The Clinical and Financial Transformation of Asia’s Largest Private Hospital

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Global Care Solutions

In January 1997, Bumrungrad Hospital opened its 554-bedreplacement facility along with a newly commissioned computersystem. A few months before the facility opened, the managementteam realized that the clinical and financial information systemsthey had purchased and customized would not be able to meetend users’ needs and cope with patient volumes. Unfortunately,due to long implementation cycles of hospital systems, they wereleft with no other choice but to open their doors with their newsystem.

Established in 1980, Bumrungrad Hospital is a recognized provider of premium private healthcare throughout Thailand and Southeast Asia. Bumrungrad is the first hospital in Asia to be accredited by the U.S.-based Joint Commission on International Accreditation. Located in central Bangkok, the hospital is a 554-bed tertiary care facility serving over 1.2 million patients annually. This translates to a daily average of over 3,000 outpatients per day with peak days touching 3,800. Patients come from over 130 countries and bring with them a large variety of languages and cultural diversity. “Approximately 35 percent of our patients are foreigners,” says Curtis Schroeder, CEO of Bumrungrad Hospital. Bumrungrad is perhaps the world’s first truly international hospital.

In January 1997, Bumrungrad Hospital opened its 554-bed replacement facility along with a newly commissioned computer system. A few months before the facility opened, the management team realized that the clinical and financial information systems they had purchased and customized would not be able to meet end users’ needs and cope with patient volumes. Unfortunately, due to long implementation cycles of hospital systems, they were left with no other choice but to open their doors with their new system. Their pre-opening worries were proved correct – the system’s functionality and performance were not enough for the new facility’s expanded capacity (at that point it was seeing only 1,200 outpatients a day with only 250 of 554 beds in use).

The Failed Computer System

Bumrungrad’s failed computer system was comprised of four integrated database servers/systems and a series of optical jukeboxes with disks containing 17 years of previous scanned patient medical records. In comparison, typical facilities of the time in the United States managed to operate efficiently with more complex systems, sometimes involving dozens of integrated servers. On a positive note, Bumrungrad had accomplished a lot with just four systems, and was certainly moving in the right direction. Failure had been contained primarily to vendor selection and local vendor support.

A saving grace of the failed system was the decision taken to scan old medical records.Without these previous 17+ years of scanned medical records, doctors at Bumrungrad would have been reluctant to use the new system.With any new system, it is not realistic to assume that all doctors will become touch typists overnight.With the ability for the doctor to enter their notes online, or to write on bar-coded sheets of paper, the system could straddle the old/new age of medical records without inconveniencing a large roster of current doctors and nurses with a shift to keyboard-based data entry.

Interfacing issues were enormous. The volume of mismatched data in the systems created a climate of mistrust of both the financial and clinical data.With a facility of over 700 practicing doctors and 2,000 other staff all calling management into question over the system, blame was unfairly passed on to the unfortunate computer department staff. In reality this blame lay fairly at the feet of those responsible for poorly configuring the ‘brand name’ systems and the nonexistent vendor support. The problem was clear – no matter how much time and effort was spent on the interfaces and data access speeds, there would always be problems with the system.

The Search for a New System

Bumrungrad Hospital knew that their new facility’s IT system urgently needed replacement, as it would be unable to cope with the projected rise in patient volumes. Sadly, the search for a new system started the day Bumrungrad opened the doors of their new facility.

Bumrungrad management drew up guidelines for a new system, and efforts to procure a new system were placed in the hands of top management including Curtis Schroeder, CEO, and Linda Lisahapanya, managing director. Mr. Schroeder commented “We needed to create an environment that would allow our doctors to practice medicine in the best way and create the best relationships with their patients. We wanted clinical information at the fingertips of our doctors to enable them to make better decisions.” This translates into a need for a system that can satisfy the requirements of doctors, nurses, radiologists, lab techs, pharmacists and at the same time, satisfy all back-office users with functionality including billing, materials management and other ancillary departments’ needs. The system would also need to:

• Produce invoices in real time for inpatients and outpatients;
• Deliver a real-time electronic medical record;
• Process the huge number of patients;
• Deal effectively both with outpatient physician practice and inpatient information processing in a single database;
• Use a single database for patient data, images, financial information and statistics;
• Keep all data online forever – no archiving;
• Have no interfaces;
• Have minimal downtime;
• Be easy and intuitive to learn (given the relatively limited experience of the local worker with information systems); and
• Not require the doctors to type.

The vendor(s) also needed to provide complete data conversion of the existing systems; no easy task due to:

• The data in the current system being of suspect data quality (due to bad interfaces) and would need to be “cleaned” before the data was exported into a new system;
• The current vendors’ lack of support and subsequent poor relations with the existing systems integrator (SI);
• 17 years of scanned medical records having been placed into a proprietary FileNet system comprised of six HP jukeboxes with over 400 optical disks. This data needed to be converted during the final months of the old system’s operational life.

To make matters even more difficult, the logistics of not only converting a system, but also making a new system operational in an existing high-volume operation is not an easy task. The replacement system and SI would need to have a very good plan for bringing a new system live without interfering with patient volumes now exceeding 2,000 outpatient ambulatory visits per day, and a full house of inpatients.

The New System

Bumrungrad set the goals and objectives and chose Global Care Solutions’ (GCS) new Hospital 2000 product suite to run their facility. It was a new product, so Bumrungrad had a lot of operational input into the system to ensure it worked in a high-volume Asian environment. The Hospital 2000 system is an integrated enterprise software solution that integrates virtually every department in a hospital. This type of system is traditionally categorized as a “Hospital Information System” (HIS). It is unique in the fact that it is an integrated solution that combines both the healthcare (frontoffice) and back-office operations in a single database, which works in virtually all languages.

The Hospital 2000 solution includes: registration, clinic systems, ward, emergency department, laboratory, radiology, picture archiving and communication system (PACS), clinical image management, pharmacy, operating theatre, enterprise appointments, billing system, purchasing, inventory, accounts receivable, accounts payable, general ledger, asset management, human resources, rostering/time and attendance, and payroll.

The new solution was to be a complete divergence from the existing multiple system architecture. The Hospital 2000 solution architecture was based on a single-server and single-database model containing the entire facility’s data, solely using Microsoft Windows 2000/2003 server and Microsoft SQL 7/2000 database platform technology. The then-current and now-failing system was based on a multiple-server solution running Sun Solaris operating systems and databases from Oracle, Ingres, Sybase and Informix. The new replacement system hardware architecture was simple; the database server was a Dell 4 processor 500 MHz Intel Xeon with Fibre Channel storage in the form of a Dell PV 660/650F. The system is still running on a Dell 4 processor system, but has been upgraded to Dell 6950 Intel Core 2 Duo 3.4 GHz (4 CPU) with Dell/EMC CX3-80 SAN running Microsoft Windows 2003 Server/SQL Server 2005.

With all of this data on one server and storage unit, many administrators would say “you’re putting all of your eggs in one basket” or “you have just created one big single point of failure.” But if this strategy is examined on a deeper level, the facility actually benefits. With a production system based on a single server/storage solution, it is now cost-effective to have a complete backup data center. This “backup data center” option would not be affordable in the old Unixbased system with multiple databases, as the technology is fragile and budgets would have been un-obtainable.

The ‘Big Bang’ Method of System Rollout

How is a new system rolled out in an existing high-volume facility? There are basically only two ways of doing it: Either parallel run systems and slowly turning off existing systems, or making the transition all in one night (i.e., big bang). There are literally no alternatives to these two options.

The “parallel run” theory is about risk mitigation and reduction. This process theoretically allows one department at a time to switch over to a new system. But it also has some very large drawbacks, namely:

• Time. Parallel running takes years to roll out to a multidepartment system.
• While the parallel-run process is going on, the computer team is generally working around the clock keeping interfaces going that now need to work in perfect synchronization between two disparate systems, often from competing and noncooperative vendors (you would probably not cooperate if your system was being turned off). All of this multiyear, round-the-clock work for the IT team makes them very tired and prone to mistakes (and possibly pushes them to search for new jobs).
• When mistakes happen, the process is elongated, as the users point fingers and say “See, I told you it would not work,” thus exasperating the computer team.
• Users will typically find every excuse they can to retain their existing systems – old systems are like old security blankets. People are very reluctant to give up old systems no matter how bad – or in the case of the blanket, dirty – they become.

The big-bang theory of bringing a system live is obviously more chaotic, as many activities need to occur simultaneously, and therefore is often seen as a higher risk than a parallel-run transition. But, the big-bang method has some interesting features.

• It is fast and you can then take advantage of the new functionality that you purchased (and get a faster ROI);
• The disruption in the departments is intense, but it is also short-lived as the users will tend to adapt quickly to any changes and “get on with it,” as the old system is now turned off and there is no going back; and
• Many analysts would argue that a parallel-run process is even more risky than big bang due to the potential risks outlined in parallel-running systems (morale issues, data mismatches, vendor opposition and politics, long switch-over times).

The biggest risk in the big-bang scenario is that the system the facility is turning on is a very poor system in respect to features and performance. But, if the facility has done its homework correctly and mitigated this risk, then big-bang certainly has its advantages.

Going Live

Bumrungrad Hospital took the option to go live with the GCS Hospital 2000 system using the “Big Bang” approach. Curtis Schroeder commented, “We turned on the new system instantly after we switched off the old one ... there was no parallel running. It was a challenge preparing the hospital staff – approximately 2,000 of them – to manage an instant switch-over to the new system.”

Leading up to the go-live date, there were obvious challenges, namely:

• How do I train all of the people?
• How do we perform the data conversion?
• How do I roll out the new PCs and not disturb the current system?

Data conversion was conducted in the old-fashioned way – dump existing system data to text files, clean up the data and then load the data into the new system. This of course was easier said than done, as the existing system had a lot of “bad data” inherited from the failing interfaces and subsequent data mismatches. The existing system also had data in English and Thai, presenting an additional challenge to the mainly European developers at Global Care Solutions who had only basic Thai language skills. In addition to the data issues, the Buddhist calendar was used inconsistently in many parts of the system, adding to the complexity when dealing with any part of the conversion involving dates. Almost the entire data conversion process was affected by date consistency issues!

December 17, 1999 was the date chosen to “go live” as it was predicted that this would be a slow time at the hospital with the Christmas holidays approaching. As luck would have it, it happened to be the busiest day they ever had (at that time) with a full inpatient census and 2,400 outpatients! At 6:30 a.m., the new system was turned on, and the existing systems were all turned off. Everything worked and the hospital never looked back.

PACS at Bumrungrad

Global Care Solutions also supplied the PACS at Bumrungrad. The GCS Amalga PACS operates on the same server and storage hardware as the hospital information system. No new servers or interfaces were needed; only some additional storage for the large radiology data generated by the 150,000 studies per year. The PACS system was implemented in January 2002. The 2006 study volume at Bumrungrad has increased dramatically to 250,000 studies per year, making it one of the largest-volume radiology departments in the world.

One of the most challenging issues of a PACS installed in a Southeast Asian facility is the local language support for non- Western character sets. Imagine seeing a patient’s name in Thai on the operator console of an MRI made in the U.S. – this generally will never occur, as most Western-modality vendors tend to ignore the fact that a few billion people do not use English as their native language.

The process of going filmless is not easy for a large facility, and is only possible with exceptional management. Dr. Chamaree, chief of radiology, states, “We have eight full-time radiologists and 33 part-time radiologists who practice at the facility. Everyone learned the system in less than three months.” She added, “99 percent of X-ray studies were reported on the GCS PACS within six months of installation.” Typically, most PACS systems take years for adoption.

The PACS has an “everything online” approach to image storage. This is a very different approach than the traditional PACS that has just 30 to 60 days of recent studies online. Traditional PACS products archive older studies on a hierarchical storage media such as an optical jukebox. With the optical jukebox approach to image storage, there are several issues that are typically faced:

• Image retrieval time is typically very slow with systems based on hierarchical optical/tape storage (at least 30 seconds per study, if there is only one user on the system);
• Doctors will tend to avoid looking at historical studies if they take too long to retrieve from the system, so patient care and the doctors’ decision-making processes are affected;
• Cost of hard disk storage has been dropping dramatically for the past few years and the trend is predicted to continue at a 50-percent-per-year price drop per megabyte; and
• When radiology studies are stored on online media (hard disks), all studies are retrieved at the same speed.

Bumrungrad Hospital now conducts 250,000 radiology studies per year. This consumes approximately 4 terabytes (TB) of storage in the production data center with a duplicate data set also located in the backup data center.With online storage media, the cost in 2006 for 4 TB of storage is approximately US$100,000. This figure compares well with the comparable annual film budget of approximately US$1 million per year. Not all of the savings can be put back on the bottom line of Bumrungrad, as other PACS-related equipment such as expensive diagnostic workstations and other hardware requirements consume some of these savings.With the cost of storage and diagnostic workstations dropping at considerable rates (50 percent per annum), more money will be put back into the Bumrungrad facility to improve patient care and customer service. Actual savings are only part of the story in justifying a PACS solution – patient care, medical staff career enhancement and customer service is where to look for the real ROI of a PACS.

The Success Story

Bumrungrad Hospital has experienced double-digit growth for the past six years to become one of the largest private clinics in the world. In Thailand, the most successful private hospitals are those that have been able to bring good-quality healthcare to the customers in a timely, efficient and pleasant manner. Patients have the choice to use public hospitals and see well-qualified physicians at little or no cost. Therefore, a key differentiating factor in their choice is time and efficiency. A hospital’s information system is the single most important investment in delivering on this expectation.

“There is no conceivable way that a hospital could cope with 3,400 patients in one day, 80 percent without appointments, with a total treatment time of 45 minutes and an accurate demand bill at the time of service without a system like Hospital 2000,” commented Curtis Schroeder. “Bumrungrad Hospital has outperformed every other listed hospital in the Southeast Asian market by a factor of two since the implementation of this system. It is a key part of our success.”

Bumrungrad Hospital has closely tracked the “before” and “after” operational effects of the implementation of the Hospital 2000 suite of products. Following are a few highlights of the assessment:

• Time to retrieve a medical record reduced from 25 minutes to virtually instantaneous;
• Patient waiting times reduced by 39 percent;
• Laboratory processing time reduced from 14.5 to 3 minutes per sample;
• Radiology processing time reduced from 57 minutes to 18 minutes per study;
• US$294,000 of radiology film costs reduced to $26,000 in hard disk storage;
• Outpatient pharmacy dispensing time reduced by 50 percent;
• Outpatient bill preparation time reduced from 22 to eight minutes;
• Accounts receivable days reduced from 15 to 10 (quicker third-party billing);
• Forms stocked reduced from 395,616 pieces on average to zero;
• Inventory turns per year increased from 11.89 to 23.52 due to real-time inventory control and automated re-ordering;
• Days to close the monthly books reduced from 30 to four days;
• 10,000 square feet of medical records storage space was converted to a revenue-producing pediatric center treating over 110,000 children in 2003; and
• Staff efficiencies: 129 full-time equivalent savings attributed to Hospital 2000.

“Hospital 2000 has provided Bumrungrad the unique capability to handle a number of patients, which generates the critical mass necessary to maintain very competitive pricing,” adds Mr. Schroeder. Hospital prices at Bumrungrad are one-tenth of those in the United States, one-quarter of those in Europe and one-third of those in Singapore.

Since implementing the system, the hospital volumes have doubled. During this same time period, administrative staff has actually been reduced. “The only way this doubling of patients and lowering of administrative staff could be achieved was by computerization,” noted Linda Lisahapanya, managing director, Bumrungrad Hospital. This has a direct effect on the bottom line: doubling of revenue, but using the same building, medical equipment and administrative staff. Much of this has been attributed to the computer system.

Another ‘Small Bang’

Bumrungrad Hospital has adopted a philosophy that hardware needs to “refreshed” periodically to keep a computer system at its peak performance and also keep the vendors interested in the facility as a customer. A computer today has a useful life that seems to get shorter and shorter as newer and faster hardware appears on the market on a daily basis. Desktop PCs can have a useful life of between three and five years, but servers and storage need refreshing every three years to keep up to date with the latest technology and provide users with big performance gains. Silicon-based chips get faster on an exponential scale (density doubling every 12 months – Moore’s Law).

After several years of operation, Bumrungrad’s new system was running with the desired performance, meeting business objectives. However, great advances had been made in computer performance in that short period of time. It was time to evaluate a hardware upgrade. Reliability and performance improvements were to be gained by simply replacing the existing Dell-based server and database storage system. New equipment was specified in January 2003, and purchased and assembled in July/August. The most difficult part of moving a live system to a new hardware platform is the migration of the data. At this point, Bumrungrad had accumulated 500 GB of database transactions and over 4 TB of PACS images and scanned medical records (now it is 900 GB and 10 TB, respectively). The goal was to have a downtime window of less than 30 minutes while moving from the production system to the new replacement hardware. Since this upgrade in 2003, another “small bang” was conducted in 2006, to move to a new Dell Server and Dell/EMC storage-based platform. Every three years, this replacement cycle will continue – as server and storage prices plummet and performance increases, it is a very cost-effective way of running a data center.

The current Bumrungrad system processes over 1.9 billion transactions per year (SQL statements), and has a peak time performance load of approximately 25 percent CPU utilization. The system sees peak loads sustaining 250 transactions per/second between 8:00 a.m. and 12:00 p.m. Bumrungrad will keep growing in patient base and computerized medical management, and will continually be improving and upgrading PCs, servers and storage.

With a highly computerized large tertiary facility, one could imagine the need for a large IT department maintaining the equipment and software. The IT department at Bumrungrad is staffed at 15 FTEs. The department has 24x7x365 operational responsibility for the system.

The Future of Bumrungrad

Bumrungrad Hospital is continuously expanding both its physical facilities and its range of services. Construction has recently started on yet another expansion building, and scheduled for completion in December 2006, the facility has a projected patient volume of 1.6 million patients per year, nearly doubling the current capacity. Inpatient beds will be expanded to 650, and radiology studies will grow to well over 250,000 per year. The entire computer system hardware will be replaced every three years. At these prices, upgrades and system replacements should not create any financial burden for the Bumrungrad facility.