An OPD Experience

The other day my wife had an appointment with her doctor at one of the well known hospitals in town. We were to see her at 8PM, but what with under construction Metro line collapsing and the resultant traffic snarls bringing the city to a halt, we were running late. Hoping against hope of catching the doctor, we reached the hospital 20 mins late.

Luckily for us, as we arrived the doctor was finishing with her last patient of the day and agreed to see my wife immediately. She indicated that some tests were needed and while she went about doing those, I might run along and pay the bills as the billing counter would be closing. She scribbled the tests on a medical form and off I went to do the needful.

Sure enough the billing counter was deserted and the billing clerk appeared to be in a hurry to rush off. As I put in my request a surly lady (let me call her N) told me to wait. I waited patiently, and again enquired about settling the bills. My wife had by then joined me as well as the doctor had finished with her. Nothing happened. Finally, I requested an audience with the duty manager, who arrived promptly. When I explained the situation to him he asked N to open her system and do the billing and for good measure added she can ‘easily do it for one patient at least’.

N finally accepted my papers and opened her billing system. After fiddling around with the system for a while, she summoned another colleague ‘D’ for help. Apparently, N was not able to find the tests on her billing list. Apparently, she did not know where to look. Her colleague D who was supposed to be more competent on the system too, could not find the tests. As I waited patiently N in true style of a government owned medical institution ordered me to move away from the counter and wait elsewhere till she sorted out the problem. (Do not forget that I am the only guy on the counter and am not holding up anything).

This is where I lost it and told her to shut up and seek help in organising my bill. The duty manager again materialised and after murmuring some instructions in N’s ears hurried away. N than started calling up some folks to figur out where and how to bill. Another guy sauntered up and tried finding a solution, he too seemed completely at sea. He disappeared just as quickly.

Finally after waiting for close to half an hour to get a service billed, I was handed over an invoice. And than it was discovered that while the procedure has been billed, a canula used during the procedure has not been billed and the entire pantomime of finding it in the system and billing the same was repeated.

“We are really having a serious problem with our front office executives. They are all new as the trained ones have all moved on to greener pastures and other hospitals. Even the duty managers, who would earlier get involved and sort out these problems deftly are new” admitted a friend of mine who works in the hospital. He also added that training people in understanding medical terminology and gaining proficiency on the Hospital Information System (HIS) takes time and by the time a new set of people are reasonably proficient, they move on. ( mostly to call centres, which pay a lot higher).

While I can understand the hospital’s problems, a bad patient experience is something most hospitals can ill afford. N and D and the duty manager had a problem understanding the medical terminology, they also lacked the empathy and a caring attitude that is a must for folks who work in hospitals. In this day and age, you can not be rude with patients. Moreover, as I pondered over this I realise that a small error in billing can have some very serious consequences. For, instance whatever tests are billed, will be run by the lab. If these are not what the consultant ordered…you can imagine the problems.

Considering all this, I would like to believe that investing in employee retention is far better than having a crop of new recruits manning customer touchpoints in the hospital. Cutting people costs in a hospital can really prove a lot more expensive than what a hospital might have bargained for.

The HIS Devil in Healthcare Experiences

Information technology is meant to enhance the quality of service and experiences delivered in a hospital. Once a patient is registered in the hospital, the subsequent visits can than be recorded and the visit log used for either customising the services or improving the experiences. It also helps the hospital maintain patient records, which can be pulled out at the push of a button. These can help the medical teams see a fairly complete patient history and allow correct diagnosis.

More intelligent systems are now deployed at state of the art hospitals, which even provide aid to physicians in diagnosing and treating a patient's condition. They also ask a question and alert the doctor if they spot an anomoly. For example if a drug prescribed to be administered is contra indicated or if it has been given by another doctor on duty two hours ago, the system can raise an alert and inform the doctor. These systems are great to have.  

The only hitch with all this is that HIS systems being used by most hospitals in India deliver far less than what they promise. I have been part of various tech committees set up to evaluate these products and oversee their implementation and I must say that there exists a big gap between what is promised, what is delivered and ironically what ends up being used. 

Here is what goes wrong.

The HI systems are just unable to cope with the OPD volumes of a busy hospital. In India patients do not show up a few minutes before their appointed hour. They usually come late and expect instant service. Quite often the doctors also come in late and invariably the HI system is under constant pressure to push the patients through. The queuing system is mostly non existant. In some hospitals nurses double up as patient care executives with little knowledge of how to tackle the HIS. Patients start venting their ire on the hapless nurses and everything breaks into utter chaos. 

The doctors are still quite at sea with the computers and myriad HIS screens. Can one really blame them? In medical colleges I am not sure if they have an elementary course in managing a computer. They also train mostly in government run busy hospitals, where they have to see 100 or more patients in an hour. Now to connect with a computer is difficult for them and in the opinion of many, an unnecessary ordeal. The patients always bring their files and the doctor if necessary can scan their history from those files. 

The billing systems are unable to cope with the multiple billing requirements and rules that need to be followed. The billing is thus rarely accurate and lot to be billed is left out. The hospitals take a hit and in meetings after meetings these points are highlighted, audit committees get to have a field day and the head of operations and the head of IT a great fight.

The clinical systems are even a worse nightmare. The nurses who are supposed to use them are completely ill equipped to handle them. They have been trained all their lives to use neatly filed multi coloured charts to monitor the condition of a patient. To force them to use laptops and state of the art HIS is pretty much like asking me to try my hand at surgery. This is just not going to work till we have nurses far more educated and better trained than what we have now. Rushing them through a typical two weeks or less training programs and  expect them to master all this is unfair.

The surgeons are far more comfortable in the OR rather than in front of a computer screen filling in post operative notes or dictating in a Dictaphone, which will be transcribed by a guy whose knowledge of medicine will fit on a postage stamp.

The HI system is also touted as a great management tool as it can spew out all manner of reports. The HIS sales team merrily demonstrates the system's capabilities by generating sample reports during their sales presentations. The managers usually fall for this. Once the system is implemented the reports become the first casualty. The system usually produces raw data, which is than manually analysed and reported. What fun!

This piece is not meant to deride the HIS systems per se. On the contrary it is a lament on how the systems are used in modern hospitals in India. The way forward can not happen without HIS smoothly running the hospitals of the future. However, to reach there we need better and more Indianised Hospital Information systems, tightly defined hospital processes, and IT savvy doctors and nurses and a bottoms up approach.

The image is from www.flickr.com