J.P. Dwivedi, CIO, Rajiv Gandhi Cancer Institute and Research Centre outlines the massive digitization of the hospital and how it is helping combat the disease more effectively.
What are your exact roles and responsibilities as the CIO of Rajiv Gandhi Cancer Institute?
CIO is typically a disruptor in nature. There are three roles, creator, keeper and destroyer.
Keepers are a lot of C-level officers or CFO, or Chief Supply Chain Officer, etc. CIO is actually destroyed and created. So whenever there are problems, or there is a requirement of trouble shooting, things are not running well, CIO pitches in. Typically not only in digital transformation, but also in process transformation and all other areas.
Filling in the blanks, wherever there are problems or areas of improvement, CIO comes in. If there are no areas of improvement reported, then I need to create areas of improvement. So it is continuously changing the face of the organization. Typically that is my role.
What are the key technology solutions used by Rajiv Gandhi Cancer Institute and what are their use cases?
Technology footprint is quite visibility from the moment you start looking for our Institute on web. We use CRM, IP telephony hospital information system ERP. We use technologies in both areas, as in biomedical technologies and information technologies, in healthcare. Both these themes are quite intermingling and merging together. We use technologies and I am proud to say whatever technology you name, and mostly we have it.
How are digital technologies helping Rajiv Gandhi Cancer Institute to tide over the current Corona crisis?
The moment COVID erupted typically there are three things that you need to keep well, in terms of man, machinery and material. So what we needed was to protect our patients, our staff and we very promptly came out with the patient app and doctor’s app. Patients can actually without leaving the comfort of their home, and If it is not necessary to see the doctor in person most of the consultations can happen from home very easily.
Open our app book, telemedicine appointments, do the video conferencing consultation and as Dr. is _ consulting and prescribing online, the prescription is available in patients’ mobile. This is one thing and the other thing we have are accurate reports on reorder levels and everything. It helped us preparing for the pandemic and storing at least six weeks of supply of essential consumables drugs and everything, so that patient care is not disrupted. So in all doctors can actually view the reports from home Radiologists, Pathologists, or wherever they are. They can view the reports, they can approve the reports or ask questions basically collaboration, video conferencing, telemedicine all these technologies essentially helped us in keeping functioning.
What about the technology being used in this app? Was it built by your own team or is it a third party application?
We actually spent significant effort in selecting, choosing lots of options that are available, but we also worked actively with our hospital information systems partner. Just to ensure that there is one single integrated database and there are no integration issues or messaging issues and that helped us. We hosted this on a cloud and, built a synchronization, a real-time synchronization. So that at least, our data centre directly is not receiving, query or messages directly from patients. Those are going to the cloud and it is synchronized in a controlled manner with that production database. We are using this HIS integrated app.
If you could share some statistics, how many people, how many patients have benefited?
Instead of becoming physically present, they have used the e-consultation. Unfortunately in cancer care, active gear cannot be given remotely. If chemotherapy is to be administered, patient has to come here. If surgery is to be performed, patient has to come here for radiation. Patient has to come here. Only thing is in post-surgery.,if there are some complaints or patients want to consult a doctor, they want to ask questions only those kinds of scenarios get covered using telemedicine. The other is maybe there are certain routine tests which patients want to undertake, and they are typically used to come to our hospital. We just advise them to take those tests from the laboratories, which are in their vicinity and go.
Probably a couple of dozen consultations happen in a day. But even that is significant because this is a good start and this will certainly take to next level when we are able to do a kind of dry party consultation. So some local healthcare is in collaboration with us and helping the patient, some medical practice that is there at least some of our work is downloaded there and we can work in collaboration. But right now this is a kind of humble start.
Does this mean it is more helpful to the patient, for follow-ups, post treatment?
Exactly, patients have the initial curiosity. Somebody wants to know about us or somebody wants to register with us. And even before the disease is diagnosed, if there is a suspicion they can register and they can talk to our doctors through our telemedicine app. Maybe lots of suspicions can be eliminated there itself and patient can find a kind of comfort. And assurance even before being our pitch, if it is confirmed that this is a disease and further intervention can happen during the physical interactions.
What are the parameters of telemedicine usage and how is Rajiv Gandhi Cancer Institute conforming to the Telemedicine guidelines?
We actually studied telemedicine guidelines and those are very recent. And, we made sure that our telemedicine app is conforming to that very fast with the consent. It is, not only one single click, but technology should force a user to actually read and be able to confirm only when a patient has scrolled through the text and then click there that yes, I agree with the terms and conditions.
It is very important if a user, wants to just quickly scroll through, it is their problem but we encourage them to at least read and incentives first and foremost. Second is that, we make sure that proper credentialing is there so that the person who is having proper user access from the provider’s side is qualified to enter that particular prescription there and provide the consultation. So we are following all the norms issued by the Ministry of Health and Family Welfare.
How does Rajiv Gandhi Cancer Institute use collaboration technologies for telemedicine?
There is video conferencing, it important to be face to face in the video conferencing as we are talking and it should be seamlessly integrated with the app and then apps should be seamlessly integrated. So we are using all these three, patients app enabling patients to collaborate with us and doctors app is actually enabling doctor to see the patient list. All the appointments that are there and one can select any one of them, click there and video conferencing starts. Of course it goes without saying that the app also enables patients to pay online. For the cons and services patients can view present and all the past lab and radiology reports and now we have enabled to view the bills as well. If patients are admitted, they can see the provisional bill also as it is progressing and for all the past admissions, they can see the bills in reverse chronological order. Whatever is required for the patient to actually see on their mobile or computer is enabled through the combination of these technologies.
What technology partners would you like to name them, especially for these vamping solutions and a hospital?
We are using all sorts of technologies. Our ERP system is on SAP and our hospital information system is called PARIS. It is from Sristhi software. The electronic health record system is also bundled in PARIS itself. And we work actively with our hospital information system partner, Sristhi software to make an oncology specific electronic health record system.
You see why EHR has failed everywhere? The reason is that we expect, we give doctors a vanilla system and we expect them to end everything. And the moment they are. passing through a dozen of planes, they will get fed up and leave it and pick up their pen and paper. And this is what we have very painfully learned.
So we have built very context specific and rich electronic health record system with the help of Shristi software. And, at present, we have very good uses that are giving us a lot of improvements, suggestions also, and we are making it better. Electronic health record system is from Shristi software.
While ERP is from SAP, d a picture archival and the communication system, managing our x-ray CT MRI, all the images are from Madison. This is also an Indian product as it is a Pune based company. The CRM is from New York’s satellite technology. We are also using a lot of productivity tools, employee productivity tools, help desk, patient feedback management. There is a company called Dream Soul. They have given us a lot of good tools that reside at the digital layer and they help ensuring that we do good IT service management. It is not limited only to IT service management, but it is also extended now to our other service departments like maintenance department, housekeeping department, people can actually log service requests there. This culture of IT is spreading throughout the organization. There are a lot of others. I mean, I have just named a few leading technology that we are using.
How does Rajiv Gandhi Cancer Institute use data-enabled evidence-based solutions?
Chemotherapy protocols means there is evidence based record there and there are very clear formula. I ran the doses of chemotherapy and those all are fed to the system. So clinical decision support system actually helps us doctors prescribing that right dose and if whatever they are prescribing, by any chance, if it is more than 5% plus or minus, the standard and range system will generate an alert. That doctor, by the way, it is too much for the special, seeing the body surface area are you sure you want to prescribe that much? and if he has been pleased state-wide similarly, maybe this tool is for the patient and just giving you an example. So a CDSS is clearly helping our doctors making more precise decisions.
There are many other areas there where technology is helping, Particularly in biomedical area, also in radiology, even in OT, where a lot of technologies out there working side by side. Our doctor’s patient is on operation table and by the time doctor is performing surgery there is a product called ENOVIA. This actually keeps a real-time chart of the patient’s vitals and keeping all the records. Every five seconds snapshots are taken, otherwise an anesthesiologist is used to take pen and pencil and a lot of their attention or their own thinking rather than paying attention to the patient. Technology has taken all these pains away from then.
What are your thoughts about products solutions like IBM Watson, which actually helps in planning the cancer treatment, especially?
It is a great tool. It was a particularly Watson for oncology that was Made in US Sloan-Kettering university with initially few thousand patients, particularly of the Caucasian race, the data was collected. Now it is extended to India also. And there are a few organizations experimenting with us. We have seriously not tried this so far but maybe in future someday we might look at it.
What is the future of clinical analytics in healthcare? What are the challenges in successful implementation?
It has great future I tell you. This is not the age of business analytics. This is the age of, I call it information, rag picking. Because now with all these IO’s and point-of-service support gadgets, a lot of data is being generated and it gets extremely difficult to actually collate this data and take meaningful information out of it.
So advanced analytics has a great role.Those days are gone when we were talking of relational databases and generating logical reports. It, when it will not work seeing this volume of data, we need to have a natural language processing and all other tools that are actually able to process unstructured data and visualize information.
It has a great future. We are also working with a company in California, on this particular aspect., It is called Mango systems.
How the Hospital Information System is integrated with ERP or other enterprise applications as well as how does it leverage analytics?
As I told you, we are using SAP as ERP system while SAP had an integration engine called BIP process integration process orchestration engine. Basically, that engine helps us integrating hospital information system with the ERP using Jason format for messaging. So it is a real time integration.
Whenever a transaction happens in HIS, message is passed on to SAP and vice versa. HIS is connected to PACS through a different integration engine and that is called Mark. But MARK is more HL7 driven. So it is more healthcare specific. At one point of time, we thought of moving everything to EIPO.
Maybe someday, we might be able to do that, but the EIPO is a very generic integration tool catering to all sorts of industries and MARK is hospital specific healthcare specific to be precise. We are still somehow keeping MARK for all non-SAP related integrations.
What are the key vulnerabilities and how to build and maintain strong security posture in healthcare information?
Now with COVID coming, everything is digital. Everything is virtually. Everything is online. So naturally when information is available online and we are encouraging our patients or prospective patients or suppliers, everyone to connect online. There is a danger as we connect to the cyber space.
Antivirus firewall will not work for the hospitals. That is for sure and we have deployed advanced security tool. I will not specify them for obvious reasons, what we are using. So you might have heard about seven layers of the OSI model equally used to protect only up to third layer. But now this is the time that we need to move on to four and fifth and six to layer of protection.
We need to use the, network traffic analysis, surveillance tools on lots of predictive models before the attack has come. That attack is in, in the cooking form is actually a building and then you destroy and the buildding stays. It is important. Obviously there are challenges and we need to be careful at various levels. Sometimes, you know, very mundane things like printer can actually open a vulnerability. A lot of attention is required in this space.
How is the IT team structured at Rajiv Gandhi Cancer Institute? How do they ensure complete synergy with each other?
I have three verticals reporting to me. one is infrastructure services, anything that you can touch and feel. The second is the application space, that is, all the running applications other than ERP. And the third stream is ERP and digital technologies. I have divided my team according to layers. So first layer goes to the infrastructure team. Second and fifth layer go to the ERP and digital technologies team. And third and fourth layers go to the applications team. These teams are interacting continuously.
Number one, division of work is very clear. There is no ambiguity in that as we have weekly meetings. We discuss with each other. There are tools where we log in, whatever requirements are from each other. Those reports are constantly coming to me on a weekly basis. We review and we see how we can better collaborate together as a team.
So how do you drive the quality process at Rajiv Gandhi cancer Institute?
We are certified hospital. And there is a dedicated quality team reporting to medical superintendent. They work very closely with us. We use again, I told you about Dream Soul. So we use patient feedback system and there are a couple of other small applications that help our quality department maintaining the measuring the turnaround times.
And a lot of process steps are measured. And they, keep track of all the incidents, all the possibilities of any deviation, any possible patient safety issues, and it, and quality are working together in making sure that we do not deviate with any of the standards that we are supposed to and hurtful.
How are newer technologies like AI, analytics and AR/VR being used in this sector?
Information technology and biomedical technology, both are coming together in, usage of the technology for overall improvement in the healthcare delivery. So, if you look at the medical technology in radiology, we are using certain EIA applications. For example, for lung nodule detection. It can detect an nodule in the lung, much more than CT MRI, and much more accurately. There is something called texture analysis. We experimented with this software also. That helps in analyzing the MRI or multi-parameter MRI in diagnosing roasted cancer, much more accurately. A lot of other AI based technologies are coming out of start-ups are working thankfully in this particular area.
And we are experimenting with many of them. We are using, as I told you, very sophisticated software in our operation theater, anesthesia is using in OBM and we are also using, DaVinci for past 10 years around, we were the pioneers in this country, starting with the robotic surgery. We started with again, prostate and moved on to certain head and neck cancers. Also, then we use a lot of preseason procedures, like a radio frequency ablation, our tastes that is, delivering chemotherapy exactly at the point of tumor, rather than giving to the bloodstream. So, these are very practical examples of the active use of technology in reducing the side effects and showing better efficacy of the treatment and a better patient experience altogether.
Obviously you talk about AI. You talk about analytics.We are working with mango science to actually, work on the advanced analytics of the electronic health record that can tell our doctors exactly how many adenocarcinoma of lung, at what stage at what is group. What treatment has been given to them, what has been the efficacy? So it helps our research also and practitioners also.
What is your IT agenda for 2021 and Beyond?
We typically give a three year rolling agenda. So we have a digital committee, chairman, secretary, CEO, medical director. They all attended every 10 weeks. I need to actually revise the strategy and visit them that we keep for three years and seek they’re not that as an industry experts also from outside, they joined us. So fortunately our organization actually pays a lot of attention. To then digital technologies and shaping up our vision and strategy for the digital transformation. Now, coming to your specific question, we will focus more on simplifying, application landscape.
So there are a number of technologies where existing integrated connected. This has been questioned all along. Whether we keep single monolithic application or we keep specialized solutions or specialized areas, but that basically makes it very heterogeneous. We will work in streamlining and simplifying our technology landscape.
We will work more aggressively on analytics. And we will work on cloud implementation also right now, mostly it is hosted in our in-house data center. At least the commoditized services would be outsourced and could be away from the experts who are providing services to majority of the. Small and medium organizations. So keeping our focus mainly on the applications and that too, on the core clinical applications, we will actually look at outsourcing whatever has been very clearly defined and could be measured in terms of performance and efficacy and work towards more, on the. Evidence based medicine, clinical decision support system, maybe something like IBM Watson and cloud adoption.