| 4. In which ways is the initiative creative and innovative?
Initially, a Steering Committee was established to examine the scope of the issues and to look at options. Led by a senior cardiologist, the committee soon realized that if their proposed solution merely addressed the immediate issues, it would only serve as a “band-aid”, and not provide a lasting remedy. It also became clear to this group that the fully integrated, enterprise wide solution they sought did not exist.
The Steering Committee undertook a complete review and inventory of every piece of equipment, software and interface that existed in relation to cardiovascular patient care. All of the data generated, be it on tape or film or paper was chronicled. Over the years as technology advanced new machines and ever more sophisticated software to support data collection was developed. As a growing cardiac specialty center, King Faisal Specialist Hospital acquired the most up-to-date technology. During this time of acquisition the technology to integrate the ever-growing array of possible imagery was not yet developed. As a consequence the Heart Centre had no less than nine separate software solutions supported by five different vendors running on myriad machines in over fifteen departments managed by hundreds of staff.
Additionally, each of these interventions required a work flow process to be initiated. For example an outpatient echo required an appointment to be generated, a scheduled spot in the queue to be assigned, an order for the exam, the exam to be assigned to a specialist for review after the technologist collected the images and a report on the findings to be generated. Behind the scenes, utilization and financial data were often collected to assist managers in examination of current care patterns and planning for future initiatives
Based on this review a strategy and roadmap was brought to senior leaders in the hospital and it received generous support.
In early 2008 a Request for Proposal was drafted and vendors were invited to partner with King Faisal Specialist Hospital to create this flagship solution.
By the fall of 2008 the proposal had been awarded and a Project Team was formed, made up of hospital employees and experts from a private company specializing in project management.
This team outlined every stage of the project; defining the scope, tasks, milestones, schedules, budgets, communication plans and purchase of hardware. This included an assessment of the underlying infrastructure of network switches, fibre optic cables, additional hardware and main servers which would be essential to support the new, more robust system.
A high level project chronology follows:
October – December 2008: Phase One
• Review project charter, resource availability, project risks and measures of success
• Architectural sign-off, review bill of materials compared against architectural design and purchased products.
• Align goals for kick off with resources needed, gain stakeholder feedback and requirements for following hospital guidelines
• Build copy of test and production environment on new hardware
• Migrate and upgrade all software to new hardware and latest software versions
• Install all new software components
• Validate functionality
• Workflow, inventory and integration assessments
December 2008 – February 2009: Phase Two
• Implement and configure clinical interfaces (field and interface customization and validation of transaction)
• Implement and configure scheduling application
March 2009 – August 2009
• Implement and configure cath structured reporting
• Implement and configure CardioChart portal integration with Cerner and Philips echo structured reporting and Apollo clinical module
• Implement and configure results reporting interface
• Implement and configure auto-distribution of reports
• Implement EP and Cardiac Surgery Structured reporting
September 2009 – November 2009
• Implement and configure bi-directional integration with Oracle Material Management
• Supply list import, balance notification and usage
• Implement and configure billing integration, outbound export
• Implement and configure CardioManager analytics application
| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The success of this project was underpinned by a resolute commitment of the senior leadership team at King Faisal Specialist Hospital. In partnering with the AlFaisaliah Medical Sytems, the hospital was able to leverage in-house knowledge of and investment in existing products and software solutions.
Along with these private sector supports the Project Team devised a detailed and comprehensive road-map to facilitate a successful outcome. Ultimately the success relied on the dedication and perseverance of multiple teams at King Faisal Specialist Hospital including the business and finance department, Health Information Technology Affairs department, project managers, researchers, education and development staff and the entire team of the Heart Centre including staff from:
• Adult Cardiology Outpatient Clinic
• Pediatric Cardiology Outpatient Clinic
• Non Invasive Cardiology Lab
• Interventional Cardiac Catheterization Lab
• Cardiovascular Surgery Operating Rooms
• Cardiac Surgery Intensive Care Units – Adults & Pediatrics
• Cardiovascular Step Down Unit
• Coronary Care Unit
• Cardiovascular Telemetry Unit
• Cardiac Holding Unit
• General Cardiology Ward
• Physicians’ Administrative Offices
• Perfusion Services
An initial and important milestone in this project was the branding of it. At the outset the project was referred to as the “Enterprise Wide Cardiac Information System & Cardiac Picture Archiving and Communication System”. After several iterations, the name “HeartNet” was coined and an appropriate logo sought. That name and logo have since come to be broadly used and recognized as an example of a successful solution for organizing multiple cardiac imaging solutions into one efficient and accessible framework.
| 6. How was the strategy implemented and what resources were mobilized?
The proposed enterprise-wide solution presented to the Executive Committee had a projected cost of more than triple the initial planned investment in the “band-aid” solution which would have served only the cath lab.
With the support of senior leaders a budget was established to support the human resources and capital expenditure required to ensure successful completion.
Specific resources were identified and rather than add-on to staff workload, key project leaders were appointed into full time roles to support the implementation. These full time roles were bolstered by many part time positions as well.
The private medical system companies we partnered with were also committed to the success of this landmark initiative and contributed effort and support commensurate with achieving that end.
As with any large project, there were multiple costs beyond the investment of operational and capital expenditures. During implementation there were naturally some delays in work-flow resulting in a decreased ability to accommodate typical service volume levels. At peak times, patient demand required an increase in personnel to meet the needs. The dedication of the HeartNet team required many long hours of overtime to complete the work at key stages of implementation. The contributions of these individuals has been recognized through conventional remuneration of overtime hours and more publically at awards and recognition ceremonies celebrating the achievements of the program both in-hospital and externally.
| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The most distinctive and valuable output from this initiative is the availability and accessibility of crucial patient information at times where critical decisions are made. As an example, recently a patient’s condition deteriorated precipitously while he was a patient on the inpatient unit. While the cardiology staff cared for his immediate needs an opinion was sought from the cardiac surgeon and from the interventional cardiologist. Each of these specialists was engaged in complex procedures with other patients in two separate operating areas at the time. Because of HeartNet they were each able to access images from their separate locations. HeartNet provided detailed information regarding the patient’s previous known cardiac anomalies, the surgical and interventional procedures which the patient had previously undergone, the most recent images of angiography, echocardiography and electrophysiology along with the current physiologic findings from the inpatient medical record in a real time format. This allowed these specialists to make an informed and immediate determination on the best course of action to save the patient’s life.
HeartNet has had a positive and significant impact on King Faisal Specialist Hospital’s ability to foster an infrastructure which supports teaching within the organization, within the region and even internationally. Students, mentors and instructors are able to review unique and complex images from terminals anywhere in the hospital. Images are readily available to educators and researchers who are able to share key findings with specialists from around the world. Recently a live transmission of a world’s first implantation of a large aortic valve was broadcast with the support of the infrastructure developed by the HeartNet team.
The HeartNet system has created a complete loop of information sharing which supports not only the patients currently being served by the system but also facilitates the careful stewardship of resources for planning future health care delivery through monitoring of financial and utilization information.
Perhaps one of the most satisfying outputs has been the sense of collegiality and shared accomplishment that comes from successfully implementing a system across so many areas and connecting so many care givers with so much meaningful information. For the clinicians at King Faisal Specialist Hospital the sense of shared accomplishment in achieving their mission to provide the best care for the patients and families they serve is very satisfying.
| 8. What were the most successful outputs and why was the initiative effective?
During roll out of the system the HeartNet team undertook continuous evaluations of the level of proficiency demonstrated by the new users of the system and were immediately responsive to areas where further training was indicated or a need for review was expressed.
The Project Team met weekly to assess the status of current activities, project milestones, project issues and identify risks. The status reports generated by these weekly meetings were summarized and shared with the Steering Committee who met monthly and on an ad hoc basis. The Executive Committee was provided with updates quarterly and when key milestones were met.
On an ongoing basis the project managers monitored and tracked the progress of the plan within the intended timeline and tailored solutions to keep the project on track. Where additional resources were required, the Project Team liaised with the Steering and Executive Committees to secure additional resources and maintain the momentum of the project.
The timeliness of reports generated from the system remains a key performance indicator of routine documentation reviews. Before the advent of HeartNet the turn-around time for getting reports of images into the system could stretch into many days as it involved having the specialist dictate a report which a secretarial pool subsequently translated, typed and printed into a paper copy for the patients’ chart. Now, the specialist enters the report directly into the system and within minutes the analysis of the diagnostic test is part of the patient’s medical record.
This project continues to have the in-house support of a project manager who monitors the upgrades, provides education for new personnel and trouble shoots any issues which arise.
| 9. What were the main obstacles encountered and how were they overcome?
One of the most challenging aspects of this endeavour was to convince stakeholders to embrace a really revolutionary concept. It required a certain leap of faith to believe in an idea which was essentially just a vision of what “could” be. We were fortunate to have the support of a visionary administrative team who backed the idea from the outset. By supporting the project with a dedicated Project Team it reduced the burden on bedside clinicians.
Change is always difficult and this proposal required significant changes in work flow, in the way tests and appointments were entered into the system, in learning new applications and how to enter data. The Project Team was responsive to this and tailored fields in the reporting system to meet the preferences of the individual caregivers wherever possible.
For the change agents who spearheaded this initiative a thick skin was sometimes required, and they admitted to having doubts along the way. Negativity was neutralized by showing fruit early and targeting frustrating areas of bottlenecks at the outset.
The lead cardiologist on the Project Team describes a critical period about 6 months into the project:
“We were faced with a fair bit of resistance, especially in the beginning. One day, the system crashed and for about 6 hours we couldn’t enter or retrieve data. We had been proactive in contingency planning and were to revert to the old manual system in the event of downtime. I expected to face humiliation from some of the more vocal resistors and a backlash of negativity and hostility. Instead the response was “when can we get the system back?” After only 6 months they were completely converted and reliant on the improved system. There was no desire to revert to the old ways. It was vindication and very satisfying.”