The document details a project on the 'Completeness of Decentralized Billing' at Sir Ganga Ram Hospital, aiming to improve the accuracy of patient billing in relation to specific consumables. It discusses the hospital's web-based hospital information system implemented in 2005 and presents findings showing discrepancies in billed versus actual usage of items like glucose blood strips and narcotic drugs. Recommendations for minimizing wastage include better staff training, strict supervision, and simultaneous data entry to enhance billing accuracy.

1. SUBMITTED BY:-
Dr. SHIRIN SAINI
(2010-12) BATCH
PG/10/042

2. ORGANIZATION PROFILE
• Sir Ganga Ram Hospital is a 650-bedded multi-speciality state-
of-the-art hospital in India.
• It provides comprehensive Healthcare services, and has acquired
the status of a premier medical institution.
• It is the only hospital in the private sector that has maintained
nearly 100% bed occupancy due to its reputation of providing the
highest level of medical services to patients from Delhi and
neighboring states.

3. • Web-based hospital information system was implemented in Sir Gangaram
Hospital in December, 2005.
• A hospital information system (HIS), is a comprehensive,
integrated information system designed to manage the administrative,
financial and clinical aspects of a hospital.
• According to (Linda Roussel, Russell C. Swansburg and Richard J.
Swanburg, 2005), a typical hospital information system consists of six
components:-
* Admission
* Medical records
* Nursing
* Patient billing
* Order entry
* Result reporting

4. PROJECT OVERVIEW CONTD.
• Billing module is one of the most supportive modules for admitting a
patient from the very beginning up to its discharge.
• Importance of Billing Module in HIS
* Automatic billing with manual overrides.
* IP monitoring.
* Generation of final bill with perfect accuracy.
* Automatic Billing of every facility or services ordered.
* Require less Staff.
* Enhance patient care in a cost-effective manner.
* Fast, Smart and Accurate bills.

5. Patient comes at the hospital Advised by the Doctor to get admitted
PHARMACY
LABORATORY
WARD STORE
During the stay of the patient in the hospital, all his/her orders like- Medicines and all the Lab
tests are entered in the HIS. The order is placed to the various locations like- Pharmacy Store,
Hematology Lab, Bio-chemistry Lab, and so likewise one such location is the Ward Store.
* PATIENT BILLING WORKFLOW AND ORDER COMMUNICATION AT SGRH

7. PROJECT OVERVIEW CONTD.
• In SGRH, Patient billing and Order communication both are the
prime responsibilities of the Ward Executives, and is
decentralized in nature.
• Completeness in normal terms means a process from the start till
the end is perfectly done according to the set protocols.
• My project “Completeness of Decentralized Billing” focuses
mainly on the accuracy of the patient billing, that is, the
number of usage of a particular consumable should exactly be the
same as that of the number of the consumable billed.

8. OBJECTIVE OF THE STUDY
• To study the accuracy of decentralized billing in relation to:-
* Glucose Blood Strips
* Newly issued Digital Thermometer
* Newly issued Hand Rub
* Narcotic Drugs

9. RATIONALE OF THE STUDY
• Strict usage and legal issue with Narcotic Drugs.
• Digital Thermometer and Hand Rub are the set protocols under
NABH Standards.
• All consumables are precious commodity. Any wastage is
associated with a significant cost.
• Essential feature of management to track the utilization of the
Glucose Blood Strips, Digital Thermometer, Hand Rub and
Narcotic Drugs.

10. METHODOLOGY
•Analytical Study
QUANTITATIVE APPROACH
DATA COLLECTION
&
DATA ANALYSIS
RESULTS COMPARED, INTEGRATED & INTERPRETED

11. • Simple Random Sampling of Departments was
done for the process of DATA COLLECTION.
Items to study Department
Glucose Blood Strips 3A Ward
Hand Rub 4A Ward
Digital Thermometer SSRB-2nd Ward Floor
CB-6th Floor
SWB-4th Floor
Narcotic Drugs Post-Operative ICU
PICU
ICU CUB 1
ICU CUB 2
ICU CUB 3
ICU CUB 4
3rd & 4th HDU

12. Data entered in Microsoft Excel and then ported to SPSS
for analysis.

13. DATA ANALYSIS
• Done using Microsoft Excel and SPSS.
• Paired Sample T-test was applied to the data of Glucose Blood
Strips.
• Cross-Tabulation analysis was done for Digital Thermometer
and Hand Rub.

14. OBSERVATIONS

15. PAIRED SAMPLES T-TEST
RESULT
FOR
GLUCOSE BLOOD STRIPS

16. H0- There is no difference between the number of glucose tests done and number of glucose
blood strips billed.
H1- There is a difference between the two.
Level of Significance chosen- α=0.05 (95%)
Test Statistic- t=1.812
Tabulated value- t α=2.78 (for 4 degrees of freedom and α=0.05)
Therefore, as |t|< t α ; we reject the Null Hypothesis and conclude that There is a difference
between the number of glucose tests done and the number of glucose blood strips billed.

17. OVERALL PERFORMANCE
470
460
450
440
430
420
410 458
400
390
380
397
370
360
TOTAL TESTS DONE TOTAL BILLED
15.37% of the difference between the Glucose Blood Strips used and billed was
observed; that is the usage was more than the number of Glucose Blood Strips
billed.

18. DEPARTMENT WISE ANALYSIS
250
GLUCOSE BLOOD STRIPS
39
200
150
8
TOTAL TESTS DONE
219
100 TOTAL BILLED
5 180
109 5
50
4 DIFFERENCES
101 64 59
23 19 43 38
0
3A WARD 3B WARD 4A WARD SSRB 2nd CB 6th
SSRB 2nd is the main area of concern with a difference of approximately 22%

19. CROSS-TABULATION ANALYSIS
FOR
DIGITAL THERMOMETER

20. • Out of the total of 43 patients:-
* 58.13% are issued as well as billed. (True Positive)
* 32.55% are neither issued and neither billed. (True Negative)
* 4.65% are issued, but not billed. (False Positive)
* 4.65% are not issued, but are billed. (False Negative)

21. DEPARTMENT-WISE ANALYSIS
DIGITAL THERMOMETER
14
12
1
10
8 NOT ISSUED & NOT BILLED
2 ISSUED BUT NOT BILLED
6
1
NOT ISSUED BUT BILLED
1 7 11
4 ISSUED & BILLED
4
6
2
5
3 1
1
0
3A WARD 4A WARD SSRB 2nd CB 6th SWB 4th

22. CROSS-TABULATION ANALYSIS
FOR
HAND RUB

23. • Out of the total of 43 patients:-
* 62.8% are issued as well as billed for Hand Rub. (True Positive)
* 2.32% are neither issued and neither billed. (True Negative)
* 23.3% are issued, but not billed. (False Positive)
* 11.6% are not issued, but are billed. (False Negative)

24. DEPARTMENT-WISE ANALYSIS
SWB 4th 9 1 2
CB 6th 3 4
ISSUED & BILLED
SSRB 2nd 7 1 1 NOT ISSUED BUT BILLED
ISSUED BUT NOT BILLED
NOT ISSUED & NOT BILLED
4A WARD 3 3 2
3A WARD 5 1 1
0 2 4 6 8 10 12 14

25. NARCOTIC DRUGS ANALYSIS
ICU CUB 1 ICU CUB 2
120
45
100
40
35 40
80 41
30
60 25
111 112
TOTAL BILLED 20 TOTAL BILLED
40 TOTAL IN FILE TOTAL IN FILE
15
16
20
10 16
5
16 16
0 0
INJ.FENTAYL INJ.MORPHINE INJ.FENTAYL INJ.MORPHINE
ICU CUB 1 ICU CUB 2

26. ICU CUB 3 ICU CUB 4
180
450 420 417
160 400
153
140
152 350
300
120 250
200
100
99 ICU CUB 3 150
100 INJ.FENTAYL TOTAL BILLED
100
80 ICU CUB 3 TOTAL IN FILE
INJ.MORPHINE 50
60 0
4 4
INJ.FENTAYL
INJ.MORPHINE
40
20
0 ICU CUB 4
TOTAL BILLED TOTAL IN FILE

27. CONCLUSION
• These were the following areas where the management has to look into so as to
minimize the wastage and the associated loss of cost:-
* Billing status of Glucose Blood Strips, as the usage is more than the
billed, which if not taken care of may lead to wastage and associated loss of
cost to the hospital.
* In case of Narcotic Drugs, Inj. Fentayl was used more often than Inj.
Morphine as Fentayl is a short-acting drug & so more often prescribed by the
Doctors.

28. • Differences were found, due to reasons like-
* Increased Work Load
* Repeated Bolus dose administration.
* Neglected change of location.
• Out of all the departments studied ICU CUB 1 and
ICU CUB 2 showed noteworthy performance.
• 3A WARD also showed a remarkable performance in
case of the Digital Thermometer Billing status.

29. RECOMMENDATIONS
• Raise awareness among the nursing staff and the ward executives.
• Strict supervision is required over the nursing staff.
• Simultaneous entry of data in the file and in the HIS.
• In case of digital thermometer & hand rub, the date of issuing the
item should be mentioned on the item itself. This was already
practiced in Casualty Block 6th floor and so this practice can be
implemented in the whole hospital.

30. RECOMMENDATIONS CONTD.
• The ward store in-charge should handle both the issuing and
the billing status.
• Before the patient is discharged all his orders should be
reviewed again so as to reduce these errors. This can be done
by the nursing head with the help of ward executives.
• A regular audit and follow-up should be carried out to help
minimize the wastage.

31. CASE STUDY
EFFECTIVENESS OF WEB-BASED
HOSPITAL INFORMATION
SYSTEM IN MAINTAINENCE OF
OT STORES
(A comparative study of pre & post implementation of HIS)

32. INTRODUCTION
COMPUTERIZATION IN SGRH 20 YEARS BACK
• FoxPro based Hospital Information System for 20 years, known as
HAPIS.
• FoxPro is a text-based procedurally-oriented programming language
and DBMS.
• Originally published by Fox Software and later by Microsoft, for
MS-DOS, MS Windows, Apple Macintosh, and UNIX.
• Database Management System (DBMS), supports relationships
between tables.
• Not considered a Relational Database Management System
(RDBMS), lacking transactional processing.

33. CURRENT UPGRADED HIS IN SRGH
• A computerized and web-based hospital information system was
implemented in Sir Gangaram Hospital in December, 2005.
• Sir Ganga Ram chose InterSystems TrakCare™ as its new HIS
because of:-
* Ease of learning, use, and configuration
* Enables simplified information sharing, faster
implementation, easier maintenance, and lower costs
* A highly reliable technology foundation built on the
InterSystems Caché®, a high performance database.

34. OPERATION THEATRE MANAGEMENT
MODULE
• Facilitates the coordination and efficient management.
• Operating Theater Management functions include:
* Registration * Movements
* Theater Inquiry * Billing
* Theater Booking * Booking Management
* Schedule * Schedule Management
* Schedule Calendar * Schedule Transfer and Copy
* Operating Theater Swap * Variance
* Care Provider Activity * Orders
* Surgical Preferences
* Prosthetics Management
* Store Maintenance

35. The present case study focuses on the
maintenance of OT Stores pre and
post implementation of TrakCare.

36. PRE-IMPLENTATION PROCESS OF OT
STORES MAINTENANCE

37. STOCK MAINTENANCE THROUGH
TRAKCARE
• As TrakCare is web-based HIS, therefore now an Automated Indent is
raised through the OT Store.
• In TrakCare there are 5 major steps for the raising the Indent:-
* Stock Transfer Request
* Stock Transfer
* Stock Transfer Acknowledgement
* Stock Transfer Inquiry
* Stock Inquiry
* Stock Location Inquiry

38. METHODOLOGY
• Purely qualitative in nature.
• Observations recorded personal interview
• The observations were recorded according to the
checklist created.

39. CHECKLIST
 Time taken for Inventory Management
 Downtime
 Requirement of Staff
 Billing Errors
 Billing & Stock Upadating Procedure
 Availability of Data
 Study of trends

40. OBSERVATIONS
CHECKLIST FOXPRO BASED HIS TRAKCARE HIS
Time for whole process 3-4 hours Hand-to-hand stock is
of Inventory updated.
Management
Very frequently happened No history of downtime
due to Index Corruption has occurred since
Downtime and it used to took implemented.
30minutes-2hours to
solve the problem.
Requirement of Staff Less More

41. Billing Errors More Less
Billing and Stock These were 2 different Hand-to-hand both
Updating exercises in Foxpro billing and stock is
Based HIS. updated. They both go
side by side.
Availability of Data Data Back-ups were Data since December
taken to undertake any 2005 is available without
kind of study. any Back-up.
Study of Trends Cannot be identified in Can be indentified.
this.

42. CONCLUSION
• With the implementation of InterSystems TrakCare, Sir
Gangaram Hospital has gained in the following arenas:-
* Better management control
* Standardization of operations and functioning
* Decrease in cost
* Reduce errors and corresponding litigations
* Better quality of service
* Development of a good brand image
* Higher growth prospects

43. REFERENCES
• State of Florida, Department of Health, A.G. Holley State Hospital, Hospital Information System, Function
Specifications Document
• Hamid Reza Kaghazch, Hospital Information System Modelling
• John D. Wiedemer, Billing system for computer software
• Mohanty Rajesh*, Rana Sarosh D**, Kolay Saroj K***, Hospital Information System in Medicare – An
Experience at Tata Main Hospital, Jamshedpur
• Haux Reinhold, Winter Alfred, Brigl Birgit (2004). Strategic Information Management in Hospitals: An
Introduction to Hospital Information Systems.
• Roussel Linda, Swansburg Russell C, Swanburg Richard J (2005). Management and Leadership for Nurse
Administrators. Contributor Russell C. Swansburg, Richard J Swansburg. Jones & Bartlett Publisher.
• F Labrèche, T Kosatsky, R Przybysz, Childhood asthma surveillance using administrative data:
Consistency between medical billing and hospital discharge diagnoses
• Ashwani .K. Ramani et.al, Hospital information system: PULSE [implementing IT in health-care]

44. REFERENCES CONTD.
• A. Winter, B. Brigl, T. Wendt (2003), Modeling Hospital Information Systems (Part 1): The Revised Three-
layer Graph-based Meta Model 3LGM2
• Sue M. Malone, Billing Error Reduction Project: A Hospital Payment Monitoring Program Special Study
• MedicaPlus- Patient Billing Overview
• Quintegra HMIS
• Nurse Training Manual at SGRH
• OT Store Billing Manual at SGRH
• Stock Processes Manual at SGRH
Website Links:-
• www.Wikipedia.org
• http://www.binaryspectrum.com/Outsource/healthcare_solutions_billing.html
• http://www.intersystems.com/trakcare/index.html
• http://www.iienet2.org/uploadedFiles/SHSNew/Tools_and_Resources/Sampling%20Plan%20for%20Billing
%20Accuracy%20Paper.pdf
• http://ipac.kacst.edu.sa/eDoc/2006/156398_1.pdf
• http://en.wikipedia.org/wiki/FoxPro_2