The new information system (IS) in the Clinical Center of Montenegro (KCCG), which was introduced in July 2023, has serious shortcomings, as part of the documentation from the old system is unavailable, and the process of scheduling examinations has not been improved either.
Since the introduction of new solutions, it happens that doctors do not have complete insight into the medical history, if the patients themselves have not saved the documentation.
The Heliant information system, made by the company of the same name from Belgrade, was introduced last year in KCCG through the project Strengthening the Health Care System in Montenegro. It cost close to one million euros, and support for this work, the total value of which was three million euros, was provided by the United Nations Development Program (UNDP). They chose the company Heliant in the tender.
Representatives of the Ministry of Health and KCCG claimed that the new system will improve the daily work of the medical staff, and provide patients with simpler, better and more efficient access to health services.
The information systems of health institutions were installed in the first decade of the 2000s by the Podgorica company MG-Soft. They made the system for the Health Fund, health centers, Montefarm, Institute for Public Health, general hospitals, as well as the basic system for KCCG. System maintenance services were charged annually close to half a million euros. Even today, maintenance amounts to that much, and most of the money over 33.000 euros per month still goes to MG-Soft, because they still reflect the systems of most healthcare institutions in Montenegro. The company Heliant, which took over KCCG, does not yet collect maintenance revenue, as their system is under a two-year warranty.
From MG-Soft they are for CIN-CG said that their system used by KCCG contained personnel records and salary calculations since 1999; administrative patient admission/discharge, invoices for hospital treatment services since 2001; specialist reports from 2013.
"The system contained data from the start of implementation until December 2021, when the maintenance contract with KCCG was terminated," stated MG-Soft.
The doctors interviewed by CIN-CG state that they cannot access the earlier documentation.
"As far as I know, Heliant does not contain data from the previous information system," he said Vladimir Pavicevic ENT specialist and president of the Health Trade Union.
"It is common to find data from previous years in the new system," MG Soft told CIN-CG.
When asked whether the lack of records can be eliminated, they answered that it is necessary to "make a detailed specification of all the necessary information that needs to be provided from the previously used system".
Of course, all this costs money, and MG-Soft says that "the price is determined depending on the specification."
Discharge lists and findings were typed in Word and PDF
Vojislav Macic, the director of Heliant, claims for CIN-CG that there was no information system at the KCCG clinics, but that the discharge lists and findings were typed in Word or PDF, so they could not be imported automatically.
"There was a previous IS at the polyclinic and all data from it is available to doctors. Specialist doctors' reports and discharge lists from general hospitals have been imported into IS KCCG and as such are visible to specialist doctors from the end of the implementation at the polyclinic in November 2021".
IT experts interviewed by CIN-CG say that every system should be well thought out before its creation, so that errors do not appear when it starts to be implemented.
The director of Heliant claims that "all the documentation that was in machine-readable form was loaded into our system according to the agreement with the competent institutions of Montenegro".
The Ministry of Health stated for CIN-CG that "there were technical problems in the operation of the web service, but also their shortcomings that led to problems in the exchange of data, which were solved and are being solved continuously".
"Previously typed documentation is visible through eKarton to specialist doctors, while the documentation managed since the implementation of Heliant is displayed through the patient's file", they answered for CIN-CG from KCCG.
The process of digitizing the health system began back in 2000. It took a long time, but by May 2018, the IS of most health institutions were integrated: the Health Insurance Fund, Montefarma, Primary Health Care - Health Centers, General Hospitals, Special Hospitals, the Institute for Emergency Medical Assistance , Institute for Blood Transfusion, Institute of Public Health, Agency for Medicines and Medical Devices (CALIMS), Health Center of the Security Forces, Private dental clinics that are part of the health network, Private pharmacies that are part of the health network and Private health institutions that are part of the health network networks.
The information systems of KCCG and the Ministry of Health are only partially connected to the Integral health IS.
Despite the aforementioned problems in the functioning and coordination of IS from the Ministry of Health, they state that the IS in KCCG does not function independently and is not outside the integral health information system, and that as part of the integral system, it "exchanges, among other things, data on central appointments, reports of specialist doctors and discharge lists as all data where there are technical conditions for that exchange to take place".
Where there are no technical conditions, patients, despite decades of improvement of the system and millions invested in it, still carry findings "on foot", do not have access to all documentation and wait despite electronically scheduled examination appointments.
These problems were also pointed out in the report of the State Audit Institution (DRI) from September last year. It was established that "through the electronic connection of information systems, the discharge lists and reports of specialist doctors from the IS Clinical Center of Montenegro are not transferred to the Integral IS of Health and are not available to the selected doctors".
In practice, it works so that the patient, after receiving the specialist doctor's report at KCCG, must personally take it to the doctor of his choice at the health center. A new round of appointments, waiting, for the chosen doctor to see the findings and give further instructions.
In the CIN-CG survey on the information system in health care, patients report dissatisfaction with the impossibility of making a direct appointment with a specialist, as well as the lack of connection between the system of health centers and that of KCCG.
"Appointments with specialists are always busy", emphasizes one of the interviewees.
"It should be possible to make an electronic appointment with a specialist and subspecialist directly, so that you do not have to go to the chosen doctor in person, or at least have the chosen doctor confirm online your referral to the specialist/subspecialist".
Patients also state that it bothers them that "the system is not connected with KCCG". "The results of blood tests, etc. done in KCCG are not visible", and they also make suggestions:
"Not everything is what it should be: the findings from the KBCG are still taken personally, even other findings. Transfusion, also personally... It's not right”.
The KCCG claim that they have eliminated this deficiency.
"The problems identified by the State Audit Commission have been resolved. The discharge lists and reports of specialist doctors of insured persons of the Health Insurance Fund of Montenegro are successfully sent to the selected doctors", they told us from KCCG.
Igor Ljutica, the president of the Union of Elected Doctors, claims for CIN-CG that there has been progress:
"We cannot boast that all the problems have been solved, but we can point out that a quality health policy is currently being pursued in this matter and encouraging steps are being taken. Recently, we have made progress, that is, the reports from the Emergency Center are visible to the chosen doctor, as well as the discharge lists".
In the DRI Report, which dealt with the segment of scheduling medical examinations through the IS, deficiencies concerning the efficiency of scheduling were observed and numerous recommendations were made. KCCG claim that the scheduling problems have been resolved.
Ljutica states that the selected doctors, under the current convocation of the line ministry, are integrated into decision-making regarding primary health care and included in working groups to solve this problem:
"The goal of the aforementioned working groups is to search for the best and most efficient scheduling model possible. The existing model did not prove to be good, and the goal is for the new one to lead to additional rationalization, where availability would be increased, while at the same time giving priority to the most urgent and vulnerable patients in the system, if they were not the first to reach the service".
In a recent analysis of the Union of Medical Doctors, it is claimed that the waiting lists at KCCG have not been reduced, and that the majority of specialist examinations and diagnostic procedures are waited for between three and six months or it is not possible to get a referral from the selected doctor at all due to the lack of free appointments. They also pointed out that the announcement that all health institutions will be connected through the digitization process has not been fulfilled and pointed out that KCCG uses Heliant software, while MG Soft is still used in primary and secondary health care.
One of the comments of the patients in the CIN-CG survey about the information system in healthcare is:
"Generally, the application is user unfriendly. Although a very useful idea, its functionality is very limited”.
Free appointments, and the doctor is on vacation or sick
Non-compliance with appointment times, absence of doctors, unresponsive system, lack of connection with the KCCG system are some of the criticisms that patients directed at the health information system, according to the CIN-CG survey.
The survey was conducted by CIN-CG during ten days in March, and 303 people, namely 10 doctors and 293 patients, responded to it.
Information system services in healthcare are used by the majority of those who responded to the survey, 94,7 percent of them, 3,28 do not use them, and only 1,97 percent of respondents answered that they did not know what it was about.
The majority of respondents are satisfied with electronic scheduling, 65,97 percent, while 34,03 are dissatisfied. 33,57 respondents had problems during scheduling, while 66,43 answered that there were none.
Doctors, 70 percent of them, rated the system they use in their work as good, and 30 percent as bad.
"The system has great possibilities and potential, but it seems that doctors and other medical personnel are sabotaging it to the greatest extent," is one of the answers we received.
When making an appointment, patients are faced with the possibility of electronically scheduling appointments that are actually already taken or unavailable.
"It used to happen that the system showed that the chosen doctor had plenty of free appointments throughout the week. After the appointment, when you go for an examination, it turns out that the doctor is on sick leave or on vacation, and you need to re-schedule an examination at the counter with a replacement doctor", is one of the criticisms.
"Waiting for two to three weeks for the first available appointment, and when you arrive at the scheduled appointment, your doctor is on sick leave, without any notice."
You make an appointment and then wait for hours for an appointment - this is the most common criticism that patients have emphasized.
"You can't go in for an examination at the scheduled time, sometimes you have to wait for hours, and sometimes the nurse says with the comment 'electronically again' that the doctor won't be able to see the patient", is one of the comments.
In the second, it is pointed out that it also happens that the doctor does not work that day, even though the system allows an appointment.
"I make an appointment and come and then they tell me that my chosen doctor is working at another location today. It doesn't work...", one of the patients wrote about his experience.
The patient who wrote that when he makes an appointment at eight in the morning, he waits again until 12 or 13 pm claims that it is a matter of inconsistency between the system itself and the state of medical institutions. He also claims that sometimes he doesn't make it to the examination that day or the doctor isn't at work that day.
"The nurse told us not to do that anymore (I mean scheduling) because few people use it because it doesn't work", is one of the comments.
It is also pointed out the possibility of making an appointment when the doctors are not actually present in the outpatient clinic.
"It is allowed to make an appointment with the chosen doctor, even though he is on sick leave or on vacation," one of the patients points out.
Another states: "It has happened on several occasions that I make an appointment for a visit, and when I come to the DZ it turns out that the doctor is absent (engaged in the local community clinic or engaged in the opposite shift)".
Patients also wrote cases like this: "I had an appointment with a doctor who, when I arrived, was told that he had not been working for a couple of years. The doctor on duty did not want to see me. Also, it is often impossible to get regular therapy through this system."
Part of the criticism of the information system related to the impossibility of making an appointment with a gynecologist:
"For the chosen gynecologist, it doesn't matter if you have an appointment or not, the only thing that counts is that you come to the counter and make an appointment right away, and then you will wait for hours".
One of the pregnant women described her experience like this: "I make an appointment and go to the DZ and they tell me that my gynecologist no longer works in the DZ." The second time, they tell me that the doctor is on sick leave... The third time, they say that the chosen doctor started his specialization two months ago. And the name of the old doctor is still written in the information system (eHealth).
He points out that no one updates it or regularly makes changes in the system:
"I was nine months pregnant, with a stomach up to my teeth, but they weren't interested in that." In Block 5 at the gynecology department, if you call by phone, they may answer, even to schedule an examination/ultrasound, you wait at least an hour and a half because you get in through the queue and everyone knows who.
A couple of IS users from Bar complained that it does not work in this municipality.
"Except for functional ones that work perfectly, such as review of findings and renewal of therapy, for the health system in Bar it is not possible to schedule an examination via electronic scheduling directly. In addition, I believe that it is necessary to digitize other processes, appointments with other specialists, receiving remittances for sick leave in electronic format, preparation and submission of documents for commissions, etc.
Another patient claims that "direct electronic scheduling is not allowed in the health system in Bar".
Another comment warns about the dysfunctionality of this system in DZ Bar:
"I make an appointment, DZ Bar has no records that I made an appointment. When the doctor is absent, there is no information on eZdravlje about the doctor's absence," says one patient and explains: "Because the health center in Bar no longer 'accepts' electronic registrations, i.e. scheduled visits, it has to be called by phone, and before it was also possible electronically, which was great".
10 doctors responded to the CIN-CG survey. Half of them wrote that they work in KCCG. One doctor from KCCG answered that the system is bad and slow, while four rated it as good, with the explanation that it makes work much easier, that it is easy to use, that there is a database, that it makes it easier to write reports, that the findings are integrated, and that is systematic and provides insight into the patient's complete medical history. Doctors from KCCG cite the slowness of the system, software crashes, poor internet connection and the lack of some diagnoses as flaws.
One doctor employed at the health center rated the system as good, facilitating the examination and search for the patient, while his colleague wrote that it was bad, characterizing it as slow and illogical.
The doctors, who stated that they were employed in the general hospitals of Bar and Nikšić, evaluated the system as good, well-reviewed, simple, intuitive, and cited slowness as a drawback.
For the development of the information system for the Clinical Center, $974.175
"As for the question about the price of introducing IZIS, we cannot give an answer because that project was led by the Government of Montenegro in cooperation with UNDP, through which the tender was announced, and therefore not the tender documentation", CIN-CG replied. from KCCG. An earlier attempt by DRI to obtain this information was unsuccessful. In the SAI report, it is said that they do not have that document in the Ministry of Health, but only in UNDP, which conducted the tender.
CIN-CG managed to get this information from the Ministry of Health: "UNDP and the Heliant company from Serbia signed a contract for the development of the Information System for the Clinical Center of Montenegro, with a total value of 974.175 dollars, which includes two-year maintenance. The two-year maintenance started from the end of July 2023".
The Ministry points out that "the introduction of IS requires changes at all levels of health care and their software, which is why the system is within the two-year warranty period in order to eliminate them without additional financial costs."
While there will be no additional costs for Heliant for more than a year, as long as the warranty lasts, as claimed by the Ministry of Health, for other information systems there will be, close to half a million euros per year. The most money is paid to MG-Soft, 35.984 per month, of which over 95 percent is paid by public health institutions.
Software costs the most per month in 18 health centers, the Security Forces Health Center, ZIKS, and the Risan Old People's Home, a total of 16.200. Each institution pays 771 euros per month for the software.
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