 2016
Electronic Health Record Use a Bitter Pill for Many Physicians: by Stephen L. Meigs,
DHA, FACHE; and Michael Solomon, PhD, MBA, in Perspectives in Health Information
Management, Winter 2016 studied the challenges of using EHRs have resulted in growing
dissatisfaction with the systems among many of these physicians. It concluded that,
• Physicians in this study believe that EHR systems need to be more user-friendly and
adaptable to individual clinic workflow preferences
• The lack of interoperability among EHR systems is hampering the electronic

exchange of health information and is causing both frustration and scepticism among
physicians relative to the value of EHRs.
• A significant gap exists between policy makers’ vision of meaningful use of EHRs
and the reality of office-based physicians experiencing the complexities of EHR use
in practice.
• Physicians Use Workarounds to Overcome Adoption Barriers
• Using EHRs Increases Physician Workload
• Physicians Do Not Believe EHR Use Results in Improved Quality of Care
• Some Physicians Believe EHR Use May Negatively Affect Quality of Care
• Physicians Perceive That Use of EHRs Both Increases and Decreases Efficiency
Recommendations of EMR Standards Committee constituted by an order of Ministry of

Health & Family Welfare, Government of India and coordinated by FICCI on its behalf, 2013
has discussed in details EHR/EMR standards, guidelines, goals and governments vision for
the adoption of HER/EMR in India.
According to these recommendations, the benefits that an EMR is expected to bring in are:
• Paperless medical history

• Reduced healthcare costs
• Empowering the stakeholders to be able to deliver right treatment at the right time
• Promote the practice of evidence-based medicine
• Accelerate research and building effective medical practices
• Usher in ease in maintaining health information of patients
• With proper backup policies increase lifespan of health records of individuals that is
from conception to cremation
• safety with access, audit and authorization control mechanisms
• Faster search and updates
This paper in detail has discussed the minimum standards that an EMR should have and the
technical specifications and standards to be used by the EMR system, such as HL7, ASTM,
SNOMED-CT, WHO ICD 10 nomenclature etc.
Country-wise Usage of Healthcare Standards
The National Health Policy 2017 states that,
• Digital Health Technology Eco - System: Recognising the integral role of technology
(eHealth, mHealth, Cloud, Internet of things, wearables, etc) in the healthcare
delivery, a National Digital Health Authority (NDHA) will be set up to regulate,
develop and deploy digital health across the continuum of care.
• The policy advocates extensive deployment of digital tools for improving the
efficiency and outcome of the healthcare system. The policy aims at an integrated
health information system which serves the needs of all stake-holders and improves
efficiency, transparency, and citizen experience.
• Delivery of better health outcomes in terms of access, quality, affordability, lowering

of disease burden and efficient monitoring of health entitlements to citizens, is the
goal.
• Establishing federated national health information architecture, to roll-out and link

systems across public and private health providers at State and national levels
consistent with Metadata and Data Standards (MDDS) & Electronic Health Record
(EHR), will be supported by this policy.
• The policy suggests exploring the use of “Aadhaar” (Unique ID) for identification.
Creation of registries (i.e. patients, provider, service, diseases, document and event)
for enhanced public health/big data analytics, creation of health information exchange
platform and national health information network, use of National Optical Fibre
Network, use of smart-phones/tablets for capturing real time data, are key strategies of
the National Health Information Architecture.
Methodology
An observational study of the OPD module of the Hospital Information System was
performed at the leading hospital in Ahmednagar, Maharashtra.
The OPD module was studied for its technical properties, its evolution, its implementation,
advantages and limitations were studied.
It is not a comparative study of the various HIS softwares but an observational study of a
single HIS OPD module.
But a comparison of its features and that of other HIS is discussed in brief.
A questionnaire was given to the end-users of the module and their responses were analysed.
A total of 20 end users were selected.
The study was performed during the month of January, 2018.
Organization:
Deepak Hospital is one of the renowned hospitals in Ahmednagar with a tendency to set new
trends in the Semi-Urban area of Maharashtra. It is the first hospital in Ahmednagar to adapt
to EMR. Also it is the first hospital to provide ICU facility with mechanical ventilation in
Ahmednagar.
Deepak Hospital was the first facility to use fully automatic biochemistry analysers in the
tier-3 cities. It is also the first hospital to provide 2-D Echo & Colour Doppler and also Tissue
Doppler and TEE facility in Ahmednagar. The interventional cardiologist affiliated to this
hospital has introduced radial route coronary angiography in Ahmednagar.
Deepak Hospital is known in the Ahmednagar for its comprehensive approach towards
patients especially the critically ill cases. Its director Dr S. S. Deepak is a leading physician,
Dr Kiran Deepak is an interventional cardiologist and Dr Vaishali is a Gynaecologist.
The hospital is strategically located. It has ICU, laboratory, radiology, OT and wards.
It is well staffed and provides cashless facilities to many insurance companies as well as
implements various government health schemes.
About the OPD module of the HIS:
It is a legacy system based on Foxpro-MS Windows architecture. It was first developed in

house, by Mr Anil Bhawar with the assistance of Mr Shivaji Pulate, as per the requirements
and guidance of Dr Deepak in 1995.
It was first developed in dbase in MS-DOS, then moved on to FOXPRO in MS-DOS and
later shifted on FOXPRO,MS-Windows platform. But after 2007, Foxpro development has
been discontinued.
Initially only registration, clinical diagnosis and e-prescription features were available. Later,
Lab Investigation module was added and lastly, billing module was introduced. Now no new
features are being added in the OPD module.
The software is stll used in OPD for general examination, history taking, lab reporting,
prescription, certificate issuing and billing.
The minimum hardware requirement for this software is
• Intel Pentium 4 processor

• 512 MB RAM
• 200 GB HHD
The main server is located at the site and the end-users have Thin-Client stations for their
operations. A parallel back-up system is available.
The entire data is stored on the server. There are three consulting rooms, one lab and one
billing counter.
All three consulting rooms can share their data from their workstations. But for security
reasons, billing counter and laboratory have not been given access to patient records.
Billing counter and Laboratory can only feed data in the system and can access only their old
data.
The OPD module is also integrated with the IPD module which has ADT (Admission,
Discharge, Transfer) and IPD billing functionality. But not all the modules have been
awarded interdependency. So there is still some need of paperwork and manual
documentation.
Features of the HIS – OPD module:
The main menu consists of following submenu tabs:
• Master
• General
• Investigation
• Diagnosis
• Prescription
• Billing
• Option
Every submenu tab gives access to additional function menus.
Short cut keys are assigned for fast and easy access.
The entire navigational access is so designed as no ‘mouse’ is needed and every function can
be easily performed by a few keyboard entries only.
Figure 1: Main Menu of HIS-OPD Module
Master Menu:
It consists of
Patient Entry
Findings (Clinical)
Medicines
Diagnosis
Test (Lab Investigations)
Each submenu has a provision of adding, editing, deleting the entries.
Figure 2: Submenu of Master Tab
Figure 3: A view of Diagnosis submenu TAB
Figure 4: A view of Test (Lab) submenu TAB
Figure 5: A view of Diagnosis Menu and its submenus
Figure 6: A view of Diagnosis Menu with 2-D Report submenu
Figure 7: A view of Prescription Menu TAB displaying available formulary
Figure 8: A view of Prescription Menu TAB displaying past visit dates of a patient
Questionnaire for the End-User of Hospital Information System: OPD Module
1. What is your education qualification? How long have you been practicing?
2. Have you received any formal computer education?
3. Which electronic communication devices do you use viz. Smartphone/ Tab?
4. Do you support use of HIS in healthcare services?
5. For how many years have you been using HIS?
6. Have you used any other HIS or health related app/program?
7. Do you believe that HIS has reduced your workload?
8. Do you believe that HIS has improved quality of your work?
9. Do you think that other organizations (IRDA/Government agencies/Insurance

companies) support your use of HIS?
10. Do you think your peers have successfully implemented HIS?
11. How do your patients perceive your decision to use HIS-HER?
12. Do you believe using HIS – EHR changes your doctor-patient relationship?
13. Are you satisfied with your current HIS?
14. Do you know various standards/ nomenclatures used viz. HL7, ICD 10, ASTM etc?
15. Are you familiar with Government of India’s views about use of IT in health sector?
16. Are you familiar with various HIS – EMR products available in the market?
Results
(Note: It is not a comparative study but an observational study.)
About the HIS – OPD module:
• The HIS – OPD module is still fully functional to its capacity, since its inception in
1995.
• It is extremely user friendly. No formal computer knowledge is necessary.
• The user interface offers only one field of entry at a time so there is no user confusion.
• The hardware requirements for this HIS – OPD are very minimal.
• The backup and indexing feature allows data backup and easy access.
• The HIS software is totally made to order, highly customised.
• Even after 22 years of inception, prompt and satisfactory technical support is provided
by the original developer.
• In a country like India and then also in a semi-urban area, where computer penetration
and computer literacy is poor, this HIS software has survived more than two decades.
• 20 end users were selected for their feedback about HIS,
6 doctors
6 from accounting dept
6 from reception and registration dept
2 from the laboratory
HIS increases Efficiency HIS Increases Workload
Doctors/Physicians Yes Somewhat
Lab Technicians Yes No
Accounting Dept Yes Yes
Reception Dept Somewhat Yes
Table 1: Feedback of HIS End-users
Formal computer Training Using smart-phone/ Tab

Doctors/Physicians MS-Office Yes
Lab Technicians None Yes
Accounting Dept Talley-ERP Yes
Reception Dept None Yes
Table 2: Technical background of HIS end users
No. of years using HIS Supports HIS use Wants new features
Doctors/Physicians >20 Years Yes Definitely Yes
Lab Technicians >15 Years Yes Some Yes
Accounting Dept >10 Years Yes No
Reception Dept >5-10 Years Yes No
Table 3: End users perception of HIS
Used any other HIS/ Health App Knowledge of HIS standards

Doctors/Physicians Yes No
Lab Technicians Yes No
Accounting Dept No No
Reception Dept No No
Table 4: HIS users; knowledge of technical standards of HIS
Knowledge Global Standards Knowledge of Indian Guidelines
Doctors/Physicians Somewhat No
Lab Technicians No No
Accounting Dept No No
Reception Dept No No
Table 5: Knowledge of HIS users about HIS standards
From the above tables it is apparent that most of the users of HIS have no technical/ computer
background or knowledge. Doctors have some knowledge of MS-Office, and accountants
have familiarity with their specialized software like Talley-ERP.
Most of the users except doctors, do not know any HIS standards, neither about any global
standards such as HL7 or nomenclatures such as SNOMED & ICD 10.
Almost all of the users have no information about the global standards/ trends in EHR and
Government of India’s IT initiative in National Health Policy. GOI – FICCI
recommendations of 2013 were not known to any users.
Yet all of the end users have declared that using HIS increases their efficiency. The
consultants described ease of accessing the past history, visit dates was an important feature
of their office practice.
The assistant doctors claimed the HIS is user friendly and saves their valuable time.
But at the same time assistant doctors, accountants-billing clerks and reception desk workers
claimed that using HIS sometimes increases their workload as the system is not 100%
paperless. So many times they have to do the repetitive tasks.
But the laboratory technicians claimed that the HIS doesn’t increase their workload as their
flow of work is suitably managed to prevent repetitive paper work.
The doctors and lab technicians thought new features are needed in the present system they
were using. New features such as assigning other UID viz. Aadhar numbers, attaching
photograph of the patient and incorporation of PACS were described as necessary. Also
availability of patient records on the mobile devices was also mentioned.
The lab people needed fully integrated LIS with device interface to reduce their manual data
entry completely.
The reception desk workers wanted a better queue management system and appointment
booking facility.
The billing and accounting workers were satisfied with the current system, as their use was
limited to specialized accounting software. But a demand of more seamless and granular
integration of the data was put forth.
All of the users agreed that the use of HIS have helped them to maintain better relations with
the patients and patient-families.
Discussion:
As described earlier, the HIS - OPD module was developed in 1995. It is FOXPRO based
software. Its features are already discussed.
But as it is legacy software, it does not offer new features which the current HIS programs are
capable of.
First and most of all is it lacks security. There is no provision of a secure log-in method. The
entries can’t be assigned to a specific user. There is no provision of prevention of
unauthorised log in and alteration of data.
The system is not centralized and there is very limited interdepartmental real time two way
communication. This results in limited functionality. For example, the doctors can generate
CPOE but they cannot get any feedback from the concerned departments like Lab or the
billing desk about the status of their order.
The registration needs an effective queue management system. The current system doesn’t
have any built in feature to manage patient flow. Also it has no capability to interface with a
third party solution for the queue management.
There is no provision to attach an additional UID and photo of the patient.
The clinical module lacks many important features such as integration with LIS, RIS or
PACS. So the doctors still need printed reports that defeats the purpose of the HER. Also
there is no way to export or send the clinical data in any format for the other users. The data
can be used only within the system. So there is no interoperability.
The billing data can be exported to ‘Talley’ accounting software in .csv file formats. It is a
fairly useful function. But any changes which take place in the data do not reflect
automatically in the ‘Talley’ data. So there is some manual work needed which needs a
trained and skilled accountant.
The system has no feature to interface with any lab equipment. The system is limited only to
data entry of lab reports and storage. There are templates for all the lab investigations and the
all the lab test results are to be manually entered into the system.
The system has no feature to generate any MIS reports. So no analysis is possible. The
system cannot give any feedback in terms of number of daily/weekly patients, their
demographics, billing history etc.
The system has no capability to integrate with hardware such as barcode readers, POS
machines, cameras etc. Also there is no provision of attaching any patient records in form of
pictures, documents, pdf etc.
Summary and Conclusions:
The project included study on design and implementation of OPD module of HIS.
The design of the HIS module was studied as well as its implementation.
The module though currently being used is very old. Due to lack of advanced necessary
features it cannot offer efficiency to the end users compared to the new HIS programs.
As it is based on FoxPro (MS-Windows) and the development of FoxPro is stopped in 2007,

there is no possibility of adding any new functionality to this software.
The newer/current programs are based on Java/Oracle and they are highly customizable and
feature rich.
Any HIS program should strive to offer real time interdepartmental two way communication.
This program has no such capability. So though it saves time, it doesn’t offer a smooth
workflow.
This system cannot integrate with lab equipments, radiology equipments, queue management
system, cameras, barcode readers, POS machines. So everything has to be done manually and
needs extra time and human effort.
As the system is based on d-base/FoxPro platform, there is no interoperability. The patient

record cannot be used/sent/accessed outside the system. If a patient demands old record, there
is no possibility of sharing the record in electronic format. Everything has to be given in print
format.
As there is no secure log-in capability and user log in record feature in the system, only
trusted and limited users can access the system to prevent the misuse.
There is no feature to use the system remotely on the mobile devices, also there is no feature
to integrate it with SMS or e-mail client. So it lacks communication capability.
There is no provision for patients to access the system in any way viz. patient portal, website
etc. The patients are entirely dependent on the organization for the access to their records.
The HIS implementation is done to a limited extent. The end-users do feel the need of new
features and functionality.
Though the end users lack technical capabilities, they have been using the system to its fullest
capability.
The management’s support and push to use EMR – EHR has helped the system to stay
relevant even after two decades of its implementation.
Recommendations:
If the organization wishes to continue with the current HIS,
1. The current HIS is legacy system based on d-base, FoxPro platform. Though the
original developer still gives support, the FoxPro platform itself has been abandoned
by MS-Windows past 2007. There would be no development in the software though
some new menus and submenus can be added.
2. There is no interdepartmental communication, so with LAN support, it is

recommended to add this communication facility to reduce time and manual work.
3. A third party queue management system program can be used to complement the
current HIS system.
4. The system cannot integrate with other devices such as lab, radiology equipment, so a
standalone LIS-RIS module is recommended considering the workload of the
institute. It shall greatly reduce the manual labour and can save time.
5. The organization can launch a static content website to serve its patients and have
better interaction with them. It can also use promotional bulk SMS facility to
complement the current HIS system.
If the organization wishes to replace the current HIS with a different software,
1. A thorough GAP analysis should be performed by a reputed third party consultant and
a suitable product should be chosen.
2. The software should be upgradable, customizable and scalable. Its various modules
should be loosely connected to one another and should function as a stand-alone
system also.
3. After finalizing the new software, master data entry and inputs from the various
departments should be collected and implemented.
4. The software should be customized to the needs of the organization and it should not
be implemented as it is ‘Off the Shelf’.
5. Training of the leaders from various departments should take place to the satisfaction
of the end users and the management. Their feedback must be considered.
6. A trial run of the system should be performed. Any difficulties whether hardware
related or user-software related should be identified.
7. If all the ‘bugs’ are removed, then and then only the system should go ‘on line’.
8. In the initial days, there should be on-site support person from the software company
and later a reliable and prompt on-line support is needed.
9. The software should help in the workflow, reduce the operational cost, time and also
help in maintaining various procedural standards as advises by NABH and JCI etc.
References:
• EHR Adoption in India: Potential and the Challenges, Meenakshi Sharma and
Himanshu Aggarwal, Indian Journal of Science and Technology, Vol 9(34),
DOI: 10.17485/ijst/2016/v9i34/100211, September 2016
• National Electronic Health Records Survey: 2015 State and National

Electronic Health Record Adoption Summary tables
https://www.cms.gov/Regulations-and-
guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincenti
veprograms
• Electronic Health Record Use a Bitter Pill for Many Physicians by Stephen L.
Meigs, DHA, FACHE; and Michael Solomon, PhD, MBA, Perspectives in
Health Information Management, Winter 2016
• EVOLUTION OF A HOSPITAL INFORMATION SYSTEM Neilson S.

Buchanan, Associate Administrator, El Camino Hospital, Mountain View,
California 94040
• Hospital Information Systems (HIS) Acceptance and Satisfaction: A Case

Study of a Tertiary Care Hospital Mohamed Khalifa, MD and Osama
Alswailem, MD, The 5th International Conference on Current and Future
Trends of Information and Communication Technologies in Healthcare (ICTH
2015)
• Improving Quality of Electronic Health Records with SNOMED, Júlio

Duartea, Sara Castro a, Manuel Santos b, António Abelha a, José Machado,
CENTERIS 2014 - Conference on Enterprise Information Systems / ProjMAN
2014 - International Conference on Project Management / HCIST 2014 -
International Conference on Health and Social Care Information Systems and
Technologies
• National Health Policy, 2017, by Ministry of Health & Family Welfare. GOI.
• Adoption and Use of Electronic Health Records and Mobile Technology by

Home Health and Hospice Care Agencies, by Anita R. Bercovitz, Ph.D.,
M.P.H.; Eunice Park-Lee, Ph.D.; and Eric Jamoom, Ph.D., M.P.H., M.S.,
Division of Health Care Statistics, National Health Statistics Reports, Number
66 n May 20, 2013
• Recommendations on Electronic Medical Records Standards In India April

2013, Recommendations of EMR Standards Committee, constituted by an
order of Ministry of Health & Family Welfare, Government of India and
coordinated by FICCI on its behalf

PGDHHM Project-A Study On Design & Implementation of Out-Patient Module of Hospital Information System

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A project on

A Study on Design & Implementation of

Out-Patient Module of Hospital Information System

Dr Hrishikesh Arvind Kalgaonkar

Roll No. 17200253

Under the guidance of

Dr S. S. Deepak (MD Medicine)

Symbiosis Centre of Health Care (SCHC), PUNE

Submitted in partial fulfilment of the requirement for the award of

Post Graduate Diploma in Hospital & Healthcare Management

Dr. Hrishikesh Arvind Kalgaonkar

Post Graduate Diploma in Hospital & Healthcare Management

Dr. Deepak S. S. (MD Medicine)

Deepak Hospital, Ahmednagar

Dr. Hrishikesh Arvind Kalgaonkar

Post Graduate Diploma in Hospital & Healthcare Management

Literature Review …………………………………………………………..page 11

Summary & Conclusion …………………………………………………..page 35

Need for Hospital Information System and its correct implementation

Need for documentation:

Huge Data Generation:

In modern medicine, tremendous amount of information is being generated. All types of

Need for quick access to information:

Privacy & Integrity management:

Need for accuracy:

The capabilities and limitations of the software shall be studied.

The final recommendations shall be based on the results of the findings.

A paper by then administrator of the facility in 1984 stated,

“The 15-year experience at El Camino Hospital demonstrates the viability of comprehensive

Adoption of EHR: Global View

According to Transparency Market Research (TMR), the industry of healthcare is in the

Implementation of Hospital Information System: Indian Scenario

Current barriers in the use of EHR Current Barriers/ Challenges

Cost High cost of implementation is the foremost barrier.

Policy To promote the implementation of EHR, there is

Standards For exchange of information and representation, most of

Computer Literacy Computer literacy is low among the government staff

Co-ordination and Lack of co-ordination and supporting infrastructure

Stage 7 Complete EMR, Data 0.4% 0.5%

Stage 6 Physician 3.4% 3.9%

Stage 5 Full R-PACS 8.0% 7.4%

Stage 4 CPOE, Clinical 1.7% 1.7%

Stage 3 Nursing/Clinical 0.7% 0.6%

Stage 2 CDR, Controlled 32.9% 32.7%

Stage 1 Ancillaries-Lab, 4.6% 4.9%

Ref: Neilson S. Buchanan, Associate Administrator, El Camino Hospital, Mountain View,

The effect of information technology knowledge, experience and skills of healthcare

Indian EHR Market

• The lack of interoperability among EHR systems is hampering the electronic

• Using EHRs Increases Physician Workload

• Physicians Do Not Believe EHR Use Results in Improved Quality of Care

Recommendations of EMR Standards Committee constituted by an order of Ministry of

• Paperless medical history

The National Health Policy 2017 states that,

• Delivery of better health outcomes in terms of access, quality, affordability, lowering

• Establishing federated national health information architecture, to roll-out and link

A total of 20 end users were selected.

The study was performed during the month of January, 2018.

It is a legacy system based on Foxpro-MS Windows architecture. It was first developed in

The minimum hardware requirement for this software is

• Intel Pentium 4 processor

The main menu consists of following submenu tabs:

Every submenu tab gives access to additional function menus.