Computarized Systems

Computerized Systems in the Belgrano Hospital

and the Promotion of Self-Governing Groups

Eduardo Rodasa, Pablo Moricib, Roberto Gallino Fernandezb, Angel Toniettob

a Division of  Medical Informatics, Hospital “Manuel Belgrano”, Buenos Aires, Argentina

b Office of the Director, Hospital “Manuel Belgrano”, Buenos Aires, Argentina

Abstract

The present paper describes the experience of introducing computerized system in the Belgrano Hospital, a health care provider located in the city of San Martin, in the periphery of Buenos Aires. It also explains and analyses what has been done since 1989, when the use of computers was initiated. Today we have in operation a local network connecting 55 computers, and the whole provides services to thirty three different working areas. All of them are operated by personnel especially instructed through permanent in-house training courses. The software in use and its implementation in the different units of the hospital are also described in this paper. By obtaining, analysing and processing a considerable amount of reliable information  thanks to the appropiate informatics tools, and by letting the hospital workers participate and self-direct this endeavour, we have been capable of better serving the population we assist.

Keywords:

Health Computer System; Hospital Computer System; Medical Informatics

Introduction

What is peculiar in our experience is the fact that our institution is a public hospital, serving a low-income population (including some nearby shanty-towns). In Argentina the prevalence of hospital information systems is very low, and therefore the pioneering experience done in our institution was a quite unusual one, as technology improvements of this sort are normally concentrated in private clinicas, serving high-income communities.

The paper also discusses the objetives stated by the hospital management responsibles, as well as the results obtained. From these assessments we conclude that the adoption of computer-based systems provided a valuable contribution to the growth of the hospital, in both institutional and human terms. This has resulted in a noticeable improvement in the quality of the curative care provided to patients as well as a valuable help for health promotion activities within the population we assist.

Materials and Methods

A hospital is a complex type of organisation, and those who are in charge must be conscious of the numerous variables involved in its management. From 1985 we have adopted a sociological approach to the organisation which has led to an increase in the participation of individuals and groups in the institution’s life. Since the beginning of this change in the organisational culture we have devoted ourselves completely to the promotion of self-governed groups.

The experience was carried out in different stages, selecting processes that allow the institution as a whole to visualise the achievement of goals and communicate the results of such efforts to the rest of the organisation. The Medical Electronic Data Processing (EDP) department of the hospital was created within this conceptual framework. The purpose of this paper is to explain and evaluate the computer-based system at the Belgrano Hospital, a public health care provider.

             1. Change in the organisational culture

             2. Participating management

             3. Reconstruction of the rewards and salary systems

             4. Promotion of self-managing work teams

The Belgrano Hospital is located in the city of San Martin, a suburb of the Province of Buenos Aires, Argentina. It’s Programmatic Area covers a population of 120,000 inhabitants, embracing large zones of extreme poverty just as many other zones of the Buenos Aires periphery. Its building structure consists of 2 sectors: one that is 60-year old and another modern sector that includes the Emergency Room and External Consultation rooms. It has 176 available beds (120 beds for adults and 56 for children) divided in sectors of Progressive Levels of Care; 24 Maternity beds, 6 beds for Adult Intensive Care, 6 in Intermediate Care and 24-hours Central Laboratory, x-rays and Obstetrics Ultra Sound facilities. It has 146 medical professionals, 119 nurses, and 81 people working as administrative personnel, technicians and maintenance; 64 medical Residents and 9 others grant-holders carrying out their post-graduate training. There are 122 employees contracted as watchmen, kitchen help, maintenance and cleaners.

Under these conditions our basic objective was to develop a strategy towards the creation of an Electronic Data Processing Center in the hospital, to provide better services to the community. We defined the Medical Computer-Based System as a combination of interrelated elements with the final aim of obtaining timely, necessary, and relevant information in the area of health care, complete in content and clear in presentation. The possibility of introducing computers in our hospital was due to various concurrent circumstances which happened at the end of the ‘80:

·   the increase in personal computers processing speed,

·   the increase of data access speed,

·   the increase in the capacity of data storage and

·   the significant decrease in the costs of hardware

The first computers dating from 1946 weighed 30 tons, occupied whole rooms and had 18,000 vacuum tubes that stopped functioning in a rate of one every 7 minutes. Today, less than 50 years later, a tiny chip has much greater efficiency and reliability. Personal computers are also now economically accessible to many institutions. To make a classical comparison, if the automobile industry had followed a similar evolution, today we would have at our disposition a Rolls Royce with the power of an ocean liner for less than 3 dollars and it would be capable of going around the world 25 times on just 2 gallons of fuel 1 .

Computers would also allow us to:

·   standardise and unify data collection

·   identify the population

·   categorise problems

·   ease internal and external hospital commu-nication

·   encourage training

·   carry out research

·   remove inaccurate methods

The introduction of personal computers was therefore decided to accomplish the objetive of developing computer-based systems in the hospital. On these premises, it was decided to:

·   work with distributed systems

·   develop individual areas

·   integrate those areas in network

In this way, several low-cost PC- type workstations were installed in different areas of the hospital. Each area was developing the programmes that best suited their needs and its personnel received appropriate training according to a plan of priorities decided by the hospital management.

Areas and programmes:

·       Preventive Medicine:

Aids Programme

TBC Programme

Nursing and undernourished Programme

Arterial Hypertension Programme

Prevailing Pathologies in patients from Pro-  grammatic Areas

·   Maternity:

Perinatal Data Base

Ultra Sound Data Base

Ultra Sound Protocol Reports

·   Neonatal Unit:

Perinatal Data Base

·   Cores V - PAMI (Elderly patients scheme):

Quick reference for 41,000 PAMI members

·   Pathology:

Code Data Base of Pathologic Diagnoses

Protocols Report

·   Laboratory:

Data Base of Laboratory Tests

Protocols Reports

·   Accounts Office and Treasury:

SAMO setting (Provincial-wide health care organisation)

Suppliers current accounts

·   Procurement Department:

Purchases Requirements

Reference Prices

Suppliers selection

National Nomenclator of Goods & Services

Reference and Directory of suppliers

Invitations for tender

Specifications for bids

Comparative Forms of prices

Minutes of pre-issuing

Rules and Regulations

Purchase Orders

Fulfilment of contracts

·   Pharmacy Warehouse:

Pharmacy stock & consumption references

·   Pharmacy:

Follow-up of Laboratory Services

Current Stock

Medicine consumption

Detailed stock movement

List of documents

Critical Stock

·   Associated Management:

Pharmacy stock and consumption references

Follow up of Laboratory Services

Collection of Data of General use for Associated Management

·   Personnel Department:

Presence control forms

Years of Service

Present Position

Absenteeism Control

Certificates

Schedule stickers

Reports to Health Department

Medical files

Overtime

·   Emergency Service Department:

Record of assisted patients data

Medical Diagnoses Code (WHO)

Certificates of medical attention

Daily attention statistics

Daily attention register in Emergency Room

·   Admittance and Discharge Office:

Record of patients to admit data

Room and bed number assignment

Statistical Report for Social Security Services

Diagnoses coding of admitted patients

On line reference of admitted patients and their location

Daily register of patients admitted

·   Reception Desk:

Data schedule assigment

Medical diagnoses coding according to WHO

Statistical report of monthly visits

Statistical report of non-profit hospital Co-operative Bonds

Daily visits to Ambulatory Clinic

·   Invoicing & Patrimony:

Invoicing to Social Security Services

Current accounts of Social Security Services

Report of hospital possessions

·   EDP Department:

Software programmes development

Costs accounting system

Systems maintenance

Human resources

Permanent training courses

Counselling and support to Medical Services

National Academic Network

·   Management (Head):

Collection of general-purposes data for Executive Direction

At present all the above tasks are ensured with a total of only 55 compatible personal computers, including models based on old and more recent types of microprocessors (XT, 80286, 80386, 80486 and Pentium). They are distributed in 33 areas, and constitute a local area network (LAN). The systems are operated by in-house trained personnel. It must be stressed that the growth of the network was done step by step, as the hospital did not have any special budgetary allocations or grants for computers procurement, and this required and implied a very carefully managed, gradual, and difficult process.

Results

The interaction and the increased performance of computer-based systems of the different areas, have allowed for the achievement of results beneficial to the community that the hospital assists as well as to the doctors and the rest of the staff.

The Preventive Medicine Department utilises the computer-based systems to detect and control important social diseases. On a daily basis, it reports to the Sanitary Area important epidemiological pathologies that are detected, for example, in the Emergency Room.

The Maternity Department utilises the Agustina Perinatal system 2, 3 .It already has a statistical record of 4,500 births. The adoption of the International Perinatal Nomenclature permits us to compare ourselves with different national and foreign centres. In this way, inter-instotutional communication is facilitated. Thus, it is not an exaggeration to affirm that computers serve the future person, still inside the mother’s womb. The database registers 153 perinatal variables and it is totally open; among this data one finds the pathologies of the mother, dates of birth, the pathologies of the new-born, etc. The system can generate all kinds of open statistics, reports, conditional or multiconditional lists, and systems that analyse the consistency of data. The statistics module allows one to calcute average, standard deviation, and the relative, absolute and accumulated charts from a selected field.

The others made to the database for information are in natural language and in Spanish.

We share the criteria adopted by the Argentine Association of Paediatrics (SAP) recommending the performance of statistical studies on a national level, and we fully support this socially important activity affirming that computer tools should serve life 5.

The Laboratory of the hospital 6  includes the following areas: Clinical Chemistry, Immunoserology and Proteins, Microbiology, Haematology and Hemostatics. It has Biochemical Residents and a course for Laboratory Technicians. The Laboratory is set up to provide 24-hours a day service and in this way it silently supports the medical work done in the hospital. The analytical process ends up with the production of the protocol of results, which arrives to the patient thanks to the labour of the administrative team in charge of collecting the data generated by different departments, printing and delivering it to their customer in a timely and adequate manner. To accomplish these tasks, besides having highly qualified personnel, the Laboratory computer has notably speeded up the delivery and storage of lab results.

We take the following quotation from a Procurement Office, “.. a group, as a team, adapts itself to work in a determined fashion. Productivity increased in our office, and the same thing happened in the organisation of tasks and the paperwork. Training for new personnel is easier. They adapt more rapidly. Errors are better detected. The presentation, quality, and guaranty of the works done improves. Differences between estimates and final costs do not occur now. I am more relaxed as regards my work. There is a smaller margin of error”.

Merchandises are controlled in the Pharmacy and in the Pharmacy Warehouse, being the information generated there consulted on a permanent basis by the Associated Management. In the Personnel Office, as in other offices of our hospital, tasks that were once routine and repetitive are now carried out exclusively by the EDP. We quote the following from an interview made in this office: “.. the computer improves the quality of the work. It’s neater and it gives exact information. It has cut down the time it takes to do the work in a notable way”. No one feared the reduction of work load that would be created by the introduction of the computer.

In the Emergency Service Department it is possible to find out instantly if a patient has been assisted, has been discharged, has been transferred to another hospital or if he/she has been admitted to a certain ward, and in which bed number the patient can be found. The coding of medical diagnoses 7 is made in accordance with the International Classification of Diseases of the World Health Organization  (WHO) and reports of pathological incidences are obtained. At the Reception Desk and at Admissions and Discharge the patients are registered in only one way by their Clinical Record number, by last name and date of birth.

A scheduled appointment is given to them or their data is registered so that they can be seen in a consultation room on demand; in the case that they are admitted to the hospital, they are given corresponding room and bed numbers. In the case of a consultation, it is possible to have all of the information available immediately.

The incorporation of the EDP in the Billing Office has speeded up the issuing of invoices to Social Security Services, with the consequent benefit to the income of the hospital. In the past the centre would loss track and miss to charge for patients that were covered by sickness schemes (only a certain percentage of the general population), diminishing the available resources for uncovered patients. A Costs Accountability System has also been implemented that is capable of informing about costs of various services in the hospital 8.

Computer software programmes are developed in the Computer Center. In this department the computer systems are maintained and permanent on-going training courses are offered to the professionals who work in the hospital. In addition, within the framework of inter-institutional and community promotion activities, an Annual Computer Course is given for 4th- and 5th-year students at Colegio Nacional de Vicente López, a nearby district high school.

The Electronic Mail system 9, connects the hospital with the National Academic Network, allowing us to communicate by computer with more than 500 health nodes in our country and abroad. With the help of  e-mail, requests of medical bibliography can be made to the National Academy of Medicine Library, and to the Buenos Aires Italian Hospital Library. In April 1993 the Belgrano Hospital signed a reduced costs agreement with the Pan-American Health Organization (PAHO) and the US National Library of Medicine (NLM), through the Foundation of Medical Informatics (FIM), in order to have access to more than 30 databases of medical bibliographical material. This search services allows for the permanent training of professionals and facilitates the realisation of research activities, with the financial support of the Co-operative Association of the hospital.

In few words, the EDP systems have eliminated guesswork, and allowed us to have reliable data, at the right time and at the right place.

Discussion

In our experience the incorporation of the EDP has improved the services offered and increased the quality of the work done by the hospital personnel, improving the quality of care given to patients and to the community.

We believe that we have fulfilled the premises that we had imposed ourselves:

·       distributed systems have been created taking in consideration the motivations of different groups and individuals,

·   the self-development capacities of different areas have been encouraged and

·   the various areas of the network have been integrated.

The last item is at present in full development and information may be shared by sections that do similar work, allowing the hospital management yo have access to consistent information whenever it may be necessary. The available of reliable data allows us to analyse it, to take decisions, and to improve the general situation in all directions.

The patients and their Clinical Record are more easily identified: analysis result, besides being reliable due to the quality of the Laboratory, are much more legible as computerised protocols. The same applies to Obstetric Ultrasounds and Pathology Reports. Warning signals of pathologies like cholera or sexually transmitted diseases are also produced, and allow health workers to act in consequence.

Perinatal statistical data 10 and preventive work from Primary Health Care Centres are obtained. The patients have benefited of reduced waiting times, with a unique number assigned to their appointment and to their Clinical Record. Higher working morale has been observed in the areas that are incorporated into the computer-based system and a cathartic effect has been produced that is spreading itself to other sections of the hospital.

Conclusions

All the above allows us to affirm the crucial omportance that the incorporation of a  computer-based system has in a public institution like the Belgrano Hospital. It is a challenge that lets us look into the future with greater optimism, to create better working condictions for those around us and for ourselves. By obtaining, analysing and processing a considerable amount of reliable information thanks to the appropriate informatics tools, and by letting the hospital workers participate and self-direct this endeavour, we have been capable of better serving the population we assist and are responsible for. We are eager to share our experience with other similar institutions, that having the same limitations of resources than us, would like to commit themselves to better serve their patients with the help of informatics and telematics.

References

[1] Enciclopedia Universal Ilustrada Europeo Americana Espasa-Calpe Annual Supplement Informatics. 1989-1990. Madrid, 1992. EDP. p . 855

[2] Fundación Neonatal - Fundación Epson: Base de Datos Perinatal. Programa Agustina. Versión 3.8/1. Buenos Aires, March 1991

[3]  Rodas, Eduardo et al. Agustina en el Hospital Manuel Belgrano. Primer Congreso Internacional de Informática Médica. Buenos Aires, June 1992

[4] Centro Latino-Americano de Perinatología (CLAP):Definitions and Applicable Terminolo-gy to the Perinatal Period. Perinatal Health 1985, Vol 2:32-34

[5]  Leder, Miguel. Agustina: La Computadora al Servicio de la Vida. PC Uses 1992, Jan-Feb. 38-39

[6] Records of the Technical - Administrative Assessing Board. Presentation of the Manuel Belgrano Hospital Laboratory. March, 1993

[7]  International Classification of Diseases. 9° Ed. WHO, Geneva, 1979

[8]  Hospital Costs. Accountant Irene Hick. Manuel Belgrano Hospital

[9]  Electronic Mail System PcCorreo. Ver. 4.0a-b, 1992

[10] Attaguile, Francisco et al. Control Prenatal y Mortalidad Evitable. XIII Conferencia Científica, Hospital Manuel Belgrano. Accesit Prize. November, 1992

Adress for correspondence:

Dr. Eduardo Rodas

e-mail: edurodas@yahoo.com.ar