E health max cover story oct 2010

MAXimising Benefits
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Posted by Elets News Network (ENN) in October 2010

MAXimising Benefits
The IT outsourcing deal puts Max Healthcare on the roadmap for becoming the best IT-enabled hospital
chain in the country.
By Divya Chawla
The Indian healthcare system has recently realised the potential of information and communication technologies
in completely transforming care delivery at hospitals. The industry witnessed its first complete IT infrastructure
technology outsourcing deal in September 2009, when Max Healthcare and Dell Services (formerly Perot
Systems) partnered for developing IT operations at all Max Hospitals. The cost of the deal, Rs 90 crore
(excluding infrastructure cost), is an indicator of the increased priority that is now being given by Indian hospitals
to IT, which is an extremely positive sign. As per the agreement, the deal will last for ten years, out of which one
year has already passed, and a lot of positive transformation has already been noticed. The unique partnership is
not only expected to provide a lot of value to Max Healthcare in terms of enhancing the quality of services and
reducing treatment costs, but it will also be a great learning experience for Dell, which marked its entry into the
Indian healthcare market with this deal.
Status update
Post its inception in September 2009, the ITO deal will last for 10 years and which, according to Dell, will
comprise of three major phases – transition, improving productivity and optimisation. As one year has passed,
the transition phase is almost over. During this phase Dell installed the entire IT infrastructure for Max, by
migrating the already existing IT infrastructure to a modern infrastructure. The entire data centre of Max, which
was housed in their Okhla office, was migrated to the Dell facility in Noida. To reduce hassles, the shifting work
was done during off hours on weekends, so that the work at the hospitals does not get affected. The entire
process lasted for a couple of months and currently all Max Hospitals are running from the data centre housed in
the Dell facility in Noida. The servers and network devices have been installed with monitoring devices that
generate alerts in case a problem arises. There is also a situation management process in place to ensure that
even the problems of highest criticality get resolved within a definite period of time.
“We now have a centralised database of all our patients”
- Dr Neena Pahuja
CIO, Max Healthcare
Give us more details about the IT outsourcing project that is being implemented by Dell.
The contract has two parts. The first part deals with end-to-end infrastructure development and maintenance with
a complete data centre upgradation in link with Dell’s central data centre and servers. Secondly, we have a
business continuity plan in long term.
As a part of the contract, we have got a resonance link that connects all our hospitals in different locations,
enables us to do audio and video conferencing using the latest tele-communication equipments, decreasing the
cost over a period of time. Besides, the facilities are also going to benefit the patient in terms of his convenience
of being served in any of the branches of Max located anywhere. We have now got a centralised database of all
our patients with latest information connected through the central data centre. The process in coordinating with
the process and selecting the vendor-partner took an end to end analysis of the terms and conditions. Before
outsourcing it completely we did a more than two years research on the pros-and-cons of the implementation of
the process and evaluation of the quality of the products to make them more user friendly, particularly for the
doctors. Then the vendor selection was done that matched closest to our requirements.
One of the critical phases in the healthcare industry is change management. Many hospitals have gone for EHR
but could not implement it properly because anything that is implemented has to be doctor friendly. Max was

MAXimising Benefits
conscious about it and took care of it from the very beginning. Any of the products that were planned to bring in
were scanned through the doctors’ comments to make it customised further enhancing its usability. In the
process of selection of any of the products we see a high engagement of the clinicians because we believe its not
the IT vendor who uses the products its the doctor and clinician who use the product. Therefore, according to our
experiences, adoption is the best policy of change management. While implementing the basic format of the
infrastructure by Dell project, all the clinicians in Max have been conveyed about all the information and
knowledge about the products, including its usage and even a minor detail about the project. Therefore, there is
no push for the IT implementation in the project, rather there is a pull from the doctors and clinicians in the
process. However, while working together in the project, Dell is only responsible for developing the infrastructure,
support and maintenance and Max is responsible for product searching, selection and procurement.
So, what is your long term IT strategy? How do you plan to integrate it with the growth plan of Max?
In long term, IT has been considered for the development of having clean and quick data and good processes so
that business research and analytics can be utilised in a bigger way through which we can carry out the best of
the practices across all our hospitals. Currently Max Healthcare is in the process of introducing and implementing
Electronic Health Records (EHR) system for better management. The next step we are looking at is ‘Future State
Workshop’ through which we will analyse all our processes to find the complications involved, if those
complications can be eliminated and the process efficiency can be re-looked at.
The idea is to give the patient the complete benefit of the upgraded method of communication and information
technology. After implementing 3G solutions, adopting the structure and practice of tele-medicine is one of the
future projects that we have in our mind which will be followed by tele-radiology. In our long term vision we have
data analysis, knowledge management system, and clinical pathways supporting the para-medics and doctors
together in our planning. With these facilities and infrastructure we think that we would prepare ourself for a total
remote monitoring system.
We are also planning to go into the system of HIE (Health Information Exchange) in the next one and half years,
if not now, where our consumers (patients) can freely take their data whenever they have the requirement. But
still a lot needs to be there in place for HIE because I see no readyness in this particular field.
I personally feel that this should be initiated through a PPP mode with strong support from the government.
Besides, Max has also initiated the process of medical e-Learning for its staffs with the training procedure for any
new IT infrastructure and product that is deployed overtime in the infrastructure. For EHR we have taken support
from the open source learning product and creating an e-Learning course which is compliant to the process and
software of EHR. This is also helping us in doing monitoring and getting feedback of the learning process as well
as the performance of the application. Now we want to replicate it with other applications and training procedures.
The second part of the transition phase comprised of the application part. With eight applications already in
place, Dell is now building an all extensive Electronic Health Record (EHR) system for Max. Based on the VistA
open source, initially developed by the Veterans Affairs (VA) in the US, the EHR at Max is expected to take some
more time before it can become fully functional at all Max facilities. Max decided upon implementing VistA by
customising it as per Indian needs, so that the best practices can be brought to India. In addition to creating
electronic health records for all in-patients, Max plans to go a step ahead by creating records for the out-patient
department, as well. This will be the first-of-its-kind initiative in India. The record for out-patients will be
maintained for a certain period of years, as required to manage data storage constraints. Max Healthcare
strongly believes that once the EHR system is in place, the benefits for management, physicians as well as

MAXimising Benefits
patients at Max will increase tremendously. A more recent update has been the conversion of the entire IT
infrastructure of all Max Hospitals on a private multi-protocol label switching (MPLS) cloud running remotely from
data centre at Dell facility in Noida. This step has set the stage for the launch of the EHR system at Max in the
coming times. The required bandwidth is being provided by Bharti and Reliance to ensure load balancing, which
is around 15 Mbps by each vendor. As the load of applications increases, Max is ready to enhance this
bandwidth to manage all applications. A significant advantage that this cloud will offer is the capability to add
more hospitals/networks as and when required without any hassles. With the MPLS cloud in place making new
hospitals/facilities IT enabled will be a cakewalk as they only need to be connected to the cloud. While the
transition phase is almost over, Dell believes that it will take another year for the productivity improvement phase
to finish, where Dell will focus on redeveloping and improving all inefficiencies, if any, to make the functioning of
all IT operations seamless. The final phase will comprise of optimising all processes. All these phases would take
around 3-4 years to get completed, before Max can actually start reaping the benefits of IT implementation.
The benefit quotient
The IT implementation at Max Healthcare will not only benefit the management and physician community, but it
will also be extremely advantageous for the patients. This would be the first time in the country when electronic
health records for the out-patient department will be maintained.
“The rapid developments at Max have happened because of the ITO model they adopted”
Dr Pankaj Gupta
Client Executive – Max Healthcare
Dell Service
What were the major challenges being faced by Max? How will Dell’s solutions help Max overcome these
challenges?
Max had an in-house IT team of about 15 people and they had a few vendors who were supporting IT services.
However, this model was not giving them enough value as a lot of capital was being invested with insufficient
return on investment. Moreover, Max was looking at having one entity that can manage all IT processes and they
wanted to outsource these services and that is how they joined hands with us.We are responsible for the
infrastructure services as well as the applications at Max. Infrastructure starts right from cables, servers, network
devices, data centres, day-to-day operations and so on. Max already has eight different applications and further
we are implementing a VistA EHR application.
We migrated the existing IT infrastructure at Max to a modern infrastructure. There was a transition project, when
we joined Max, in which we started from a point where the data centre was situated in Max Hospital at Okhla. We
migrated that to our data centre and all other Max hospitals are now running from our data centre at Noida. This
was a huge project, which lasted for a couple of months. We also took over 14 of their people, who are now a
part of our team. As a strategic decision, we did not take over the office of the CIO because somebody was
needed to be there at Max as a signing authority. We put automatic monitoring devices on the network devices
and servers. If there is any sort of problem in the functioning, the monitoring devices raise an alert. If the issue is
not acted upon within a certain time frame, people are required to sit on a SitMan bridge, which is a situation
management process. On the network side, we migrated everything to an MPLS cloud. The infrastructure is now
ready, and we just need to put all other applications.
Tell us about the governance process that has been put in place at Max.
We set a complete governance process for Max internally. We did this because this is part of our model and we
want to bring in the best practices to Max. For this, we set up a Clinical Reference Group (CRG), which is headed

MAXimising Benefits
by a very senior physician within the hospital. This group has physicians and representatives from almost all
departments. Further, we have sub-committees of the CRG. We consolidated all sub-committees so that when
the EHR comes, a joint decision can be taken. We also set up an HIS council for Max to prioritise all processes
on the admin side of the business. This council is headed by one of the hospital administrators. On top of these
two councils, we have another council which is headed by the CEO. Any decisions taken by these two councils
gets rolled up in the governance council and the policies become implemented throughout. On top of the
governance council, there is an executive council, which has members from both organisations at the board level
as well as very senior executive level. Initially decision making was difficult, however, with the governance
process now in place these issues have got resolved.
Why did Max choose VistA for its EHR?
VistA was developed by and for the Veterans Affairs (VA) in the US, which is an equivalent of Military hospitals in
India. All VA hospitals, about 1000, in the US, run on VistA. A very few organisations have implemented VistA
outside the US. As per the FOIA act in the US, VA could not have proprietary rights over the software because it
was developed using the tax payers’ money and hence it was put in the open source and that was the time when
World VistA was created. Max wanted to pick up the open source VistA to build best practices on it that can be
used anywhere in India.
VistA has everything that is required for a hospital to run. It has the clinical functions for all departments and the
ancillary functions including laboratory, radiology pharmacy. The only thing that VistA lacks, from an Indian
context, is billing and material management.
Although, this would be a big challenge for Max in terms of storing such huge amounts of data generated by the
OPD, yet they are confident that the benefits achieved because of this will outweigh the challenges. Moreover,
each and every patient at Max will be provided with a unique URL, that will store all patient information. They can
access this URL from anywhere in the world and have instant access to their clinical data, be it – laboratory
reports, radiology images, drug details or any other clinical data. This means that the patients would not need to
carry their paper records anywhere as all all information would be available online. For physicians, taking
decisions and offering treatment would become much simpler as they would have access to all patient data,
instantly. Moreover, as the healthcare industry moves towards evidence-based medicine, the data availability
because of the EHR module, would present all information specific to a particular diseases, making the process
extremely simple and foolproof. Further, with computerised physician order entry (CPOE) based system in place,
the job of the physician will be further simplified as they will receive continuous guidance from the system.
Similarly, the decision making process for the management will become much simpler as soon as they have
availability of sufficient data. The management would be able to strategise in the right direction and bring in the
best class care. This would not only help them enhance the quality of services offered, but will also help in overall
business growth.
On the infrastructure side, with the completely modernised infrastructure in place, the chances of system failure
or any sort of mishaps have almost been reduced to nil. Further automatic monitoring devices have been
installed everywhere, that would immediately raise alerts in case of any problem. Dell has included a unique
situation management process called the SitMan bridge, with which all queries and problems will get resolved in
a definite period of time. With so much in place already, Dell believes that Max Healthcare is yet to realise the
real benefits. At the end of the first 3-4 years, when the optimisation phase is over, that is when Max will reap the
maximum benefits from this system.

MAXimising Benefits
Max Healthcare IT Outsourcing Project: Snapshot
Phase I:Infrastructure Upgradation
 Entire data centre of Max, housed in Okhla office, has been shifted to Dell facility in Noida
Phase II: Building on Extensive Health Record System for Max
 Based on VistA open source, it is being customised as per Indian needs
 Creating records for out-patient department, which is first-of-its-kind in India
 Entire application to nest on MPLS cloud so any new hospital gets active once it gets connected
Phase III: Building New Applications on the Robust Infrastructure
 Implementing 3G solutions for telemedicine and teleradiology
 Creating Health Information Exchange
 Patient can access all historical data by just filling password on the respective websites
According to calculations made by Max, the entire project would reduce the average time of stay of a patient in
the hospital by one day. Further adding to this, reduced paper costs will help Max save around `2.5-3 crore, per
year. While, the challenges for both Dell and Max have been many, this deal is expected to bring them much
more than they would have expected. Max is confident that the completion of the entire project, would put them
on the top as far as use of IT is concerned within a hospital environment. The deal would put Max on the
roadmap for achieving their aim of becoming a world class level 7 hospital and have the right technologies to
bring in a safe environment, increase accessibility of healthcare and reduce waste as much as possible. On the
other hand, the deal would provide Dell Services the right learning experience in the Indian healthcare market.
The biggest benefit that this would provide would be for the Indian healthcare industry is concerned by setting the
trend for enhanced IT adoption and IT outsourcing by Indian hospitals.
“The ITO Deal Has Been a Positive Learning for Us”
- Dr Pervez Ahmed,
Max Healthcare, India
Dr Pervez Ahmed, a visionary and a leader in the field of healthcare, has been the guiding force
behind the implementation of the IT outsourcing partnership between Max Healthcare and Dell
Services.
Pravin Prashant and Divya Chawla spoke to Dr Ahmed about the actualisation and implementation
of IT services at Max, through this deal.
Give us an overview of Max Healthcare and its future plans in terms of growth and expansion?
Max Healthcare, currently, has six hospitals and two diagnostic centres, which are all located in the
national capital region, comprising of 1000 beds. We are currently in the process of building four
new hospitals at Shalimar Bagh, New Delhi; Bhatinda, Mohali and Dehradun. All these hospitals will
start operations between June and October 2011, after which we will add around 1200 beds and

MAXimising Benefits
have a total of around 2000 beds. We are also open to looking at opportunities for mergers and
acquisitions. In addition, we are planning to set up an educational facility, which will be on the
health sciences side in Greater Noida in around 4 years from now.
At the end of our horizon of growth, we expect to have around 4000 beds in another five years, most
of which will be in the NCR or the Shatabdi region. We want to concentrate our growth in North
India because logistically it is a more scalable model.
We have three super-speciality hospitals in Delhi located in Saket, Patparganj and the upcoming
hospital in Shalimar Bagh. Further, we have multi-speciality hospitals located in Gurgaon, Noida, and
Pitampura. Diagnostic centres are located at Panchsheel. Max Healthcare has also partnered with
Nova Medical Systems, which is an ambulatory surgical product for Northern India.
We are very conscious of the quality of product that we provide. Our entry in the tertiary care is only
four years old and in this short period, we have been able to reproduce scalable, consistent and high
quality experiences. Once we get the formula correct in a very tight logistical area like this, we can
look at opportunities for expansion and providing the same experience in other parts of the country.
To be able to deliver quality care consistently, we have opted to install an Electronic Health Record
(EHR), along with which comes business and Management Information System (MIS).
What were the problems you were facing in your present system, which helped you move towards
outsourcing?
We have had a home grown Hospital Information System (HIS) for the last 5-6 years, which has been
doing a fairly decent job as far as finance and accounting are concerned. However, competitive
advantage to deliver quality medical care requires the integration of clinical diagnosis, procedures
performed, and the expenditure and cost. The proposition is to be able to provide the highest
quality care at the lowest possible cost to customers and patients.
To allow customers and insurance companies to choose the highest quality clinical provider, the
outcomes need to be measurable, reportable and reproducible. We, therefore, realised the need to
move from a simple HIS to an EHR, which coupled on top of the HIS can give us the ability to have a
true MIS and help us take strategic decisions. As the industry matures in India and we move forward
towards disease management, where the focus of care would be the patient, the requirement for
adequate information would be immense and that is not possible without an EHR.
The increased amount of work and scope required for an IT infrastructure, was not something that
we were willing to invest in as that is not our core area of operation, because of which, we looked at
outsourcing. We negotiated with Perot and have outsourced them for a long term and this has
worked quite well for us. The data centre migration has occurred, although with a few hiccups, but
overall it has been a very clean process. We have backup for disaster recovery both at the Dell
Services centre as well as at servers in our Okhla office. Hence, we are secure now, which is very
important as we get more and more electronic. It has been a positive learning curve process both for
Dell Services and Max Healthcare and it will be extremely beneficial in the long run.
How does your project benefit from the complete ecosystem, which includes management,
doctors and patients? What is the RoI?
In the areas of patient stay and paper saving, there is a potential benefit of about `2.5-3 crores per
year. The benefits are plenty for the patients and the quality of service offered. For instance, the use
of barcode system will eliminate all medication errors as all drugs bought from the pharmacy will be

MAXimising Benefits
barcoded against the nurse and the patient. As far as the patient benefit is concerned, after the
integration process is complete, each patient will have his/her own URL, which will work through a
cloud, and provide the entire clinical history.
This data can only be accessed by the patient, physician and primary hospital. The patient will have
to give confirmation to allow physicians within the Max network to access his/her data. Special
permission will be required for personal information like the HIV status. Currently, we do not have
the HIPAA norms, however we still use them as a baseline.
The deal is worth `90 crore and after adding the hardware, the total IT applications for 10 years
will cost us around `120 crore. If the scope of the work increases, additional expenses will be set up
As a CEO, how do you look at this project? Will this project help you in better decision making for
all your activities, be it finance, business development, expansion or customer satisfaction?
The business information that we are able to get out of the system, will give us an opportunity to
strategically decide on the products, which we need to develop. It will also help us in growing more
in terms of clinical management and business. Technology is an enabler and it is going to enable us
to perform in any area in the best efficient way.
If the data is easily available then the speed and efficiency to be able to implement something will
be much faster. This will help the business achieve all results that it aims to achieve including
financial excellence, quality excellence, and safe environment.
This is a huge step as far as I am concerned, for reducing cost of healthcare and making it more
efficient by eliminating the need for patients to carry paper records.
eHEALTH Bureau Dell Services and Max Healthcare have announced that Dell Services has converted
the information technology infrastructure of all eight Max Healthcare facilities into a private MPLS
(Multi-Protocol Label Switching) cloud running remotely from Dell Services Data Centre in Noida.
This cloud infrastructure deployment makes Max Healthcare one of the most technologically
advanced Healthcare chains in India with a near plug ‘n’ play capability for information technology
deployment as they add more hospitals/facilities to their network. Further, the private cloud
improves the availability of their healthcare information systems and analytical tools and sets the
stage for the rollout of Electronic Health Records (EHR) for enhanced patient care. In September
2009, Max Healthcare and Dell Services, formerly Perot Systems, entered into a 10-year agreement
valued at USD 20 Million (Over INR 90 Crore) under which Dell Services provides infrastructure
management and EHR implementation to Max Healthcare.
Dell Services manages all IT operations for Max Healthcare, including infrastructure management,
data hosting, applications portfolio management, project management office, service desk and
clinical adoption of VistA EHR system (an EHR platform developed by the U.S. Department of
Veterans Affairs).
Dell Services has completed the migration of the information technology infrastructure for the eight
Max Healthcare hospitals to the Dell Services Data Centre in Noida. Max Healthcare’s Health
Information System (HIS), which forms its business backbone as well as all other software
applications are now operating on a private cloud.

MAXimising Benefits
According to Dr Pervez Ahmed, CEO and MD Max Healthcare, “Max Healthcare is now on a private
MPLS cloud running remotely from Dell Services Data Centre in Noida. As a next step, we are looking
forward to rolling out electronic health records (EHR) to bring an enhanced patient care.
” Today’s critical healthcare systems require resilient infrastructure to ensure that patient
information is always available to clinicians. Through our partnership with an innovative healthcare
delivery network like Max Healthcare we look forward to working with them to improve healthcare
in India,” said Tim Olivier
See more at: http://ehealth.eletsonline.com/2010/10/11436/#sthash.ihZM698A.dpuf
Summary of outcomes beyond the published article: Max Healthcare was the largest ever full ITO
and Clinical Transformation Account of Perotsystems International. $20M deal across multiple years.
Total Business Transformation done including technology, process, people and business. This
includes Enterprise Architecture, Operations and Projects:
Phase I: Infrastructure Upgrade completed
1. - Centralized Service Desk for L1 support and triage to L2 and L3 teams
2. - Converted the P2P network to a MPLS private cloud
3. - Servers from all 7 Max hospitals migrated to a remote data centre at Dell
4. - HIS and all SW applications of 7 Max hospitals are now running from the Dell data center
5. - Homegrown HIS re-engineered for stability, scalability and HL7 integration with VistA EHR
6. - Physical, Network and Data level security established
7. - Operations management as per SLAs
8. - Governance process for decision making
Phase II:
1. - Customization of Opensource VistA Electronic Health Record System. Max Healthcare is the
largest VistA implementation outside the VA and anywhere outside the USA.
2. - Implementation of CPOE, CDSS, BCMA, ePrescription
3. - Developed standard master data e.g. Service master, Lab master, Drug master, etc.
4. - Order sets, Notes Templates
5. - HL7 based Enterprise Application Integration using Mirth.

MAXimising Benefits
6. - Clinical transformation as per ADOPTS methodology
Business Benefits realized by Max Healthcare:
1. - Private Cloud IT Infrastructure: plug-n-play environment for new facilities
2. - Business downtime due to infrastructure and HIS outages is history
3. - Process Re-Engineering -- 1000 beds in 7 Hospitals; expanded to 1500 beds in 11 Hospitals.
4. - Standardized operations without disruptions reduced the waste and improved the topline.
5. - Near paper-less, > 95% Adoption in Clinical.
6. - Achieved full NABH and HIMSS Stage 6 accreditations later.
7. - Hospital was able to attract FDI investments.
The grand success was lost somewhere in the merger of Perotsystems with Dell Services [now
merged with NTT Data]. Though the success achieved in Max is unprecedented and still largely
unmatched.

E health max cover story oct 2010

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