A shot in the arm

Critical condition

In addition to the growing tangles of red tape in SA hospitals, the healthcare system is reported to be battling to cope with the influx of patients suffering from HIV/Aids related illnesses and staff shortages caused by the exodus of healthcare professionals from the system to greener pastures abroad.

Those professionals who remain in SA hospitals say they are struggling to cope with the vast amounts of administrative work they are required to do in addition to actually nursing or doctoring patients.

Karin Engelbrecht, a nursing lecturer at the University of Johannesburg, says nurses are knee-deep in paperwork.

"Nurses have a lot of administrative duties, it is part and parcel of being a nurse, but the problem is that there is too much administration and too few nurses."

A practicing nurse at a leading private hospital, who asked not to be named, says that she is snowed under by the amount of administration required.

"We have to write tedious reports on everything we do and everything we administer, we then still take responsibility for the medical aid billing as well as for the hospital inventory. At the end of each shift we are expected to do stocktaking."

She says she spends roughly a third of her time performing non-nursing duties. This she says, is "very stressful" when already there is a ratio of one nurse to three patients.

"In a section like mine, which is the emergency unit, international standards and norms stipulate a ratio of one nurse to one patient simply because of the urgency of the situation, but we often have two or three patients who need urgent attention at the same time."

Seemingly on the ball

A possible answer to help alleviate the administration burdens heaped on nurses is the implementation of an information system that could automate and manage patient records, billing and general administration.

According to IBM`s expert in health information systems implementation in the public and private sector, Diane Reynolds, SA was one of the first countries to attempt a National Health Information system (NHIS).

"The rationale behind the implementation of health information systems was to breathe life into the ailing system by delivering patients` clinical information to the medical staff, reducing the copious amounts of administrative duties that plagued clinicians, as well manage the payment of bills and help in accounting of inventory and human resources information. This was seen as key to quality healthcare in SA," she says.

Government has been rolling out health information systems since 1994 when it first issued a tender for 400 hospitals and 4 000 clinics. The tender was cancelled at the insistence of the provinces, which wanted to have their own health information systems.

In 1996, the Limpopo province (Northern Province at the time) was first out of the starting blocks with a provincial information system tender for its 43 hospitals.

IBM won the R193 million contract and then enlisted six local partners to help with the implementation. The system would be a financial management system to manage patient records and human resources information, as well as assisting with other administrative functions.

According to Reynolds, the implementation of the system was marred by a series of unfortunate events. "We had no experience in implementing such a system as it was the first of its kind in SA." Only a handful of case studies existed at the time that could be used as models to be applied in the South African context.

"Consequently, we did not anticipate some of the challenges we would encounter," says Reynolds. She reveals that during the three-year implementation, IBM and its partners perpetually had to navigate around infrastructure challenges."

"Whenever we went to a hospital site we found recurring problems. There weren`t any plug points positioned to plug in a PC. The sites did not have any LAN cables needed to network a hospital, nor did they have any desks to place PCs on."

She adds, "Moreover, we had to contend with an unreliable 64K line for a WAN. The system didn`t require large amounts of bandwidth, but what we had was inadequate."

The culmination of all the problems with this implementation was that it was deemed a failure, says Reynolds.

Back on track

In its desperation to see the NHIS project become a success and help relieve the pressure felt by the countries nurses, the government grew impatient with this maiden implementation and ordered it be overhauled and replaced by another system.

Government then made a sudden about-turn and ordered the new system to be deracinated and replaced by the initial system by IBM.

Countrywide, government`s decision in allowing for more hit-and-miss health information system implementations tangled SA hospitals and clinics into a mesh of incompatible systems and databases.

In June last year, the State IT Agency (Sita) issued a tender inviting potential suppliers to submit bids for the procurement of an electronic health records system. The tender was valued at about R500 million.

The tender document stipulated that the system would "provide a longitudinal collection of personal health information of a single individual, entered or accepted by healthcare providers and stored electronically".

SITA says the goal now is to integrate health records systems in the country by bringing together all the different health information systems, develop a population healthcare base, and improve administration, planning and policymaking at both national and provincial level.

E-mail a diagnosis

In 1999 the government turned to telemedicine in its bid to deliver better quality healthcare to the disparate rural population.

The telemedicine projects are still under way, with the most notable projects in Mpumalanga, Limpopo, and the North West Province.

The rationale behind telemedicine is to help people in the rural areas who have limited access to basic health caused by geographic isolation, scarcity of doctors, poor public transportation services and unavailability of health facilities.

Dr Moretlo Molefi, the director of the Telemedicine Research Centre at the Medical and Research Council of SA, says: "By using telemedicine in our healthcare we will be able to bridge the socio-economic disparities in the healthcare sector that divide our country. Patients would finally have the opportunity to access quality healthcare, regardless of time and space."

"Most of the clinics in SA are run by the nurses and not by the doctors. We saw it as crucial that we support these nurses. Patients in the rural areas do not have access to specialist doctors, so we find that nurses leave their nursing duties and travel long distances to transport patients to where they can get specialist attention."

Molefe says: "With help from the Department of Science and Technology, we were able to develop a system that allowed nurses to upload medical cases along with the photographs and send them via e-mail to the relevant physicians."

"The system and communication technologies have improved since then to allow for scans, X-rays and video images, sound bites and even video-conferencing from remote sites to areas where specialist doctors are available."

Since the implementation of telemedicine, Molefi reports some rural hospitals and clinics have been able to reduce the number of patient referrals, while others are still "meandering through obstacles",

"In one of our hospitals in Mpumalanga, patients are no longer transported unnecessarily. Patients are now able to get expert attention from their hospital beds."

In some hospitals, she says, we have installed these systems and the nurses struggle to use them because of the complicated human user-interface, we have since designed easier-to-use interfaces and in the process of educating the nurses.

She adds with the new user interfaces the training has been streamlined to two our sessions. "We are finding that the nurses are taking about two hours to learn how to use the new interfaces."

Smart hospitals on the horizon

Earlier this month, acting Health Minister Jeff Radebe revealed that at least 29 hospitals with hi-tech equipment are under construction across the country. The government has set aside R1.2 billion this financial year, as part of its hospital revitalisation programme. He let on that the budget would be increased to R2 billion.

Radebe also recently officially opened the newly-revamped Pretoria Academic Hospital. Speaking at the opening, he said the hospital had cost between R700 million and R1.2 billion to revamp, with another R500 million spent on its equipment.

The minister highlighted how the hospital`s modern technology would enhance its efficiency and patient care.

"The digital and electronic data system, for instance, will improve the capturing, storage and accessibility of patient information, as well as provide a foolproof backup system to protect patient records," he said.

The Pretoria Academic Hospital was completed in 2004 and has been fully operational since April 2006.

Peripheral hospitals in underlying rural areas in Limpopo, North West Province and Mpumalanga plug in to Pretoria Academic Hospital for distance consultations and other telemedicine.

Major challenges

When it comes to implementing e-records systems, Accenture`s Wayne Borchardt says there are challenges in changing the mindset of the stakeholders involved, "Doctors are averse to changing their processes, so a significant change management effort needs to take place to encourage adoption and usage of systems."

IBM`s Diane Reynolds notes strong management is needed when implementing systems. "From our very first implementations, we learnt that without a paradigm shift from medical professionals and without strong support from management, such implementations will not be possible."

She adds, "We know that the technology works, but it is a matter of training people to use it and this takes time, money and requires much patience."

Dr Moretlo Molefi from the research medical centre says, in her experience, introducing the right technology at the right level and with proper training, the technology will have a huge impact on the healthcare system.

"The important thing to remember is that the healthcare specialists are central to telemedicine`s success, without buy in from them it will not work."

It clear that as government continues to wade through the challenges of delivering quality healthcare to its citizens, it is increasingly turning to ICT to deliver a much-needed remedy.