Creating better vision
18th March 2008, The Financial Express

As India's Sankara Nethralaya hospital took on more applications to meet patient needs, its network went on a blink, leaving the hospital blind for hours. When the problem moved from being an irritant to life-threatening, it knew only a network management system could save it. It was 1978 when the country saw the birth of what was to become one of India's best-known medical institutions. It was the year when an eye hospital took upon itself to deliver free treatment to its patients. Sankara Nethralaya is all that and more. The charitable hospital that was conceived by Sankaracharya of Kanchi, has many awards and accolades against its name -- including the best managed charitable hospital in India. Today, in its 30th year, equipped with the latest technology, this super specialty hospital treats more than half a million patients annually. But long before it started to see this many patients, the hospital realized that it was imperative to have an IT-enabled infrastructure. And, today, it uses technology extensively for all its operations.

But, beneath this success story and the awards lay a sorry picture of a tired network infrastructure. In November 2007, the hospital installed a comprehensive EMR system (an electronic medical records system maintains patient records in a digital format). "The EMR is life critical," says M.K. Manavalan, Head-IT, Sankara Nethralaya. "If a doctor in an operation theatre needs to verify something, he or she turns to the tablet PC or laptop" that runs on the EMR system. The EMR system also offered analytical data. Critical surgeries have separate modules, which, over a period of time, has been able to prescribe evidence-based medication. That's not all, even the drug inventory used the EMR system. "The store prescribes and disburses medicines according to expiry dates, so even inventory management is on the network," he says.

The EMR like most other apps in the hospital runs off a network. As the hospital banked more and more on its network, it began to show signs of strain and over time, network performance became a life-threatening issue. To make matters worse, the network did not have a proper monitoring system. Soon, the hospital began to be plagued by long hours of downtime, often because of network problems. This resulted in functional delays of the system, which had a direct impact on patient services. "The last time it happened, we had a downtime of seven to eight hours, when there was no billing either. There was a lot of traffic that got stuck, it was a total collapse," remembers Manavalan. Ironically, locating some of the problems took about several hours while fixing them took a few minutes. "Identifying the trouble used to take so long because we had a very large network of at least 40 to 50 components," points out Manavalan. But when you run a hospital, a few minutes of downtime can be fatal. Sankara Nethralaya needed 100 percent uptime service from its IT infrastructure and every day it waited for that, it put the lives of its patients in danger.

Removing the Blur

Sankara Nethralaya maintains almost 1.8 million records including those from the day it started functioning. Scanning these was a huge task. With almost half a million patients added every year, this pile of records was only getting bigger. And as it grew, the hospital was also aiming at acquiring international standard processes. One of these came in the form of the EMR system. These 21st century applications, however, put strain on the network. It was then that the organization started looking for an network management system (NMS). Manavalan evaluated a number of products and applications to find one that fit the hospital. He says that to be chosen the solution had to be more than a NMS tool. "Apart from its main role of displaying the network, we needed something more, in terms of sending information to other teams by SMS," he says.

IBM's NOC Inside, an automated subscription-based solution with IT infrastructure as an integrated application, was just what the doctor ordered. With NOC Inside, the hospital could automate IT monitoring, IT inventory management and IT service desk operations. It was important for the solution to multi-task because IT at the hospital multi-tasked. During a critical operation, for example, IT stands in because anesthesia monitoring is also IT enabled. A patient's vital functions and other reports need to be immediately accessible on the network, so that steps can be taken to administer anesthesia and post-operative care -- both advised by the EMR system.

Manavalan explains why he chose NOC Inside, "We had evaluated a few other network management tools, both in terms of hardware and software, but none of them provided an integrated solution like NOC Inside. It provides software and hardware inventory as well as helpdesk management with SLA measurement, and comes along with core network monitoring requirement." The application generates daily reports that keep track of the hospital's entire hardware and software inventory and ensure software license compliance. Dashboards facilitate real-time measurement of IT service performance and generate alerts whenever there are problems. This helps nip network errors in the bud.

The system automatically calls the helpdesk if it finds a network problem in any of its network monitoring areas. "For example, a switch in one of the ports may be down. So, before the user comes to us, there will be a call from the NMS and we can take care of it immediately," says Manavalan. The system never stopped surprising the hospital with what it could deliver. It also identifies and allocates the bandwidth required for a Sankara Nethralaya's branch that is being set up in a remote location. "Before this NMS tool was implemented, we had to rely on calculated guesses to figure out how much bandwidth we needed for a new branch. After the implementation, we are able to clearly monitor IT requirements. In our Calcutta branch, for example, we wanted to go for 800 Bytes per second (Bps), but thanks to NOC Inside we found out that we required only 200 Bps," says Manavalan.

This was important because the hospital wanted to open more branches to add to those it had already opened Chennai Kolkata Rameshwaram and Bangalore. Currently, the hospital's management is planning to open a branch in Mauritius. The solution also came bundled with an IT advisory service capability that employs a specialized analytics engine. This studies the network, acts as a consultant and recommends action plans for the network. But as convenient as the solution sounds (it took only 12 days to implement), it was not devoid of challenges.

From a Coma to OPD

While the system would assure the hospital of 100 percent uptime, persuading the management was quite a task. "Our management wanted to know why we couldn't settle for just a network management system. Our point was that this application would add so much more value," says Manavalan. In the end, they came around. In retrospect convincing the management was worth it. Says Dr. Lingam Gopal, chairman, Sankara Nethralaya, "Our operations are not just business critical, but more than that, they are 'life critical'; therefore we need sophisticated tools like NOC Inside, which make a big difference to our network uptime."

Every process that NOC Inside has eased is a business benefit. Apart from providing the hospital with a 360-degree view of its infrastructure, Manavalan's biggest benefit was the elimination of downtime. "With NOC Inside even potential problems are identified, so within a minute we know which machine's application is giving away," he says. He also realized that NOC Inside would make running other applications easier. "With this tool I can monitor the performance and activities of other applications. Take the EMR system, for instance. The NMS tool has a database in which it collects a lot of data on traffic monitoring. Based on that it can generate various reports," he says.

In addition to the expected benefits that the system provides, Manavalan is happy with the customized package that IBM provided. "We need to verify our IT assets every month or every quarter to classify them and calculate our current asset list. Every year, we need to verify our software licenses, and we also need to confirm whether we are compliant. With NOC Inside, this has been totally automated" removing many manual hours of inventory taking. At any point of time, the hospital now knows the number of licenses it has and if it is meeting compliance standards for various applications. Considering the fact that these areas required many man-hours, this is a huge business advantage too. "We could say that we save almost two man-months every year, thanks to NOC Inside's asset management capabilities," says Manavalan. Quantitatively, the system has reduced manual intervention by almost 60 percent, he says. This solution also generates a daily report that keeps track of the entire hardware and software inventory and ensures software license compliance. The NOC Inside tool also has a service desk component, which allows the user to log on automatically into the system and the helpdesk will allocate the right service engineers to the place. It acts as a centralized call center database management system (CMDP). "There were around 75 to 80 network calls booked in our helpdesk per month," says Manavalan, "which needed manual intervention to identify the issue and resolve it. After the implementation of NOC Inside, our network calls per month has gone down to 32, which is around 40 percent of the original number -- a whopping decrease in network calls."

Introducing the ROI concept to investment decisions at a hospital is not very prudent, since often, the returns are in terms of added services. So just cost was not a consideration. "I was focusing on the value-added points," Manavalan says, "and also, the vendor's cost was an advantage. This is a subscription-based model, so it worked both ways." In addition to not being exorbitantly priced, NOC Inside also saves manpower costs. This was a substantial saving and proved useful, especially for Manavalan, who had to use it as an ROI tool to convince management.

As Lingam points out, what is critical to business could also be critical to saving a life. So inversely, what the business can save (by being more efficient) is not looked at in terms of money -- but in terms of lives. "We normally quantify the area of investment on life-based criticality, not only with money saved. Earlier, the downtime we suffered was bad. Over an eight-hour period, we could say we lost at least [US$2,134]. Though, there is a huge saving, we look at the investment more as a life-critical activity," Manavalan says.

At peace with its NMS, Sankara Nethralaya's IT team is now looking at the next level of IT implementation. "We will be investing in developing Ophthalmology PACS and a data mining application which will help in clinical decision support system, preferred practice pattern and evidence-based medicine," he says. And today, with NOC Inside, the hospital, which had a myopic view of its network infrastructure, has broadened its vision and has gone beyond just a corrective surgery. With a system that delivered more than it promised, Sankara Nethralaya can now afford to rest on its laurels.