DigiCards and Suandok Information System (SIS) Network for Seamless Healthcare
Maharaj Nakorn Chiang mai Hospital, Faculty of Medicine, Chiang Mai University

The Problem

The Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai University, is a 1,400 bed university hospital. As a largest tertiary hospital in northern Thailand, the hospital provides modern medical care and serves as a medical education and research center. Additionally, the hospital also operates as a referral center for hospitals in 17 provinces of northern Thailand with a population over 10 million.

The hospital provides healthcare services to more than 3,000 outpatients daily or over a million visits annually. Previously, our hospital faced many service related challenges including patients with end stage or complicated conditions including multiple organ disorders (diseases) in need of specialized treatments. Managing these cases required time and sophisticated investigative procedures.

For the past 50 years, the Maharaj Nakorn Chiang Mai Hospital had used paper based medical records and drug prescriptions. Quite often, a patient may need to be examined by many specialists in a single visit. The situation created problems in searching, preparing, and storing of medical records. Medical personnel often had to wait for patients' records to be delivered to outpatient department. Due to low physician per patient ratio, physicians had to examine more than 10 patients hourly. The time constraint together with unfamiliarity of typing patients' data directly into computers, writing patients' data on paper on OPD cards was preferable option for most physicians in the hospital.

Having over 130 outpatient examining rooms distributed among 5 buildings created challenges in daily retrieving, delivering, and storing of medical records. These tasks required manpower, time, and resources to accomplish. Distance between buildings and high human resource requirement could adversely affected medical record logistics.

Relying on personnel to manage medical records under these conditions was inefficient and sometime caused errors including loss of medical record and very long retrieval time.
In order to provide healthcare service, personnel with different capacities required prompt and timely accessed to patient record daily. Having to record patients' treatment at appropriate time, prompt and timely access to medical record was essential but was not often met due to long record retrieval time and inability to find the record when required. Transferring patients' record among different departments produced no value for patients and should be minimized. Problems with medical record management involved not only misplacement and inability to locate the record that had been check out but also included the requirement of large facility to store patient related documents that by law needed to be kept for at least 5 years.

Additionally, the Maharaj Nakorn Chiang Mai Hospital accepted patients referred from other hospitals. In the past, information transferred between the two hospitals was limited to referral notes. This minimized the collaborations between the hospitals to properly manage patients’ conditions during both while staying at the hospital and when returning to the community hospitals.

Solution and Key Benefits

 What is the initiative about? (the solution)
An annual increase in the number of patients receiving services at the hospital compounded the problem with medical records management as described earlier. In 2007, hospital administrative team and related personnel brainstormed to find the best solution to the problems encountered by the hospital.

With diverse experiences and computer proficiency among the healthcare personnel and physicians, the administrative team through meetings came up with 2 possible solutions to the problems.

First option was to use full electronic medical record which was difficult to implement on an organization wide basis due to diversity of hospital’s staff and the complexity of each patient even with the same problem. Effective use of information technology was not realized due to the lack of physicians' skill to type on computer keyboard. Even checklist approach was difficult to accomplish especially for severe cases with multiple diseases and multisystem impairment. Besides, records of abnormal findings and surgical procedures were better communicated through drawing the lesions.
The second option was scanning medical records. Patients' records were scanned and kept as analog data on the hospital's medical Information system. With this approach, physicians still used the traditional record on OPD cards which will be scanned. This was expected to cause less resistance to change among healthcare professional.

Because of these reasons, the hospital's administration decided to select the second approach and named it “DigiCards (Document Imaging System)”. The system required physicians to record patients’ history, physical examinations, investigation and treatment plan on regular OPD cards which were then immediately scanned into the hospital’s data management system. Barcode system was used for tracking and sorting patient record.

Time and the number of steps required for retrieving, tracking and filing of medical records were also significantly reduced. Steps for these processes were reduced from 10 to 4 and the time was reduced from 250 to 21 minutes. The walking distance for hospital personnel reduced from 283 meters to 0 meter; thus, promoting faster workflow and personnel satisfaction.

The initiative also reduced cost and manpower. At the medical record department, the number of staff required to retrieve medical records reduced from 10 to 1 person each day. As for outpatient departments, the number of assistant nurse needed for transferring and tracking medical records among different departments was reduced from 30 to 0 after the initiative. The time for medical record transfer from medical record department to outpatient unit decreased from 2 hours to 0.

Patient’s satisfaction and healthcare personnel were increased due to shorten service cycle time. Medical records were readily accessible via computer from any examining rooms without manually request and search for the records.

Adapted technology of scanning medical records is the solution to meet the need in working environment of an over 1,000-bed hospital with low physician to patient ratio and over 1 million patient visit annually. This innovation provided the best solution to the hospital's challenges concerning medical record logistics and information management. It also shortened time and improved accuracy of data input for the hospital's information management.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
Through brainstorming with many healthcare service sectors, the hospital director and hospital administrative team initiated the DigiCards project with allocated finance and human resource.

The Maharaj Nakorn Chiang Mai Hospital's IT team developed a system to record and store medical records in a digital image form. System design and appropriate utilization of organization's resources including timely and continuous improvement of information accuracy and system effectiveness in accordance with patient safety and security were essential. More importantly, the implementation agreed with physicians' routine practice in writing patient records on OPD card; thereby, minimizing resistance to the usage of new system and promoting satisfactory collaborations among the personnel. The DigiCards system consisted of the following work processes.

Digital scanning of medical records and application of barcode to classify and archive scanned images. The image database system was designed to store medical record images using minimal space while retaining image sharpness. The DigiCards was designed to be simple to use and integrated with laboratory results and radiological reports from the hospital's IT system that could be cataloged for simple information retrieval.

One year after OPD card scanning, the initiative was also expanded to include Inpatient departments. Physicians could follow up patients’ conditions in any hospital wards without having to request for hard copy of the medical records. The benefits of DigiCards extended to patient follow up after discharge and to our stakeholders. As a partner and recipient of patient management benefits, community hospitals also help to determine details of information to be transferred.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The hospital's strategies for implementing the initiative are as follows:-
The 1st Strategy: Utilizing information technology to transform and modernize hospital service and management to international standard. This will minimizing patients’ time spent in the hospital and maximize patient satisfaction for the best quality and efficiency of healthcare service.
The 2nd Strategy: Promoting participation from workforce and stakeholders in implementing the hospital's new strategies. Additionally, participation from other hospitals in the patient referral network through the use of Suandok Information System (SIS) helped with patient management and follow-up. This system allowed other hospitals real time access to referred patients' conditions and management at the Maharaj Nakorn Chiang Mai Hospital. This will help in improving healthcare service quality for patients in rural areas to the same standard as that of patients in urban areas.
The 3rd Strategy: Increasing service mind among hospital's workforce was attributed partly through decreasing workload by eliminating and minimizing unnecessary and non-value producing work process. Less stressful conditions perceived by the workforce would help to promote a “service mind” in accordance with the hospital’s credo “We take care of you as a member of our family, and serve you with our hearts”.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
Policy making
The policy was formed at meetings to rectify problems with hospital medical records. The team decided on the DigiCards project because it was the most appropriate initiative for large hospital's context. Action plans concerning medical record transfer for each responsible unit were formulated with inputs from hospitals in the network.

To create awareness of the new initiative, responsible personnel and work groups were invited to provide feedbacks. Other means for communicating the implementation included the meetings, training and computer screen savers.

Phase 1: Information review and preparatory phase
In March 2007, the study team investigated the number of files to be scanned and the IT team developed software and hardware to coordinate medical informatics. Barcode system was used for different types of document for scanning and filing medical records according to patient, location and date.
Hardware specifications were determined and purchasing plans were made.

Phase 2: Starting pilot project at OPD:
Medical record and OPD teams were responsible for scanning old and recent patient records and for appending information to the DigiCards system. Scanned documents were kept in medical record department.
Computer software developed in-house was used to store patient files according to date and time of each patient visit. Levels of security to get access of patients’ medical records were restricted and determined by secured passwords.

Monitoring & evaluation for improvements
Three months after implementation (September–October 2007) in pilot OPD, several problems were identified and evaluated for possible solutions. Those included missing scanned files and incorrect filing. So rescanning was done at the medical record department for double check. After several solutions in January 2008, the initiative was implemented in every examining room.

In 2010, the project was expanded to include medical record department for inpatients thereby completing full implementation of DigiCards for the entire hospital. All relevant personnel were satisfied with the new system and traditional medical record management was discontinued.

This year, 2011, e-discharge summary (medical report) and network mailbox, useful for information management, were integrated into the successful DigiCards system. Information from patients who were referred from community hospitals was readily available online and can be accessed by only authorized referring physicians to keep track of treatment progression in real time.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The main hospital obstacles encountered during the first 6 months of the implementation had to use both the traditional medical record system and the new system in parallel. Retrieving medical records and scanning of older documents practically doubled the staffs' workload.
Resistance to new system change was also found among some physicians and nurses due to lack of understanding of the new system's benefits.
Overcoming obstacles required hospital director's perseverance and continued communication of the long term benefits towards common goals of providing better patient service and reducing future workloads. An important key success factor was to complete the scanning of all older medical records as soon as possible. After almost 1 year, all patient medical records were scanned into the system. However, request for hard copy medical records was still allowed when necessary.
Weekly meeting was organized to solve problems and to promote participation and effective communication. The initiative success was attributed to our workforce's and community hospital personnel's attitude, determination and commitment to raise service quality and to improve healthcare delivery to all patients.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
To complete the scanning of available old medical records of all the patients within 1 year, it was necessary to employ extra 4 persons overtime each day 7 days a week.
Budget was also allocated to purchase a server, hardware, and scanners for all outpatient units and inpatient wards.

The hospital IT team, with 7 IT personnel, monitored the system and developed related software. Initial hardware investment cost, mostly scanners, was relatively low but the benefit was worthwhile and suitable for developing countries. The cost of initial investment may deter the implementation of initiative. Using DigiCards changed the working culture tremendously but still retained the familiar practice of physicians. With the help from assistant nurses with document scanning, the medical records were always updated in real time.

For the key benefits, DigiCards system increased the efficiency and effectiveness of hospital's management and services in the following aspects.
After the initiative, the time taken to retrieve medical record was reduced thereby minimizing patient waiting time. The clients’ benefit was apparent in a steady reduction of service cycle time from 2.5 hours in 2006 to 1.1 hours in 2010. The reduction in patient waiting time contributed greatly to the increased clients' satisfaction. After project implementation, statistical data from clients’ satisfaction survey at out-patient department showed that satisfaction increased significantly from 2008 to 2011: 81.9%, 82.1%, 88.0%, 90.5%, respectively.

Simplifying work process and medical record processing steps also significantly increased workforce satisfaction. Satisfaction survey of physicians and nurses increased from 49.8, 62.1, respectively in August 2009 at the beginning of implementation to 85.0, 95.0, respectively in April 2011.

Scanning of patient records also improved medical record retrieval. After the DigiCards initiative was launched, the medical retrieval rate at outpatient departments increased from 50% in 2008 to 100% in 2011. (No medical record loss!!!). The digital records facilitated interdepartmental consultations. Because of rapid access to medical record from any place in the hospital, patients received faster services and interdepartmental consultations could be accomplished with minimal delay. This would be most beneficial in the emergency department patient with the immediate medical record retrieval.

The initiative improves the quality of care because all healthcare professionals were able to access patient history, treatment-related information including drug allergy and patient follow up. The communication between physicians and nurses was greatly enhanced. Nurses could prepare patients before examination by physicians faster and pharmacists could immediately aware of physician diagnosis and drug prescription. The system reduces medication errors and greatly increases patient safety.

Moreover, simple and simultaneous access to medical records via DigiCards system allowed physicians, specialists and researchers to compile and analyze data leading to an improvement in clinical training and research.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
To establish a complete and thorough medical record system (DigiCards), additional computer software were incorporated. The applications provided pertinent patient information that would allow comprehensive patient services.
Internal customers including physicians and nurses were satisfied with the initiative due to faster and simpler access to medical records; thus, helping to reduce resistance to change and facilitate new transformation. As stakeholders and external customers, referring physicians from other hospitals using online system were also satisfied with the new initiative.

Customer satisfaction was also increased because of a reduction in service cycle time.
After initial investment cost for scanners, no additional investment was required. Thus, total lifetime investment was low but generated efficiency and effectiveness of the service system making the initiative suitable for large hospitals in countries with native and official language other than English.

The initiative also helps to promoted continuing medical education. Through the hospital networking, physicians in community hospitals can learn and increase their competency from electronic discharge summary generated from the Suandok Information System (SIS). The SIS and DigiCards, implemented for both OPD and IPD cases, was the medical innovation that promotes seamless integration in patient management among the hospitals in the network.

After medical diagnosis was given, drug prescription for each outpatient visit and inpatient discharge could be entered into the SIS that provided patient medication records for every visit including drug interactions and adverse drug reactions. Individual patient treatment history provided in the e-discharge summary (medical report) for each admission was sent back via mailbox after midnight automatically to the referring hospital for continuity of patient care.

After implementing DigiCards system, many government and private hospitals came to observe and learn from our experience. Since their visits, 5 major hospitals in Bangkok and 4 hospitals in Chiang Mai have been successfully implementing their own DigiCards system. Even Court of Justice applied the DigiCards concept to improve their work process.

The use of DigiCards system by scanning of patients' medical record at the Maharaj Nakorn Chiang Mai Hospital was implemented in many hospitals in Thailand and was shown to improve medical record management

Lessons Learned

 What are the impact of your initiative and the lessons learned?
Because the recording and scanning of patient records using DigiCards system occurred in real time, the information was readily available for all specialists treating the same patient in each visit. The system also enhances patient safety by allowing better management of medication to prevent drug overdose and unnecessary drug interactions.
Although the initiative was implemented at the Maharaj Nakorn Chiang Mai Hospital, the patient care at community hospitals was also improved. Through SIS, information in DigiCards could be communicated back to referring community hospitals in the form of e-discharge summary (medical report) after patients were discharged from the Maharaj Nakorn Chiang Mai Hospital. Information in e-discharge summary available including diagnosis and treatment plan would help the community hospitals to manage patients properly and to follow up patients at the local hospital without having to travel back to the Maharaj Nakorn Chiang Mai Hospital. Patients would save time and traveling cost without compromise on the quality of treatment due to the network care team approach.
Moreover, sharing of medical records among hospitals in the Suandok Healthcare Network integrated perfectly with the hospital's concept of “One Region One Big Hospital” allowing patients to receive quality medical care from any hospitals in the network without borders or boundaries.
Ultimately, the initiative improved the quality and efficiency of medical services through the use of information technology to facilitate medical information transfer among the Suandok Healthcare Network.

Lessons learned
Our experiences gained during the implementation of the initiative showed us that were scanning of medical records was suitable for certain big hospital in Thailand and countries those had their own languages and majority of people did not have high English proficiency but needed to use English medical terms.
Additionally, the big hospital in developing countries with a large number of patients and less proficient typing skill of healthcare personnel, scanning of patients' records was shown to be beneficial. The initiative, suitable for minimizing service cycle time in hospitals with more than 1,000 beds and more than 3,000 visits per day, benefited both the workforce as internal customer and patients as external customers.
These complementary applications and systems produced a comprehensive patient information system that could be systemically analyzed benefitting not only medical services but education and research as well.

It is clear that challenges concerning medical record logistics and information management encountered by large hospitals with overcrowded outpatient departments can be solved readily by implementing the DigiCards system. The initiative not only revolutionize method of data input for the hospital's information management system but also significantly improve timeliness, accuracy, quality and efficiency for all the people involved in patient care. There is without a doubt that the DigiCards system integrated with the Suandok Information System (SIS) Network provides a seamless healthcare that will promote a better health and wellbeing for all.

Contact Information

Institution Name:   Maharaj Nakorn Chiang mai Hospital, Faculty of Medicine, Chiang Mai University
Institution Type:   Government Agency  
Contact Person:   Watana Navacharoen
Title:   Associate Professor  
Telephone/ Fax:   66818831992
Institution's / Project's Website:   www.med.cmu.ac.th
E-mail:   wnavacha@med.cmu.ac.th  
Address:   110 Inthavaroros, Muang District
Postal Code:   50200
City:   Chiang Mai
State/Province:   Chiang Mai
Country:   Thailand

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