| 4. In which ways is the initiative creative and innovative?
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Prior to the beginning of each project a Project Document (PD) is created. The PD is collaboratively developed by SEHA IT, SEHA Procurement and the EMR software vendor (Cerner Corp) and signed off by SEHA Legal, as well as SEHA Administration, based on the Delegation of Authority. The PD identifies key components of the Project such as Scope, Timeline, Deliverables, Vendor Resources, and Key Milestones along with their associated Payment. The PD also includes an initial Project Plan.
At the beginning of each Project a “Project Sponsor” is chosen who is a key decision maker for the Project. The Project Sponsor is a leader within the business area most affected by the software that is being implemented. Every SEHA Business Entity (includes hospitals and clinics) identifies the appropriate staff to participate in the Project forming the Project Team.
In addition to the Project Sponsor a Project Charter is developed at the start of each Project. The Project Charter documents key elements of the Project such as the Project Overview/Scope, the Business Need and the Anticipated Benefits/Desired Outcomes and also serves to educate the Project stakeholders on the timing of events over the course of the Project.
The first series of Project team meetings are called Current and Future state design sessions. Design sessions are conducted to:Gather information about the Current state of processes impacted by the Project, Educate the Project team on the functionality that is being implemented, serve as a forum to ask questions and discuss concerns about the Project, Agree and decide on the Future state design for the Project.
Testing of Malaffi applications focuses on the data and location / facility specific information, particularly workflows, collected by SEHA Applications Team. There are a number of test cycles which comprise the full range of testing, validation, and acceptance sign off.
Project Risks are documented and monitored via a Risk Issues Assumptions and Dependencies (RAID) log in order to manage the Risk during a Project.
Monthly Executive Status Summaries (ESS) is a standard component of each Project. The ESS is distributed to the Project stakeholders according to the established Communication Plan. The ESS includes milestone statuses as well as hours logged to the Project by the vendor resources. This enables us to manage the vendor resources time against the budgeted hours as well as allows us to audit who is logging hours to the Project.
Project Management templates and Project specific documentation is maintained on the Malaffi SharePoint site. This aids in standardizing processes, ability to find documentation when needed, assisting when auditing Projects, and knowledge transfer.
A Post Conversion Audit is conducted at the end of each Project. The intent of the auditis to document the results of the Project against expected outcomes, record lessons learned for future implementations, and understands if there are gaps in training that need to be addressed.
Since 2008 the Malaffi teams have successfully implemented over 70 applicationsthroughout SEHA. These Projects have been recognized in Press Releases, Publications in local papers, and Regional Awards.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Internal Stakeholders: The Malaffi Steering Committee is comprised of top executives and clinical representation from all of the SEHA Business Entities and the SEHA Home Office. This Committee is responsible for leading the strategy and prioritizing the projects within the Malaffi Program, allocating funding for approved projects as well as promoting/endorsing the appropriate level of standardization and best practices.
SEHAPhysicians, Nurses, and other Clinical staff benefit by leveraging automation to electronically send medication, lab, radiology, and other orders and receive results in real time, enabling the ability to view a comprehensive Electronic Medical Record across the inpatient and outpatient locations, easily consult on a patient’s condition, utilizing decision support rules that are intended to alert the care giver of situations that might harm a patient.
External Stakeholders:The citizens of Abu Dhabi are our number 1 stakeholder. Every person could at some point in their life be treated at any of the SEHA hospitals and/or clinics.
The Health Authority of Abu Dhabi (HAAD). As the healthcare regulator within the Emirate of Abu Dhabi HAAD has reporting requirements which we met as a result of the clinical and financial data generated via Malaffi.
The Abu Dhabi Education Council (ADEC). Malaffi is used in the schools by our Ambulatory Healthcare Services (AHS) nurses to register and record health information on students. This includes recording allergies, immunizations/vaccinations, and medications.
Daman and other health insurance providers.Accurate and thorough electronic “eClaims” (bills) are critical to SEHA’s continued financial stability and reduced reliance on government funding. Malaffi is the system used to generate eClaims and to receive the required reimbursement from the various health insurance companies.
Physicians working for the Abu Dhabi Police have View Only access to prisoner electronic medical records.
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| 6. How was the strategy implemented and what resources were mobilized?
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Since 2005 SEHA has spent greater than AED 2 Billion to implement Malaffi, inclusive of the resources mentioned in this section. The Malaffi Program has required many resources to ensure the success of the individual projects. The main resources contributing to the Malaffi Program include; Financial – SEHA funded the procurement of the software/licenses, hardware, Professional Services/Consulting, and Malaffi Team salaries.
Human Resources including; The Malaffi Team – the Malaffi Home Office and SEHA hospitals and clinic teams have been the driving force behind each project. Team members include Project Managers, Clinical and Business Analysts, Interface and Integration Architects, as well as numerous specialty positions.Clinical Staff – all of the SEHA hospitals and clinics contribute subject matter expects that participate in the design and workflow decisions required to implement software to automate complex clinical processes.
Professional Services – contracting with Cerner to provide Professional Services to lead and assist in the implementation of the software and hardware.Consulting Services – In the early stages of the Malaffi implementation SEHA contracted with Dell (formally Perot) to assist in several projects from a project management and transformational lead perspective.
Software–Purchasing the Cerner software as well as the software support and maintenance.Hardware – Malaffi relies heavily on the right hardware being available in a variety of locations such as on the nursing unit, in the Operating Theater, in the mobile vans that travel to various events as well as to the Abu Dhabi schools, in the clinic sand at the point of care. Malaffi utilizes PC’s, Computers/Work Stations on Wheels (C/WOW’s), tablet PC’s, barcode scanners, and connectivity devices used to interface bedside medical devices such as monitors and ventilatorsand lab instruments.
Procurement of the above resources was done in accordance with SEHA procurement policy. This involves the identification and documentation of technical and non-technicalrequirements, development of RFP’s, creation of selection committees comprised of staff from many areas within SEHA, vendor bid evaluation from a technical and financial perspective, tender awarding and contract creation.
This significant investment in Malaffi can be leveraged to expand to non-SEHA medical facilities as determined by the government of Abu Dhabi as well as to connect to a Health Information Exchange (HIE).
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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As mentioned in question one it is well documented in numerous research projects and publications that automating hand written orders reduces the incidence of mistakes due to illegible hand written orders, in particular medication orders. Within one year of going live with Computerized ProviderOrder Entry (CPOE) and implementing medication process improvements related to ordering, dispensing, administration, and monitoring of medications a greater than 65% reduction in medication errors was realized at the first SEHA Hospital to go live with Malaffi.
To read Radiology films/images taken at 25+ SEHA Ambulatory Healthcare (AHS) clinics, AHS Radiologists had a daunting task to travel between diverse locations across the Emirate of Abu Dhabi. To read Radiology films/images in the Al Gharbia Hospital Region in the western region of the Emirate of Abu Dhabi, Radiology staff needed to travel between the AGH facilities and struggled to keep up with the workload.To continuously improve patient care, SEHA needed quicker turn-around-times (TAT) for reading, diagnosing and reporting of AHS clinic and Al Gharbia Hospital Region Radiologic exams. To this end SEHA implemented a Picture Archiving and Communications (PACS) system utilizing Malaffi to digitalize Radiology images and centralized the storage of these images making them available from even the most remote location. Radiology exams that previously took 2 to 3 days to read are now read and available in the patient electronic medical record within 2 hours.
Starting in early 2012 SEHA began the roll out of an advanced medication process improvement initiative within Malaffi called Positive Patient ID (PPID), also known as Closed Loop Medication Administration. PPID uses barcode technology to scan a patient’s wristband and medication when giving the patient a drug. The software checks the patient and medication information against what is entered in the patient’s Malaffi record and warns the nurse if there are inconsistencies. Barcode scanning of the patient and medication at the bedside automates checking of the “5 Rights” of medication administration; right patient, right drug, right dose, right route, right time.
Evidence based order sets have been and continue to be developed within Malaffi. These groups of orders (e.g., medications, lab, radiology, nursing tasks, diet, etc.) are based on documented research/evidence, designed for specific patient conditions and/or diseases (e.g., Pneumonia Order Set, Acute Respiratory Distress Order Set, Diabetic Order Set, etc.) and ensure physicians are ordering the appropriate tests, medications, etc. for the patient’s condition.
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| 8. What were the most successful outputs and why was the initiative effective?
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SEHA uses industry recognized project management tools and Project Management Professional (PMP) techniques to track the progress of the Malaffi projects. These include the following;
Project Charter – documents key elements of the Project such as the Project Overview/Scope, the Business Need and the Anticipated Benefits/Desired Outcomes and also serves to educate the Project stakeholders on the timing of events over the course of the Project.
Testing of Malaffi applications focuses on the data and location / hospital specific information, particularly workflows, collected by SEHA Application Teams. There are a number of test cycles which comprise the full range of testing, validation, and acceptance sign off. These cycles start with smallest pieces of data or process (UNIT testing). The next round, (SYSTEM Testing) relates to testing all components within each Malaffi solution area. After successful completion of both UNIT and SYSTEM Testing, each solution area is then tested as a part of the integrated approach (INTEGRATION Testing). The final Test Phase is USER ACCEPTANCE testing, which validates that the application, and system as a whole, meets the SEHA requirements in the PRODUCTION environment. For each test cycle there are high level criteria to start and complete each Phase.
Project Risks are documented and monitored via a Risk Issues Assumptions and Dependencies (RAID) log in order to manage the Risk during a Project.
Weekly Status Summaries are a standard report the team uses to ensure team members are aware of the project progress.
Monthly Executive Status Summaries (ESS) is a standard component of each Project. ESS includes milestone statuses as well as hours logged to the Project by the vendor resources. This enables us to manage the vendor resources time against the budgeted hours as well as allows us to audit who is logging hours to the Project.Event Activity Report (EAR) - In order for the vendor to receive a Project Milestone Payment, an EAR must be filled out and signed by SEHA and Vendor Project Managers as well as SEHA and Vendor Executive Management overseeing the Project. This is another check and balance to ensure the vendor is meeting the project Deliverables.
A Post Conversion Audit is conducted at the end of each Project. The intent of the audit is to document the results of the Project against expected outcomes, record lessons learned for future implementations, and understands if there are gaps in training that need to be addressed.
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| 9. What were the main obstacles encountered and how were they overcome?
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The majority of obstacles encountered were related to resistance to change and learning curves of the clinical staff. SEHA has older clinicians who were used to manual paper records. Changing from paper to electronic medical records required a significant change in their practice and training on basic computer skills was a challenge before introducing the workflow changes.
There was no standard form of identity which resulted in patients presenting their Birth Certificates, Passports, Driver’s License, etc. To overcome this obstacle SEHA is implementing a standardized registration process that includes the use of the National ID as well as a new technology involving the scanning of the patient palm vein pattern. We have also implemented scanning of health insurance cards during registration.
Educating the community on the benefits of Malaffi was necessary since we were changing the way care is delivered to our patients. Thisrequired us to launch a significant education campaign to make our patient’s aware of this new technology, its features and functions and how Malaffi benefits them.
Limited ability to expand in the data center hosting Malaffi posed an initial challenge as the implementations progressed. This required a migration plan to move to a data center that could accommodate our technical requirements as well as our need to expand.
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