United Nations Public Service Awards Case Studies

Gujarat is one of the largest states of India with population of over 50 Million spreading all over 25 districts.
Health and Family Welfare Department (HFWD) look after healthcare facilities and administers public health policies in the state and governs 24 district hospitals and 6 medical college associated hospitals.

HFWD has responsibilities of collecting vital statistics for effective health management, Food and drug control administration, Store management and procurement of drugs and medical education. It is responsible for controlling/curing Tuberculosis, AIDS, Malaria, blindness etc. HFWD is also part of National health care programs for removing polio and other critical health threats. The health care programs offered by the department spread over many areas such as mental health care program, Maternal and Child Health program, Universal Immunization Program, Diarrhea Control Program, Acute Respiratory Tract Infection Control Program, and other nutritional deficiency control programs.

The above important areas were being dealt by various health program officers and the information so generated was compiled and brought out as basic health statistics. HFWD needed an integrated solution to administer all the sections of all the district and teaching hospitals locally and to track statistics and patient information over the state. In order to take prompt decisions at appropriate time required a holistic view of the functioning of all district level hospitals at the state head quarter level. This mandates integrated information system deployment across the hospital processes.

The Hospital Management and Information System (HMIS) developed by Tata Consultancy Services (TCS) has been envisaged to not only help the administrators to have better monitoring and control the functioning of hospitals across the state using decision support indicators but also assist the doctors and medical staff to improve health services with readily reference patient data, work flow enabled less-paper process and parameterized alarms and triggers during patient treatment cycle. It generates as well as maintains Electronic Medical Record (EMR) and makes it available across the hospitals. HMIS is state-of the-art healthcare solution to provide better care to patients by addressing all the major functional areas of the hospital & the entire gamut of hospital activities.

The Targeted beneficiaries of the project are:
• Patients & their relatives. (Government Hospitals)
• Doctors & Supporting Staff (Government Hospitals)
• Health Commissionerate, Govt. of Gujarat.
• Health & Family Welfare Department, Govt. of Gujarat.

What is the initiative about? (the solution)
The extent of reduction in time to deliver a service as observed in a couple of Hospitals are as follows: Activity Before HMIS After HMIS Registration (OPD / IPD case) 120 sec 20 sec. Discharge Summary 10 mins 1 min X-ray / Laboratory reports 10 mins 1 min Certificate issue 2-3 hrs 1 min Administrative / Analysis / Indicator reports 15-30 days 1 min Following points summarize few of the achievements implemented: • Unique Medical Record Document (MRD) Number across state for better tracking and tracing of patient. • Parameterized indicator comparison across hospitals using data warehousing concepts. • On-the-fly what-if analysis support by easy-to-use front-end screen for users. • Support for event/time based trigger through SMSes, bar coding for pharmacy tracking and employee attendance smart card access integration support. • Workflow management • Easy patient tracking. • Work Flow Management for users to easily access pending task. • Authorization • Authorization rights to higher authority to enhance level of security. • Prevent unauthorized access to system. • Critical transaction approval or rejection by higher authority. • Compliance with National and International Standards • ICD-10 : International codification for diseases. • HL7 : Messaging standard. • DICOM : Imaging standard. • NABH and NABL standards compliance. • Scheduled automated data replication over WAN for day-end data synchronization. • Solution to facilitate planning and monitoring of medical and health services at all levels of organization unit. • Bilingual online help (Local language + English support). • Multiple levels of security in the software, so that the data pertaining to various functions of the hospital remains confidential. • Drug Database Integration. HMIS has empowered the target group consisting of citizens, State administrators, Medical Superintendents, Health care staff viz. Doctors, Nurses, etc. Each hospital is unique in its requirements and priorities. HMIS is an end-to-end solution to the healthcare industry which offers the flexibility of allowing a hospital to choose from various modules as per the hospital specific needs.

Who proposed the solution, who implemented it and who were the stakeholders?
HMIS project was conceptualized by the department of Health & Family Welfare, Govt. of Gujarat with an involvement of TCS domain consultants and ICT experts to ensure the quality health using ICT as the tool to provide standard clinical & diagnostic tools, hospital management tools and integration of management information at the state level so as to ensure online review & monitoring. The implementation of HMIS project was envisaged across all 30 teaching and districts civil hospitals of the Gujarat state for enabling digitization of medical records of citizens and rural masses along with an objective of improvements of operational procedures. This was aimed at management of vital patient records, analysis of the critical health indicators so as to provide an updated planning & policy tool as decision support system to the administrators. Government of Gujarat engaged services of Tata Consultancy Services Ltd. (TCS) to develop the software applications for HMIS project. The application was developed based on the requirements given by the government, hospital administrators, doctors & healthcare staff. ICT has helped to achieve the following objectives of HMIS project: • Improved Patient Care by providing unique identity number enabling user-friendly maintenance and retrieval of electronic medical records during life-time follow-up visits. • Creation of Electronic medical records and shared across hospital by integration of same at state level. • Improve clinical & diagnostic services through Technology enabled workflow driven processes to cut down on manual transmission of data - cutting on time delays and human errors and ensure data integrity. • Streamlining of Operations by templatized data recording and seamless integration between various functions for smooth patient movement within various service departments. • Early alerts on disease trends/Cause of deaths on International codes. • Increased Focus on hospital management and on time management through increased efficiency in delivery of health care services. • Effective Administration and Control by pro-active monitoring of quality health service indicators and cost of per-patient quality services. • Management tool for comprehensive drug management. • Provide planning & policy tools for cost analysis. • Provide financial tool for billing, accounting and budgeting. • Integrated state-level holistic view of the resource utilization including skilled manpower, high-tech equipments and facilities. • Online review & monitoring tool for monitoring of identified indicators and comparison of efficiency and performance among hospitals, services by doctors, financial data and staff. The Project stakeholders are: • Patients & their relatives. (Government Hospitals) • Doctors & Supporting Staff. (Government Hospitals) • Secretariate and Commissionerate of Health and Family Welfare and Medical Education, Govt. of Gujarat. • Total Solution Provider. (Tata Consultancy Services Ltd.)

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 HMIS developed by TCS is to provide better care to patients by addressing all the major functional areas of the hospital & the entire gamut of hospital activities. HMIS design was startegised considering monitoring of pre-defined health indicators and a few exception reporting to help informed decision making by the hospital management and state level administrators for policy and strategic decisions. • A Bottom-Up approach was used to arrive at user requirements and build architecture design of the HMIS solution across the Gujarat State following a piloting concept to get user acceptability and stabilize the application usage. • The first phase included Gap analysis of functionality offered by Tata HMIS and the specific functionality requirements that the users across the state desired. A series of presentations of existing functionality vis-à-vis user interview was adopted as process to document user requirements. This was in iterative manner and could be completed with 3 rounds of such demos and discussions. SSG Teaching hospital (1800 beds) and Gandhinagar Civil hospital (200 beds) were selected as Pilot Hospitals for such user interaction, freezing of requirements and piloting the customized HMIS • On successful live functioning of HMIS by users for full 3 Calendar months at Gandhinagar Civil the HMIS was rolled out in the remaining hospitals. • All of the identified users were trained for their scope of work, as covered as part of HMIS before locations start using the HMIS. As support for capacity building, TCS provided a dedicated team of nearly 40+ on site support executive who provided handholding to the users on a daily basis. • To further strengthen the capacity building process, HFWD identified a few IT Savvy personnel from each location, who were trained by TCS as Champions and Single Point of Contact for technical trouble shooting and user hand holding in each of the Hospital. • Additionally, a Centralized Helpdesk was setup at the Secretariat where a team of TCS support executives is available on call to answer queries and make possible changes immediately on remote support basis. • This led to total of 6000+ user configuration in all Hospitals, located across the entire State. • Each hospital has its local server room, where 2 twin CPU servers are configured as backup to each other and hosting Application and DB server software. • All users located at particular location access the HMIS from local servers and add the data to the local DB server. An un-attended scheduled replication script gets the incremented data updated every mid-night to the centralized server to provide the as-on-last working day EIS dashboard to the secretariat. • Few of the decision making users such as IAS officers and others management level users located across the state have access to the application through Gujarat State Wide Area Network (GSWAN). Therefore, this is a hybrid connectivity architecture comprising of decentralized access and centralized MIS/ EIS server configuration for state-wide view.

b. What were the key development and implementation steps and the chronology? No more than 500 words
Project has following phases: • Project Start Up -Project Plan and Project Profile • Analysis – User Requirement Specifications Document Sign Off, System Test Plan • Design – Functional Design Document • Construction / Customization – Application Code • System Testing • Acceptance Testing – User Manual, Operational Manual, Sign off for the Application • User Training • Pilot Implementation (at 2 sites) • Rollout at 6 Major and 24 District Hospitals (including Pilot site) • 24* 7 support on required basis for one year at major hospitals • Office hours support for remaining 24 district level hospitals • Warranty support for 3 years (in parallel with the 24*7 support) • Annual Maintenance Contract The current status of HMIS project is as follows: No. of Users 7000 + No. of Modules 30 Size of Database (Total size till Nov. 09) 2 -2.5 GB at each hospital. 53 GB at central server No. of Non Teaching Hospitals covered 24 No. of Teaching Hospitals covered 6 No. of LIVE Hospitals 29 No. of registrations (Average Daily) 600 per hospital. Overall Gujarat 18000 + Average No. of Transactions Approx 1,00,000 per hospital per month (For Average Hospital) No. of Users Trained 3200 +

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
The major challenges involved in getting HMIS project to the current stage were as follows: • Overcoming the initial resistance by government employees • Large number of users with little computer knowledge • Having a modular design for easy maintainability • HFWD was not having a standardized procedures, and the process to monitor, and measure the progress of National Health Mission, National Health programs and State health mission was on adhoc basis. • The Hospital locations are scattered across the state and coordinating for requirement gathering from users contributing from all location and creating infrastructure for system implementation was not an easy task. • Doctors and para-medicos typically rejected the proposal to key-in data as they keep on examining patients, due to either genuine high workload or due to human tendency of not changing the way one is doing the business. Following strategies were adopted, • To overcome most of these obstacles Health Commissioner introduced an IT committee comprising of key users such as specialty doctors, nurses, administration and accounts users, pharmacy and lab technicians etc. • The Commissioner took regular fortnightly review meetings involving all the stakeholders till the time the project got stabilized. • Commissioner setup a dedicated Project Implementation Unit, to express the infrastructure building and preparing server rooms as well as get LAN setup at each user connects. • HFWD also appointed AHAs and system administrators across all locations for monitoring hospital processes and measuring HMIS progress and usage. • A special process was approved to hire data entry operators for heavy transaction service desks across the hospitals for each location, from the funds of Rogi Kalyan Samiti, which expedited data capture as it was generated and the risk of user rejecting application due to additional work load was overcome by such arrangement. • Regular refresher trainings and orientation for users was a key to keep them engaged with usage of the application and ensure their dependency on the application.

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
HFWD used services of GIL for procurement of the hardware and infrastructure bought-out items following prescribed procedures. Inter-location connectivity was setup by the Dept of Science and Technology exploiting the Gujarat State Wide Area Network (GSWAN) for connecting all hospitals and data replication. HFWD assigned HMIS implementation task to AHAs, RMOs and CDMOs as key responsibility. They in turn had created location wise champion’s team to manage daily functioning of HMIS. Project, mandated TCS to provide onsite hand holding support for 12 months and remote support for application for 36 months after go-live, to ensure the application got stabilized and reasonable usage was achieved across the state. HFWD also has initiated internal approval process to extend Annual Maintenance Contract for HMIS with TCS to sustain and manage the project.

Is the initiative sustainable and transferable?
HMIS project is sustainable over a period of time due to the following factors: • User Convenience (Local language support) • Uniform & Integrated System • Adequate Security & Authentication provisions • Role Based Access • Reliable planning for Database Backup and Recovery • Application Availability (Back-up server at each local site + Central server) • Assured Data Confidentiality • Change Management • Training & Support Following aspects of the project are addressing the sustainability related issues. Capacity Building: • Regular training on various modules of HMIS application is imparted to all the users based on their roles in HMIS usage. Training objectives and contents are defined and customized as per the user’s level in organization hierarchy. User Feedback: • Selected users are invited for brainstorming sessions and application demonstrations, where the domain specialist share their views and deliberate on various administrative, and operational issues related to the application. This helps in incorporating the right changes and implementing them in the right manner. Hand Holding: • As part of HMIS implementation model, users at all levels were provided hands-on training where they were actually mentored for using the system for their business activity and help them during operational issues. Hand-holding also helped in resolving the change management related issues which again increased the sustainability of the project. Committee formulation: • High powered committee at the secretariat level and Project Execution committee at the Directorate level have been formed. Project Execution committee was involved in overseeing day to day issues and ensuring resolving of all operational issues during project implementation. High powered committee was involved in giving the broad direction to the project and resolving any policy related issues.

What are the impact of your initiative and the lessons learned?
With the help of HMIS, HFWD of GoG is able to provide quality service to patients and waiting time to avail the services is reduced in following manners: Parameter Description Before HMIS After HMIS OPD waiting Time Time between patient gets registered into the system and the doctor examining the patient 1H - 0M 0H - 20M Lab waiting Time Time between the lab test request being raised and the lab test result entry (Further bifurcation into the sample collection time) 1H - 20M 0H - 30M Radiology waiting Time Time between the radiology test request being raised and the radiology test result entry into the system 0H - 15M 0H - 10M Registration to Dispensary Time Time between patients gets registered into the system and medicines issued to patient against given prescription 1H – 20M 1H - 00M A strong foundation has been laid through HMIS for providing better services to the entire stakeholder’s of Health System. This project is considered to be a benchmark project for the state of Gujarat in this era of e-Health. The application provides various services to different kinds of stack holders are as follows: Citizens: • Less waiting time. • Longer life of patient records. • No need to carry bulky files along as all the information is available online through the application. • Efficient health services at hospitals due to digitized history records. • Standardized charges for health services. • History available on finger tips – so better care and treatment. • Online Information about doctor availability. • Easy to find various services in the hospital through information kiosk in local language. Doctors and Healthcare staff: • Increased efficiency due to easy access to electronic medical records (EMR), templates for treatment recording cycle and ICD10 codification support. • Can be well-appraised for all patients using parameterized SMS alerts. • Templatized data recording of patient treatment and seamless integration between various functions which reduced time-to-serve patients with quality patient care. • Building knowledge-base for research & development support by individual doctor or organization. State Administrators, Medical Superintendents: • State-wide holistic view of hospitals’ day-to-day functioning. • Monitoring of pre-defined health indicators. • Decision support based on exception reporting using alerts and triggers. • Management Information System comprising of status update reporting. • Monitoring of effectiveness of National Programs and identifying areas of improvements.


Institution Name:		Commissionerate of Health
Institution Type:		Government Department
Contact Person:		Smt. V. L. Joshi Joshi
Title:		Commissionerate of Health
Telephone/ Fax:		079 - 23253271
Institution's / Project's Website:
E-mail:		cohealth@gujarat.gov.in
Address:		Block No 5, 3rd floor,
Postal Code:		382010
City:		Gandhinagar
State/Province:		Gujarat
Country:		India

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information