United Nations Public Service Awards Case Studies

The problem of manual Medical Records is quite complex. A distinguished American physician has commented “The (paper) medical record is an abomination …it is a disgrace to the profession that created it. More often than the chart is thick, tattered, disorganized and illegible; progress notes, consultant’s note, radiology reports and nurses notes are all co-mingle in accession sequence. The charts confuse rather than enlighten; they provide a forbidding challenge to anyone who tries to understand what is happening to the patient.” Bleich, H., MD, Computing Vol 10 no 2, p70, 1993

These words surmised the situation of patient records before the initiative. Each patient has multiple files as there are no centralised records, a visit to a different health-care facilities will result in a new file being created for the same patient. It was very difficult to get the complete information about a particular patient’s medical history. As such medical professionals have to depend on asking the patient during treatment and consultation. These steps are usually not effective as most patients do not give an accurate feedback and follow up treatment can be laborious. It resulted in the increased in the cost of treatment due to duplicate diagnoses and medication. It is also time consuming for the medical staff (Doctors, Nurses and other paramedical staff) to trace and piece the information of the patient as there are many versions of the statistical and administrative reports. There was no way for auditing and tracing these reports as there was a lack of raw data available for due to significant number of lost files and duplications as a result of manual record keeping.

What is the initiative about? (the solution)
The e-Health application, called Al-Shifa, is an in-house system designed and owned by MOH. It is designed with the consultation and collaboration between the in-house developers, the end-users (medical staff) and adapting practises of other renowned medical facilities in the world to suit the operational environment of Oman. The system maintains an audit trail that records the previous information prior to making any changes, the details of the changes made, and the details of the user that made the changes and the date and time of the changes. As the patients’ data cannot be lost and presented to medical professionals in a more suitable format, there is tremendous gain in time to understand the patient’s health situation and provide appropriate treatment. This resulted in 60 % of time saving in tracing the personnel who last treated the patient for clarification and follow-up. The system complies with international standards and consideration of interoperability is thought through during the design and development phases. These made Al Shifa highly scalable, some of the services that were integrated in the system are: • SMS and e-mail services – Patients are informed and reminded about their appointment in the health care institutions. • Appointment management – Appointments and schedule of the patients are now handled by the system. • User-defined search - It provides comprehensive and on-line inquiry reports based on the user-defined search criteria. Al Shifa retrieves and displays only the relevant information that can be viewed from any workstation within the healthcare institution with adequate profile security. • Automated Laboratory and Radiology Equipment Interfacing - Diagnostic test result are fed to the system automatically, that reduces the human data entry error and saving technicians time by 70%. • Billing module – The Billing module calculates fees and treatment cost, business rules are in-built to the system to handle exceptions like birth spacing, immunization. All treatments for Omani, GCC nationals and expatriates working for the Omani Government are provided free of charge. • Drug expiry management – Al Shifa will alert the relevant personnel on stock level of medication two months before the expiry date, so the excess quantity can be shared by other institutions. This results in lowering the cost of holding too much excess stocks and most importantly, ensures that the level of stock are healthy and will not go into a situation of shortages.

Who proposed the solution, who implemented it and who were the stakeholders?
All technical implementation were done by the Ministry in-house team. If there are external vendors used, the Directorate General of IT will oversee and list all specifications. The stakeholders include all the medical personnel involve the operation of healthcare delivery system, Health Program manager, hospital and healthcare services managers. For defining requirements there are various committees. For instance there is a Supreme IT committee that gives general direction and approves various IT projects and budget. There is a Primary Health Care (PHC) Task Force that reports to the Supreme Committee and defines the requirements of the PHC applications and each major hospital has an IT Committee that also report to the Supreme IT Committee.

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The main objectives of introducing ICT to health care services through developing an e-health application (Al-Shifa) are to enhance the quality of health services and make them more accessible to the public. H.E the Minister of Health emphasized that when introducing ICT to health care, it should be done in a way to improve the quality, reduce cost, eliminate duplication, and collect quality data. The strategies used to implement the initiative are: • Roll-out – New health institutions built will be equipped with Al-Shifa. Each year, existing institutions without Al-Shifa will be scheduled into the roll-out plan. Currently, 80% of all the Government health-care institution in the sultanate are already utilising Al Shifa. • Training – In parallel to the roll-out of Al – Shifa, key personnel from different institutions are also trained on the system. So far more than 20,000 staff are trained. • The IT Support includes the non-stop operation (hardware, software and network) of these systems in healthcare institutions, end-users support within each healthcare institutions and training for new staff. The IT Support is organized as follow: o The First line of support is provided by regional staff for Primary Healthcare Care IT support available in each region and each Regional and Tertiary hospital has its own IT Support Staff. o The Second line of Support is provided by the Directorate General of Information Technology from the Ministry’s HQ, where there are specialized IT staff such as Database Administrators, Network engineers, software specialists, ect.. Through time, the e-Health application (Al-Shifa) has allowed for accountability, transparency, and has reduced the time needed to provide care for patients. The plan that was adopted to achieve these objectives was based on understanding the users’ needs, learning from past experience, and resource allocation and dedication of staff. Currently, implementation strategies are focused on having a connected, consistent, and cohesive National e-Health Record Repository that includes improved information flows between providers and better continuity of care with other providers through shared registries, such as a client registry, provider registry, service delivery location registry, and a services registry.

b. What were the key development and implementation steps and the chronology? No more than 500 words
The history of computerization in the Ministry of Health started in 1987 at Royal Hospital, Sultanate of Oman. The Ministry of Health (MOH) created a specialized and dedicated Unit for IT called Computer Department in 1990. In 1992, a committee of clinicians, health administrators, IT personnel and other medical staff was created with a mission to define a computerization strategy of MOH institutions. The committee recommendation was to develop an in-house hospital information system based on the needs and requirement of Oman. In November 1997, His Excellency the Minister of Health approved a pilot project in a small health center and gave a go-ahead to implement the system in all health centers and started building a comprehensive system for hospitals. The strategy adopted then was to equip each newly build health institution with computerization and every year some old institutions will be selected for computerization. After the initial computerisation of the various healthcare institutions, the Ministry of Health in Oman collaborated with WHO consultants and mapped out strategies to meet the needs of healthcare in Oman while reducing maintenance costs, and in 1996 the initiative was started and funds were allocated.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
Initially, the main obstacle was changing the pen-and-paper culture that existed for years at the health care institutions in Oman. The management faced, and continues to face, the problem of changing user’s mindsets, especially those from older staff who were not exposed to ICT in their field of work. In addition, the management needed to get the buy-in of the user and convince them of the benefits of the application as well as achieving user acceptance. Initial teething problems during the migration of the old system to the new system were met with resistance and the lack of knowledge of using the new system made the user reluctant to change. In brief the change management was the major obstacle. These obstacles and challenges were overcome, eventually, through constant and consistent senior management support, user involvement and extensive staff training. This has lead to the e-Health application becoming an integral part of providing health services to the public, to which the users contribute generously with their knowledge in their field and input for improvements. Due to the nature of staff continuously turn-over in the health care institutions, requirements and needs also changed, training is an ongoing process alongside with it, feedback and comments from the users are taken into consideration in the further development, enhancement and implementation process. Besides, training, regular meetings are held with users of different levels in order to come to gather new user requirements and feedback on the components of the application. The trainers are chosen carefully, and further training is given to them to take up the challenging job of training users. In terms of technical obstacles, the management and development team faced the problems of cost accumulation, and Windows clustering for running the application on a Windows NT platform Therefore, there was a re-direction to port the application on Redhat Linux platform, which is easily managed. Redhat Linux was found to be better in terms of clustering, minimal maintenance, and easy access to resources and support from the Internet.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
Ministry of Health did provided resources (technical IT manpower, infrastructure) to build Al Shifa. The health and medical knowledge came from the existing medical staff employed by the Ministry of Health. The cost of building Al Shifa is about Rial Omani 1,500,000/ (about US $3,800,000) and was fully paid by the Ministry of Health. The Technical IT staffs were recruited as Ministry of Health staff, the software and necessary hardware were purchased from the local market. In 2005, Ministry of Health invited the WHO e-Health experts to visit and evaluate the initiative. The visiting delegation was impressed with the system and especially in the cost prospective. It was told that for developed countries, the IT cost of the Ministry of Health is estimated to between 2 and 2.2% of the Ministry’s overall budget, while in Oman, it is only 0.7 to 1.2% of the Ministry of Health budget but we managed to improve the efficiency.

Is the initiative sustainable and transferable?
The expertise in Medical and IT fields are from the Ministry of Health own internal staffs, the issue of sustainability and transferability take a complete different dimension in criticality. There are time to time turnover of medical and IT expertises but it is always ensured that replacements are brought in and these have never be a serious treat to the continuity of Health Information Technology (HIT). The system is also highly scalable and can be customised for another organisation.

What are the impact of your initiative and the lessons learned?
A well planned introduction of Health Information Technology (HIT) in healthcare institutions pays. The initiative is successful; the healthcare institutions can hardly operate appropriately without it. It has created transparency in the processes of healthcare delivery system where duplication and inefficiency can be removed in order to improve the healthcare itself and at the same time contain the cost. The system is in operation in over 80% of Ministry of Health healthcare institutions and some other Omani Government healthcare delivery system also. The system is fully in operation since 1997 and evolved accordingly this speaks of the succes.


Institution Name:		Ministry of National Economy
Institution Type:		Government Agency
Contact Person:		Nasser Al- Shamli
Title:		Director
Telephone/ Fax:
Institution's / Project's Website:
E-mail:		dir-net-com@moh.gov.om
Address:		P O box 393
Postal Code:		100
City:		Muscat
State/Province:		Muscat
Country:		Oman

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information