| 4. In which ways is the initiative creative and innovative?
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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.
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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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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.
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| 6. How was the strategy implemented and what resources were mobilized?
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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.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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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.
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| 8. What were the most successful outputs and why was the initiative effective?
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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.
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| 9. What were the main obstacles encountered and how were they overcome?
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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.
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