Ministry of Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Bahrain’s healthcare system is a source of pride. Through the 26 health centers, two main hospitals and four peripheral hospitals serviced by over 4,000 health professionals, the more than 1.2 million citizens and residents enjoy universal access to healthcare through a large range of services, from primary care through to the most specialised and complex treatments. The Kingdom of Bahrain is considered one of the leading countries in the implementation of cutting edge information technologies for the modernisation of infrastructures. It holds the third position in Asia in e-Government, thirteenth worldwide and the tenth among free market economy countries. Before 2011 the presence of Health Information systems implemented Bahrain was very limited and usually related to administrative work. There was barely any clinical management through electronic services. In spite of the quality of health care services and the experience of health professionals, there was an important room for improvement and efficiency to be covered with health information systems. - Need to quickly transfer health information amongst professionals - Need to get a safer system. With paper there is always a potential risk of losing requests, patient files… - Need to minimize the risk of mistakes that may cause a damage in patients - Need to access unlimitedly to health records to increase the quality of care. Physical health file means that the historical record of the patient is never completed and never available when needed) - Need to obtain as many data as possible in order to take better informed policy decisions - Need to interconnect all levels of health care in a continuous and smooth flow - Need to reduce costs Besides, most health professionals were demanding for new tools to achieve a better performance in their daily task.

B. Strategic Approach

 2. What was the solution?
The Bahrain Economic Vision 2030 (2010) a government proposal, stipulates the universal availability of quality healthcare and by 2030, positions Bahrain as a leading centre of modern medicine in the region. Based on this strategical roadmap, the Ministry of Health was decided to implement a National Health Information System, I-SEHA, as a key component of enacting the Ministry’s vision to improve healthcare services. So in April 2011, INDRA, a leading multinational company in the implementation of health information systems, was entrusted to deploy the Bahraini Government’s National Health Information System. I-SEHA provides a modern, intelligent and integrated informed healthcare system. It is more than a mare paperless/filmless project and integrates clinical and administrative solution for primary and secondary care, and patient information will be compiled in a single Electronic Health Record, available where and when needed. As iSeha is a country-wide platform available at all healthcare providers, a patient can easily and instantly be referred to a specialist at another facility with all his information intact and accessible on real time. So the system warrantees the continuity of care. A physician may also request a diagnose test through I-SEHA right in front of the patient and, once the test is done, obtain the results and check them displayed on the screen. So there is no need to carry physical patient files, radiology images, or lab results. Everything is stored in the paperless I-SEHA system. The system also covers all medical requests (laboratory, radiology, medical prescriptions) through an electronic flow. And everything is linked in a workflow with the support of a secured database. Although I-SEHA is an information system its main objectives are the following: - To enhance the quality of patient care and safety as a result of a better flow of health information among professionals. - Increase patient satisfaction with the system - Improve and warrantee the continuum of care within the current flow (from primary to secondary care) - Facilitate citizen access to health services - Reduce costs - Facilitate clinical safety supporting of professional access to information - Optimize and standardize clinical processes - Increase the knowledge related to health (patients health and healthcare activity)

 3. How did the initiative solve the problem and improve people’s lives?
I-SEHA is one the most ambitious health projects in the region and up to date technologies have been put in place to make it happens. Everything is innovative and creative in I-SEHA but some key elements can be highlighted in this sense: - I-SEHA is a globally unique and innovative system since there isn’t any other previous experiences worldwide of having a unique health information system for primary care and specialized care. - I-SEHA is a global system which includes several applications/modules interrelated in a workflow: electronic health record, scheduling and appointment, pharma prescription and dispensation, dietetics, invoice & billing, amongst many others. - I-SEHA includes an strategic collaboration with British Medical Journal (BMJ) the prestigious scientific group in order to offer doctors evidence-based support in their clinical decision making, concerning assessment, diagnosis and treatment. - I-SEHA includes electronic prescription which is an innovative and paperless drug prescription and dispensing model by which patients do not need to go to the doctor to order repeat prescriptions.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The project could be divided into five major phases: 1. The initial phase is planning and vendor selection. The key components of this stage included the identification of potential uses and benefits of the system, cost analyses and, communication with staff and articulation of goals. Afterwards the vendor/system was chosen, the contract negotiated and the commitment from the staff obtained. 2. The second stage was the existing workflow analysis and the needs of the Ministry of Health. To do that, end users such as physicians, nurses or clerks played an important role as key informants. 3. The third one was to prepare a customized version of the different modules included in I-SEHA. Once developed these modules needed to be properly tested and validated. 4. The fourth one was the awareness, training and user support. This stage is also crucial to the success of the implementation. Without the required skills to work with I-SEHA nor the will and motivation to do it, it would not have been possible to move ahead with the project. 5. The fifth and final stage is the optimization. To optimize the use of I-SEHA, all health care centers need to continuously customize and update the system to meet user and patient needs, train staff on an ongoing basis, compare projected and actual costs, and use the system to meet organizational goals and improve outcomes (e.g., utilize a dashboard). The deployment process was made gradually. It first started with a brand new hospital (King Hamad University Hospital) since the process is much easier due to the fact that there is no need to substitute any previous system. Afterwards, I-SEHA started in Primary Care centers with Scheduling and appointment module (first) and health electronic record (secondly). In parallel the deployment in the biggest hospital, Salmaniya, started with Outpatient Department. The deployment criteria was carefully chosen in order to minimize a negative impact of the system substitution.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The Health Information Directorate (HID) from the Ministry of Health of the Kingdom of Bahrain has been the leader, designer and coordinator of this project, monitoring the activities of the vendor. However, during all stages, healthcare professionals have played a key role in the successful implementation of I-SEHA and were cathegorized in three groups: Champions: Persons who build and sustain strong enthusiasm about the change, reminding everyone why the change is occurring in the first place, the many benefits that have come and will come from the change process. Key Users: Key users had a strong understanding of the business processes within their respective areas. They contributed to the development of new methods and procedures and act as key educators to others within their organization. End Users: They were the healthcare givers, clerks, pharmacists, radiologists...who use the system to process transactions and extract data. Users will be trained in the use of the new system and involved in the later stages of the implementation. Besides, clinical core teams were created to build up a permanent flow of information in both senses, from clinical to technical perspective and viceversa. Finally it is worth to mention that a project of the magnitude of I-SEHA exceeds the natural limits of the action of the MoH, encouraging and strengthening collaboration with other ministries and areas. The Ministry of Finances because data regarding costing of health services will be more accurate and the saving impact of I-SEHA will be remarkable: avoid repetition of tests, removal of the film, minimize prescription mistakes, etcetera. Defense because this Ministry has its own health services and I-SEHA system encompass them into a single information system. And finally the collaboration with Education Ministry because health promotion polities must be based on synergies between health and educative sector to achieve a long-term impact in the population.
 6. How was the strategy implemented and what resources were mobilized?
In terms of financial resources the funding of this project came from the MoH budget. As per technical issues, Bahrain's Ministries of Health and Defense awarded Indra, a leading multinational company, the development and global operation of all the applications of its National Healthcare system network, including hospitals and health centres for an execution period of 11 years. The team consisted of managers and consultants from Spain with experience in the implementation of national healthcare systems as well as IT professionals from Bahrain's university environment. The support was provided from Indra's Spanish Software Labs network. To facilitate I-SEHA deployment a Helpdesk system has been put in place which offers support to all users and to infrastructure elements, playing a key role for the success of the project. The Helpdesk provides a wide variety of services such as preventive activities, maintenance, monitoring, channeling complaints and suggestions and troubleshooting assistance. To offer this assistance, there is a telephone hotline and email available 24 hours a day /7 days a week in both Arabic and English. HelpDesk counts on 49 professionals divided into 7 teams specialized in different areas of expertise to give support to I-SEHA.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
There are many factors which have contributed to the success of I-SEHA. However five of them must be highlighted because of their relevance 1. Highlight the quality element rather than the technological one. I-SEHA was framed when presented to the staff and all relevant stakeholders. It was important to connect with clinicians about EHRs in terms of quality as well as making implementation less about the technology and more about a larger strategic plan to promote better patient care. The project aimed that clinicians and leaders framed new technology as a vehicle to promote clinical practice change rather than as an end in itself. 2. Implementation speed. An important decision organizations must make is whether implementation should occur fully at once across all units of the organization, often referred to as the “big bang” approach to implementation, or if partial/gradual implementation, where all or parts/modules of the Health Information System are gradually implemented across units, would be more suitable. Both approaches were followed with I-SEHA depending on the specificities of each module and area. However, and regardless of the implementation speed, continuous quality improvement and other ongoing work to train staff were required. 3. Strong leadership. The importance of leadership support and commitment from the top levels was continuous, as well as bottom-up physician leadership and input. Up front, honest communication with staff about implications for their workflow and workload throughout implementation was also also helpful. All these could not have been possible without enough stability within the organization and ability to manage change 4. Workflow and analysis planning. Planning for changes in user workflow was one of the first and most important goals at the beginning of the project. Planning for and understanding workflow redesign from a managerial perspective improved HIS implementation by helping organize the process, gain staff buy-in, facilitate staff readiness, coordinate between processes, and improve adherence to operational and clinical protocols. 5. Participation of Bahraini healthcare professionals in the design period. Some end users, highly motivated and experienced in their fields were selected as key informants to provide feedback and knowledge from their perspective. These inputs were essential to customize and fine-tune the software and the final solutions in order to better adapt to the need of Bahraini professionals.

 8. What were the most successful outputs and why was the initiative effective?
From the strategic and operative point of view several committees were created in order to follow the status of the deployment. At the highest level it was created a Steering committee composed by high representatives from the MoH and also from Indra. The follow-up was based on the agreed master plan. There was also a financial follow-up system to deal with budgeting and payment issues. From the results point of view a series of evaluation tools were put in place in order to ensure a proper follow-up: - Usage statistics. Data collected through I-SEHA allowed to review and draw conclusions on the usage of the system. The business intelligence system provided data on real time so the monitoring of the performance was done regularly and frequently. - Clinical data. Again, clinical data gathered, structured was regularly analysed, creating dozens of reports. - Qualitative analysis. A network of key informants (key users) was created so they could report regularly. Their feedback was very valuable since they provide qualitative information that, afterwards, was contrasted with quantitative data. - Satisfactory surveys. Hundreds of questionnaires were delivered on regular basis to monitor the satisfaction of health care providers about many issues: the usability, the speed, the quality of the training, etc. All inputs gathered from these methods were seriously taken into consideration and actions plans were designed and implemented accordingly.

 9. What were the main obstacles encountered and how were they overcome?
Health Information systems are not about technology. They are about equipping organizations to reach critical business objectives by providing people with technical capabilities that make new things possible and by engaging people in changing their behavior to effectively use the new capabilities to generate results. To overcome this it was necessary to implement three different and parallel strategies: - Create a network of key professionals (leaders in their fields, centers…) and communicate frequently and openly on the status of the project. - Create and implement a robust internal communication plan to empower the employees and ensure they carry a unified and coordinated message. Internal communications provided the critical data points needed - Outline the purpose and benefits of meaningful use. It was very important to find out what role each employee will play in attesting for meaningful use an to help nurses, physicians… to see the real and long-lasting impact (improving communication between clinicians, eliminating errors, removing redundancy, improving the quality of care your patients… The transition period was also a challenging issue. In such a huge and gradual deployment, we have encountered many situations in which both systems, the old and traditional one (paper) and the new one (electronic) live together in the same hospital, area… This have generated some difficulties and confusion which only could be solved with frequent training, constant communication and a strong support area (help desk) which was at the disposal of end users 24 h. x 24h. 365 days x year.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
• Help doctors to coordinate care and protect safety. For example, an EHR may also alert one doctors if another doctor has already prescribed a drug that did not work out for a patient, saving you from the risks and costs of taking ineffective medication. • Get the information accurately into the hands of people who need it. Coordinating information among care providers can be a daunting task, and one that can lead to medical mistakes if done incorrectly. When all providers can share your health information via EHRs, each of them has access to more accurate and up-to-date information about care. That enables providers to make the best possible decisions, particularly in a crisis. • Reduce paperwork. As more information gets added to the EHR, doctors will have more of that data available. This means fewer and shorter forms to complete, reducing the health care “hassle factor.” • As iSeha is a country-wide platform available at all healthcare providers, a patient can easily and instantly be referred to a specialist at another facility with all his information intact and accessible on real time. So the system warrantees the continuity of care Since the referral module was set up in primary care, around 3.500 people are being referred electronically by month. The referral system allows any physician from primary care centers to arrange an appointment for the patient to a specilialized care on the fly, so the patient can leave the primary care center with the appointment date in his/her hands. • Reduce unnecessary tests and procedures. Those tests may have been uncomfortable and inconvenient or have posed some risk, and they also cost money. With EHRs, all health centers can have access to all test results and records at once, reducing the potential for unnecessary repeat tests. • Generate hundreds of data per minute which are essential to support the decision making process. I-SEHA includes a business intelligence module and the reporting system which gathers and offers the requested information in a user-friendly manner. Regular reports on key indicators are generated such as length of stay, bed occupancy, number of inpatients, amongst many others. The reporting system can also monitor the performance of an area or physician considering the number of patients attended, prescriptions, referrals, requests etcetera. This reporting system is available in all health care centers. • Better decision making process: The knowledge generated from Big Data would help MoH leaders and policy-planners to better adjust policies, programs and strategies at short, mid and long-term. Now, for exemple, the MoH we can take wiser decisions on where to allocate human and material resources in the territory. Or, due to the availability of updated and reliable data on vaccination or morbidity rates, we are in the position of preparing more focused and efficient health prevention programs.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
I-SEHA is an avant-garde project in the Persian Gulf in terms of implementation and operation of an integral healthcare system. The Bahraini framework for I-SEHA could not be more positive. In the last few years, Bahrain has made a strong commitment for E-Government activities, using digital tools and systems to provide better public services to citizens and businesses. I-SEHA then fits in a more strategic long-term nationwide vision which, somehow, warrantees its financial and political support. Besides, the implementation of I-SEHA entails an important return of investment due to several financial savings: o From avoided tests and improved efficiencies o From filmless in radiology (approx. 250.000 Bahraini Dinar per year o From reduction in hospital length of stay as average o From clinical documentation and storage o From reallocating nursing time from manual documentation to direct care o From reduction of errors because of handwritten prescriptions o From reduction in serious medication errors o …. These savings would also contribute to the financial sustainability of I-SEHA at long term. While the potential for measurable cost savings are impressive, the real return on investment comes from the many intangible benefits that we cannot yet accurately measure and translate into monetary savings, e.g. better quality of care, improved patient safety, increased patient satisfaction… I-SEHA has improved the actual reimbursement system, minimizing the risk of mistakes since provides certain task automatization. To end this point it is important to highlight that I-SEHA includes funcionalities which may facilitate future integration –for both data and billing - with private hospital networks. And lastly, it is important to point out that the MoH will soon be able to perform real cost analysis versus budgeting approximation model being used nowadays thanks to statistical data analysis at the service of financial decision-making process.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
- Technology is a means, not a goal itself. While many organizations focus on complete installation of new technologies as a goal in itself, the MoH of Bahrain has always believed that this is a means to improve institution’s performance goals. - Planning and vendor selection. The selection of systems that will best meet the organization’s needs, defining the implementation strategy, and determining the speed or pace at which implementation will occur are key issues during the first stage. - Workflow design. This is a key issue since all Health Information systems must take into consideration changes in work process and routines, general inconveniences and time costs. - Training and user support. Experience has shown the importance of investing heavily in and requiring upfront training for all staff members in order to avoid negative impacts on workflow, costly setbacks, and productivity losses. - Change management strategy is very important since it helps the technological deployment process and minimizes the risk of resistances. - Health care professionals are the real value of health systems. Technology must never substitute human touch and professional criteria. In other words, computers should never be an obstacle to eye contact between patient and healthcare giver. - The commitment of professionals and stakeholders is absolutely essential to get satisfactory results from this process. And it takes time and several strategies. - It is a long and demanding process, full of obstacles and difficulties. So, more than ever, determination and a clear roadmap is essential to reach the end. - End users opinion must be taken seriously into consideration. They are those who will finally use the system and decide whether or not it is worth to embrace it. - The patient should not be left aside in the process. A continuous communication with them increases his/her satisfaction with the healthcare system and helps to recognize its value.

Contact Information

Institution Name:   Ministry of Health
Institution Type:   Government Agency  
Contact Person:   Isa Ajlan
Telephone/ Fax:  
Institution's / Project's Website:  
E-mail:   iajlan@health.gov.bh  
Postal Code:  

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