2.
LITERATURE REVIEW
2.1 INTRODUCTION
The literature review presented in this chapter is formulated mostly from research
journals, articles and research papers of various scholars. Also the literature survey
includes articles and whitepapers extracted from web sites and international magazines,
journals and forums.
The literature review covers three distinct areas; namely, e-health or paperless hospitals,
Business Process Re-engineering and the information domains.
2.2 PAPERLESS HOSPITALS
A healthy population is a legacy to a country. It increases overall productivity of the
country. The budget of Sri Lanka allocates a comparatively large percentage for health.
Maximum benefits out of that money can be gained by making health care effective &
efficient. If we are able to implement the concept of a paperless hospital [4], [5], [6] with
the process of government re-engineering it would be a big achievement in the
Information Technology era. It would ultimately contribute increasing towards
productivity in Sri Lanka.
Even though with the development of information and communication technology the
electronic based health activities are heavily discussed today, Dr Bill Dodd suggested a
“HEALTH INFORMATION BANK” [7] many years ago. In 2000 Ramsaroop and Ban
Goon went beyond that concept and introduced a “universal access card”. It is similar to
an ATM Card and allows withdrawal and transfer of selected information from a personal
health account, at the bank of health [7]. This concept is more advanced than today’s
electronic health records. [4], [7], [8], [9].
Many observers have stressed that the health care system is a social element which has
been among the slowest to understand in information technology. The reason behind it,
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was its unique practical and strategic functionalities and its need to incorporate
effectively with the work environment [8]. But today information technology and medical
professionals have been able to overcome those challenges.
Computer based medical and health records will be more than a mere electronic version
of the traditional paper records [8]. It is a hierarchical structure of the patient’s records
[9]. At every visit records are updated methodically.
A paperless hospital is a total solution for manual paper work in a hospital. It brings all
the departments in the hospital to an integrated model. An enterprise network is the basic
structure. It includes [8],
1. Admission room
2. Admission officer
3. Out-patient department
4. Wards
5. Laboratories
6. Radiology department
7. Pharmacy
8. Stores
9. Administration
It can even be extended to a global level. This is a single entry place to a medical world
[8]. All the clinical matters, administration, financial matters and information to research
can be addressed through the channel.
A hospital comprises different functions. Computer based technology can be used in
different ways to achieve above functions. Some of those functions are [8],
1. Collecting data
2. Maintaining database
3. Maintaining electronic medical records
4. E–prescription
5. E–order placement
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6. Online laboratory reports
7. Data retrieval
Collecting general data and maintaining the database [10]-[15] is very important for a
hospital. It gives a basic idea of the number of patients registered in the hospital and the
respective clinics.
Maintaining electronic medical records is a very important part in the paperless hospital.
Basically it contains a discharge summary and plan of management. It is very convenient
for doctors and they can see the past records within a few seconds [9]. Such a project
helps a lot in saving time and space of storage. Also the inactive files can be easily
identified and thereby the time to access files can be reduced. It avoids file misplacement,
as well [4]. Medical records are accessible online and the data is up to date. Online access
of analyzed data is also available. Even bar coding can be used to facilitate document
identification and tracking [5].
By the end of the year 2007, the government of Finland was expected to introduce new
legislation to store medical records in electronic format. It explains how infrastructure is
developed and how it is maintained. They have taken measures to achieve a high level of
security [4]. Son Llatzar hospital is the first hospital in Europe to work without paper and
film. Migual Eabrer, IT director of Son Llatzar hospital said “the table PC smoothes our
work process by letting us completely eliminate paper while still ensuring that our
doctors and nurses have direct access to patient information everywhere in the
hospital”[6].
Some hospitals use electronic medical charts that contain all patient information such as
medical reports, medications, X-rays and ECGs. Since EKG introduction there is no need
to again enter paper documents to electronic format. It will eliminate converting errors.
They create a portal integrating doctors, nurses and administration to access medical
records effectively [6].
Web based personal health records will revolutionize communication with patients and
their clinics. It allows online appointments, messages, and laboratory reports, access of
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health records and referrals of health records. A USA survey revealed that only 13% keep
electronic records and only 1% keep web-based medical records. 70% of online
households believe personal health records improve quality of health care. It also
revealed that electronic solutions narrow the information gap in health care. Out of the e-
health record users, 90% say that it is a tool that is easy to use [7].
However there still is an argument whether we should move to paperless hospitals or not.
Motivation is very limited among most of the doctors. They think it is not worth to fill
some information which is not directly related to their job. [5].
Electronic prescription orders the patients’ drugs from the pharmacy on line. Then
patients can collect the drugs from the pharmacy by proving the identity. Singapore
government’s project of paper documents to electronic documents were implemented step
by step. It commenced in April 2004 and ended in March 2007. E-prescription has been
100% successfully adapted by clinics [12].
Security of the electronic health records is a main concern in the health sector. Through
legislation, some countries like Finland try to achieve the patient’s confidentiality [4],
[16].
Database supports the continuous tracking of a large number of patients and contributes
to medical research on diagnosis, prognosis and treatment. These data, supervised by the
relevant authorities can be evaluated to make recommendations for future activities [10].
A paperless hospital gives solutions for a cost saving inventory management system
whilst maintaining optimal stock levels. It provides for efficient patient registration and
appointment scheduling [16].
A total solution implementation is very crucial in a paperless hospital. It has to consider
different practical aspects [17]. Maintenance of the system is the next major part [18].
The above text elaborates the importance of the paperless hospital and the active
contribution that is required to make it a success.
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2.3 BUSINESS PROCESS RE- ENGINEERING
“Re-engineering is the fundamental rethinking and radical redesign of business processes
to achieve dramatic improvements in critical, contemporary measures of performance
such as cost, quality, service and speed [19]”.
Business process re-engineering is defined by Michael Hammer as, “The fundamental
rethinking and radical redesign of an entire business system – the business processes, jobs,
organizational structures, management systems, values, and beliefs to achieve dramatic
improvements in critical measures of performance”[20].
Business process re-engineering is the current trend in Sri Lankan government
organizations and Information and Communication Technology Agency (ICTA) highly
encourages the movement towards it.
A case study at a Singapore hospital concluded that business process re- engineering has
allowed modelling the gamut of operating theatre activities quickly and efficiently, from
patient admission to disposition [21]
“Gunasekaran and Kobu describe six models for modelling and analysis of business
process re-engineering” [22].
1. Conceptual models
2. Simulation models
3. Object-oriented models
4. IDEF models
5. Network models
6. Knowledge-based models
Richard and Paula have identified five essential steps to BPR planning [23],
1. Develop or validate the strategic plan.
2. Develop or validate the business systems plan.
3. Develop or validate the annual business plan.
4. Construct performance cells (performance measures) for processes.
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5. Establish the process improvement project business case.
There are a few key areas to address for effective completion of BPR,
1. Are the project objectives clearly driven from the enterprise’s strategic goals and
operational objectives?
2. Have the core business processes and critical success factors been identified?
3. Have the critical business issue(s) been identified as well as the core processes that
have the greatest impact on critical business issue(s)?
4. Have the current costs been analyzed for the core processes?
5. Has a process improvement and management plan been developed?
Maria and Valerie have identified five determinants of hospital BPR success [24],
1. Clearly define the roles, tasks and expectations for individual team members and
the project team as a whole;
2. Perform a thorough process analysis to identify and eliminate non-value-added
activities as an integral part of the process redesign effort;
3. Have regularly scheduled meetings between project managers and team members,
and for larger projects, meetings between managers and each level of the project
organization structure;
4. Develop a detailed plan covering specific requirements such as personnel, tools,
software, procedures, maintenance before the project implementation phase starts;
5. Keep in mind that technology alone is never to be accepted as a solution but as an
enabler for the new/redesigned business processes.
At the same time Richard and Paula have identified eight features of successful BPR
efforts: [23],
1. A team-based effort guided by a proven, structured methodology that is aided by a
powerful set of methods and supporting tools.
2. A focus on business processes rather than functions.
3. Cross-organizational process restructuring.
4. Challenges established assumptions.
5. CPI activity enabling both incremental and paradigm shift change.
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6. A “Think Globally, Act Locally” approach.
7. A well planned effort with clear goals, defined business metrics, and measurable
results throughout the effort.
8. Technology that can support the change.
Business Process Re-engineering (BPR) efforts are reported to be failing to meet their
goals at a rate of 70% [23] and there are three primary reasons attributed to failing BPR
efforts. The first reason is the lack of an adequate business case resulting in unclear,
unreasonable, or unjustifiable expectations for what is wanted or expected to result from
a BPR effort. A second reason can be the absence of robust and reliable technology and
methodologies for performing BPR so that there is a failure in executing BPR efforts. A
third reason is an incomplete or inadequate implementation [23].
There are eight common features of failed BPR attempts.
1. Multiple, uncoordinated initiatives.
2. Lack of commitment to establishing an in-house (organic) capability.
3. Insufficient or inadequate methodology, methods, and tools.
4. Attempt to outsource key decision-making.
5. Failure to concurrently address business, information system, and organizational
change together with process change.
6. Inability to leverage information technologies and re-align information systems
quickly enough to make a smooth transition.
7. Inability to align process-intent with enterprise vision and goals, organizational
structure, and job performer management.
8. Lack of top level commitment and understanding.
2.3.1 Organizational Structure
Organizational structure is the fundamental hierarchy of the institution and it describes
how the job tasks are formally divided, grouped, and co-ordinated. There are a few key
elements that policy makers need to address when they design their organization's
structure [25].
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Work Specialization
Work specialization is the degree to which organizational tasks are sub-divided
into individual jobs. With too much specialization, employees are isolated and do
only a single, tiny, boring jobs. Many organizations enlarge jobs or rotate
assigned tasks to provide greater challenges.
Departmentalization
Departmentalization is the basis by which individuals are grouped together to
form departments and departments are grouped together, to form total
organizations. There are five approaches in departmentalization.
1. Functional - by common skills and work tasks
2. Divisional - common product, program or geographical location
3. Matrix - combination of the Functional and the Divisional
4. Team - to accomplish specific tasks
5. Network - departments are independent providing functions for a
central core breaker
Chain of Command
The Chain of Command is the unbroken line of authority and responsibility along
which orders are passed within a unit and between different units. Orders are
transmitted down the chain of command, from a higher officer to a lower officer
who either executes the order personally or transmits it down the chain as
appropriate, until it is received by those expected to execute it. Ultimately it
clarifies who reports to whom.
Unity of Command
Each individual participating in the operation reports only to one supervisor to
whom he or she is directly responsible. This eliminates the potential for
individuals to receive conflicting orders from a variety of supervisors, thus
increasing accountability, preventing freelancing, improving the flow of
information, helping with the coordination of operational efforts, and enhancing
operational safety.
Span of Control
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Span of control is the number of subordinates a manager can efficiently and
effectively direct. This limits the number of responsibilities and resources being
managed by any individual and today, management professionals specify that any
single person’s span of control should be between three and seven individuals,
with five being ideal. In other words, one manager should have no more than
seven people working under them at any given time. If more than 7 resources are
being managed by an individual, then they are being overloaded and the
command structure needs to be expanded by delegating responsibilities. If fewer
than three, then the position’s authority can probably be absorbed by the next
highest rung in the chain of command.
Centralization
Centralization is the process by which the activities of an organization,
particularly those regarding planning of decision-making become concentrated at
a single point in the organization.
Decentralization
Decentralization is the process of dispersing decision-making governance closer
to the lower-level employees.
Formalization.
Formalization is the degree to which jobs within the organization are standardized.
2.4 INFORMATION DOMAINS
An information domain is a combination of data model, data management and data
repository.
2.4.1 Data Model
A data model in software engineering is an abstract model that describes how data is
represented and accessed. There are 6 types of data models [26].
• Database model
• Data structure diagram
• Entity-relationship model
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• Geographic data model
• Generic data model
• Semantic data model
2.4.2 Data Management
Data management consists of ownership, related roles, responsibilities, security and
query optimization.
Preservation, access and exposure are the three main data management responsibilities.
An institution should have a long term focus for preservation. There is some evidence,
that open access leads to increased accessibility and increased citation rates. This may,
over time, encourage more researcher openness. The contents of the repository also need
to be exposed and discoverable. This can be via a range of techniques such as search
engines [27].
Ownership of data has several responsibilities [28],
1. Definition of data
2. Authorization of access and validation of security
3. Support the user community
4. Data packaging and delivery
5. Maintenance of data
6. Data quality
7. Management of business rules
8. Management of metadata
9. Standards management
10. Supplier management
The concept of data ownership is a management issue, as information is bought, used,
created, modified, propagated, and sold, throughout an organization [28].
‘“The ownership issue is essentially a control issue. This includes control of the flow of
information, the cost of information, and the value of information. A few of the many
issues that complicate the notion of data ownership are value, privacy, turf, fear, and
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bureaucracy. This list is by no means inclusive, and we make no attempt to resolve them
but only to expose them. That control includes not just the ability to access, create,
modify, package, derive benefit from, sell, or remove data but also the right to assign
these access privileges to others” [28].
There are many parties claiming for data ownership [27],
1. Creator as owner
2. Consumer as owner
3. Compiler as owner
4. Enterprise as owner
5. Funding organization as owner
6. Decoder as owner
7. Packager as owner
8. Reader as owner
9. The Subject as owner
10. Purchaser/Licenser as owner
11. Everyone as owner
The final paradigm is the model of global data ownership. Some feel that monopolization
is wrong and data should be available to all with no restrictions. Clearly, in the business
world, this is a radical view, and it has its benefits as well as detriments.
Determination of the roles that are associated with each set of data in the enterprise and
describe the responsibilities of each role is important in information management. There
are few important roles in an organization [27].
Chief Information Officer
The CIO is the chief holder of accountability for enterprise information and is responsible
for decisions regarding the acquisition, storage, and use of data. He or she is the ultimate
arbiter with respect to dispute resolution between areas of ownership and is the ultimate
manager of the definition and enforcement of policies.
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Chief Knowledge Officer
The chief knowledge officer is responsible for managing the enterprise knowledge
resource, which dictates and enforces the data sharing policies, as well as overseeing the
general pooling of knowledge across the organization.
Data Trustee
The data trustee manages information resources internal to the organization and manages
relationships with data consumers and data suppliers, both internal and external.
Policy Manager
The policy manager maintains the data ownership policy and negotiates any
modifications or additions to the data ownership policy.
Data Registrar
The data registrar is responsible for cataloging the data sets covered under the policy as
well as the assignment of ownership, the definition of roles, and the determination of
responsibilities and assignments of each role. The data registrar also maintains the data
policy and notifies the policy manager if there are any required changes to the data
ownership policy.
Data Steward
The data steward manages all aspects of a subset of data with responsibility for integrity,
accuracy, and privacy.
Data Custodian
The data custodian manages access to data in accordance with access, security, and usage
policies. He or she makes sure that no data consumer makes unauthorized use of accessed
data.
Data Administrator
The data administrator manages production database systems, including both the
underlying hardware and the database software. The data administrator is responsible for
all aspects related to the infrastructure needed for production availability of data.
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Security Administrator
The security administrator is responsible for the creation of and the enforcement of
security and authentication policies and procedures.
Director of Information Flow
The director of information flow is responsible for the management of data interfaces
between processing stages, as well as acting as an arbiter with respect to conflicts
associated with data flow interfaces.
Director of Production Processing
The director of production processing manages production processing operations,
transference of data from one production source to another, scheduling of processing, and
diagnosis and resolution of production runtime failures.
Director of Application Development
The director of application development manages requirements analysis, implementation,
testing, and deployment of new functionality for eventual turnover to the production
facility.
Data Consumer
A data consumer is an authorized user that has been granted access rights to some data
within the enterprise.
Data Provider
A data provider is an accepted supplier of information into the system.
Certain security aspects of a Grid infrastructure are tightly coupled with Data
Management. Identifying these issues, and adapting the Data Management components
accordingly, is of vital importance [29]. Queries are one way for an application user to
access a data store. A set of application queries is considered to be optimally executed if
it minimizes a cost model such as a mixture of response time and throughput. The aim of
a query execution plan is to determine which replicated files to access in order to have
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minimal access costs. We do not want to elaborate much further on a cost model here
[29].
2.4.3 Data Repository
Data repository is the theory behind Storage and Replication of data. One of the core
problems that any data management system has to address is the heterogeneity of
repositories where data are stored. This diversity is made explicit in terms of how data
sets are named and accessed in all these different systems. For instance, in some cases
data are identified through a file name whereas other systems use catalogues where data
are identified and selected by iterating over a collection of attributes or by using an object
identifier [29].
Replication can, on the one hand, be regarded as the process of managing copies of data.
On the other hand, replication is a caching strategy where identical files are available at
multiple places in a Grid environment. The main purpose of replication is to gain better
response times for user applications by accessing data from locally “cached” data stores
rather than to transfer each single requested file over the wide area network to the client
application. Fault tolerance, and hence the availability of data, are key items of
replication [29].
James Robertson has identified the following 10 key principles to ensure that information
management activities are effective and successful [30].
1. Recognize (and manage) complexity
2. Focus on adoption
3. Deliver tangible & visible benefits
4. Priorities according to business needs
5. Take a journey of a thousand steps
6. Provide strong leadership
7. Mitigate risks
8. Communicate extensively
9. Aim to deliver a seamless user experience
10. Choose the first project very carefully
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