What happens when an opportunity emerges to create a new hospital, literally from the ground up? Further, what happens when that opportunity presents itself in a developing country like Botswana, with a very different healthcare professional history, and a completely different set of operational elements than would be the case in the average U.S. facility development project?
Jeff White and Guy Scalzi, two principals in the Pittsburgh-based Aspen Advisors consulting firm, can say exactly what might happen in such a situation, as they—the Dallas-based White and the New York City-based Scalzi—have been involved in an exciting project of just that sort in Botswana. In fact, they were the key information technology leaders for Bokamoso Private Hospital, which opened as an all-digital, 200-bed hospital, in an area outside the country’s capital, Gaborone, and near the border with South Africa.
Bokamoso Private Hospital is owned by the Bokamoso Private Hospital Trust, which was formed by a public-private partnership between the Botswana Public Officers Medical Aid Scheme (BPOMAS) and PULA Medical Aid Fund, a private, not-for-profit healthcare provider organization. The state-of-the-art facility, which opened for care in January, has an EMR in a paperless environment, a radiology information system (RIS) and picture archiving and communications system (PACS), and a highly redundant medical-grade data network, including wireless service with 100 percent coverage across the hospital, as well as PCs mounted on mobile carts, and wireless IP phones. All of these elements are part of an IT implementation based on a strict U.S. $6 million IT budget. In addition, White and Scalzi became heavily involved in the planning for an uninterruptible power supply, and in the IT training of the hospital’s clinical staff (drawn from the U.S., Europe, and all over the world, as well as from Botswana), and of its IT staff, in the clinical information systems being implemented.
In a recent interview, White and Scalzi shared with HCI Editor-in-Chief Mark Hagland their experiences in facilitating the ground-up IT build at Bokamoso, and the lessons learned from their unusual and enlightening experience.
Healthcare Informatics: How did you two become drawn into this very interesting and unusual project?
Guy Scalzi: There are two insurance companies in Botswana, and a lot of their members tend to leave for South Africa for surgeries. So they decided to build their own specialty surgery hospital, and to concurrently open a medical school. They hired a retired dean from Duke University to manage the medical school. And they hired a management company called OR International to provide management reporting to the board, and to recruit the administrative people and clinicians. OR International hired me to be the interim CIO from August 2008 through the opening on January 11 of this year. Then they hired a permanent CIO. We built a data center and the wireless infrastructure. I did a system selection with the CMO and CNO; we selected a core clinical information system product from India. OR International wanted a paperless, filmless hospital, as much as possible. And because this was a totally new hospital, with totally new medical staff recruited from all over the world, it had no legacy systems or even legacy data. It was totally ‘green-field.’
HCI: How big is the hospital?
Scalzi: It’s a 208-bed hospital with eight operating theaters and an additional 30-bed rehab unit, with a footprint to build another 100 beds eventually. The medical staff is comprised of about 40 doctors recruited from the U.S., Canada, South Africa, Europe, and the Philippines, with an additional 80 to 90 physicians who are local and who are being trained in the surgical specialties. There are about 240 nurses, who are all pretty much local, with the exception of about 10 senior nurses from the U.S. and South Africa, who have augmented the staff and helped to train them. The people who run the hospital wanted a Western-style hospital with Western-style management techniques, staffing, and technology. And we drove a lot of the information technology to adhere to those standards.
HCI: What is the core EMR?
Scalzi: The core EMR is a product called RCare Magnum, from a company called SRIT, which is based in Bangalore, India. The product is live in about 60 hospitals around the world, including in the six clinics of a prison health system in North Dakota.
HCI: What is the health insurance framework around care at Bokamoso?
Scalzi: There is a national health system in Botswana, with 12 national hospitals throughout the country; the scope of care is mainly emergency and general medical, with no specialized surgery.
HCI: So people have to have private insurance in order to access care at Bokamoso?
Scalzi: There is a national automobile insurance plan that covers automobile accidents and injuries. So the patient population is drawn basically from the middle class of the country, including government and private workers.
HCI: What is the census like, and what are the most common surgeries?
Scalzi: They’re seeing about 200 ambulatory patients a day, with an inpatient census around about 50. The most common procedures include labor and delivery, with around 100 deliveries a month now. In terms of surgeries, they’ve been doing orthopedic procedures, including a lot of endoscopies in their GI suite; and general surgery—gallbladder surgery, appendectomies, things like that. They’ve got a full cardiac catheterization suite, and are recruiting cardiac surgeons. Eventually, they’ll do open-heart surgeries.
HCI: And the hospital has a very international medical staff, correct?
Scalzi: Yes, and English is the language of care and operations.
HCI: Are you still actively involved?
Scalzi: No, we pretty much wrapped up our involvement at the end of June, and we’re now answering questions about our experience. They’re growing into what they have; they’ve got a good director of IT, someone they’ve recruited from South Africa. Their IT team has 17 people, including four trainers. There are also a few permanent people from the software vendor in India.
HCI: Tell me about the vendor selection and implementation process?
Scalzi: They wanted a product selected by January 2009. We started the process in August 2008. They wanted it paperless, filmless, and with a common database. I talked to Cerner, Epic, and Meditech in the U.S. Epic didn’t want to do business in Africa, and Meditech, Cerner, and Eclipsys were too pricey. My budget was $1.5 million for software and implementation. So we found two products in India, Wipro and Religare. Both companies have software that do everything. We chose Religare, and it’s everything—admitting, billing, scheduling, lab, radiology, pharmacy, PACS, physician and nursing documentation, supply chain, HR, even oncology; and there’s an Oracle image database and database. We selected them in January 2009 and the hospital went live January 11. We were up with a training system a couple of months before that.
HCI: How has it worked out?
Scalzi: It’s been great. Of course, there were all the usual problems of getting the doctors to enter orders, and getting nurses up to speed. They’re doing a new release with a much more graphical interface. Lab, radiology, and pharmacy are going well. Patients are registered both inpatient and outpatient, in the same record.
HCI: Tell me a bit about the technical aspects involved in IT implementation?
Jeff White: We approached the design of this as being an opportunity to bring in world-class computing systems for them. We were careful not to bring in too much bleeding-edge, that could be potentially unsupportable. There isn’t a big volume of professionals in Botswana with a lot of healthcare IT experience. So we went with Cisco wireless voice for the hospital, with a wireless network throughout the hospital, and a redundant network. We used a Cisco phone system with a traditional PBX switch, so we’d have one telecom vendor. And we went with Dell for the hardware. Southern Africa is a growing market for Dell.
HCI: Have there been any power outage problems?
Jeff White: Absolutely. The hospital can experience power outages four to five times a day. But the hospital has three generators to keep it running. There, everything is on red plugs. It’s like its own little city in terms of power generation. We have a hospital-wide UPS system to where desktops will stay on during that transition from street power to generator power. And being a smaller country and a developing country, even procurement logistics were relatively challenging. Cisco, Dell, Oracle. Things just took extra time to obtain from the vendors.
HCI: In terms of IT management, the folks there are doing OK?
Scalzi: Yes, they’re learning; none of those 17 people had ever worked in a hospital before. We did a lot of training, especially Jeff and his team, on the vendor side. And the vendor has four of their own trainers at the hospital. And we get a phone call a week.
White: In addition, this hospital has 102 residential units, like apartments. They were built by the hospital, and many of the expatriate employees are living there. The hospital is the phone company for them, the Internet service provider for them. We put in phones, even phone accounting software, for them. And Guy mentioned the typical vendors and devices—Philips, Siemens, etc., are involved, and all pretty fully integrated with the core systems.
Scalzi: Yes, and of the 17 people, four are biomedical engineering people.
HCI: So the 17 IT people are Botswanans, but without healthcare experience?
Scalzi: Yes, reasonably good technically, but without healthcare IT experience. There are a couple of government hospitals with Meditech registration systems, but that’s about it. And in South Africa, the information systems are about where we were 10 years ago, with the islands of data and such.
HCI: Overall, what have the lessons learned been?
Scalzi: The good thing is, you don’t have any software standards to adhere to, but that’s the bad news, too; you have to make things up. So you’ve got to make up your own standards, and policy and procedure manuals. Among the lessons learned: there’s never enough training. And it’s much easier to do a green-field hospital than to try to integrate and migrate from older systems, even if you have to train people to use a computer for the first time in their lives. And that a group of international professionals can work together never ceases to amaze me. And that a group of 10 physicians from different countries could do rounds and do fine. And the radiologists were from the Philippines, and had never worked on PACS before, but they loved it, and within 20 minutes, they had gotten it! And there were the huge logistics issues—ship by boat, or air-freight it?
HCI: What elements in all this might be of interest to CIOs?
Scalzi: The fact that the hospital has one common database, with no interfaces, would excite them. And it works. And it’s not best-of-breed, and you don’t necessarily have the best lab system or the premium nursing documentation system, but it works well.
White: Yes, and then there was the issue of developing the standards [for IT operations]. Even in this situation in a developing country, they wanted it to be very much like a U.S. hospital. In fact, when you visit there, the hospital feels very much like you’re in an American hospital. And to achieve that meant the development of standards, and building the IT organization as soon as possible. Initially, we didn’t get enough IT people on board right away, because it was difficult to identify candidates. All in all, in terms of staffing, when you’re creating an organization from nothing, it’s much more challenging than creating an additional hospital in a three-hospital system, for example.