Testing & Integration Issues in implementation of Advanced Health Infor.

Mngt System

Testing & Integration Issues in implementation of Advanced Health Information Management System Udai Singh, Ashutosh Pandey, Amit Kumar
Abstract- Retrofit of Hospital Information system in a running hospital is very challenging task. The difficulties are found to increase with the size of the hospital. C-DAC is in the process of implementing a total computerization of Postgraduate Institute of Medical Education and Research (PGIMER) a premier institute in public sector in India. This paper presents the Testing and Integration issues during this implementation. Keywords: Hospital Information System, Implementation Difficulties, System Testing, Test Life Cycle, User Acceptance Testing. 1. Introduction AHIS is defined as a computer system designed to ease the management of all the hospitals medical and administrative information and to improve the quality of healthcare by Degoulet and Fieschi (1997) [1]. With the introduction of AHIS into hospitals, improvement in patient care as well as hospitals management, collection and retrieval of accurate and complete medical information, lower operational and treatments costs, less time to reach patient medical data, interpretation of clinical data and warnings for exceptional medical cases such as drug to drug interaction were expected from AHIS. AHIS implementation is more difficult than the implementation of other e-Governance application systems, due to the critical nature of working of a hospital and adaptation in hospitals is a complicated task compared to other information systems in different business areas. System infrastructure design, requirement specification, master data collection and definition, integration with other systems, localization, and training and final system test are the main activities of implementation. Each of these activiteis has to be completed with utmost care, considering the reengineering requirements, 24 x 7 nature of operation of the hospital, and the related difficulties in conversion from a manual system to an automated system, without disruption of services. C-DAC has been involved in implementation of a turnkey solution for computerization in PGIMER, Chandigarh from 2007 onwards. The system consists of 8 Servers, 15 TB of SAN Storage, and about 1000 Thin Nodes spread over 13 buildings of the hospital over a fibre-optic backbone network, which runs to about 13 Kms. This paper presents the testing and integration issues during the implementation of this project. It is organised as follows: Section II: gives the description of the hospital. Section III: describes the Testing Methodology. Section IV: describes the Implementation of AHIS Section V: gives the conclusion.

Proceedings of ASCNT 2010, CDAC, Noida, India, pp. 211 220

211

Udai Singh, Ashutosh Pandey, Amit Kumar

2. Description of the Hospital The Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Ministry of Health and Family Welfare, Govt. of India started functioning in 1962, which was subsequently covered under the Act of Parliament on April 1, 1967. The broad objectives of the Institute are to train postgraduates in all the important disciplines of medical sciences, to conduct research of the highest order and to provide patient care of the highest standard. Over the years, it has become a very renowned institute in the city. The major infrastructure includes Nehru Hospital with 1268 beds, two Research Blocks (A and B) for basic sciences, Advanced Pediatrics Centre (APC) Block for children ailments, New OPD Block for Outpatient services, and Oral Health Sciences Block for dental services. The number of daily outpatients is of the order of more than 5000 and the annual strength of inpatients is more than 90,000. Emergency services are provided round the clock. All these advanced centers have their own OPD, Ward, Lab, Operation Theatre, and Emergency services. Table 1 gives the number of rooms and beds corresponding to various departments. Departments/ Wards Count/ Rooms Beds

OPDs 26 Outpatients Special Clinic 91 General Wards 31 819 Private Wards 5 100 ICU 11 169 Emergency 14 170 Advanced Pediatric Centre 214 Advanced Eye Centre 60 Advanced Cardiac Centre 90 Total 178 1622 Table1: Number of rooms and beds Source: Actual data for Year 2009, from PGIMER Chandigarh The objective of implementation of Advanced Hospital Information System (AHIS) for PGIMER is to provide online support to various hospital operations. It aims at keeping track of patients, doctors, materials, samples etc. for efficient working of the hospital. Figure 1 gives the modules implemented. It consists of patient-centric modules like Registration, Emergency, OPD, Labs, OT, Blood Bank, Pharmacy, Patient Medical Record, Patient Medical Billing, etc. and the support modules like Transport, Enquiry, Appointment, Diet Kitchen, CSSD, Linen & Loundry, Bio-Medical Waste and Maintenance, etc.

212

Testing & Integration Issues in implementation of Advanced Health Infor. Mngt System

Fig.1: Details of Modules implemented 3. Testing Methodology The AHIS is tested under different conditions, before product acceptance by client. AHIS phase I has undergone through White Box as well as Black Box methodology. The Testing Lifecycle followed is given in Figure 2. 3.1 Test Planning Activities at this stage would include preparation of high level test plan-(according to IEEE test plan template). The Software Test Plan (STP) is designed to prescribe the scope, approach, resources, and schedule of all testing activities. The test plan identifies; testing items, features, type of testing, resource, schedule, risks, testing condition (manual/ automated, etc.). Almost all of the activities done during this stage are included in this software test plan. This planning will be an ongoing process and it is reviewed frequently.

Fig.2: Testing Lifecycle followed in AHIS

213

Udai Singh, Ashutosh Pandey, Amit Kumar

3.2 Test Analysis & Design Regular meetings were held between testing teams, project managers, and development teams, to check the progress in the development which will give a fair idea of the development of the project and ensure the completeness of the test plan created in the planning phase, which will further help in enhancing the right testing strategy created earlier. Subsequent to this, the functional validation based on SRS was developed to ensure that all system requirements are covered by one or more test cases identify which test cases we also have to define areas for Stress and Performance testing. The Test case format is shown below in Fig. 3. Once the environment setup is complete, the independent modules are built & smoke test is performed to check the broad functionalities. Further to freeze the functionality of the application once it is presented to the User for their acceptance before delve into the detail System testing with their reviewed test cases.

Fig.3: Test Case Format 3.3 Execution & Verification In this phase all the manual test cases are completed, scripting of the automated test cases, stress and performance test cases needs to be completed. Review of Test Cases & their defect incorporation is also done in this phase only. Integration tests with other AHIMS modules are performed and errors (if any) are reported. An example is shown below in Fig.4:

Fig.4: Test Case Example After test case was executed, the result status is noted as shown in Fig. 5:

Fig.5: Executed Test Case

214

Testing & Integration Issues in implementation of Advanced Health Infor. Mngt System

3.4 Re-testing In this phase the Test Cases Run Report Bugs Review test cases (if needed) Add new test cases (if needed) bug fixing Retesting (test cycle 2, test cycle 3.). In these cycles we track our resource as shown in the below excel sheet and its up dated every week. This will reflect the man-days effort. Activity wise effort spent is shown in Fig. 6.

Fig. 6: Activity wise Effort spent 3.5 Bug Life Cycle Fail condition is logged and this initates the process of defect tracking lifecycle. This is a system for receiving and filing bugs reported against a software project, as given in Fig. 7 and tracking those bugs until they are fixed. Bugzilla version 3.4.1, its a defect tracking tool, was being used successfully for reporting bugs. This tool is being used by the QI team & is successfully working in synchronization with the projects of the CDAC Noida. Metric-based defect tracking monitors where defects originate.

Fig.7:Tabular Report of Defect Tracking Tool 3.6 Final Testing and Release Executed remaining stress and performance test cases, documentation for testing was completed/ updated, also check the User Feedback points that were given at Demo session in the client side that are incorporated or not. If not incorporated, than a new bug is logged and status is tracked till closure. 3.7 Post Implementation The testing process is evaluated and lessons learnt from that testing process are documented. Line of attack to prevent similar problems in future projects is identified. Create plans to improve the processes. The recording of new errors and enhancements is an

215

Udai Singh, Ashutosh Pandey, Amit Kumar

ongoing process. Cleaning up of test environment is done and test machines are restored to base lines in this stage.

Fig.8: Test activity outcome 4. Implementation of AHIS It is stated that the implementation of software consumes up to 1/3 of the budget of a software cost Project delivery combines the deployment of the AHIS Application with managing the Requirement change accepted during Demo and UAT. This software implementation management is crucial to avoid the failure that is not delivered successfully, is delivered but is not used or used minimally, is delivered but its level of business use and therefore benefit does not justify the project cost. Prior to starting the Project Deployment Process, the project should be evaluated and approved. The Project Evaluation Process includes performing all requirements mapping architecture review and vendor contracting/SLA As per the SLA options for delivering the AHIMS project was big bang. But CDAC has the opinion that Phased deployment will be more appropriate for the PGIMER.

216

Testing & Integration Issues in implementation of Advanced Health Infor. Mngt System

4.1Big-Bang Deployment This type of deployment is the release software to all users at the same time. All the modules or builds are constructed and tested, and then they are all put together at the same time. Benefits It is very quick as no drivers or stubs are needed, thus cutting down on the development time. Drawbacks are Usually yields more errors, since these errors have to be fixed and take more time to fix than errors at the module level, this method is usually considered the least effective. Because of the amount of coordination that is required it is also very demanding on the resources. 4.2 Phased Deployment This type of deployment is release software to users over a period of time. For example Hospitals Building Location Wise->Module Wise->Department Wise. By facing various implementation difficulties in Big-Bang approach and client level constraints, Phased-Wise Implementation approach got introduced. Consequently reducing project risk because if there is some problem the business impact is reduced. For Patient Registration Module same approach has been followed (currently in trial phase) and as per PRS (Problem Report Sheet) data, system is successful and users are accepting the automation process over their old manual process. 4.3 AHIS Project Implementation Management Model The projects need to decide on the best way to release a software solution. The following model was introduced. Cleanup of the "test" environment following successful completion of testing and setup the Original master data given by client/user itself. Preparation of project deployment in the Hospital such as setting up user accounts to access the system and ensuring their Master Data for various AHIMS modules. Implementing User Acceptance Test and accepting those changes which come under Project Scope by verifying with Change Control Procedure. Deploying the AHIS Application modules to the "production" environment ready for normal Hospital use and go-live in subsequent phases: Building wise Module WiseDepartment Wise User level wise. Plan for mechanism to back out of production software deployment if the process goes wrong for some unexpected reason, restoring the business to its predeployment state.

217

Udai Singh, Ashutosh Pandey, Amit Kumar

Fig.9: AHIS Project Implementation Management Model 4.4 Managing the Requirement Change of Project Delivery Project deployment to the different units such that they are able to use it from a specified date/time is not enough by itself. Managing the requirement change is an essential part of project delivery and that needs to include: Building awareness within the application users of the software solution through their own administrative staffs. Developing business support and momentum to use the solution through stakeholder (mainly Implementation manager) engagement and put development team/design team and involving the third-party support team in touch with the right people on client-site. Business plan to exploit the use of the solution and to scale up the numbers of users. Planning and executing the training plan for End-users and Administrators with maximum involvement of third party support team. Setting up and operating a customer board (Module committee) to manage the evolution of the application. 7. Conclusions Involve QA earlier: Invite QA team members to requirements and design meetings. This allows them to point out testing issues before you write a single line of code. They can also begin writing test cases long before they receive a build, which improves testing efficiency. Implement testing early: Testing should begin before the alpha stage of development. Implementing peer code reviews and unit testing reduces the number

218

Testing & Integration Issues in implementation of Advanced Health Infor. Mngt System

of defect found by QA late in the process. The earlier you discover defects, the easier and cheaper they are to fix. Refine Quality metrics: Frequent releases help maintain mindshare. However, you damage your reputation if these are low quality releases. Make sure you include quality measurements at each process milestone. Measuring quality at each stage of development helps mitigate risk. Do not move to the next stage of development if the software does not pass the quality metrics. Measure the Impact of Quality: Implement a new quality metric and track its impact on the number and type of defects reported. The ROI of quality is often subtle. Be sure to gauge the changes in customer satisfaction as a result of these metrics as well. Phase-wise implementation approach should be followed for large projects to reduce project risks and in occurrence of problem business impacts can be reduced. Always Prepare and Review back out plan to restore stable deployments and load balancing techniques.

In this paper we have addressed implementation of the Hospital Information system in a running hospital is very challenging task, also suggested few points to prevent implementation difficulties of AHIS project so as to how to make the AHIS success in an Indian public sector hospital. Acknowledgment The authors wish to thank Dr. George Varkey, Executive Director CDAC Noida and Ms. R.T. Sundari, Consultant CDAC Noida for supporting this work and valuable feedbacks. We also thank Mr. P K Srivastava, Sr. Project Manager CDAC Noida for his help in data collection. References |1| |2| |3| |4| |5| Degoulet and Fieschi Implementation difficulties in Hospital Information System Department of Management of Information System Bogazici University 1997 Tender Document, Post Graduate Institute of Medical Education & Research (PGIMER). Post Graduate Institute of Medical Education & Research (PGIMER), System Requirement Specification (SRS). Gap Analysis Document (GAD) version 10.0.0.1, Post Graduate Institute of Medical Education & Research (PGIMER). Idowu, P., D. Cornford, et al. "Health informatics deployment in Nigeria." Journal of Health Informatics in Developing Countries, 2, from http://www.jhidc.org/index.php/jhidc/issue/view/4, 2008. Igira, F. T., O. H. Titlestad, et al. Designing and implementing hospital management information systems in developing countries: case studies from Tanzania-Zanzibar. HELINA 2007/12th JFIM. Mali, Service d'informatique medicale, 2007. Eks, R. "Health information systems: failure, success and improvisation." International Journal of Medical Informatics 75: 125-137, 2006.

|6|

|7|

219

Udai Singh, Ashutosh Pandey, Amit Kumar

|8| Collins, T. and D. Bicknell Crash: learning from the world's worst computer disasters, 1998. |9| Rez, A. J. S. "Challenges to information systems implementation and organizational change management: insights from the health sector in Ecuador." The Electronic Journal of Information Systems in Developing Countries 16(6): 1-16. Ball, M. J., 2003. |10| Simon & Schuster Ltd. Frame, J., J. Watson, et al. "Deploying a Culture Change Programme management approach in support of information and communication technology developments in Greater Glasgow NHS Board." Health Informatics Journal 14(2): 125-139, 2008. |11| Gordon, A. N. and R. E. Hinson "Towards a sustainable framework for computer based health information systems (CHIS) for least developed countries (LDCs)." International Journal of Health Care Quality Assurance, 2007. |12| Berg, M., J. Aarts, et al. "ICT in health care: socio technical approaches." Methods of Information in Medicine 42: 297-301. Cassels, A. (1995). "Health sector reform: key issues in less developed countries." J Int Dev 7(3): 329-347, 2003. |13| Chandrasekhar, C. P. and J. Ghosh "Information and communication technologies and health in low income countries: the potential and the constraints." Bulletin of the World Health Organization 79(9): 850-855, 2001. About Author Mr. Udai Singh is working as a Project engineer in CDAC Noida for past 3years. He is also registered as ATM (Appraisal Team Member) in SEI (Software Engineering Institute) and help CDAC Noida in attaining CMM Level 3. His research interest includes Object Oriented Software Engineering, Software Testing and Software Quality Assurance.

Mr. Ashutosh Pandey has a total work experience of 4.7 years and working as a Project engineer in CDAC Noida for past 3years. He is also registered as ATM (Appraisal Team Member) in SEI (Software Engineering Institute) and help CDAC Noida in attaining CMM Level. He has been working in the area of Software Testing and Software Quality Assurance.

Mr. Amit Kumar has a total work experience of 5years and working in CDAC Noida for past 3years. He is also registered as ATM (Appraisal Team Member) in SEI (Software Engineering Institute) and help CDAC Noida in attaining CMM Level 3. He has been working in the area of Software Testing and Software Quality Assurance.

220