AL-Care Medical Information System: Developing Local Experience

Mukhtar S . A. AL-Hashimi, Ph.D. Bahrain Defence Force, Military HospitaWniversity of Bahrain

P.O. Box 33821, Isa Town, State of Bahrain

alhashmi@ batelco.com.bh Fax (973)- 644301

ABSTRACT

Medical Information Systems (MIS) are gaining acceptance in developed countries, and starting to difSuse in some developing countries, due to pressure exerted on improving the quality of health care for their societies, while containing health care cost on one side, and market pressure on the other side. The purpose of this paper is to report on the first Bahraini experience, with respect to medical information system and its implications on the medical practice in Bahrain Defence Force Hospital (State of the Arabian Guy), starting from the assessment methodologies, development and implementation strategy, user evaluation and return value. There are several reasons why the Bahraini experience is unique and different than that of the westem world, among these are - the assessment study, implementation strategy, training and support from both clinicians and management, in addition to the culture factors.

In summary, AL-Care is a fully in-house and ongoing MIS system, developed at the Military Hospital of Bahrain Defence Force with local expertise since 1993. The main objectives were to facilitate access to patient information through an on-line comprehensive centralized database, to provide clinical data for better patient management and resource utilization, to provide financial data for patient cost control, to provide statistical data for decision making and planning, and finally to establish a model to be followed in the Gulf region.

Amongst the patient care applications currently operational are the following:- comprehensive patient registration, patient clinical summaries, appointments and attendance, pre-admissions, admissions, patient bed transfers, patient meal order, automated patient file acquisition, patient discharges, bed utilization, new bom clinical and emergency modules, in addition to computerized pharmacy system and physician drug ordering.

Today, AL-Care is becoming the driving force fclr monitoring the utilization of services for each given medical specialty or medical unit as a “Costing Center”, resulting in a role model that will determine the hospital costing system, based on the “Costing Center” theory. Such a system will lead to an understanding of the average cost of the patient visit, and the cost of one night in the hospital for each clinical department, and ultimately the cost per diagnosis in a given hospital.

Introduction

The continuing increase in medical knowledge and information since 1940’s, has made it difficult for medical students and physicians alike, to learn and utilize this ever-increasing body of knowledge for better health care [l]. It has now become essential to find an efficient means to manage medical data and information, and retrieve it when necessary, to aid the health care providers in their duties. A Medical Information System (MIS) is a tool that has the potential of improving or achieving better quality of health care, while aiding in cost control.

The main advantages of the medical information system are the speeding up of communication, elimination or reduction of redundancy, minimization of the error rate in data entry by setting verification rules for the users at entry level, as well as organization of data to aid in the decision-making process regarding diagnosis and therap!,.

MIS is now gaining popularity world-wide, due to the increasing need to have quality health care for peoplc, at the same time containing health care cost and market pressure to a minimum[5-8]. Considerable interest h a been raised in the potential of MIS by health care authorities in developing countries, where some questions asked have been [9-111, “For what purpose, where, and how can a MIS be used in my medical environment?” As a result, many developing countries have found themselves

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facing a major challenge. The challenge here is to assess the appropriateness and the implications of technologies that are based on their needs and the environment. The aim of an effective technology assessment is to balance economic capabilities and human needs [12]. The subjective assessment approach is an expensive and time consuming approach. In this approach, a team (mostly from private consultancy companies and interest group) conducts a comprehensive on-site assessment of a country health care system, and determines the readiness of that country. This process must be repeated for each country on a case by case basis. Although this approach is widely used, it is limited by the knowledge and experience of the team involved, and subject to personal bias.

Based on an extensive search and review for a tool that can assess a country’s readiness for a MIS, it was concluded that there are no such tools in existence. This finding leads, in previous studies by the author, to examine the view of world health organizations with respect to medical informatics technology, and to develop a decision tool for assessing a country’s readiness to implement a medical information system. This decision tool generates scores for 165 countries, with respect to their readiness for a MIS by both the Binary and Offset Methods . In summary, Bahrain was found to be ready for the implementation of MIS by both the Binary and Offset methods. In another study by the author, the potential of medical informatics for the members of the Eastern Mediterranean Region of the World Health Organization was assessed.

The view of World Health Organization (WHO) concerning the implementation of medical informatics technology by a country, is based on the need to understand the medical informatics potential, the assessment of the appropriateness of selected modules, the establishment of a national informatics policy leading to a short term and long term strategy, as well as the establishment of training facilities.

Bahrain was selected as a case study, where preliminary findings suggested that Bahrain has the need for a MIS, the necessary infrastructure, government support, and most impmtantly, has the user acceptance to adopt this technology. In 1985, a decision was made by the Ministry of Health to purchase a ready-made MIS system to be implemented at another leading hospital (i.e., Salmaniya Medical Center), operating with a total capacity of 750 beds. Based on the above studies, a national medical information system was designed for Bahrain. To implement the MIS system, Bahrain Defence Force Hospital (BDF hospital), was selected to develop

MIS System, called AL-Care. Bahrain Defence Force Hospital has a bed capacity of 300, and is the second largest hospital in the country operated by the Defence Ministry.

The main mission of the BDF hospital is to provide health care services for the military and interior forces (i.e. both primary and secondary health care), emergency services for the public, specialized medical services for referral patients, government elite group, in addition to medical services for private patients for a minimum fee. Currently the clinical facilities within the BDF Hospital are the Accident and emergency unit, Primary health care unit, Dental clinics, Consultant clinics, Inpatient services, and the highly acclaimed Cardiac center. All Bahraini nationals and other residents are entitled to free health care services and treatment.

AL-Care Strategy:

The idea of computerization at BDF hospital started in the early 90’s. The leadership at the Bahrain Defence Force Hospital has been committed to the concept of using computers to improve the quality of health care for their patients. From the onset, a decision was made to introduce computerization in the hospital with the following design and development strategy-:

1) throughout the hospital. 2) To improve quality of patient care. 3) To have an on-line system functioning around the clock. 4) To develop the system on comprehensive centralized relational database management system. 5 ) To develop the system with local expertise. 6) To minimize development and operation cost (i.e. fractional). 7) To have user involvement at all levels of the development cycle through an open-door policy. 8) To train the potential users before and after implementation. 9) To establish an MIS model that can be

followed at the national level and regional levels.

To improve access to patient information

In summary, the AL-Care system provides the user with a system that will incorporate data, information and knowledge, leading to the best quality patient care,

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proper management, and optimization of resources, which can lead to cost containment.

AL-Care System

The major computerized systems implemented at the BDF Hospital are AL-Care, Medical information system, Personnel system, Inventory management system, Accounting system, Budget allocation and monitoring system, Pharmacy system, and Document retrieval system. However, AL-Care is the largest computerized project and an on-going one, where a comprehensive on-line hospital management system, linking the vital areas of a hospital via a network of workstations, provides instant information for smooth and easy operation. In order to move towards the concept of a paperless hospital that would involve the health care provider directly with the system, a decision was made recently to apply this concept, to both the General Practitioner and Outpatient Consultant clinics.

&-Care is designed to help and assist hospital personnel in their duties by enabling instant information flow, providing financial, statistical, and clinical data for better planning, storing and retrieving data for better patient care, reporting, processing and updating patient information, and helping the hospital to cut down operational costs via various cost saving schemes. Amongst the patient care applications that are currently operational are the following:-

Comprehensive patient registration module is based on a unique national identifier, that eliminates duplication of patient numbers that are assigned to each patient with a validity date. One unique feature is the classification of patients based on the entitlement scheme, that gives different levels of medical coverage within the hospital based on a mathematical matrix.

Patient clinical profile module is designed with the aim to give the health-care provider with a quick snap- shot of the patient clinical status. This module contains the following components for a given patient, namely, clinical base parameters, allergy details, given blood transfusions, drugs given from a different source of encounters, family history details, existing disabilities, existing chronic diseases, surgery details and vaccination details.

Appointment module comprises of the appointments for the medical staff, private practice, and medical support facilities such as Laboratory, Physiotherapy and

Radiology. Each appointment is linked to the actuial attendance of the patient on the specific appointment date.

Pre-admissions module is the reservation of admissions for a future date, initiated at the Consultant clinic, along with suggested procedures and activities to be performed prior to the actual admission. This module triggers a requisition of the patient file upon admission confirmation, that results in the patient reporting directly to the wards.

Admission module encompasses all other types d admissions that are not scheduled, such as direct and emergency admissions. During admissions, the patieint bed in the required ward is put on hold, and confirmed on arrival of the patient in the ward.

Automated patient file acquisition module is based on existing patient appointments for a given clinic. This process is initiated by a request at the clinics, and results in either files being issued, or put on hold or not being issued if they are in use at other clinics. The key feature of this module is the ease of monitoring the movement of patient files within the clinics, till the return of those files at the end of the day.

New born clinical module is designed to give thie medical staff the complete history of both the mother and father, together with the current details of the new-born. The key components of this module are the mother profile, obstetrics history, present pregnancy details, father profile, baby profile, staff profile and the first weekly follow-up details. Another important feature here is the automatic registration of the new-born.

AL-Care is noted for the unique features that it incorporates, such as the use of the national unique identifier, the entitlement code associated with a service, the family service number assigned to a patient, an automated suggested discharge date computed during the admission process, patient cost control, the validity check on a patient file, an inexpensive development scheme, the very first national experience gained in MIS, and finally, system ownership and independence.

The training strategy used for AL-Care is unique i n that it is divided into two phases. The first phase is calletd “Prior to System Development and Design”, where a in- house training center was established with the objectives of providing the potential staff with the following:-

1) Training of hospital staff on basic computer skills.

2) Explaining the hospital long-term and short- term vision with respect to AL-Care system.

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3) Introducing the concept of medical informatics relevant to each medical practice.

4) Supporting the hospital staff in their need for a computer training program.

5 ) Preparing the staff psychologically for the new change (i.e. computerization of the hospital for the transition period).

The second phase is called “Post systedxnodule implementation”. In this phase, an overall presentation of the module objective and the return values are explained to the users, while training them on modules related to their work. Persons are assigned from the development team with teaching skills to train the user, thereby acting as application manager, and providing on-line and hot- line support. Finally, as part of the training objective, the hospital helps the staff in the process of selecting their home computer for personal usage.

End User Evaluation

Since all systems are designed for end-user needs, they must be evaluated from time to time. The evaluation can play an important part in the future direction of the organization, with respect to computerization. The AL-Care system and the supporting team were subjected to evaluation by the user on April, 1996. An evaluation survey was designed and distributed on a random sample of seventy seven clinical users of the system. Some of the findings indicate that the majority of the nurses thought that the training was competent (n=67, 87%). As for the level of support that the computer

department staff provide to end-users, the majority (n=63, 82%) thought that end user support was adequate. The majority of the nurses prefer computers over the manual system (n=52, 68%). Sixty six nurses (86%) feel that the bar code scanners that automate some user entry functions are helpful. The findings of this survey were considered positive, given that the entire computer department staff comprises nine persons, including the software and hardware support team. Table No. 1 shows some of the user evaluation for the programs currently used by their department, and the level of ease that each user associates with an application.

Table No. 2 shows the level of importance that the nurses attach to the computerization of some of the daily tasks performed by them. The Table takes into consideration the fact that 80% or more was the selection criteria for making decisions regarding which module to be computerized next. On an average, the computerization of nursing documentation received a score of 58%, the patient clinical information received a score of 68%, patient’s drug order received a score of 28%, lab order and results retrieval received a score of 71%, and patient file acquisition a score of 80%.

Computerization Impact on the Orga Computerization has made significant impact on

the hospital operations, ranging from cost awareness to proper utilization of resources at different levels of management, resulting in the following factors:

Table 1 .: Nursing Attitudes Toward Some of AL-Care Applications.

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No. 1. Nursing Documentation

2. Patient Clinical Information

3. Patient Drug’s Order

4.

How Important to Computerize the:

n=6 1

n=7 1

n=69 Lab order and Results Retrieval

n=69

n=70 5. Patient File Acquisition

1) Improved access to patient care information. 2) Enforcement of standards and policies. 3) Re-engineering the process and better work flow. 4) Optimization of resources. 5) Better data for decision-making which is made on the basis of data provided by the system. 6) More control on admission, bed utilization, patient care activity, and patient stay at the hospital. 7) More control and savings on drugs issued

from the pharmacy.

100% 80% 60% 40% 20% 0% 44 14 10 1 8 23

51 17 7 4 6 15

19 9 9 3 4 16

51 20 14 3 0 12

60 20 7 3 3 7

AL-Care can now be considered a role model, that bases the hospital costing system on the “Costing Center” theory, where Patient and Services are the main entities. Patients reside at the clinical department for treatment, while all necessary services are applied or requested from other departments. During admission, the patient is assigned to a clinical department. Each clinical department is interrelated with other existing departments directly or indirectly, through ordering or utilizing services. Logically, all patient’s direct and indirect expenses should be passed and charged to the clinical department, leading to accumulative costing of all charges at the clinical department, where the patient is admitted. Relating the expenditure to the patient statistics, we can obtain the average cost of the patient visit, and the cost of one night’s stay at the hospital for each clinical department, and ultimately the cost per diagnosis. One of the important features of AL-Care is determining the discharge date at the admission time, on the basis of primary diagnosis or revised diagnosis. Here every diagnosis has an average length of stay for BDF hospital,

calculated from the AL-Care database. With this feature, the hospital can monitor the appropriateness of admission for each inpatient.

Conclusion

AL-Care system has contributed to the hospit a1 mission in providing a high quality health care system, while containing health care cost, by facilitating access to patient information through an on-line comprehensive centralized database, providing clinical data for better patient management and resource utilization, providing financial data for “Patient Cost Control”, providing statistical data for decision making and planning and finally, establishing a role model to be followed in the region.

There are many return values associated with in- house development such as, the ownership of the system design and source code, the designing of a system without compromising the user needs and which is specific to the hospital needs, gaining valuable experience and saving costs, and finally supporting government efforts iin

training local manpower. Future work will continue {to concentrate towards the concept of a paperless hospital, through a comprehensive “Patient Care System” that includes all clinical, administrative and financial components.

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