primary healthcare full solution
ministry of health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Bahrain’s healthcare system is a source of pride. Through the 28 health centres, one main hospital and four peripheral hospitals serviced by over 5,000 health professionals; the more than 1.3 million citizens and residents enjoy universal access to healthcare through a large range of services. The Kingdom of Bahrain is considered one of the leading countries in the implementation of cutting edge information technologies for the modernization of infrastructures. It holds the third position in Asia in e-Government, thirteenth worldwide and the tenth among free market economy countries. Before 2011 the presence of Health Information systems implemented in Bahrain was very limited and usually related to administrative work. There was barely any clinical management through electronic services. In spite of the quality of health care services and the experience of health professionals, there was an important room for improvement and efficiency to be covered with health information systems. Some of the most important problems that required new tools and innovative processes to solve them were: • Communication between health professionals was slow due to manual data transcriptions and physical file transfer between hospitals and health units, and within the health unit itself. Papers used to get lost or damaged, with no back up; and access to the patient record was not readily available. • No tools were implemented to maintain and control the performance of health professionals and ensure the adherence to universal medical standards and guidelines. This caused confusion within the versatile population of the Kingdom of Bahrain, which is a homogeneous mixture of multinational citizens and residents. Multiple visits to one complaints office to the other, and paper work which dragged on for years because of the inefficiency of information dissemination and lack of continuity of care. • Patient security and privacy of documentation (health record) was non-existent, especially in a closed-knit community like the one in the Kingdom of Bahrain where connections to each other are less than six degrees of separation. So having medical files transported by porters, especially containing sensitive information like sexual abuse or cases of HIV meant unwanted exposure. This fact used to discourage patients from discussing sensitive medical cases with their health professionals. • Considering the widespread chronic disease of Sickle Cell in Bahrain, narcotic medication doses administration used to get out of hand. Patients used to go from one health unit to the other to receive doses of Morphine without accurate documentation or communication between health professionals. Additionally, human mistakes like unclear hand writing and errors in documentation caused incorrect decision making which contributed in an increased population of Sickle Cell Disease patients who are addicted to narcotic medications. • No global coding for diseases and/or diagnoses, since each physician comes from a different background and studied medicine in a different country. A unified and global catalogue was not implemented on the level of the Ministry of Health in the Kingdom of Bahrain. • Increased costs due to repetition of unnecessary investigations like lab and radiology tests, which is due to miscommunication and undocumented information. This used to cost the MoH millions of Dinars.

B. Strategic Approach

 2. What was the solution?
For the intelligent, passionate and energetic Bahraini youth empowering the wheels of change in this small yet powerful Kingdom, a change needed to be made. Fully understanding the impact of a change of this magnitude, a step by step plan was devised strategically with the support of the highest ranking management bodies, together with carefully selected healthcare professionals to implement the National Healthcare System I-SEHA. The MoH in the Kingdom of Bahrain decided that the problems faced were standing in the way of economic and technological progress, especially since the Kingdom aims to achieve a unique vision of stipulating the universal availability of healthcare. Therefore, within the scope of the National Healthcare Information System (I-SEHA) which was implemented by the leading Information Systems Spanish company INDRA, is overcoming obstacles one by one through the Primary Care full solution initiative: • Enable continuity of care: integration between all Primary care health units (Clinics/ Health Centres) and on a bigger scale with secondary care hospitals. This integration provides a secure and unique patient electronic health record which is shared between all health professionals who participate in the patient’s episode, providing them with all the necessary information anywhere / any time. • Unique Electronic Health Record, the patient as centre of the solution: since any health unit is comprised of specific and specialized sections, each one providing a distinctive service to the patient, a strong mode of communication and summarization is critical. This project includes modules which assemble perfectly to best serve all patients throughout the treatment duration. • Moving from Centralized Repository to MoH Data Warehouse: At first, different departments of the MoH came together and agreed that all the content gathered by the Primary Care full solution should be in one single, centralized and standards-based repository. But while the patient level care information the clinical data repository provides is important, MoH teams ambitioned a better solution that would provide a single source of truth across the entire health system: a Healthcare related Enterprise Data Warehouse. By nature of its design, the entire organization would have access to the knowledge they need. By pulling all of this data into a single source of organizational truth, analysts could provide reliable and repeatable reports.

 3. How did the initiative solve the problem and improve people’s lives?
The first and most important problem solved by the Primary Care solution of I-SEHA was the lack of communication and collaboration between healthcare professionals. Currently, a patient who visits a specific family physician can continue his or her care plan homogeneously with any other family physician with neither loss of medical information nor dependability on physical file transfer. Waiting time has drastically improved, and the implementation of a focused standard of medical practice and global guidelines for niches of patients proved to yield positive results for the well-being of the population in the Kingdom of Bahrain. Additionally, the structured approach of dividing patients among physicians, and implementing audit trails which were not possible without I-SEHA, reaped substantial benefits to the overall management of the MoH, and ultimately to all citizens and residents. Among the tools which are being utilized is assigning each healthcare professional with a unique username (linked to the national Identification Document). This means that all medical actions are documented and can be traced in cases of malpractice. Furthermore, strict constraints are put in place for all health professionals in terms of what they can and cannot do. Authorized access is granted to specific professionals and rights to add, modify and delete any piece of data from the patient’s electronic health record are granted based on the policies of the MoH. Besides normal EHR data access controls, special tools are available for physicians to lock any piece of information in order to protect and ensure patients’ privacy. Perhaps the most significant and measurable advantage is the ability to document, track and control administered doses of medications through the fully integrated prescription and dispensation system within all health centres and hospitals of the Kingdom of Bahrain. Patients now have a single electronic health record with all details related to medications received like the dose, frequency and route; as well as a timestamp of receiving the dose and names of both the requesting and administering professionals. Physicians have access to cutting edge technology which contains tools to enhance decision making, like the availability of focused alerts for allergies, pregnancies, chronic diseases, including specific alerts for cases of contraindications and interactions. This is strongly contributing to reducing human mistakes and ultimately enhancing the well-being of patients of all ages and backgrounds. Moreover, having a standardized set of diagnoses (globally used and supported by the World Health Organization) enables physicians to provide the most suitable personalized care plan based on universal health standards. This also acts as powerful mean of statistical reporting and in turn facilitates decision making; and ensures that all people in the kingdom of Bahrain receive the same treatment with no bias towards a specific type of patients or another. Provide a health care system which is not based on social class, race, colour, wealth age or gender. I-SEHA’s Primary Care solution provides a modern, intelligent and integrated healthcare system. It is more than a mere paperless/filmless project and integrates clinical and administrative solution for primary health care. The system warrantees the continuity of care. All data is stored in the paperless primary care system. The system also covers all medical requests (laboratory, radiology, medical prescriptions, vaccines and medical orders) through an electronic and dynamic flow. Everything is linked in a workflow with the support of a secured database, so there is no need to carry physical patient files, radiology images, or lab results. Audience will be the general public (all Bahraini and non-Bahraini people) and the MoH employees.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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
 6. How was the strategy implemented and what resources were mobilized?
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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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.

 8. What were the most successful outputs and why was the initiative effective?
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.

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
• Help doctors to coordinate care and improve patients’ safety. For example, an EHR may also alert one doctor if another doctor has already prescribed a drug that did not work out for a patient, saving you from the risks and costs of taking ineffective medication. • Get the information accurately into the hands of people who need it. Coordinating information among care providers can be a daunting task, and one that can lead to medical mistakes if done incorrectly. When all providers can share your health information via EHRs, each of them has access to more accurate and up-to-date information about care. That enables providers to make the best possible decisions, particularly in a crisis. • Reduce paperwork. As more information gets added to the Electronic Health Record, doctors will have more of that data available. This means fewer and shorter forms to complete, reducing the health care “hassle factor.” • As primary care solution is a country-wide platform available at all healthcare providers, a patient can easily and instantly be referred to a specialist at another facility with all his/her information intact and accessible on real time. So the system warrantees the continuity of care since the referral module was set up in primary care. More than 3,500 people are being referred electronically per month. The referral system allows any physician from primary care centers to arrange an appointment for the patient to a specialized care on the fly, so the patient can leave the Health center with the appointment date in his/her hands. • Reduce unnecessary tests and procedures. Those tests may have been uncomfortable and inconvenient or have posed some risk, and they also cost a lot of money. With Electronic Health Records, all health centers can have access to all test results and records at once, reducing the potential for unnecessary repeat tests. • Generate hundreds of data per minute which are essential to support the decision making process. The system includes a business intelligence module and the reporting system which gathers and offers the requested information in a user-friendly manner. Regular reports on key indicators are generated such as length of stay, bed occupancy, and number of inpatients amongst many others. The reporting system can also monitor the performance of an area or physician considering the number of patients attended, prescriptions, referrals, requests etcetera. This reporting system is available in all health care centers. • Better decision making process. The knowledge generated from Big Data helps MoH leaders and policy-planners to better adjust policies, programs and strategies at short, mid and long-term. Now, for example, the MoH can take wiser decisions on where to allocate human and material resources in the territory. Or, due to the availability of updated and reliable data on vaccination or morbidity rates, we are in the position of preparing more focused and efficient health prevention programs

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
• Due to having a unique username and password linked to the national ID of all healthcare professionals in I-SEHA, all actions are documented and flagged with a timestamp which facilitates tracking of all actions and changes. Medical mistakes can be identified, and health professionals held accountable for any cases of malpractice. • Availability of controls which reduce misuse of the services provided. For example, a sick leave medical report can be issued only once per day. Another example is controlling drug abuse by both healthcare professionals and patients through a sophisticated inventory system. A third example is setting a specific duration during which duplicated lab tests are rejected, which increases efficiency, reduces redundant costs for the MoH and prevents exposing patients to unnecessary painful procedures. • According to the regulations of the government in the Kingdom of Bahrain, non-Bahraini patients who have no sponsorships are required to pay a small fee for consultations. The implementation of I-SEHA in Primary Care health facilities ensured that no physician would be able to start any medical actions for patients before those patients payed the consultation amount, which significantly reduced exploitation of the services provided by the MoH to non-Bahraini patients. • Since each physician in Primary Care has a specific number of patients assigned to him/her per day in I-SEHA, patients’ rights of being treated is ensured by giving each patient the appropriate duration which is suitable for the service provided or type of consultation given. On the other hand, this increased the commitment of physicians, making them more accountable for the list of patients who they have assigned. The impact of these initiatives is being measured through: • Tracing problems or medical mistakes, and trying to both predict and avoid them before they occur, especially ones of a sensitive medico-legal nature. Monthly and timely statistical reports and setting a workload for each physician and health unit are main contributors in this case. • Having the flow of cash from healthcare units compared to the number of paying patients, and deducting the refund amounts electronically and easily (through the Invoice and Billing module in I-SEHA) proved to be strong weapons in the fight against fraud. • Pharmacy inventory systems implemented via I-SEHA in Primary Care centres and clinics allow comprehensive audit trails in order to identify any exploitation by healthcare professionals.

 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 MoH provides a high quality antenatal and postnatal healthcare information system implemented in all Primary Care units, and especially through the Mother and Child clinics, to ensure equally fair rights of treatment for all patients regardless of age, gender, colour, social status or wealth. Physicians are empowered with standardized protocols and a strong decisions support system in I-SEHA, which enables swift referrals to more expert units of care in cases of high pregnancy complications. Also, having a protocol system in I-SEHA means that all women are given the best possible care both during and after pregnancy. These specialized clinics also cover a broad range of women related problems like breast cancer screening and premarital compatibility screening. Furthermore, a powerful childcare vaccination structure is put in place in all Primary Care health units. The tools provided by I-SEHA facilitate the continuity of the same vaccination schedule throughout the child’s developmental age: from 2 months up to 6 years; allowing healthcare professionals to get the full picture of the vaccination status at a glance. Also, physicians and nurses can link and unlink patients to vaccinations schedules based on the specific nature of the patient’s medical status.

Contact Information

Institution Name:   ministry of health
Institution Type:   Ministry  
Contact Person:   isa ajlan
Title:   computer systems analyst  
Telephone/ Fax:   +973 36333605
Institution's / Project's Website:  
E-mail:   iajlan@health.gov.bh  
Address:  
Postal Code:   p.o box 12
City:   manama
State/Province:   manama
Country:  

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