E-Referral (Ministry of Health (MoH) - Oman) Mr. Abdullah Al Raqadi, DG of Information Technology I. Background information The problem of manual Medical Records is quite complex. Each patient has multiple files as there are no centralised records, a visit to a different health-care facilities will result in a new file being created for the same patient. It was very difficult to get the complete information about a particular patient s medical history. As such medical professionals have to depend on asking the patient during treatment and consultation. These steps are usually not effective as most patients do not give an accurate feedback and follow up treatment can be laborious. It resulted in the increased in the cost of treatment due to duplicate diagnoses and medication. It is also time consuming for the medical staff (Doctors, Nurses and other paramedical staff) to trace and piece the information of the patient as there are many versions of the statistical and administrative reports. There was no way for auditing and tracing these reports as there was a lack of raw data available for due to significant number of lost files and duplications as a result of manual record keeping. The process of Referral for specialized treatment or referral of investigations between the Primary Health Care (PHC) to Secondary and or Tertiary Care is a complex process. Not only is the referral takes a long time to process, there is no feedback or acknowledgment if the referral documentation reach the intended referred institution. Even though the documentation for referral was produced from the computer systems, the process was completed manually. Fax machine or the normal mail system was used to deliver this documentation. The referral documentation was not standardized and for the investigation referral, important information like the laboratory tests name and range were also not standardized. The minimum time for a referral to be processed was 3 days and there were no means to manage and control the Referral Process. II. Goals & timeframe The main objectives of introducing ICT to health care services through developing an e-health application (Al-Shifa) are to enhance the quality of health services and make them more accessible to the public. H.E the Minister of Health emphasized that when introducing ICT to health care, it should be done in a way to improve the quality, reduce cost, eliminate duplication, and collect quality data. 1
The strategies used to implement the initiative are: Roll-out New health institutions built will be equipped with Al-Shifa. Each year, existing institutions without Al-Shifa will be scheduled into the roll-out plan. Currently, 80% of all the Government health-care institution in the sultanate are already utilising Al Shifa. Integration with the current system - The main strategy is not to let the user felt that it is another new system as it is human tendency to be less responsive to change. As Al Shifa HIS (Hospital Information System) is already implemented in most healthcare institutions belonging to the Ministry of Health, it was easy to include system like the e-referral application as an add-on component on each installation. Using e-referral as an example, a central Engine will route the referrals to desired destination at the same time building the necessary information for the central management and local management at each institution. The objectives of this initiative were to: 1) Create transparency in the Referral Process, so it can be properly manage and audit. 2) Reduce drastically the process time 3) Eliminate error prone manual data entry Training In parallel to the roll-out of Al Shifa, key personnel from different institutions are also trained on the system. So far more than 20,000 staff are trained. The IT Support includes the non-stop operation (hardware, software and network) of these systems in healthcare institutions, end-users support within each healthcare institutions and training for new staff. The IT Support is organized as follow: o The First line of support is provided by regional staff for Primary Healthcare Care IT support available in each region and each Regional and Tertiary hospital has its own IT Support Staff. o The Second line of Support is provided by the Directorate General of Information Technology from the Ministry s HQ, where there are specialized IT staff such as Database Administrators, Network engineers, software specialists, ect.. Through time, the e-health application (Al-Shifa) has allowed for accountability, transparency, and has reduced the time needed to provide care for patients. The plan that was adopted to achieve these objectives was based on understanding the users needs, learning from past experience, and resource allocation and dedication of staff. The history of computerization in the Ministry of Health started in 1987 at Royal Hospital, Sultanate of Oman. The Ministry of Health (MOH) created a specialized and dedicated Unit for IT called Computer Department in 1990. In 1992, a committee of clinicians, health administrators, IT personnel and other medical staff was created with a mission to define a computerization strategy of MOH institutions. The committee recommendation was to develop an in-house hospital information system based on 2
the needs and requirement of Oman. In November 1997, His Excellency the Minister of Health approved a pilot project in a small health center and gave a go-ahead to implement the system in all health centers and started building a comprehensive system for hospitals. The strategy adopted then was to equip each newly build health institution with computerization and every year some old institutions will be selected for computerization. After the initial computerisation of the various healthcare institutions, the Ministry of Health in Oman collaborated with WHO consultants and mapped out strategies to meet the needs of healthcare in Oman while reducing maintenance costs, and in 1996 the initiative was started and funds were allocated. Continuous effort was put in for developing the system, in 2007, the e-referral Engine was developed started operation by 2009 the application was installed in all healthcare institutions of the Ministry of Health III. Project s added value and importance The e-health application, called Al-Shifa, is an in-house system designed and owned by MOH. It is designed with the consultation and collaboration between the in-house developers, the end-users (medical staff) and adapting practices of other renowned medical facilities in the world to suit the operational environment of Oman. The system maintains an audit trail that records the previous information prior to making any changes, the details of the changes made, and the details of the user that made the changes and the date and time of the changes. As the patients data cannot be lost and presented to medical professionals in a more suitable format, there is tremendous gain in time to understand the patient s health situation and provide appropriate treatment. This resulted in 60 % of time saving in tracing the personnel who last treated the patient for clarification and follow-up. The system complies with international standards and consideration of interoperability is thought through during the design and development phases. These made Al Shifa highly scalable, some of the services that were integrated in the system are: SMS and e-mail services Patients are informed and reminded about their appointment in the health care institutions. Appointment management Appointments and schedule of the patients are now handled by the system. User-defined search - It provides comprehensive and on-line inquiry reports based on the userdefined search criteria. Al Shifa retrieves and displays only the relevant information that can be viewed from any workstation within the healthcare institution with adequate profile security. 3
Automated Laboratory and Radiology Equipment Interfacing - Diagnostic test result are fed to the system automatically, that reduces the human data entry error and saving technicians time by 70%. Billing module The Billing module calculates fees and treatment cost, business rules are inbuilt to the system to handle exceptions like birth spacing, immunization. All treatments for Omani, GCC nationals and expatriates working for the Omani Government are provided free of charge. Drug expiry management Al Shifa will alert the relevant personnel on stock level of medication two months before the expiry date, so the excess quantity can be shared by other institutions. This results in lowering the cost of holding too much excess stocks and most importantly, ensures that the level of stock are healthy and will not go into a situation of shortages. e-referral Engine - It involves first the streamlining of the Referral Process itself, deciding on the clinical documentation standard for referral for treatment and adopting standard for the investigation including, the name, code of investigation and the ranges and a decision to adopt SNOMED as a standard coding for Investigation. There are three immediate benefits to the e-referral Engine: 1) The speed of processing the referral what used to take 3 days now takes seconds to process 2) The automated sending of feedback and 3) The Central and local management at each healthcare institution of the referral process IV. Challenges: Initially, the main obstacle was changing the pen-and-paper culture that existed for years at the health care institutions in Oman. The management faced, and continues to face, the problem of changing user s mindsets, especially those from older staff who were not exposed to ICT in their field of work. In addition, the management needed to get the buy-in of the user and convince them of the benefits of the application as well as achieving user acceptance. Initial teething problems during the migration of the old system to the new system were met with resistance and the lack of knowledge of using the new system made the user reluctant to change. In brief the change management was the major obstacle. These obstacles and challenges were overcome, eventually, through constant and consistent senior management support, user involvement and extensive staff training. This has lead to the e-health application becoming an integral part of providing health services to the public, to which the users contribute generously with their knowledge in their field and input for improvements. 4
Due to the nature of staff continuously turn-over in the health care institutions, requirements and needs also changed, training is an ongoing process alongside with it, feedback and comments from the users are taken into consideration in the further development, enhancement and implementation process. Besides, training, regular meetings are held with users of different levels in order to come to gather new user requirements and feedback on the components of the application. The trainers are chosen carefully, and further training is given to them to take up the challenging job of training users. In terms of technical obstacles, the management and development team faced the problems of cost accumulation, and Windows clustering for running the application on a Windows NT platform Therefore, there was a re-direction to port the application on Redhat Linux platform, which is easily managed. Redhat Linux was found to be better in terms of clustering, minimal maintenance, and easy access to resources and support from the Internet. V. Relevance of the project to the respective Action Line E-referral system promotes collaborative between medical centers, health professionals and patients at the first level. The system improved and extends health care and health information systems in the sultanate through saving all information of the patients and saving time. The system complies with international standards. Conclusion A well planned introduction of Health Information Technology (HIT) in healthcare institutions pays. The initiative is successful; the healthcare institutions can hardly operate appropriately without it. It has created transparency in the processes of healthcare delivery system where duplication and inefficiency can be removed in order to improve the healthcare itself and at the same time contain the cost. 5