i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 180–188

journa l h omepage: www.i jmi journa l .com

Development of an in-house hospital information system ina hospital in Pakistan

Faisal Sultana,∗, Muhammad Tahir Azizb, Idrees Khokharc, Hussain Qadrid, ManzarAbbasc, Amir Mukhtarc, Waqar Manzoorc, Muhammed Aasim Yusufa

a Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH&RC), 7A, Block R3, JoharTown, Lahore, Pakistanb Department of Pharmaceutical Services, Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH&RC), 7A, Block R3,Johar Town, Lahore, Pakistanc Management Information System, Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH&RC), 7A, Block R3, JoharTown, Lahore, Pakistand Quality Assurance Department, Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH&RC), 7A, Block R3, JoharTown, Lahore, Pakistan

a r t i c l e i n f o

Article history:

Received 28 May 2013

Received in revised form

5 December 2013

Accepted 7 December 2013

Keywords:

Hospital information system

Hospital-finance

Quality improvement

a b s t r a c t

Objectives: To review our experience of development and implementation of an electronic

hospital information system, its costs and return on investment as well as incorporation of

some key quality standards.

Methods: Cost and saving trends of the project were calculated using different tools includ-

ing project expense, cost saving through cessation of printing radiology films and paper.

Net present value with payback period was utilized to evaluate the efficiency of the health

information systems. Qualitative improvements in different healthcare functions were also

analyzed.

Results: The total saving of the project was approximately US$ 5.1 million with net saving

of US$ 3.5 million for the period from 2001 to 2011. The net present value of the project is

US$3.2 million with a payback period of 3.4 years.

Conclusions: Electronic hospital information systems and health records hold the potential

to be useful tools for quality improvement and error reduction. Adoption of such systems,

however, has been slow and erratic, worldwide. Utilizing the concept of net present value,

development of such a system may be financially viable for some institutions. Instead of sim-

ply replacing paper, these systems may also be used to improve information management

and improve quality of patient care.

1. Introduction

The aim of any medical institution is to be able to providehigh quality medical care to its patients. Yet, medical errors

∗ Corresponding author. Tel.: +92 42 35905000; fax: +92 42 35945205.E-mail address: faisal@skm.org.pk (F. Sultan).

1386-5056/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reshttp://dx.doi.org/10.1016/j.ijmedinf.2013.12.004

© 2014 Elsevier Ireland Ltd. All rights reserved.

remain an important cause of mortality and morbidity in hos-pitals [1]. There have been great expectations of reduction

of such risks as a direct result of institution of informationsystems in hospitals over the last four decades [2]. Use of hos-pital information systems (HIS) may be an important tool in

erved.

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eduction of errors in the health care setting. Specific inter-entions which may have an impact on improving quality havencluded computerized physician order entry, clinical decisionupport systems and computerized notification of critical lab-ratory alerts [2,3]. In the United States, the Health Insuranceortability and Accountability Act of 1996 (HIPAA) has provideddditional impetus in this field. Taken together, these factorsay all lead to an increase in the heretofore poor uptake of

omputing by the healthcare industry in the developed world4]. At the same time, electronic health records (EHR) also posepecial risks, as highlighted in a recent review [5].

Development and implementation of hospital informationystems present particular difficulties in developing countries,nd we present here our experience of successful in-houseevelopment and implementation of an integrated hospital

nformation system in Pakistan. We have also attempted touantify savings achieved specifically in two areas, namely

mplementation of a paperless laboratory reporting systemnd a film-less radiology department. This article does notresent direct clinical benefits or indirect financial, planningnd research benefits that the system may have had. We arenaware of a published report from our country on this sub-

ect.

.1. Setting

haukat Khanum Memorial Cancer Hospital and Researchenter is a modern tertiary-care cancer center located inahore, Pakistan with a referral base from all over the coun-ry and adjoining regions. The hospital opened in 1994 androvides full service cancer care to the indigent who com-rise approximately 70% of the cancer patient population. Toupport this endeavor, the hospital’s parent trust raises phil-nthropic donations (approximately US $20 million a year)rom within the country and from the Pakistani diaspora.his 180-bed hospital has 1800 employees and sees over 6000ew cancer patients each year. In addition, the hospital has aationwide chain of phlebotomy centers to provide diagnos-

ic laboratory services to the general population. In 2011, thereere over 142,000 outpatient visits, 7600 admissions, 7800 sur-

ical operations, 54,600 chemotherapy visits, 44,500 radiationreatments, 144,000 imaging procedures and 3.25 million lab-ratory tests. The pathology laboratory receives specimens foresting from 90 sites from all over Pakistan. In view of theize and complexity of the operation, use of computing forutomation, quality assurance, safety and effective financialanagement is a natural evolution.

.2. Development process

he master plan for the hospital envisaged a hospital wideomputer network and a 250-node 10 mbps network wasnstalled prior to the hospital’s formal opening in December994. A decision was made to use the Decentralized Hospi-al Control Program (DHCP) developed by the United Stateseterans Administration. This provided email, registration,

cheduling and some aspects of pharmacy and radiologyeporting at text terminals. Other functionalities available inHCP could not be deployed due to non-availability of exper-

ise in this programming environment within Pakistan. At a

f o r m a t i c s 8 3 ( 2 0 1 4 ) 180–188 181

review in 1999, it was discovered that various clinical depart-ments were using a multitude of individual software programsto meet their needs. In the non-clinical areas, the financialrecords were maintained in a locally developed program butwere not connected to any clinical data. Human resourceand other administrative departments were similarly discon-nected from one another. A task force was appointed to reviewthe situation and recommend a way forward. These recom-mendations formed the basis of an overall plan to develop acomprehensive clinical, financial and administrative packageto meet the needs of the hospital. Formal approval from thehospital’s board of governors was sought and obtained prior tothe implementation of what was perceived to be a gargantuantask.

A decision was taken to use Oracle products (Oracle Corpo-ration, Redwood Shores, CA, USA) for developing the system.With this objective in mind, a team of information technologyprofessionals was created, starting in 2000 although formaldevelopment did not start until 2001, when a core group hadbeen formed. The team was given a brief to develop a fullyintegrated hospital information system with clinical, admin-istrative and financial domains. A steering committee headedby senior management and clinical leadership was formed forweekly review of progress, prioritization and implementation.A patient-centered approach was taken to develop modulesand these were prioritized based on perceived benefits tothe organization. The development proceeded with continuedand direct input from end-user departments. Implementationwas phase wise and approximately reflected the developmentcycle. Development, training and implementation teams weremade up of the same individuals and live support was given toend-users during the implementation phase of every module(Table 1). The first module (patient registration and schedul-ing) was implemented in April 2001. Mandatory computerizedphysician order entry was implemented in February 2002.This was followed by pharmacy (internal process flow andinventory management) in the same month. Other significantimplementations included: radiology (April 2002), pathology(November 2002), surgery and inpatient modules (May 2003)and the blood bank (March 2004). A radiology imaging moduleand picture archiving and communication system (PACS) wasimplemented in 2004 to coincide with the acquisition of digitalimaging capability in the department, whereby images fromradiology equipment were sent directly to database serverswhere they were integrated with the patient record and shownin the HIS. Physician notes were implemented in May 2006via a combination of structured, semi-structured and free textentry options. Experiments with voice recognition were notsuccessful. A parallel process of archiving old paper chartsusing high-speed scanners has been pursued. This archivedinformation is tagged to specific records and is viewable inreal time from the electronic interface. In parallel with thehospital’s aim to gain international accreditation, a numberof recognized patient safety goals and techniques have beenincorporated in ongoing development to add to the value ofthe system. Examples include mandatory falls risk assess-

ment, built in “time out” prior to procedures, requirementof dual signatures for key interventions and multiple othersteps. A timeline of significant implementation dates is listedin Table 1.

182 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l

Table 1 – Key modules and implementation dates.

Module Implementation date

Patient registration andscheduling

April 2001

Patient financialassessment

June 2001

Human resources module January 2002Physician order entry February 2002Pharmacy, including

inventoryFebruary 2002

Radiology process flow andreporting

April 2002

Medical records – codingand tracking

April 2002

Pathology modules,including machineinterfacing

November 2002–February 2004

Outcome analysis modulesfor common cancers

December 2002–January 2004

Financial modules March 2003–December 2004Inpatient units –

admissions anddischarges

May 2003

Surgical modules May 2003Blood bank March 2004Critical laboratory alerts 2005Physicians’ notes May 2006Corporate patient billing December 2006Endoscopy December 2008Materials management,

procurement life cycleDecember 2009

Fixed assets management December 2009Radiation oncology December 2010Chemotherapy December 2011

ularly test their own contingency plans, which allow themto continue their operations on manual forms in case of any

Cardiology December 2012

After 10 years of development and implementation, thehospital information system has largely automated work-flowin the hospital. All patient information is captured in the sys-tem including billing and financial information and all suchinformation can be viewed via a rights-based access controlsystem. At the current time, access to the system is not pro-vided to external referrers or other physicians. Such externalinteraction with the system is limited to access to reports ofpathology tests and radiologic studies. Patients coming to theHospital or to one of its phlebotomy centers or a diagnosticcenter, for investigations ordered by an outside physician areallocated a unique identification and access code. This allowsthe patient to view and print their reports, at a time advisedat the time of test booking, directly from a dedicated area onthe Hospital’s website.

Pertinent human resource information, procurement,inventory and assets/materials management as well as var-ious financial modules (general ledger, payroll, financialsupport, donations management, payables, receivables, bud-geting, physicians’ professional fee and others) are part of thishospital wide system.

Maintenance and improvement have been ongoing inparallel with development, at times creating very high expec-tations amongst end-users. So far, the hospital has continued

to support this. Open source releases have been consideredbut not actually been implemented.

i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 180–188

1.3. Challenges and solutions

Resistance from staff was expected and encountered, espe-cially at implementation of major modules. Reasons includedinertia, fear of a new system, poor computer literacy, poorcommand over the English language amongst some membersof staff and fear of work delays during the learning period.Medical staff often cited limited time to learn the new systemas well as fear of change. Resistance to change was amelio-rated by a number of measures, such as individual discussionsof expected benefits and use of computer expertise resources.The latter consisted of continuous teaching by the develop-ment team members, both at the time of implementation aswell as at the time of any post-implementation alterationsof the system; the latter were primarily instituted to shortenexisting process flows based on real-time feedback from end-users. Implementation of individual modules was carried outduring low activity times and initially in clinical settings withlower workloads and greater existing acceptance of comput-ing. Since feedback was more likely to be given by the mostinterested and vocal end-users, some real-time changes frominterested but naïve users led to changes that sometimes hadto be reversed. Very often attitudes changed markedly onceshort-term benefits were realized. Examples include immedi-ate availability of reports such as blood counts (crucial in anoncology environment), online viewing of radiology images,availability of analytic data, notification of alerts (via emailand system pop ups), the ability to access the system remotelyfrom outside the Hospital as well as direct documentationof service provision and billing by physicians. Involvementof practicing physicians in the development process broughtcredibility when dealing with medical end users. Institutionalconcerns regarding legal acceptance of the electronic recordby courts had to be addressed but were helped by the exis-tence of an ordinance issued by the Government of Pakistanregarding electronic records [6].

Despite appropriate multi-level redundancy, two majorbreakdowns of the system (one lasting 36 h) required tem-porary reversion to a paper system. Contingency planningcarried out in parallel helped to avoid major disruption ofwork. Fine-tuning of this emergency planning has continuedin parallel with additional investment in hardware tech-nology, as well as software, to avoid or ameliorate furtherbreakdowns.

Now that the Hospital is virtually paperless (with onlypatient consent forms and certain monitoring informationstill recorded on paper), the importance of uninterruptedavailability of the system is more critical than ever. The hospi-tal has thus invested in an off-site server room, which housestwo backup servers that store the same real-time informationas the main server, so that operations could continue seam-lessly even if the main server, or even the area of the buildingin which it is housed, were to be rendered unusable. In addi-tion, real-time backups are taken at regular intervals, whichcan be restored on any new server to resume operations fromthe point of the last saved transaction. Departments also reg-

breakdown, thus ensuring that disruption of patient care isavoided.

i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 180–188 183

Table 2 – HIS development costs in US dollars.

Expense category 2001–2006 2007 2008 2009 2010 2011 Total

Salaries and benefits 260,987 111,205 160,935 223,253 246,724 296,491 1,299,594Hardware 26,567 5889 9096 10,949 24,789 37,513 114,804Maintenance 12,907 6299 9866 10,637 9722 10,689 60,119

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Licensing and professional services 21,065 3873

Supplies, stationary, insurance, etc. 28,531 3992

Total 350,057 131,258

. Methods

he direct cost of the project was calculated using data onalaries of development staff from June 2001 to December011 and by analyzing records of purchases, software licens-ng and maintenance costs for the project. Training costsere calculated from data available from the Human Resourceepartment.

Yearly estimates of the total number of prints and the costncurred were calculated on the basis of invoices, receiptsnd numbers of patient reports issued by the relevant clini-al departments, including Pathology, Nuclear Medicine andadiology, as well as by other departments, such as Phar-acy, Finance and Materials Management (MMD). The cost

f the impact of automation on the throughput level of ourtaff was also evaluated. Staff throughput was analyzed inhe Finance, Materials Management and Pharmacy depart-

ents, which were selected because it was felt that theirect impact of automation, including on staff throughput

evels, was easily calculable and more tangible here than inther departments. Pharmacy staff productivity was analyzedhrough items dispensed per employee, while in Finance andMD; total transactions including finance vouchers, patient

nvoices, patient receipts, monthly corporate bills, purchaserders, material receipt notes, and stock issue notes prepareder employee before, during and after HIS implementationere assessed. The productive capacity of all three depart-ents was critically reviewed and benchmarked during cost

alculation. Similarly, savings as a result of cessation of radi-logy film printing from April 2004 were also calculated. Foraluation, we utilized net present value (NPV), payback periodnd internal rate of return (IRR) with the limitation of partialalculation of intangible items [7,8].

. Results

xpenses incurred in development of the HIS are summarizedn Table 2. The total cost of development of the informationystem was thus US$ 1,299,594; implementation of the entire

Table 3 – Saving in US Dollars as a result of cessation of printing

Saving category 2001–2006 2007 2008

Paper printing 98,283 46,053 51,978

Radiology films 142,105 147,368 178,947

Manpower 415,403 307,216 491,736

Total 655,791 500,638 722,661

a Finance, MMD and Pharmacy Department only.

3543 5361 1022 15,356 50,2217693 5157 8063 19,742 73,177

191,133 255,357 290,318 379,792 1,597,915

system (including costs incurred prior to software develop-ment period) was US$ 298,321. The total cost of the projectover the ten-year time span was US$ 1,597,915.

A summary of savings as a result of cessation of paper andfilm printing, including workman saving, due to automationis listed in Table 3. The number of staff required per spe-cific task in the selected departments decreased over timefollowing HIS development and implementation. HIS automa-tion helped to reduce the time needed to perform tasks andso led to increased productivity. Workman saving or fewerstaff is one of the elements described in Table 3. The totalfinancial savings (paper printing, radiology films and man-power) as a result of HIS implementation were approximatelyUS$ 5.1 million with a net saving of US$ 3.5 million for theperiod 2001–2011. These figures reflect only the hospital’s ownpatients and do not include patients referred for tests fromoutside the institution for which printing of reports and filmsis likely to continue for the foreseeable future. Additionally,there may have been differences across the different depart-ments and some may have benefited disproportionately dueto the nature and flow/volume of work, as well as their ownrequirements for automation but this was not calculated.

The discounted payback period was calculated by measur-ing the number of years required to recover the original HISinvestment cost from the discounted net cash flows, which issummarized in Table 4. Hence, SKMCH&RC HIS payback was3.4 years. This payback period also considers the cost of cap-ital, which shows the breakeven year after covering the debtand equity costs. This HIS implementation project had a shortpayback period, indicating greater HIS project liquidity. Also,since cash flows expected in the longer term are usually lessexact and more risky than near-term cash flows, the paybackof our HIS project is an indicator of a low risk project.

One of the limitations of the discounted payback periodmethod is that it ignores cash flows that are paid or receivedafter the payback period. In order to improve the effectiveness

of our HIS project evaluations, we also applied the net presentvalue (NPV) method. We used NPV because project cash flowsare reinvested at the relevant firm’s required rate of return;the IRR assumes that it is reinvested at the IRR. Since IRR is

of paper and radiology films, combined with fewer staff.a

2009 2010 2011 Total

69,570 87,509 127,620 481,014189,474 273,684 284,211 1,215,789588,044 756,762 878,518 3,437,678847,088 1,117,955 1,290,348 5,134,482

184 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l

Tabl

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4

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pay

back

per

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SK

MC

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HIS

(in

US

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lars

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2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

0

1

2

3

4

5

6

7

8

9 10

Net

cash

flow

(35,

714)

(38,

305)

7186

42,1

17

129,

003

201,

444

369,

379

531,

528

591,

731

827,

635

910,

558

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NC

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30,7

96

84,9

78

119,

547

197,

485

256,

015

256,

768

323,

543

320,

684

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(35,

714)

(70,

223)

(64,

391)

(33,

595)

51,3

83

170,

930

368,

415

624,

430

881,

198

1,20

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cost

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1)

=

11%

.

i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 180–188

higher than the required rate of return, in order for the IRRto be accurate, the relevant firm would have to keep findingprojects that would reinvest the cash flow at this higher rate.The HIS of SKMCH&RC is not meant for re-investment, thusNPV is a more accurate measure of its value. This was calcu-lated by finding the present value of all inflows and outflowsand then discounted at the HIS project cost of capital. The HISproject NPV was calculated by taking the sum of all discountedcash flows. NPV calculation is summarized in Table 5. Gener-ally, if NPV is positive, the project should be acceptable. TheNPV of this project is US$3.2 million, implying that the HISgenerates more cash than is needed to service ‘debt’ and thisexcess cash accrue solely to the institution. Additionally, wealso calculated the IRR, which is actually the expected rate ofreturn. Here our IRR is 86%, which is very high as compared toour rate of return of 11%, showing that the HIS is increasingthe wealth of the institution.

4. Discussion

Overall we found that the SKMCH&RC HIS project showedexcellent results in terms of return on investment and assetutilization. Additionally, it is useful to consider all of the mea-sures (payback, NPV, IRR) because each one provides decisionmakers with a different piece of relevant information. Dis-counted payback provides an indication of both the risk andliquidity of the project. If a project has a long payback period,and is therefore tying up money for long periods, it is illiq-uid. We felt that the NPV was the best single measure ofprofitability because this measured the direct dollar benefitto the institution. NPV did not provide information about thesafety margin which is inherent in the cash flow forecast butIRR does provide this. So, different measures provide differ-ent information. Computing or quantification may help; moreweight might be given to one measure over another, but itwould be imprudent to ignore the information provided byother methods.

We analyzed and tried to calculate the manpower require-ments before and after adoption of the HIS. Individual capacitywas difficult to assess but some sense of this can be hadfrom workman studies. It is generally apparent that automa-tion of clinical and administrative functions enables thehealthcare providers to improve their operational effective-ness, consequently reducing costs and medical errors, whileenhancing quality of care. Additionally, one study confirmedthat the automation of a hospital’s information systems issignificantly associated with reductions in mortality, com-plications and cost [9]. For Pharmacy, Finance and MaterialsManagement departments, we examined different activities,including direct relevant activities, which affected the overallstaff burden related to paper printing, sorting, photocopying,faxing and recording. The impact of automation of all theseactivities on workman savings was calculated and quanti-fied for the period after HIS implementation. Several studieshave focused on a return on investment, staff productivity and

differential cost analysis between film-based radiology andPACS. Greater staff productivity has been shown as a resultof reduction of costs associated with these activities, such asreducing staff levels needed for managing films, eliminating

i n

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180–188

185

Table 5 – Net present value of SKMCH&RC HIS project (in US Dollars).

Cash flow Year

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

0 1 2 3 4 5 6 7 8 9 10

RevenuePaper Saving 0 6776 13,219 17,581 21,765 38,941 46,053 51,978 69,570 87,509 127,620Radiology film saving 0 0 0 0 42,105 100,000 147,368 178,947 189,474 273,684 284,211Workman saving 0 0 40,691 73,069 136,902 164,741 307,216 491,736 588,044 756,762 878,518

Revenue – 6776 53,910 90,650 200,772 303,682 500,637 722,661 847,088 1,117,955 1,290,349

Out flowSalaries and benefits 27,881 35,193 30,947 35,030 55,940 75,996 111,205 160,935 223,253 246,724 296,491Hardware 3528 4453 3214 3389 5173 6812 5889 9096 10,949 24,789 37,513Maintenance 1005 1269 725 2341 4232 3336 6299 9866 10,637 9722 10,689Licensing and professional services 1444 1823 790 7224 2527 7256 3873 3543 5361 1022 15,356Supplies, stationery, insurance, etc. 1856 2343 11,048 549 3897 8838 3992 7693 5157 8063 19,742

Out flow (total) 35,714 45,081 46,724 48,533 71,769 102,238 131,258 191,133 255,357 290,320 379,791

Net flow (35,714) (38,305) 7186 42,117 129,003 201,444 369,379 531,528 591,731 827,635 910,558DCF factor 1.0000 1.1100 1.2321 1.3676 1.5181 1.6851 1.8704 2.0762 2.3045 2.5580 2.8394Discounted CF (35,714) (34,509) 5832 30,796 84,978 119,547 197,485 256,015 256,768 323,543 320,684

NPV 3,255,282IRR 86%

NPV = Net present value, IRR = internal rate of return, CF = cash flow, DCF = discounted cash flow.

186

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4 )

180–188

Table 6 – Qualitative improvements in selected electronic functionalities in HIS SKMCH&RC.

Sr. # Selected electronic functionalities in HIS SKMCH&RC Qualitative improvement Applicable JCIAa standards

1 Clinical pathways (febrile neutropenia, sepsis, radiationtherapy, DVT prophylaxis)

Consistency developed in the treatment for patients fallingunder these guidelines

COP 3, QPS 2.1

2 Discharge summary Automated ACC 3, ACC 3.1, ACC 3.2, ACC 3.2.13 H&P: patient/family education questions and sheet Documentation improved with regard to patient and family

education in all medical chartsPFE 2, PFE 2.1, PFE 6

4 Alert messages tab Reminder to relevant user to ensure people do not ignoreimportant tasks including critical lab results, pain alerts,referral alerts, drug–drug interaction, drug allergy, etc.

–

5 Post anesthesia care unit note templates (nursing + anesthesia) Automated ongoing, systematic collection and analysis of dataon the patient’s status in recovery support decisions aboutmoving the patient to other settings and less-intensive services

ASC 6

6 Handover/receiving nursing templates Improved coordination of patient care activities, resulting inefficient care processes, more effective use of human andother resources

COP 1, COP 2

7 Specialized assessment templates High-risk patients and services identified automatically withthe provision of high-risk services

COP 3

8 Incident reporting – online Helps staff in reporting potential risks, reporting incidents,injuries, handling hazardous and other materials. Also helps togather, analyze and review data and take necessary steps forimprovement

FMS 11

9 Assessment forms of nutritionist and physiotherapists Automation AOP 1.6, COP 510 Discharge planning template Helps in ensuring timely discharges, and in ensuring that the

care process is communicated to the patient and family,especially for patients who have special post-discharge needs

AOP 1.11, AOP 1.2

11 Fall care plan Mandatory in the system to evaluate patients’ risk for falls andtake action to reduce the risk of falling and to reduce the riskof injury by utilizing clinical decision support system

IPSG 6

12 Chemo checklist/verification – online Improved the safety of high-alert medications use IPSG 3, COP 1, COP 213 Interpreter list The ability of the system to identify all staff (name and current

duty location), who are currently on duty, who speak a selectedlanguage

MCI 3

14 CPOE including specialized chemo ordering module Prescription errors reduced –15 Clinical pharmacist menu Improved clinical pharmacy services with high interventions

acceptance rate (supported with clinical decision support toolsincluding drug interactions, dosage alerts, drug-labadjustment, etc.

MMU 4, MMU 7

16 Adverse drug reaction reporting Mandatory to report all adverse reaction/effects online, whichresult in improved patient safety re medication therapy

MMU 2.1, MMU 7

a Joint Commission International Accreditation Standards for Hospitals (COP = care of patient, QPS = quality improvement and patient safety, ACC = access to care and continuity of care, PFE = patientand family education, ASC = anesthesia and surgical care, FMS = Facility Management and Safety, AOP = assessment of patients, IPSG = International Patient Safety Goals, MCI = Management ofCommunication and Information, MMU = Medication Management and Use).

a l i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 180–188 187

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Summary pointsWhat was already known on the topic?

• Health information technology should lead to moreefficient, safer, and higher-quality care.

• High cost project.

What this study added to our knowledge?

• Clinical decision support system influences the inter-action between the physician, patient and orders withbetter clinical outcome.

• There is a positive qualitative improvement afterimplementation of electronic hospital informationsystems.

r

i n t e r n a t i o n a l j o u r n a l o f m e d i c

he cost of chemicals, transportation and inventory carryingosts [10,11]. One of these studies showed that the NPV of radi-logy film-based operations is higher than PACS operation [10].ur findings, specifically in regard to savings in radiology aftertopping printing of films are consistent with these studies.adiology film cessation is one of the major saving parameterse included in our study but we limited our study to financialnalysis only, with a net saving of US$ 1.2 million (from 2001 to011) for the radiology department only. Other aspects, suchs improved efficiency through improved report turnaroundimes and immediate access to images from multiple clinicalites, are two major additional benefits of PACS which are con-idered to more than compensate for the initial higher costsssociated with implementing PACS. Our work provides a clearicture of the success of paperless systems in a diverse set oflinical and non-clinical departments and cancer hospitals.

A comprehensive HIS has different electronic function-lities in all clinical areas including electronic notes inll specialties, treatment records, electronic referrals, testrdering and results, medication and non-medication orders,dmission and discharge orders and instructions, consulta-ion requests, endoscopy requests and reports and clinicalecision-support systems that provide up-to-date infor-ation, doses and drug interactions. Joint Commission

nternational Accreditation (JCIA) standards for Hospitalseflect the continued dynamic changes that are occurringround the globe, specifically in the acute environment12]. SKMCH&RC has made frequent changes to its HIS totrengthen the association between quality measurement anduality improvement, and in order to render it compliantith JCIA standards. The current physician ordering systemsave improved workflow efficiency in terms of legibility andompleteness of orders. In addition, it has removed inter-ediary physician tasks, has allowed immediate access to

ospital clinical guidelines and ordering sets and has resultedn fewer work disruptions due to asynchronous transfer mode,

hile allowing viewing of the same patient data concurrentlyy multiple users. Furthermore, the current system can beiewed remotely, from diverse distant sites, including physi-ians’ homes and doctors’ offices. Effective use of this systemas led to the virtual elimination of verbal orders and hasreatly enhanced efficiency in terms of order execution. Qual-tative improvements in selected electronic functionalities areummarized in Table 6. The availability of such healthcarenformation is radically improving the quality of patient carend helping to save lives.

A similar rate of return may not be possible in other facil-ties. This may have to do with the ability of the system toontribute to automation and scalability that it brought to ourarge network of laboratory collection centers and the millionsf tests that are performed by the hospital. In other words, theusiness model of the hospital is such that economies of scaleould be applied in our setting. Multiple attempts at electronicecords implementation are ongoing in other hospitals ande have offered guidance, support and in some situations the

echnical solution itself.

This study shows that the initial cost of implementing a

aperless system can be very high but an electronic HIS isore cost-effective than paper records in the long run. Fur-

hermore, the inventory cost of paper records and paying staff

• High rate of return project.

to organize, file and maintain them is eliminated with elec-tronic records. An electronic HIS can be frightening at first,but such emotions are usually short-lived, once the benefitsthat a paperless record system offers become apparent to all.

Source of funding

None.

Author contributions

All authors contributed equally.

Competing interests

None.

e f e r e n c e s

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[12] “The Joint Commission International Standards forHospitals”, http://www.jointcommission.org