Between August 2012 and June 2013 I would make
half a dozen trips to India, ranging in length from a
week to a month. I did not seek outside funding for
this endeavor, although NH ultimately reimbursed
my travel expenses. During that eventful year, I had
the rewarding experience of overseeing the project’s
progress from a concept to a working pilot program
implemented in the cardiac surgery intensive care unit
(ICU) at NH.
The “Silicon Valley of India”
From Dr. Shetty, I became aware of an imminent collaboration between NH and a large technology company that had agreed to supply an experienced team to
build a pilot of the clinical software. My first month-long trip to Bangalore involved two main activities:
learning how the city’s ICUs functioned and meeting
our technology partners.
But first, I had to work out the logistics of life in Bangalore (known as the Silicon Valley of India). I rented a
“serviced apartment,” meant for frequent business travelers, with private security and staff available to cook
and clean but cheaper and more low-key than a hotel.
I selected a neighborhood called Koramangala for its
proximity to shops, restaurants, a gym, other educated
young professionals, and relative proximity to NH’s
1,000-bed cardiac hospital, where I would be working.
From Koramangala, my daily commute was a 20-minute
taxi ride on a privately operated toll highway; it was
well worth the $1 each way to avoid the traffic gridlock.
To learn how the ICU functioned, I integrated
myself with the residents and fellows in the adult cardiac unit. I rounded each morning with the team. I
attended the weekly cardiac surgery mortality conference, finding it remarkably similar to our morbidity
and mortality conferences. I took note of practices that
differed from what I was used to and tried to absorb
them so that our software design would reflect the local
environment at NH. These differences ranged from
basic terms and drug names—they call epinephrine
“adrenaline,” in the British tradition—to more fundamental issues like scope of practice for ICU nurses.
At the kick-off meeting with the software engineers,
we established objectives and a timeline for our col-
laboration. I remember feeling intimidated by all the
software jargon, but the engineers probably felt the
same way about the medical jargon the health care
professionals were using.
After that meeting, members of the software team
began shadowing health care providers in the ICU.
They would stand at a patient’s bedside for an afternoon, watching nurses administer medications, measure vital signs, and remove tubes and drains. This
was all new to the software teams, and they found
the experience intense. One morning, I had to tell our
young business analyst that “his” patient—the one he
had been shadowing—had died overnight. It was an
emotional but important task for me to break the news
to him and debrief the event.
Negotiating what to build
On my third trip to India, NH administrators gave us
an office. I arranged desks and chairs in a converted
hospital room, with a wall oxygen supply and a sink
in the corner. We had to walk through a pediatric ICU
to reach our office, so the sounds of the hospital were
all around us.
Many other people, departments, and projects were
competing for resources at NH, but I figured out ways
to get what we needed. It helped being a surgery resident; I could enter the operating theatre and, during
a lull in the operation, ask questions of the senior surgeons and anesthesiologists.
Part of my role involved working with the NH clinicians to develop content for the software. As a first
step, I documented all of the data we needed in an
electronic medical chart. This task was much easier for
me than it would have been for the technology team.
Using my clinical knowledge and a surgical textbook,
I wrote a list of the vital signs, lab values, and the basic
items and services necessary for the care of a postoperative cardiac surgery patient. I cross-referenced my
list with the paper ICU charts at NH and entered the
information into an Excel document. It likely would
have taken months for nonmedical personnel to elicit
that kind of information from local physicians.
Later, as we began to incorporate more complex
medical content, I would gather a group of senior
MAR 2015 BULLE TIN American College of Surgeons
EHR IN INDIA