PROJECTS

The tsunami in the Indian Ocean, in December 2004, seriously affected health care in Sri Lanka by damage to  hospitals, loss of records and displacement which exposed the affected population to increased risk from outbreaks of infectious disease. In order to ensure effectiveness of the rehabilitation measures and to help prevent outbreaks, the collection and transmission of health information from the periphery became a top priority of WHO.

Monitoring population health as it presents to healthcare services is called disease surveillance. If it covers all diseases, it is multi disease surveillance (MDS). In 2005, the Sri Lanka country office of WHO established computerised MDS systems in a number of large hospitals in tsunami-affected areas. In 2006, part of the project in the government hospitals of Batticaloa District of the Eastern Province was taken over by the Austrian/Swiss Red Cross at the request of the Epidemiology Department of the Health Ministry, the Provincial Health Services and the directors of the hospitals. The Austrian/Swiss Red Cross Consortium was the main sponsor, with additional funds coming from the Austrian newspaper the Kurier and Siemens Austria.

The project was managed by Lunar Technologies, starting in July 2006 and running to the end of 2007. With the help of computer hardware and software, it was designed to provide an electronic record of diagnostic information on all patients treated in the hospitals. The main objective was to improve the notification of communicable diseases using e-mail. In each hospital, a computer network was set up with a server connected to workstations. The Medical Officers of Health offices also received a computer connected to the Internet via telephone.

Lunar Technologies re-wrote the MDS program that had been produced by WHO with the help of the computing department of the Eastern University, using the Caché database (www.InterSystems.com). We worked in close consultation with Health Ministry staff especially the Epidemiology Department, the RDHS of Batticaloa District and the directors of the Batticaloa Teaching Hospital and the District and Rural hospitals. The project was supported technically by the WHO country office in Colombo.

Alongside computer hardware and software, training was one of the largest parts of the project. All the hospital staff responsible for data input were trained in basic computer use followed by intensive training on the job. Basic training was carried out in the computer laboratory of the Eastern University; hands-on training was done in the hospitals. After 12 months support, the hospitals were able to manage the systems by their own staff.

The experience gained in the first project in Batticaloa District proved that the concept of simple computerized patient records is viable in Sri Lanka if adequate technical and material support is given to hospitals after installation. Because of this success, the Austrian/Swiss Red Cross was requested by the Health Ministry to extend the project to the other two administrative districts of the Eastern Province, Ampara and Trincomalee. All three districts were severely affected by the tsunami, but in Ampara District it was mainly the area close to the sea. For this reason only the coastal health district of Kalmunai was included.

The project plan was to install computer systems in the three large hospitals of the area and the 10 smaller hospitals, and to develop an improved version of the MDS software. As in the previous project, hospital staff were to be given training on basic computer usage and network management, as well as on-the-job training. It was hoped for computers to replace the paper records and the books written by hospital staff. The main objective was now to support improved patient care, but the previous objective of providing information for public health management and planning remained.

In the first project, the database deliberately concentrated on disease surveillance as this was the most important priority in tsunami-affected districts. However, it was not long before health care staff in the hospitals realized that the computer could provide them with much more assistance if they could record detailed patient medical records. Even in government hospitals, which do not have typically computerised functions such as billing, appointments and waiting lists, computerization of patient information could greatly increase the quality of care and the efficiency of the clinical staff.

As is now well known, the project was an astonishing success, and the staff of nearly all the hospitals started to keep computerized medical records. To this day the OPD clinic in the Trincomalee General Hospital is paperless and has been so for 5 years. In nearly all the smaller hospitals of the second project, the systems are still in use for recording OPD visits and admissions. In the last few months of the project, the new software was also installed in the hospitals of the first project.

Unfortunately funds for a complete project as had been planned, with one-year hands-on training and an orderly hand-over of the project to the healthcare authorities, were not available from the Austrian/Swiss Red Cross and the 4-years planned for the projects were reduced to three. In the fourth year of activity in the Eastern Province, funding for project was therefore taken over by Lunar Technologies with the approval of the Swiss Red Cross and the EP Provincial Department of Health Services. But after six months, the PDHS was able to mobilise funds to restart the project and to maintain, which continues to this day.

Although MDS is a very useful program, the fact that is was written using a proprietary database (Caché) is a big drawback to its widespread use in the emerging economies of South Asia. In order to resolve this issue, Lunar Technologies was contracted by the RDHS Kegalle in 2010 to convert the MDS software into an open-source patient record database based on the free software LAMP (Linux, Apache, MySQL, PHP) and to pilot it in five hospitals in Kegalle District. Funding for the project was provided by the World Bank, channeled through the Information and Communication Technology Agency (ICTA), a Sri Lankan Governmental agency responsible for extending e-governance throughout the country. The project included general computer and medical record training in all 5 pilot hospitals.

Installation of the network and the computer hardware took place in each pilot hospital while the training was being carried out. For the staff training, 10 workstations were put into one large room in each hospital, usually an auditorium, and connected to a small server. As in the Eastern Province, the first 2 hours of training for each group covered general computer knowledge, use of the mouse and an introduction to touch typing with 10 fingers. This was followed by 2-3 hours practice on the HHIMS software. At the end of the half-day of training, hospital staff could usually go to their workplace and start working on their own computer which was now installed there.

In accordance with the wishes of our client, the main thrust of the programming effort was to improve speed and user-friendliness of the OPD medical record. As a result, the main benefit of HHIMS over MDS was seen in busy out-patient departments where clinical records, prescriptions, laboratory requests and treatments could now be produced by the doctor without using paper. There was less acceptance of the system in the wards, where it had not proved possible to program as user-friendly a system as the hand-written “Bed-Head Ticket” used for admitted patients. The unstructured and largely narrative form of these manual tickets make them easy to write to, but difficult to extract a structured and systematic medical record from. We tackled this problem with our later project in collaboration with the staff of the Pain Clinic in the NHC.

As can be seen from the previous project, HHIMS initially concentrated heavily on a fast and comfortable out-patient record. The hospitals that were attracted to HHIMS were therefore those with heavy logistic work-loads in the ambulant section of the hospital. The ICTA was therefore pushed in the direction of covering all the functions of the OPD doctors that take up their time. As a result, the ICTA contracted Lunar Technologies to develop a number of additions to the OPD module of the initial system, taking it beyond the previous MDS functionality. These additions therefore involved mostly the out-patient department record, and were designed to make it more streamlined and user-friendly.

In the improved version of HHIMS the patients could be searched for automatically by the OPD doctor using a bar-code reader (see the reader on the doctor's table) and an OPD appointment system was developed. To speed up patient identification, patients were provided with a token for each appointment printed with a bar-code on a POS-printer. This made it very easy to look up the patient in the database and to display their past history on the screen. The Patient registration and the Visit medical record modules were also completely re-written.

This improved system was installed in the Dompe Base Hospital at the beginning of 2012 and is one of the most successful and heavily used of all the HHIMS systems up to date. It was also piloted in five other hospitals, 3 in Anuradhapura district, Dambadeniya and Kinniya. Although there were unique requirements in each hospital, the systems were installed in the same way in order to simplify the implementation, documentation and overall management of the hospitals in preparation for other future implementations throughout the country.

In December 2012, Lunar Technologies received a contract from the RDHS Colombo District to install the distribution version HHIMSv1.3 in the Base Hospital - Avissawella. The installation was finished in December 2012 and the system was opened by the Provincial Minister of Health, Jagath Angage and the Health Services Deputy Minister Lalith Dissanayake on 11 January 2013. 

The installation, training and program modification was supported by a grant from South Korea.

Word of the success of the installations especially the one in the District Hospital – Dompe, soon started to circulate, and assisted by the enthusiastic publicity by the staff of the hospitals. However this publicity led to a wider discussion of the implications of the increasing computerisation of health records in government hospitals in the country and the importance of interoperability and standardisation. The ICTA therefore contracted Lunar Technologies to re-write HHIMS using a structured framework that followed these international standards. The software functionality was also made more flexible, so that different hospitals could adapt it to their own needs. This was done through a system of Questionnaires that users can create from the ground up and integrate into the standard record structure of the software (OPD/Clinics/Admissions).

This new software was designed and reviewed by two of the hospitals in the previous project (Dompe & Dambadeniya) and is currently being piloted in four hospitals (Panadura, Mahaoya, Mangalagama and Point Pedro).

The Commercial Bank of Ceylon donated the computers for the Pain Clinic and set up a Local Area Network (LAN) with laptops and PCs. WiFi provides the communication and connection to the Internet is established via a GSM modem. Lunar Technologies provided the software and training.

We initially installed the first version of HHIMS in September 2013 for training and for users to get used to the computer. However, as the development of the new version was being carried out at the same time, we could replace it with HHIMSv2 when actual patient data entry started, in March 2014. There was close collaboration with the Clinic staff during the development to design the Questionnaires – a major new feature of HHIMSv2. These are used to enter more details on patient registration, structured patient histories using Problem-Oriented Medical Records (POMR), follow-up consultation notes using SOAP records, and clinical diagrams on which symptoms and findings could be drawn by the doctors.

The introduction of the POMR and SOAP notes into the National Hospital might have far-reaching effects on the future direction of medical record software in Sri Lankan hospitals. The concept of flexible Questionnaires managed by hospital staff themselves and requiring little programming skill, might provide the breakthrough that those of us working in this field have been looking for. We will learn a lot more once more hospitals staff start to use the new version of HHIMSv2 (now in beta-test phase) to replace their current narrative manual notes.

The inventor of the Problem-Oriented Medical Record (POMR), Dr Larry Weed, once said: “Why do pilots, who are as well trained as doctors, rely on questionnaires and highly structured records while doctors rarely do? Perhaps it's because pilots fly in the same plane as the passengers.” If you want an introduction to the POMR and have an hour to spare, you should look at this excellent talk by Dr. Larry Weed @ https://www.youtube.com/watch?v=qMsPXSMTpFI

We must acknowledge the help and collaboration of Dr. Gihan Piyasiri who worked tirelessly to advise us on the production of the questionnaires when he was the director of the NHC Pain Management Unit.

A contract was signed with the RDHS, Kalutara, in April 2014 to install the beta test version of HHIMS (version 2) in the Provincial Base Hospital – Panadura. Training and installation started in May 2014 and full-scale patient registration started in June 2014. Doctors started entering the OPD record in September 2014. It is expected to be fully operational with computerised ordering of laboratory tests and treatment by November 2014.

During the initial period of patient registration, it was noted that printing the Patient health ID card on POS-printers was not convenient for the patient as the slips produced faded after several weeks. The patients were therefore obliged to photocopy the card. In order to deal with this issue, the hospital purchased several label printers which use the thermal transfer technology (with rolls of wax-carbon paper). These printers now produce excellent quality labels that are waterproof and long-lasting. The label can be stuck on to a blank card or an old card used for another purpose (such as a phone card). The cost of a label (plus carbon ribbon usage) for one Patient card is 1 Rupee.

A new feature of HHIMS developed for this hospital is an appointment display screen to show patients which OPD doctor is free to see them. These are normal television screens (32”) which also speak the appointment number in Sinhalese. Similar screens are installed at the dispensary and outside the treatment rooms to display the number of the next patient to receive medication or treatment.

In September and October 2014, the database in the Base Hospital, Dambadeniya was converted from HHIMS version 1.3 to HHIMS version 2. This proved to be a difficult task due to the considerable changes to the internal tables that had been made after the first version was programmed (in particular the handling of medications and User privileges). However, it was possible to convert the data and transfer all the previous patient information into the new database. As the staff of this hospital are quite experienced in the use of the old system, they were able to point out features that were present in the first version that had not been fully implemented in HHIMSv2 This had the beneficial side-effect of testing the re-write to ensure that all the previous functionality in HHIMSv1 was available.

This conversion is not a simple process and has to be carried out by a programmer. It will therefore not be offered by Lunar Technologies as a standard package.