The Ministry of Health, Bhutan decided to move towards digitization of their health record system in order to improve the patient care and operational efficiency. Their existing process is paper-based. In order to digitize, Ministry of Health decided to implement Bahmni in the hospitals. The whole digital system was named as ePIS.
An experience report of the ThoughtWorks team who did an initial workshop can be read here : Beyond Inceptions: Aligning with the Social Sector.
I am going to narrate our further experience while doing implementation.
In Bhutan, the health care is free of cost for everyone. The hospital system has a hierarchy as shown below.
Patient load at Referral hospital and District hospital is more than 500 patients each day. BHU 1 and BHU 2 (i.e. Basic Health Unit type 1 and type 2) generally have patient load of about 50–60 patients each day. Outreach clinics are present in the remote areas of the Bhutan where Health assistants from BHU 2 travel and provide medical care.
What is ePIS?
ePIS stands for Electronic Patient Information System. Bahmni is a part of ePIS which will be used to store the patient information in the digital format in order to replace their existing paper based system.
Need for ePIS system
Currently in Bhutan the patient medical records are maintained in the paper based system. Below are some of the reasons to move towards ePIS
· Patient forget to bring the old papers while coming to hospital
· Maintaining the patient records in hospital takes lot of resources
· Generating the reports and performing any kind of research on the data is very difficult
· Manual errors while capturing the data
· When patient moves from one hospital to another then he/she needs to carry all the medical records along.
· Ministry bears cost of printing the papers.
Big picture of ePIS:
Pre-pilot visit to Paro district hospital:
Paro is a town in the Paro valley of Bhutan. It is a historic town with many sacred sites and historical buildings scattered through the area. It is also home to Paro Airport, Bhutan’s sole international airport.
For the rollout we decided a phase wise approach. In Phase 1 we will be deploying Bahmni in three facilities which includes Paro district hospital, Phobjikha BHU 1 and Drukgyel BHU 2. In this phase, deployment and adoption at Paro DH will be challenging as the patient load is as high as 500 patient per day. We are starting the pre-pilot at Paro DH.
We, a team of three ThoughtWorkers visited Paro DH from 4th May to 15th May 2017. The purpose of the visit was
· To deploy Bahmni in the server present in Paro DH
· Analyse any gaps in infrastructure for piloting ePIS
· Showcasing the end user what is ePIS and collecting their feedbacks
· Understanding the current Laboratory information system
· Understanding Mother and child health (MCH) program and Non-communicable disease (NCD) programs
Bahmni deployment issues:
When we started deploying Bahmni we faced some challenges. The Dell Poweredge server was a new hardware for the team. We faced the issue while installing the CentOS due to incorrect RAID configuration.
We were not able to get the login page of Bahmni and OpenMRS due to missing report compatibility module which was later manually deployed. Sync between OpenELIS and EMR also failed due to missing link to an OMOD file.
We also faced network connectivity issue between client and server due to defective network switch. We performed trial and error method to identify the faulty switch. After removing one of the switch from the network we were able to get the consistent connectivity between the server and the client.
We fixed these issues one by one and finally got Bahmni up and running on the server. The joy was immense.
Testing connectivity from the registration desk:
We performed a test to check the connectivity from the registration desk. We registered a patient in the Bahmni using the desktop present at the registration desk. The information got saved in the server and we were able to pull back the record successfully.
Showcasing to the end user:
After getting the system ready we performed a showcase to the end user. This was the first showcase with the client from the starting of the project. In the audiences, CMO, Admin and other senior doctors were present. We received a positive feedback in this showcase. They were happy to see the system very close to their paper forms. The receptionist from the hospital was very excited to use the system as it would save a lot of papers and she doesn’t has to fill data for the returning patient.
Some changes were requested by doctors to make the system more adaptable like
- Removing extra field from some of the forms
- Making the medication tab as a text field to make it easier for the doctor to prescribe medications
- Removing the billing part from ERP as they don’t charge for medicines
The outcome of the entire visit was quite positive. We were able to identify the issues which we could have faced during the actual deployment. We successfully deployed and showcased Bahmni from the hardware present in the hospital. This gave confidence to the end users in the system as it was running on their hardware. Another achievement was to involve the end users in our development cycle and making them understand the importance of the regular showcases to solicit feedback
We will be traveling in the month of June for the rollout at two facilities — Paro DH and Drukgyel BHU 2. We will be training the end users in Bahmni during this visit. As a part of capacity building the ICT team from Ministry will be shadowing us during the entire visit to understand the deployment, support and end user training process. We are looking forward to this visit as much as hospital staff are excited to use the system !!