HeartNet
King Faisal Specialist Hospital & Research Centre

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In 1976 Saudi Arabia became the world’s largest oil producer. The ensuing development of public service infrastructure which accompanied the rise in economic growth brought with it a sea change in major components of the foundations of social service. Delivery of specialized health care was no exception to this phenomenon. Riyadh, the capital city of Saudi Arabia is home to some 6 million people and King Faisal Specialist Hospital & Research Centre is a leading provider of advanced cardiovascular care with a catchment area extending well beyond the city limits and indeed to all regions of the country. It is somewhat paradoxical that the combination of new technology and historical, even ancient customs brought about the crisis which this initiative addressed. Saudi Arabia has a rich history of well-established and time honoured social traditions. Unfortunately, some of these traditions, particularly marriage within family circles, contribute to higher rates of Rheumatic Heart Disease and Congenital Heart Defects due to homosanguinity. These are conditions for which there are very often life-long consequences and patients who suffer from these cardiac anomalies routinely undergo myriad medical procedures throughout the course of their lives; from the first hours after birth until well into their sixth and seventh decades of life. As the increasing wealth of the kingdom allowed for unprecedented growth in the hospital sector, health care providers found themselves able to extend coverage to previously underserviced minority populations. Increasingly this population of non-urban and Bedouin people were coming to Riyadh for advanced cardiovascular care. As the numbers of patients served increased so too did the volume of data generated by complex diagnostic and interventional procedures. By 2007 it became clear that the technology supporting the collection and dissemination of this data was failing. Up until that time, as each new technology was introduced a different method of data collection, storage and retrieval accompanied the technology. An Echocardiogram was stored on a hard cassette and housed in the Echo lab. A coronary angiogram was stored on unique disc and housed in the Cath Lab. Electrocardiograms were produced on paper records, radiographic or nuclear medicine diagnostic on another unique software. There was no integration of the information, access was isolated and scattered, multiple and duplicitous manual data entries were required for each patient and for the clinician it was increasingly difficult to collect the complete spectrum of information required for appropriate diagnosis and treatment. All of the essential tests could be performed but the total picture was not readily available. The cardiac surgeon undertaking open heart surgery on a 2000gm neonate needs to have the most complete set of diagnostic images to ensure success. Later, when that child returns as a toddler, as a youth and as an adolescent, the serial images from ultrasonic echocardiography, angiograms and electrophysiology are critical to diagnose the severity of the ongoing condition and undertake effective therapy.

B. Strategic Approach

 2. What was the solution?
The central strategy for this initiative was aimed at correcting more than just the immediately identified problem of storage. Coronary angiography is the gold standard in determining the patency of coronary blood vessels. Similarly echocardiography images are vital to determining the health and function of the cardiac valves, many of which are compromised in the course of advancing rheumatic heart disease. These and other exam results were scattered around the organization, in various geographic locations; requiring the disc or tape or piece of paper to be manually retrieved from the specialty area or viewed only in that area. No one piece of information could safely be ignored. And none of the information was integrated. An obvious solution would have been to simply extend the storage capacity or purchase a new system with more storage capacity but those overly simplistic solutions would not have solved the problems of scattered data and inaccessibility of centralized, coordinated information. The design of this solution was beautifully aligned with meeting both the current and anticipated future patient demand as well as the strategic priorities of the organization. Through a series of informal information-gathering meetings aimed at examining the issues the scope of the problem and magnitude of the ideal solution became clear. After a careful review with members of the cardiology, information services and technological staff, one of the senior cardiologists proposed a visionary solution. He imagined a system where all the data would be available in any clinical area at any time. He proposed a robust umbrella software application with enough memory and future capacity as well as enough flexibility to integrate as many as nine disparate systems. The vision included archiving historic patient data, some of it going back more than 20 years, and an expansion of system functionality to include financial, staffing, inventory and workload utilization analysis. Additionally, the design included billing system features and a report writing mechanism so expert analysis and interpretation of the images would be available immediately to anyone authorized to access the system. The strategy for implementing this daunting and unprecedented solution would involve hundreds of staff from many different departments and would take years to complete. This senior cardiologist founded a Steering Committee and crafted the initial project initiative which received generous endorsement from the Executive Committee and the CEO. During the strategy development and project implementation the Steering Committee met regularly to guide the process, monitor progress and oversee key elements of the project. A working Project Team was also formed, drawn in part from the care-givers who would ultimately be the end users of the system and the most direct interface between the people served and the service system. This team formed the backbone of the implementation of this landmark system and is responsible for the success it now enjoys.

 3. How did the initiative solve the problem and improve people’s lives?
One of the hallmarks of a truly innovative initiative is that it looks beyond the ordinary to the very limits of what is possible. The ability to look beyond the immediate situation, and to dream of solutions not yet realized elsewhere is remarkably creative. At that time the gold standards in medical technology involved very specialized systems built in a vertical dimension. Silos of advanced imaging existed for each specialty (angiography, echocardiography, etc.) but it was not a priority for vendors to create effective integration between the systems. This solution owes its success, in part to the fact that the genesis of it came from the bedside and was informed by a clinician with an intimate and deep knowledge of what both the patient and clinician needed to make the best decisions for quality outcomes. There was no model to copy. There was no similar system in place to imitate. This notion of having vast amounts of data available at point of care to physicians, nurses, researchers, technicians, managers and patients was completely novel at the time.

C. Execution and Implementation

 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.”

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
For physicians, nurses, technologists and anyone involved in patient care, the major advantage is having the electronic patient record available and loaded with all the cardiac investigations that the patient has ever had. It would be difficult to overstate the impact of this benefit. A clinician could be in his or her office, in the Emergency room, in the Operating room, a remote clinic, or at home and have access. In fact, while maintaining safeguards and patient confidentiality an authorized clinician can have full and immediate access to the HeartNet and all of the patient’s important data from any web-enabled location in the world. Obviously for the clinician this is convenient and efficient. It allows for better, more informed decision making. As a professional there is significant satisfaction in being able to examine all the information and make the most informed decision for your patient. For the patient, not only did this mean that their hospital experience was more efficient, more easily navigated and less onerous in terms of travelling with CDs and tapes and files from place to place, but it could easily mean a difference of life and death. The conditions our cardiac patients suffer from are complex and lifelong. It is critical that the entire history is understood and that the anatomy of heart valves, muscles, vessels and electrical impulses is fully appreciated prior to making a final decision on the best option for care. King Faisal Specialist Hospital now holds one of the richest databases of digitized cardiovascular images in the world. It is a significant resource for researchers and clinicians alike. This solution provided a complete loop of the patient care record, from the archived reports of previous visits, surgeries and procedures, to electronic scheduling of cardiology investigations, up to the minute vital signs and laboratory results with copies of the reports and images available immediately. In addition, online management reports, health care provider productivity reports, revenue reports, stock, supply and device usage reports allow for enhanced decision making in delivery of efficient patient care. This realized efficiency has allowed for increased capacity to serve larger numbers of the public. The impact and improvement in delivery of services has been profound. Previously populations in underserviced and remote regions could be faced with a days long journey to obtain specialized cardiovascular care. Now they can be monitored remotely from their home villages. Cardiologists in outlying centers can be provided with comprehensive reports and images or may seek informed second opinions from specialists through HeartNet connectivity. These advances also led to an increase in patient satisfaction and an increase in clinician satisfaction. The chances for error were reduced both because of the elimination of manual entry of name and medical record number and because decision making could be based on complete information. Additionally cost savings were realized as unnecessary duplication of investigations decreased. Volumes of inpatient and outpatient service levels are routinely monitored as are wait-times for appointments and patient satisfaction scores. These measures confirm the claims made here. HeartNet allows for exciting applications in terms of education and research as well. It has the capability to join existing registries by pooling data from the system with a simple design. For example at the moment data is collected in concert with the European Association for Cardiothoracic Surgery, the Society of Thoracic Surgeons and the American College of Cardiology. Anonymized data for groups of patients, procedures or outcomes is of particular interest to researchers and is easily collected using this powerful tool.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The HeartNet solution is supported by ongoing upgrades and contract-ensured vendor support. The organization budgets a generous depreciation allowance for software applications. This, in addition to the administrative commitment to protect the HeartNet support staff, ensures sustainability in terms of ongoing system maintenance and future development opportunities. New staff are routinely provided with training and coaching from the HeartNet staff along with troubleshooting whenever it is required. The design of the system and intentionally comprehensive work flow patterns ensure that a level of efficiency and integrity is sustained in the delivery of care. For instance, an order must be entered into the system and the concomitant prerequisites of the procedure initiated before the device or machine will even activate. It is not possible to subvert the logical and safe progression of care as built into the design. This sequencing has been integrated into the daily work flow and contributes to the sustainability of the initiative. At presentations in hospital, in the region and internationally, King Faisal Specialist Hospital has showcased the implementation, success and ongoing benefits of the HeartNet solution. The Ministry of Health, in consultation with King Faisal Heart Centre, is working to extend the reach and capabilities of HeartNet to other centers around the kingdom. The Jeddah site of King Faisal has already implemented this solution which allows for seamless coverage of King Faisal patients across the kingdom. A further initiative is underway to align other referring hospitals to the HeartNet technology which will allow specialists at King Faisal Specialist Hospital to access up to date cardiac images from other centers and offer second opinions and treatment options to patients at remote sites. While the system is delivering everything it was designed and intended to do, there are ongoing plans to further expand and tailor the solution to create individual dashboards which will enable users to quickly analyze data relevant to their practice or department and further aid in delivery of top quality care to the public we serve.

 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 population of Saudi Arabia who are affected by congenital and chronic cardiac conditions require long term and life-long care to achieve optimal quality of life. The solution to managing and accessing critical data regarding their condition also required a long term solution. At the outset, options were available which would merely plug an immediate gap. A certain amount of courage and vision was required to think beyond replacing what was broken and move towards what was perhaps possible. The key learning here for all involved was about vision. Imagining what can be done and putting in place the resources to effect meaningful and long-lasting change is worth the effort. The old adage of “if it is worth doing it is worth doing right” applies. Once the vision was adopted and the magnitude of the project scope revealed, dedicated teams were established to assure success. This was not a project which could have succeeded as an add-on. It required strategy and dedicated project management. It is possible to overcome the anxiety practitioners experience when losing an old system. It is possible to overcome the lingering doubts dwelling in the hearts and minds of anyone who has been promised a technological solution only to watch in frustration as it fails to deliver and creates more work and problem than ever it hoped to solve. In fact it became clear it was easier to adapt the technology to the practice than it was to have the people adapt to the prospect of new technology. The key to effectively dealing with these fears and anxieties is to adopt a position of enlightened understanding and respectful enquiry. By involving the specialists who would become the end users at every step of the process and by listening to their concerns and tailoring solutions to meet their needs an environment of positive collegiality was fostered. The specialists at every level were united in their compulsion to deliver the best and most efficient care for patients and in this unity a shared drive to succeed was forged.

Contact Information

Institution Name:   King Faisal Specialist Hospital & Research Centre
Institution Type:   Government Agency  
Contact Person:   Majid AlFayyadh
Title:   Dr.  
Telephone/ Fax:   +966114423921
Institution's / Project's Website:  
E-mail:   mfayyadh@kfshrc.edu.sa  
Address:   PO Box
Postal Code:   11211
City:   Riyadh
State/Province:   RIYADH
Country:  

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