Digital Pen
Ministry of Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In masses gatherings of people from all around the world, the chances of bringing infectious illnesses and spreading it or even emerging new strains of viruses and illnesses is always a potential nightmare. For healthcare leaders in charge of monitoring such masses wellbeing the responsibility is humongous and the mistakes are devastating. Early detection is necessary, and having the right tool is essential. There was a serious need to launch a modern, simple, and yet cost effective initiative that would provide a tool for electronically capturing healthcare statistics of masses healthcare services provided, in order to facilitate early detection of disaster trends and help healthcare leaders real-time monitoring that allows them to act immediately on any intervention needed for assuring prevention of disasters & infectious out-breaks spreading. Major Problems: Before the initiative; masses healthcare statistics where labor intensive, inaccurate and retrospective. Conducted months after the event could only be of help for future planning, while impossible to be of value for real-time management. Social Groups Affected: • The masses of people requiring optimal healthcare services during masses gatherings (pilgrimage). • Masses Healthcare leaders requiring accurate real-time statistics for immediate decision making during masses gatherings. Description: Saudi Arabia is the country hosting Hajj, a mass gathering in which 1.6 billion Muslims (about 23.4% of the world population) has to come at least once in a lifetime to perform Pilgrimage to Mecca (hajj). Each year more than three millions pilgrims comes for a few days to perform Hajj. For this huge yearly event, all governmental sectors are top alerted, and kept at their full capacity to provide the best service possible for the pilgrim guests. Ministry of Health is one of these sectors involved in such service. It has major burdens during the Hajj season: where it has the duty & commitment to provide the pilgrims with the best health care facilities, services, & medications. The Ministry has to mobilize resources to deal with the increased high-load associated with the busy Hajj period, to keep alert to combats any health disaster: such as infectious outbreaks, fire, natural disasters. Continuous monitoring & statistical analysis is essential for Planning and management of Hajj health services. Using HIS (classical Hospital Information System data entry approach) in tents and mobile hospitals is not practical; similarly building hospitals to be operated only for few weeks, a year is not cost effective. Till Hajj 1432 (Nov 2011), Patient encounter records were done the classical way using ordinary paper.. (Patient info: Gender, Nationality, doctor diagnosis, treatment plan, & medication prescriptions ,etc). Retrospective Statistical analysis was done few months later: where data entry clerks would enter manually all the papers fields into computerized system over the next 2-3 months where this data would be summarized and reported through a Business Intelligence system to helps in decision making for the NEXT year. Such process was very labor-intensive. Associated with high rate of data entry errors, and producing late statistical tools that helps decision maker not real time but for future seasons.

B. Strategic Approach

 2. What was the solution?
Strategy: A consultancy research was initiated in order to search for a new approach that would provide more user-friendly, less labor intensive, more real-time methodology that would help in collecting data and represent it to healthcare decision makers in Hajj season right on the spot. The Saudi Ministry of Health and its Consultants headed by Innovative Technology Est, had entertained the consideration of several alternative options of modern technologies. That research concluded in that using Hospital Information System classical data entry methods (keyboard + PC + LED monitors, or even laptops) at the point of care in tents and mobile hospitals was thought to be not practical, while using innovative modern tablets or digital pen and paper might be a more preferred practical alternative. The feasibility of the digital pen and paper technology was proposed as a better alternative to tablets since it was expected to has the advantage of overcoming change management (training curve would be easier since it resembles the old classical paper approach) During the patient encounter the doctor /or any service provider would simply write on a form of what seems to be an ordinary paper for the users, but actually those papers has a unique dot pattern printed on its background that facilitate stroke capture by a miniature camera embedded in the digital pen behind the ink cartridge. By performing what is considered to be a natural straight forward writing process, data is simultaneously captured by the digital pen, recording the exact stroke shape and location, with time stamps associated with pen strokes. Doctor (or any health service provider) fills the digital paper using the digital pen, in a process similar to what they use to do with ordinary paper. Camera of Anoto Pen: captures handwriting on digital paper Digital Paper having Digital Pattern for identification of exact location of scriptures As the digital pen is put in its docking station, data transfers automatically from the pen to a remote server, through a USB server device, without the need for a computer beside the pen. Data uploaded in a structured format to the digital pen server, would be processed and then sent to the data repository, from which business intelligence software would start to build statistical data graphical presentation from the accumulation of data collected from several hospitals or primary care centers. A friendly graphical user interface was developed to provide healthcare managers and decision makers a handy multi-touch interactive dashboard to view cumulative patient data.

 3. How did the initiative solve the problem and improve people’s lives?
Digital pen and paper application in health services is not new but applying it in mass health services situation as a technology that produce maximal quick automation requiring minimal end-user training coupled with spontaneous reporting that monitors masses health and alert healthcare leaders for potential disasters is innovative.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The digital paper forms were designed based on the old ordinary legacy papers, but the new designs took in consideration the requirements of the digital pen technology, in the new e-forms the change was approximately 10-20 % when compared to the legacy paper forms. Initial proof of concept was conducted on five Medical Centers on the first year (2012), followed by expanding the process to incorporate two major hospitals in addition to the first five medical centers (2013), aiming at reaching twenty five medical centers and twelve hospitals involved in Hajj Mass Healthcare services on (2014). Initially regular PCs was used for transferring date from USB cradle of the digital pens, later on PCs were replaced by USB Servers, cutting down significantly on the cost and making it very simple and cost effective to implement. As receptionist, doctors, nurses, and pharmacists interact with patients, they reflect their patient encounters on the e paper forms, upon docking the digital pen to a USB server, data is spontaneously synched to a virtual PC on a remote server. Data gathered from two field hospitals and five primary care centers, was processed in our business intelligence software server. After which collected data was converted into meaningful graphs that summarizes Key Performance Indicators and presented to healthcare leaders and decision makers through an interactive dashboard on a 150-inch interactive multi-touch screen in the health command center. Similar dashboard would also be available on mobile web-based multi-touch tablet devices for those top healthcare leaders.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Interdisciplinary focus groups were conducted at each site to evaluate user’s utilization including physicians, nurses, pharmacists, and receptionists. Business Process maps were generated using Visagi reflecting different roles and all actors involved. Feedback from all stakeholders was elicited. And based on such analysis and feedback modification of implementation strategy was applied to enhance the functionality. For example, User feedback was employed to identify the best location for the pens and for the docking stations; in reception area, doctor’s rooms, nurses’ observation rooms, dressing rooms, pharmacy booths, & wherever a service provider exists. The proposed pen location was consistent across sites. Similar user feedback was used to modify paper forms structure for future use.
 6. How was the strategy implemented and what resources were mobilized?
Human Resources: - Ministry of Health Planners - Ministry of Health IT Teams - Digital Pen Domain Experts IT Personnel - Ministry of Health Service Providers including Doctors, Nurses, Pharmacists & Receptionists Technical Resources: • Creating a Special Datacenter that guarantee availability and security • Hardware: Digital Pens, Docking Stations, USB Servers. • Specialized Software Solution: Applications that collect data from e-Papers & eventually presented as KPIs for Health Leaders. • Specialized Dashboard Applications that allow healthcare leaders to monitor the data collected from multiple healthcare centers. Supplies Resources: - Digital Papers Financial Resources: The Project was financed by the Ministry of Health; Finance was utilized to cover research and development, hardware requirements, consumable supplies, and Human Resources mentioned above.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
1. Simple User Friendly data capture requiring no training and no users’ change management: The digital pen and paper technology provided a feasible user friendly solution for capturing patient-doctor encounter data in Mass-health care situation. 2. High Service Providers’ Satisfaction Rate: The technology was associated with improved satisfaction of end- users performing data collection (Doctors, Nurses, Receptionists, and Pharmacists). 3. Complete Patient Service Cycle: Usability of the digital pen was significantly improved through pre-implementation workflow process evaluation and mapping (e.g. linking digital pen forms to cover the whole cycle, starting from the reception of the patient, the doctor patient encounter, the nursing observation and dressing, the pharmacist delivery of prescribed medications, till discharge). 4. High Healthcare Leaders Satisfaction Rate: The technology was associated with improved satisfaction of healthcare decision makers, since it had allowed them to make right-on- time decisions based on real accurate statistical data. 5. Immediate Response of Healthcare Leaders to Potential Threats: (this is the most valuable outcome of this initiative): This innovative approach provided a real-time monitoring facility that allows healthcare decision makers to act immediately on any intervention needed for assuring prevention of disasters and combating infectious out-breaks spreading .

 8. What were the most successful outputs and why was the initiative effective?
In such masses gatherings of people from all around the world, the chances of bringing infectious illnesses and spreading it or even emerging new strains of viruses and illnesses is always a potential nightmare. For healthcare leaders in charge of monitoring such masses wellbeing the responsibility is humongous and the mistakes are devastating. Early detection is necessary, and having the right tool is essential. With an interactive dashboard on a 150-inch interactive multi-touch screen in the command center, coupled with mobile web-based multi-touch tablet devices, the health care leaders were able to monitor the Key Performance Indicators generated from our business intelligence software server gathered from two field hospitals and five primary care centers on a real-time basis. Drill down functionality allowed them to zoom on any area of suspected concern, and enquire more and send field teams for further actions. Examples of KPIs presented on command control dashboards Guarding against out-breaks: - Census of Patients given care - Diagnosis of Patients serviced - Body systems affected by diseases diagnosed. - Geographical Distribution of patients seen across medical centers Measuring Quality of Service - Patient Queue Time from Reception to Doctor - Patient Queue Time from Doctor to Pharmacist - Patient Queue Time from Doctor to Dressing / Observation. - Patient Discharge Status Measuring Productivity Rate - Service provider availability - Service Center Census compare to other centers - Service center census over 24 hours

 9. What were the main obstacles encountered and how were they overcome?
1. No Major obstacles apart from working at a time constraints: Although the planning had been given excellent attention, the only obstacle was related to routine logistic processes that had delayed the award of project budget. In order to avoid any delays, extraordinary cooperative efforts from Ministry of Health personnel and other parties had to be activated in order to overcome the high pressure of importing certain equipment and printing the digital forms in a relatively short period. 1. highly stressful, highly demanding situation of Mass Health services. 2. Almost no learning curve is needed for a

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
1. Fast automation of health services in chieving this automation. 2. Highly accurate real-time statistical analysis delivered to healthcare leaders for real-time decision making. 3. High satisfaction rate at all levels of stakeholders starting from onsite service providers, right to the top of the pyramid of healthcare leaders and decision makers.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
This initiative value stems out of two key aspects 1- Being the first large scale application of Digital Pen and Paper Technology for supporting masses healthcare situations (in this case the Hajj to Makkah) 2- Being a successful experiment that is highly transferable and replicable. It can be replicated anywhere across the globe where masses healthcare situation exists.

 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)
The digital pen and paper technology is unmatched with regard to staff acceptance, with almost no learning curve needed for users to adopt it. The integration into existing workflow processes was so smooth since it has utilized the previously used processes almost with no change. Although the change management was negligible from the perspective of the users, yet the return of investment was humongous from the perspective of the value added to the health care leaders and decision makers. Cost was significantly reduced by utilizing USB servers, eliminating the need for personal computers or laptops beside every pen device In addition, continued work is needed to maximize data acquisition accuracy resulting from occasional users not filling some data fields. Application of such technology was a great success and excellent return of investment to support Masses healthcare services, lessons learned from this experience can be replicable for other mass healthcare gatherings across the globe.

Contact Information

Institution Name:   Ministry of Health
Institution Type:   Government Agency  
Contact Person:   Walaa Khayyat
Title:   Business Development  
Telephone/ Fax:   +966112124679
Institution's / Project's Website:  
E-mail:   wkhayyat@moh.gov.sa  
Address:  
Postal Code:   11176
City:   Riyadh
State/Province:  
Country:  

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