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Healthcare, Policy

A new order in an old hospital

By Jianggan Li | 30 October 2009

As the Deputy Director of Macau’s Health Bureau, Dr Chan Wai Sin is very conscious of the challenges facing e-health adoption in the territory.

“Macau is very small,” he says. “The government needs to take the lead in e-health and create a central health record database.”

Chan is also the Director of Hospital Conde S. Januário, better known as its Portuguese acronym CHCSJ. Established in 1874, the government-run hospital has 476 beds and receives around 280,000 outpatients annually.

Referring to the FutureGov Great Debate on whether hospitals should develop their IT systems in-house [Pages 42-43, FutureGov June 2009], Dr Chan says that the government had considered outsourcing that to a private company. However, as Macau’s IT sector is small, the government fears that the company might only complete half of the project and the government would have to take over.

A city of just over 500,000 residents, Macau has three general hospitals. In addition to CHCSJ, there are the 466-bed Kiang Wu Hospital founded in 1871, and the 60-bed Macau University of Science and Technology Hospital(MUST), which opened in 2006. A complex list essentially reveals that the government covers all the medical costs for around 70 to 80 per cent of the population.

CHCSJ has computerised outpatient management and basic orders. Its IT team is currently developing a billing system as well as implementing PACS.

As the central database envisioned by Chan, CHCSJ’s information system, straightforwardly named the Hospital Information System, was developed in-house. The management had wanted to buy a package from the market. However, after having evaluated a number of different systems, they came to the conclusion that none of them suited the unique situation of Macau’s healthcare sector.

All the software engineers who participated in the original development have since left the hospital. But the issue of knowledge retention that prompts many hospitals to refrain from in-house development didn’t crop up.

“We had so many arguments against buying and customising a system,” he explains. “In-house development avoids such conflicts in an old hospital, where the existing culture is deeply rooted.”

International

None of 13 tertiary institutions offers western medicine courses. Therefore all the western medicine doctors are trained in Mainland China, Hong Kong and other jurisdictions. The patient cases that Macau can’t resolve itself are normally sent to hospitals in Hong Kong for further consultation.

Hoping that a centralised database will allow easy retrieval of records by partner specialists in Hong Kong, Chan is determined to make every bit of the e-health initiative international, by adopting HL7 data exchange standards and other measures. “Macau is small. So it is important that we adopt international standards,” he says.

Although the official languages of the territory are Chinese and Portuguese, Dr Chan prefers that the records to be kept in English. Even though on the neighbouring mainland Chinese is almost exclusively used, understanding of English records there is much less of a problem than understanding Chinese records anywhere else.

At the moment, there is no mandate for doctors to use English, as most specialists educated on the mainland express the case more clearly in Chinese.

The other two hospitals in Macau both use the Chinese language for medical records. This makes interfacing HIS from different hospitals meaningfully more difficult, as a Chinese language system always requires a more sophisticated interface engine.

Physician resistance

A bigger issue for Chan is physician resistance. “If the doctors use the system, everyone else will do so to suit the workflow,” Dr Chan explains. “But that’s a big ‘if’.”

He says he is somehow envious of MUST Hospital. As a new and small hospital, they have the luxury of trying out many new systems and technologies without much difficulty. “In an old hospital, whatever you do you are destined to face lots of resistance and even protests, especially from senior consultants,” he says, adding that as a solution, the hospital has equipped these renowned clinicians with personal assistants for information input.

“This is not ideal, but it’s the best compromise we could settle on.” Even whether to key in the patient’s name first or ID code first could cause strife, Chan reveals.

“People who have not undergone this normally find it hard to understand how difficult it is.”

To resolve this, CHCSJ’s HIS allows physicians to customise their input interface to input information in a fashion they are most comfortable with. “It’s a gradual way for them to appreciate the information system,” Chan says. “And more meaningful input has been generated from them along the way.”

Neighbouring Hong Kong’s approach of heavily involving doctors in e-health projects is being adopted in Macau as well. Not only that, he says that doctors involved in development can play a vital role by promoting the system, often voluntarily, and effectively.

Chan goes on to explain that specialists often express scepticism about a new system without having tried it out. Therefore if a fellow doctor can tell his colleagues ‘that has been taken into consideration when we developed the system’, they will have much more confidence when they it out. “Having fellow doctors promoting the system for us is very important,” Dr Chan says. “It is much more effective than messages from the IT department or the hospital management.”

“Otherwise, if an IT savvy doctor is not involved in development, it is very easy for him to dismiss the system and create negative feeling among his fellow doctors,” he adds.

“Implementing any change in an old hospital is always tricky,” Chan concludes. “As the manager, I need always to keep my eyes open and make improvements gradually in a sensible way.”

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