4. In which ways is the initiative creative and innovative?
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The project has brought to light to Bahrain’s healthcare professionals the huge amount of clinical data that is available and how difficult it is for clinicians to find answers to clinical questions.
Electronic health records (EHRs) are used increasingly to assist clinicians in this process; however, resistance to the implementation of technology-assisted care is not uncommon and has certainly been a constant in this project. To overcome this resistance, the implementation team has used the diffusion of innovation (and provided key users with suggestions for applying these concepts) to enhance the implementation of an EHR that can support evidence-based practice. Other innovative aspects:
• A 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.
• Protocols for each chronic case which needs follow up and investigation like Diabetes Sickle Cell disease and child screening.
• Dental map that covers all needs of dentists and hygienists with customized indicators for diagnosing each tooth and adding specific “status of treatment “and procedures.
• Online system to handle some of the most significant care services personally like: booking online appointment, re-scheduling appointment, cancelling appointment and view personal information.
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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 Kingdom of Bahrain has implemented a series of social, political and economic initiatives to improve the quality of life for all Bahraini nationals and residents. Enhancing the health sector in the Kingdom was one of the government priorities to ensure a quick, easy and equitable access to high quality healthcare to all Bahrain’s residence.
MoH plays a major role towards achieving the Kingdom vision of 2030 by tackling the challenges and ensuring the resource utilization optimization in addition to the enhancements and protection of the population health. Accordingly, MoH’s strategy for the coming ten years is focused on ensuring a sustainable system towards a healthier Bahrain and to position the Kingdom as a leading centre of modern medicine.
Based on this strategical road map, MoH decided to implement a National Health Information System I-SEHA. And Primary Care full solution project is part of that. MoH entrusted INDRA with the implementation of this information system.
INDRA is a global company of technology, innovation, and talent, leader in high value-added solutions and services. INDRA Health Care Solutions are shared among 32 million people, 5.600 hospital and healthcare centres around the world.
INDRA strategy is to provide a new global healthcare system model focused on citizens and based on criteria of accessibility, clinical safety, sustainability and interoperability, where: Citizens not only interact with their healthcare records, but become the focus of the healthcare system. Information is available where and when it is needed, with no geographical boundaries. Professionals receive the information they need at any given moment.
The solution and it’s wide range of different specialized clinics through the 29 health centres is serviced by more than 5,000 health professionals and to more than 1.3 million citizens and residents who enjoy universal access to healthcare through a large range of services
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6. How was the strategy implemented and what resources were mobilized?
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Primary care 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 MoH. 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 Primary care solution. 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 the project 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 primary care system by enhancing the system interface and make it more friendly, include new features that facilitate the usage of 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).
Primary Care deployment was made gradually. Phase one of the deployment was first piloted in September 2012 which included the following modules: Scheduling and appointments, Radiology and Electronic Health Records. The pilot period was 4 months in one health centre, and this period proved to be of critical importance to detect any gap and to validate the workflow while using the system.
After stabilizing the system and all major issues reported by the users were solved, the rollout among all health centres started in January 2013 and took 4 months for scheduling and appointments and 6 months for Electronic Health and Radiology. During this period a huge effort was devoted for the implementation to succeed in this deployment.
After the successful deployment of the first phase, the project started phase two which is the full solution deployment which included: lab request, invoice and billing, prescription and part of specialized clinics. This phase was piloted for four months before rolling out in the remaining health centres which took place in March 2015. The deployment completed successfully in all PC HCs after 6 months.
The third and last phase was to deploy the remaining specialized clinics and workflows such as Dental and vaccination modules. Finally, the deployment criteria was carefully chosen in order to minimize a negative impact of the system substitution.
In order to facilitate Primary Care full solution deployment, a Helpdesk system was put in place to offer support to all users, including infrastructure elements. This helpdesk is playing a key role for the success of the project, since it provides a wide variety of services such as preventive activities, maintenance, monitoring, channelling complaints and suggestions and troubleshooting assistance.
This assistance, is offered through a hotline and email available 24 hours a day, 7 days a week in both Arabic and English languages. The helpdesk is a dedicated team of more than 50 experienced specialists divided into 7 teams, who provide continuous support to the project.
The full amount of the project was funded by the Government for the span of the project.
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7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The Health Information Directorate (HID) from the MoH of 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 primary care solution and were categorized 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. They were the clinical team and the super users (Doctors and Nurses) chosen from different health centres.
Key Users: Opinion leaders with 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. Each module and area has a specialized key user which is the focal point of contact for any issue regarding the system.
End Users: They were the healthcare givers, clerks, pharmacists, radiologists...who use the system to process transactions and extract data. Users were trained in the use of the new system and involved in the later stages of the implementation.
Integration with other governmental entities: Primary Care full solution optimizes the usage of the existing information technology in the other Government Organizations such as Government Data Network, Financial Management Information System (FMIS), and Human Resource Information System (HoRISon). Also, to achieve the integrity of the governmental system, integration between those systems and Primary care system is taken into account.
All implemented application is adhered to National Data Services (NDS) guidelines in sharing data taking in consideration the patient medical record privacy and confidentiality.
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8. What were the most successful outputs and why was the initiative effective?
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The most successful outputs of I-SEHA in Primary Care health centres include gaining the Canadian Accreditation from one of the most prestigious health organizations in the world: Health Standards Organization (HSO). This places Bahrain at the top ranks in terms of health information quality, ensuring that all residents enjoy the best possible treatment plan, adhering to international medical standards.
Additionally, having a unified EHR which is shared between all health professionals in Bahrain guarantees the smooth flow and enhanced exchange of patient medical information within both primary and specialized points of care. This is playing an essential role in improving the continuity of care in a technologically secure environment. Besides that, the system contains highly specialized medical guidelines for all health professionals, ensuring compliance with the highest quality global standards. Some of these standards include the WHO vaccination schedules, antenatal, diabetes and other chronic diseases.
Since the implementation of I-SEHA inventory system within the Primary Care health centres, better management of stock movement in and out of health centres is clearly evident. Costs of purchasing and re-purchasing medications dropped substantially, enabling management to track and fine tune the process in an effective manner.
Furthermore, using less and less papers in daily transactions strongly contributes to the shared world-wide effort which aims to conserve the environment and fight global warming.
In terms of efficiency, Primary Care solution in I-SEHA places more focus on the quality element rather than the technological one, incorporating careful strategical planning towards implementation methodologies. Strong leadership, support and commitment from top management within the MoH added to the successful transition throughout the phases of the project. Participation of highly motivated and experienced Bahraini healthcare professionals in the design period proved to be a key element in customizing and fine-tuning the software and final solutions.
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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 and by engaging them in changing their behaviour to effectively use the new capabilities to generate results.
Primary Care full solution project managers encountered several challenges during the different implementation phases, but the main ones were:
The transition period (moving from paper records to electronic): In such a huge and gradual deployment, and the complexity of having interconnected health centres many situations were encountered in which both systems, the old traditional one (paper) and the new one (electronic) exist together in the same hospital, area.
User’s resistance to change:
• Create a network of key professionals (leaders in their fields, centres…) 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 important to find out what role each employee would play in attesting for meaningful use and 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).
Additionally, project managers designated a change management team, who made a great effort to ensure that all the users were ready to accept and make good use of the system before each deployment started.
Also, to overcome the typical difficulties of this type of projects and to avoid possible confusion among healthcare employees, frequent awareness and training activities were carried out. Constant communication and a strong support area were a priority, so end users also have a helpdesk at their disposal 24x7x365.
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