May 13, 2009, 10:48 AM — Electronic health-care systems have become a hot topic around the world, with governments providing stimulus programs to hurry the trend along. A renowned hospital in Thailand provides something of a model for the benefits of an e-health system, but it also highlights a challenge that medical centers in more developed economies may face.
Thailand's Bumrungrad International Hospital has digitized as many aspects of hospital work as it can, enabling it to more than double the number of patients it can handle each day, increase safety and cut its patients' bills. "It’s made a significant difference," said Chang Foo, the hospital's chief technology officer.
Bill payment, human resources, record keeping and inventory are now all done electronically, allowing the hospital's staff to get more work done. Doctors no longer wait around for patient records, such as X-ray or blood test results, to be delivered by hand. And wasteful duplication has been eliminated because doctors can see what tests have been done already and access results immediately.
Digitization has also improved safety. Bumrungrad has an e-prescription system that helps to eliminate errors from illegible handwriting, and allergy alerts that warn doctors if they are prescribing medications that are unsuitable for a patient and can suggest alternatives based on the symptoms observed.
Microsoft was so impressed with the hospital’s software system, which was developed by a company called Global Care Solutions, that it bought the company. It now sells the software almost everywhere, outside of North America, as the Amalga Hospital Information System (HIS).
Bumrungrad's old way of doing things, using paper and film, resulted in thick file folders in sprawling record rooms that had to be collected and updated by hand. Only one attending doctor could see them at any given time. Should a specialist on another floor of the hospital want to see blood test results, they might have ordered a new test just because they didn't know what was in the file.
The most obvious benefit has been in the number of patients Bumrungrad can handle safely in a day. In 1999, the hospital could handle up to 1,500 people per day, but now Bumrungrad sees 3,000 to 4,000 patients a day with no increase in administrative staff, beds or rooms.
That increase in efficiency is one that other countries would like to replicate. The U.S. and the U.K., for example, are pushing forward on plans to use information technology to improve health care. To increase the uptake of such systems, the U.S. has earmarked US$19 billion for spending on health information technology, while the U.K. has set aside £12 billion (US$17.5 billion).
But the adoption of electronic health records has been slow in many countries despite the apparent advantages. A study published in the New England Journal of Medicine last month found that only 1.5 percent of U.S. hospitals had a comprehensive electronic health record system, while an additional 7.6 percent had just a basic system.
There are a number of reasons why e-health efforts have not moved more quickly. Privacy has been a major concern, with fears that insurance companies might deny coverage to people they know are suffering from an illness, making the security of digital records vital.
Cost is another major factor. Electronic health record systems can cost between $20 million and $200 million, a big investment for hospitals in the middle of a recession. Bumrungrad's tab was less expensive because it worked with Global Care Solutions to streamline its system, and as a private hospital operating in a relatively low-cost environment, it was able to set aside more funds for new technology.
The New England Journal of Medicine study says U.S. hospitals cite cost as the top barrier to building an electronic record system, followed by concerns over maintenance cost and resistance from physicians. The huge budget passed by the U.S. is an attempt to solve the funding problem, but even that figure "is a long way from being sufficient to cover the total cost," according to market researcher Ovum.
But there is another hurdle, and one that Bumrungrad was fortunate not to face: the problem of legacy equipment. Ironically, hospitals that moved aggressively in the past to computerize their health systems may now face the biggest challenge in creating a unified electronic records system.
In the U.S., for example, IT systems entered hospitals through expert physicians and specialty departments, who often introduced various types of equipment and proprietary software from preferred vendors. Over time, the number of different IT systems multiplied at individual hospitals, making the collection of data into a single health record an integration nightmare.
One of the top medical centers in the U.S., The Johns Hopkins Hospital, for example, uses software from dozens of vendors, including Microsoft, GE, Eclipsys, Meditech, Siemens and SAP, running on hardware ranging from IBM to Dell to Apple and more.
Of course, Johns Hopkins is even unique among U.S. hospitals because it's a research hospital attached to a university, not just a care provider. The specialists working there demand the best tools possible for their jobs.
"We'd be reluctant to settle for a system that's 'good enough'," said Stephanie Reel, vice president of information services at Johns Hopkins. "We have very demanding scientists, doctors and nurses, so we go for the top of the line systems... and there's a cost associated with that."
The unique IT tools for each specialty area have created a complexity and cost that is not sustainable, she said. But many of the systems may not ultimately be necessary. Just as most people only use a fraction of the features in their word processing software, some specialty IT systems at hospitals may be overkill, she believes.
"In the U.S. we’ve become much more accustomed to saying we need something that’s highly specialized to our discipline and I think the reality is somewhere in between," Reel said.
That wasn't a problem for Bumrungrad, an example of a hospital that has benefited from the U.S. experience. Some of the software developers at Global Care Solutions previously worked on hospital IT systems in the U.S. and Europe, and were able to bring best practices to the effort.
The software maker was also able to troubleshoot issues specific to Bumrungrad by working with doctors and nurses.
The result of a single software set for all Bumrungrad departments is a system able to communicate with itself throughout the hospital, and manipulate data in any way the hospital deems useful.
The hardware is also simplified to use equipment from one vendor, Dell.
Bumrungrad’s entire system, including backup, includes two database servers, Dell 1950s, three application servers, also Dell 1950s, and Dell/EMC CX3-80 SANs for storage. Every PC, monitor and printer at the hospital is also from Dell, making it easy for the IT staff to take out and replace broken computers. Around 20 people work for the IT department at Bumrungrad, far fewer than at U.S. hospitals of a similar size.
U.S. IT systems are so complex that Microsoft sells an entirely different software for electronic medical records there, called Amalga UIS (Unified Information System). As the name suggests, the main function of the software is simply to unify the data collected by all of the other proprietary systems at a hospital to create an electronic medical record.
Bumrungrad's experience suggests that an e-health records system will become essential once other hospitals see the cost reductions and other benefits. The safety improvements alone at Bumrungrad could slash costs in the U.S. by reducing the errors that lead to lawsuits.
"I have seen the actual effect, when physicians are nervous about litigation," said Pat Downing, a founder of Global Care Solutions and now senior director of Amalga HIS products at Microsoft. "They order more than, perhaps, they need to, to protect themselves. Frankly, there is also a lot of over-ordering related to poor coordination of care, when doctors do not know what other doctors are doing in real time."
Microsoft is far from alone in its interest in e-health systems. Large vendors from IBM to Philips as well as companies such as Allscripts, Cerner and Eclipsys have been buying up or partnering with promising companies focused on medical technology.
And evidence of the benefits of e-health records continues to mount.
A study published in the Archives of Internal Medicine in January reported that one part of an electronic health record alone, automated medical notes, was associated with a 15 percent decrease in hospital deaths. An electronic health record means no more misplaced notes.
Eliminating paper records also prevents the spread of deadly organisms. Viruses and germs that cause diseases hitchhike on X-rays, envelopes, clipboards, paper and the people that carry them from place to place throughout a hospital.
Digitization can also help in simpler ways.
Bumrungrad cleared out the room where patient record folders were stored after uploading data to the digital record. In place of the sprawling file cabinets is a children's clinic able to treat 110,000 children annually in a spacious, 300 square-meter area (10,000 square feet). There’s even a play room.