Case
Teaching Notes
Supplementary Resources
Abstract
At the end of 2012, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine (henceforth referred to as “Xinhua Hospital”) had completed construction of its Phase I electronic medical records (EMR) project.
On the Kongjiang Road in Yangpu District of Shanghai, people thronged outside the Xinhua Hospital. Beyond the bustling crowd at the clinic, and the noisy construction works of the Pediatric Surgery Clinic Medical Center Building, there was a building where Xinhua Hospital President Xu Weiguo was preparing for the Phase I EMR project summary meeting in his office. In 2011, hospitals in China had faced IT reforms and system upgrades. Among the first pilot hospitals for EMR, Xinhua Hospital had extended the EMR system to the entire hospital, which reached Level 4, after two years. However, in retrospect, Xu Weiguo pondered what Xinhua Hospital could have done better to successfully implement the EMR project, and more importantly, going forward, what Xinhua Hospital needs to do in order to achieve Level 5 in 2013 and Level 6 in 2014? In regard to the project's next phase and Xinhua Hospital's long-term information strategy development, what lessons could be learned?
This case was prepared for inclusion in Sage Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.
2024 Sage Publications, Inc. All Rights Reserved
Resources
Appendix II: Definitions of Proper Name Abbreviations Mentioned
Abbreviation | Definition |
EMR | Electronic medical records are digital healthcare records of health institutes' inpatients (or healthcare recipients) and outpatients prepared as a result of clinical diagnosis, treatment, and guided medical interventions. |
HIS | Hospital information systems are broadly defined as information systems that adopt modern technologies (e.g. computer hardware and software technology and network communication technology) to conduct integrated management of human resources, logistics, and financial flow in different hospital departments. These systems also collect, save, handle, extract, transmit, summarize, and process operational and financial data generated in different stages of medical activities. |
CIS | Clinical information systems collect, save, handle, extract, transmit and summarize data generated in different stages of medical activities, and thus generate different types of information. They support hospital medical care staff in clinical activities, enrich and accumulate clinical medical knowledge, and provide data to assist in diagnosis and treatment and clinical decision, in order to enhance medical care quality and work efficiency. |
GMIS | Global medical information service is a system that combines external data to the hospital with internal data using IT technologies. |
PACS | Picture archiving and communication systems are used in hospitals' photography room. |
LIS | The laboratory information system is a set of systems designed specifically for a clinical laboratory. |
RIS | The radiology information system is a management system used in radiology departments for registration, triage, preparing diagnostic imaging reports, information inquiries, and statistics. |
CDR | The clinical data repository supports the EMR system. It stores complete clinical information and medical data of patients. |
CMV | Controlled medical vocabulary is a collection of standard medical vocabulary that is scientifically categorized and coded. |
CDSS | The clinical decision support system assists the decision-making of medical practitioners. |
CPOE | The computerized physician order entry system is used by physicians to enter medical instructions for patients during the clinical treatment process. The system aims to assist the entire lifecycle management of physician orders. |
SCDE | The structural computerized documentary entry system provides clinical data center management that includes the collection and application of structuralized, standardized and complete EMRs. |
ESB | The Enterprise Service Bus is the connection hub in the network. It forms the essential component in establishing enterprise network services. The ESB cannot only eliminate the technical differentiations between applications, but provide a series of standard interfaces. |
Source: Public information.
Appendix III: Informational Phases of China's Healthcare Industry
System | Focus | Constructions | Current Status | Category |
Hospital Information System (HIS) | Charging | Information management at department and hospital levels (e.g. financial charges management system, human resources management system, etc.) | mature period | Hospital Information System (HIS) |
Clinical Information System (CIS) | EMRs | Electronic Medical Records (EMR), Picture Archiving and Communication System (PACS), Laboratory Information System (LIS), Radiology Information System (RIS), etc. | peak period | Hospital Information System |
Globe Medical Information Service (GMIS) | Regional health care | Regional uniform hospital information, population health records, health information platform, community health information system, uniform rural health solutions, information management system for new rural cooperative medical system, medium and small hospital information system | initial period | regional public health information system |
Sources: Central China Securities, GuoDu Securities.
Appendix IV: Forecast on Healthcare Industry's Structure and Growth Rate for 2009-2014
Note: MIS (management information system) is a fundamental management system (e.g. cost accounting management system, OA system).
Source: Central China Securities, IDC.
Appendix V: Policy Timetable for Healthcare Information
Time | Policy Document | Launch Authority | Main Content |
October 2002 | National Healthcare Information Development Framework (2003–2010) | Ministry of Health | This policy stipulated the inclusion of information construction into the overall healthcare industry development plan. It proposed further accelerating the building of public health information systems, and speeding the applications of information technologies in extensive areas, such as healthcare services, preventative health care, healthcare supervision, research and development, and education. |
2003 | Guidelines for Establishment of New Rural Cooperative Medical System | Ministry of Health, Ministry of Finance, Ministry of Agriculture | This policy suggested establishing the new rural cooperative medical system. Since 2003, governments of provinces, autonomous regions, and municipalities piloted the policy in two or three counties or cities, and progressively extended the implementation afterwards. The goal is to have a new rural cooperative medical system, which provides protection to rural residents, and implemented across the country by 2010. |
May 2006 | National Information Development Strategies for 2006–2020 | State Council | This policy specified that stepping up the health information establishment was one of China's focused information development strategies. It also proposed building and improving a fast and efficient public healthcare information system with nationwide coverage, the overall planning of EMRs, promoting the information sharing and business synergy among healthcare, medicine and health insurance, and supporting medical system reforms. |
May 2007 | 11th Five-Year Plan for Healthcare Industry Development (2007 Document No.16 issued by the State Council) | State Council | The national plan stated the overall goals of China's healthcare industry development by 2010. They included establishing a preliminary, basic healthcare system framework covering rural and urban residents, a relatively standard new rural cooperative medical system and a three-level (county, township, and village) healthcare system. In addition a relatively comprehensive community healthcare system, the national essential drug system, and a relatively standard public hospital management system. |
April 2009 | Guidelines for Further Health System Reforms, and Implementation Plans for Recent Focuses of Healthcare System Reforms (2009–2011) | Ministry of Health | The two policies state four points – to build a rural, village, and community healthcare information network platform (focusing on the creation of resident health records); to promote hospital information establishment (with hospital management and EMRs as the focuses); to prompt collaboration between city hospitals and community healthcare institutes by use of network information technology; to construct the basics of a basic healthcare system covering city and rural dwellers by 2020. |
June 2009 | Construction Guidance for Regional Healthcare Information Platforms Based on Health Records | Ministry of Health | The document was produced to promote regional healthcare information construction centering on health records, in order to complement the deepened health system reforms. |
December 2009 | Ministry of Health's Guidance on Standardizing Management of City and Rural Residents' Health Records | Ministry of Health | It indicated targets in accordance with the central government's uniform requirements in resident health record creation: 5% in resident health record completion rate for rural regions, and 30% for urban areas by 2009, and later 30% and 50% by 2011. The targets also included preliminarily building a health record creation, use, and management system that covers city and rural residents, meets the grassroots needs, and is uniform, scientific, and standard by 2020. |
December 2009 | Fundamental Framework and Data Standards of EMRs (Trial) | Ministry of Health, State Administration of Traditional Chinese Medicine | The standards combine the characteristics of Chinese and Western medicine, describe the basic concepts and system structure of EMRs, and create templates for EMR clinical documents. They also standardize the data element standards for the data combinations of EMR clinical documents. |
October 2010 | Technical Solutions for Construction of Maternal and Child Health Information Systems Based on Regional Healthcare Information Platforms (Trial) | Ministry of Health | The document systematically illustrates the basic concepts, overall design ideology, and business requirements relating to the establishment of the new-generation maternal and child health information system. Additionally, it states business, functional, and information models for the maternal and child health information system. The solutions are regional governments' technical guidance and standardization basis for building maternal and child health information systems. |
December 2010 | Notice on Information Construction Project Management Plans for Village Health Centers in Central and Western Regions for 2010 | Ministry of Health | The notice suggests equipping 90% of village health centers in central and western regions with computers and 70% or above rural residents with healthcare cards. It also advocated developing and integrating information software in health centers, and accelerating the construction of regional (prefecture and county levels) healthcare information platforms. |
April 2011 | Construction Guidance for Healthcare Integrated Management Information Platforms (Trial) | Ministry of Health | The guidance elaborates in detail the construction of the health integrated information system in terms of the overall ideology and methods. It aims to eliminate information silos and information islands, as well as the interconnection between different health institutions. |
July 2011 | Technical Specifications for Residents Health Cards | Ministry of Health | The document stipulates both the specifications and standards of Residents Health Cards in material, data, safety and application, in order to promote hospital Residents Health Cards establishment, as well as achieve the goal of health system reforms. |
October 2011 | Level-Classification Evaluation Methods and Standards of EMR Systems' Functional Application (Trial) | Ministry of Health | Under this policy, EMR system applications are classified into 8 levels, and the 37 evaluation criteria focus on EMR system functions and effective applications in scoring. The policy created a grading evaluation system suitable for China's health institution EMR systems, providing development guidance on EMR system establishment for different healthcare institutes, as well as leading health institutions to scientific and reasonable development of EMR systems. |
October 2012 | Implementation Plans and Roadmap of Deepened Health System Reforms In 2011–2015 (2012 Document No.11 issued by the State Council) | State Council | Among the major targets of the health system reforms for 2012–2015, health information is one of the highlights for accelerating basic health system construction. The document states aims including apparent increase in health information levels, continuous improvement of the regulation system, and strengthening health care supervision. |
Source: Ministry of Health, GuoDu Securities, information organized by the author.
Appendix VI: EMS Development Stages in Gartner Model
Source: Xinhua Hospital.
Appendix VII: Basic Requirements in Level Evaluations of
China's EMR System Applications | ||||
---|---|---|---|---|
Level | Description | No. of Basic Criteria | No. of Selected Criteria | Minimum Total Score |
Level 0 | No EMR system is yet in place. | – | – | – |
Level 1 | The department is conducting initial data collection internally. | 6 | 18/29 | 27 |
Level 2 | Data are exchanged within the department. | 11 | 13/24 | 60 |
Level 3 | Data are exchanged between different departments. Primary medical decision support is available. | 18 | 8/19 | 85 |
Level 4 | Information is shared through the entire hospital. Intermediate medical decision support is available. | 19 | 8/18 | 120 |
Level 5 | Data are uniformly managed. Data from different departments are integrated. | 21 | 8/16 | 140 |
Level 6 | There is closed-loop management of medical data throughout the process. Advanced medical decision support is available. | 24 | 6/13 | 170 |
Level 7 | There is a complete EMR system. Medical information is regionally shared. | 24 | 6/12 | 210 |
Note: In the “No. of Selected Criteria” column, “18/29” indicates that among the 29 selected criteria at least 18 should meet the standard.
Source: Level-Classification Evaluation Methods and Standards of EMR Systems' Functional Application (Trial).
Appendix VIII: Management Structure of Xinhua Hospital
Source: Xinhua Hospital Annual Report (2011).
Appendix IX: Overall performance and Financing Statement of Xinhua Hospital
Overall performance | 2011 | 2010 | change |
Total number of hospitalized patients | 69,031 | 66,000 | 3,031 / 4.59%↑ |
Total number of discharged inpatients | 69,008 | 65,959 | 3,049 / 4.62%↑ |
Total number of outpatient visits | 2,732,836 | 2,502,184 | 230,652 / 9.22%↑ |
Total number of patients' visits to emergency service | 560,383 | 547,348 | 13,035 / 2.38%↑ |
Total number of outpatients and emergency patients | 3,293,219 | 3,049,532 | 243,687 / 7.99%↑ |
Total number of surgical patients | 41,007 | 39,434 | 1,573 / 3.99%↑ |
Turn-over rate (times/bed) | 47.48 | 47.25 | 0.23 / 0.49%↑ |
Occupancy rate | 109.82% | 112.83% | −3.01% / −2.67%↓ |
Average length of stay (days) | 8.45 | 8.55 | −0.1 / −1.17%↓ |
Ratio of drug income to operating income | 39.74% | 40.11% | −0.37% / −0.92%↓ |
Source: Xinhua Hospital Annual Report (2011).
Appendix X: Coverage of Xinhua Hospital's Phase-I EMR System
EMR Scope in Xinhua Hospital
Source: Xinhua Hospital.
Appendix XI: Xinhua Hospital's EMR System Implementation Roadmap
Source: Xinhua Hospital.
Appendix XII: Organizational Structure of Xinhua Hospital's EMR Project
Source: Xinhua Hospital.
Appendix XIII: How to Consider and Select EMR Products?
- It should meet the requirements of the Standards for Functions of EMR System, and Technical Plans for Establishment of EMR-based Hospital Information Systems, both released by the Ministry of Health.
- It should provide the typical functions of the above-mentioned EMRs and all functions of paper medical records. In addition, it can be used to enter, save, handle, and inquire about medical record messages through a computer.
- The functions of the EMR system framework model are from six components: the clinical data repository (CDR), controlled medical vocabulary (CMV), clinical decision support system (CDSS), integrated platform, integrated doctor and nurse workstations, and EMRs.
- Study the controlled medical vocabulary (CMV) to see if it is standard and complete, and use medical terminology standardized internationally or in China (e.g. SNOMED, ICD-10). In cases where self-made glossary is used, you should be vigilant.
- Does it have an integrated platform or integrated functions? What is the integrated technology? Can the integrated functions enable seamless connection within the surrounding environment, so as to realize data exchange and sharing?
- Does the product provide a medical knowledge base and clinical decision support? Or does it just offer a medical information database?
- Do the EMRs include an integrated doctor and nurse workstation? Do they support mobile workstations?
- Does the product have complete CPOE (computerized physician order entry) functions? Can the product realize close-loop physician order management?
- Does the product have clinical pathways? Are the clinical pathways integrated with EMRs without the need for a second-time operation?
- Does the product truly provide clinical decision support? The required considerations include the scope and depth of its functions, and if it benefits the management of clinical medical care quality?
- Does the product have comprehensive and reliable safety design, support EMR authentication, and safeguard patients' privacy?
- Are the product's functions similar to Xinhua Hospital's areas of expertise? Does the product meet Xinhua Hospital's different requirements?
Source: Xinhua Hospital.
Appendix XIV: Typical Day of Xinhua Hospital's Resident Medical Staff
(Source: Xinhua Hospital)
Diagram 1: Descriptions of Diagnosis Process
Diagram 2: System Alerts for Newly Hospitalized Patients | |||||
---|---|---|---|---|---|
Ward | Bed | Hospitalization NO. | Name | Gender | Age |
NO.3 sickness zone in cardiology | 02 | 975581 | He [New] | Male | 44 |
NO.3 sickness zone in cardiology | 03 | 975514 | Sun | Male | 74 |
NO.3 sickness zone in cardiology | 04 | 975216 | Cui [Transferred] | Male | 38 |
NO.3 sickness zone in cardiology | 05 | 975105 | Gu | Male | 62 |
NO.3 sickness zone in cardiology | 06 | 975754 | Mao [Transferred] | Male | 72 |
NO.3 sickness zone in cardiology | 07 | 975159 | You | Male | 55 |
NO.3 sickness zone in cardiology | 08 | 975763 | Luo | Male | 86 |
NO.3 sickness zone in cardiology | 09 | 975269 | Zhu | Male | 64 |
Italic names: Patients hospitalized within the last 48 hours
Bold italic names: Patients hospitalized between the last 48 and 72 hours
[New]: Patients hospitalized today
[Transferred]: Patients transferred today
Diagram 3: Recording of Digitally Mobile Ward Rounds, and Image Accessing and Display
The resident physician was operating the system, and the attending physician reading the patient's hospitalization records.
Diagram 4: Chief physician Reading Paper ECG (Electrocardiogram)
Diagram 5: Interface for Creation of Electronic Physician Orders
The interface for creating electronic physician orders shows basic patient information, the start time, valid period, type, contents, specifications, doctor, execution status of physician orders, etc.
Diagram 6: Clinic Consultation Sheet Printed through EMS System, and Completed Paper Clinic Consultation Sheet
The medical consultation sheet in the first photo was requested through the system. It contains basic patient information, requested consultation time, requested consultation department and consultation request purposes. The second photo shows the lower half of a medical consultation sheet on which the physician manually wrote their consultation notes.
Diagram 7: Typical Case Analysis – Typical Day of Resident Medical Staff
Diagram 8: Body Temperature Graph Manually Marked by Nurse
This case was prepared for inclusion in Sage Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.
2024 Sage Publications, Inc. All Rights Reserved