SIGMA2012 Symposium on IT Governance, Management, and Audit.

College of IT, Universiti Tenaga Nasional, Malaysia

2012

A study on the challenges of Jordan public health care governance: A case study in implementing HAKEEM
Dua A. Nassar Department of Information System Universiti Tenaga Nasional 43000 Kajang, Selangor, Malaysia Nassar_doua@yahoo.com Dr. Marini Othman Department of Information System Universiti Tenaga Nasional 43000, Kajang, Selangor, Malaysia marini@uniten.edu.my

Hasniza Yahya Department of Information System Universiti Tenaga Nasional 43000 Kajang, Selangor, Malaysia yhasniza@uniten.edu.my

Abstract Electronic Health Record (EHR) is a digital health record of a patient which contains information such as medical history, medications, allergies, radiology images, and billing information. This system allows sharing of patient information across different health information systems. Today, many countries have adopted EHR due to its ability to provide better service to its customers. One of the countries is Jordan. The EHR in Jordan called Hakeem holds great promise to improve the Jordanian health care system. However, implementing Hakeem has a lot of issue and challenge. Based on interviews and literature review, this paper highlights the challenges and proposes recommendations to overcome the challenges. Keywords E-healthcare; EHR; EMR; Hakeem

As such, this paper will discuss several guidelines to overcome these challenges in Hakeem implementation and proposes ways to govern, and manage these challenges. There are two objectives in this paper. The first objective is to look at EHR in general in terms of definitions, types and benefits, then look at EHR specifically in Hakeem project in terms of issues and challenges faced by the project. The data is collected through interview, other research on EHR, and observation. The second objective of this research is to provide a guideline and recommendations to overcome these challenges. OVERVIEW OF HAKEEM PROJECT Hakeem is an Arabic word which means a doctor in English. The project is a comprehensive open source health information system and EHR system known as VistA, which was deployed and implemented by the US Department of Veterans Affairs. Many countries have already used VistA and customize it according to their needs. [10] The idea of Hakeem was first proposed by the late King of Jordan, King Hussien Bin Talal. He had encouraged the government to intensify the quality of work in the health sector. He beliefs that The human is the most valuable thing we have. His son, King Abdullah Bin Al Hussien, who become a King after his death, also has the same belief as his father. In 2009, Hakeem started as a pilot project which includes one hospital and one Comprehensive Health Center; under the supervision of an electronic health services company. This company holds a partnership between the Kingdom's main healthcare stakeholders: the Ministry of Health, Ministry of Information and Communication Technology, Royal Medical Services, King Hussein Cancer Center, King Hussein Institute For Cancer and Biotechnology, the Royal Health Awareness Society, and The Private Hospitals Association [11]. After the success of the pilot project, King Abdullah announced that Hakeem project will be implemented in all public hospitals in 2010. The main objective of Hakeem was to improve quality of patient care and safety.

INTRODUCTION For several years, Electronic Health Record (EHR) System has a great potential in the developing countries [1]. EHR is a repository for all patient electronic health information. It has several types such as Primary Patient Record (PPR), Secondary Patient Record, Consolidated Health Record (CHR), Shared EHR, and Virtual EHR [14]. The use of EHR may provides many benefits to people, society, and country. Recently, many countries have adopted EHR to improve the quality of their service, decrease the medical errors, improve patient care and safety by accessing accurate information at anytime, improve the operational and office efficiency without having to repeat processes such as information gathering, testing, or conducting interviews, reduce costs, and improve communications between specialist [2,3,4,5]. In the middle east, Jordan is one of the countries that has an advanced health care system. Over the years, it has been working to expand and improve its health care services and patient care. In 2010, Hakeem project (EHR) has been launched as the first national E-health initiative in Jordan. This project was started by the Electronic Health Solution Company, which is a non-profit, integrated from different public and private health providers. Although EHR has been implemented in many countries including Jordan, the implementation of EHR still face many challenges. The most difficult challenge was in terms of poor usability because the system was neither easy to use nor learn. It does not help in making the work easier either [1,2, 6,7,8,9].

SIGMA2012 Symposium on IT Governance, Management, and Audit. College of IT, Universiti Tenaga Nasional, Malaysia

2012

A. Hakeem Phases In 2010 statistics, the Jordanian Health care sector consists of 45 public hospitals and 84 comprehensive medical centers. In order to complete the implementation of Hakeem in all hospitals, it requires three phases of implementation. First phase (Pilot1): The first phase has been completed in the year 2011. The Electronic Medical Records (EMR) have been deployed in one public hospital and Amman comprehensive health center. This phase was implemented from 2009 until 2011. Second Phase (Pilot2): The second phase has started from November 2011 by deploying EHR in two public hospitals and one comprehensive health center (pilot1 plus one public hospital). Third Phase ( Shared EHR): The third phase of Hakeem implementation is to deploy, and connect the EHR in all Jordanian public hospitals, and comprehensive health centers . In Jordan, patients take their medical care in one comprehensive medical center or public hospital where they live by producing their medical cards. It is hope that when this phase complete in future, patients can get their health care around Jordan using their national identification numbers only. This phase is expected to be completed in six years. Figure 1 below shows the proposed third phase of Hakeem implementation.

called Medical Record Number and many other related information. Laboratory Information System: This system is used to collect orders, laboratory instruments results, patient schedules, billing, and other administrative information. Radiology Information System: This system is used to track, schedule, report, and distribute patient data and image. Pharmacy Information System: This system is used to record the dispense of medications, to fill the prescriptions, and to record the payment for medications. Computerized Physician Order Entry: This system is a clinical electronic order dealing with laboratory, pharmacy, and radiology services. The purpose is to provide services such as ordering, alerting, customizing order sets, and reporting results. Clinical Documentation: This system is used to produce electronic reports regarding physician, nurse, and other clinician notes , flow sheets, discharge summaries, transcription document management, medical records abstracts, and many other.

Figure 2: Hakeem Components [21]

HAKEEM CHALLENGES Implementing EHR is not an easy task. There are several challenges currently faced by any EHR initiatives. Some challenges are general and some are specific to certain countries or organizations. Below are some of the general challenges faced in Jordan and many other countries in implementing EHR. Financial challenges: One of the biggest challenges in EHR implementation is the financial issue [17]. In 2005, a study was done to estimate the cost of EHR implementation which was calculated at $63,000 per bed. This means that the cost to implement EHR in all hospitals and medical centers are very high [18]. This becomes the biggest problem to the Ministry of Health (MOH) in Jordan since Hakeem project needs a lot of budget for the following: o Implementation cost: the cost is very expensive since most of the public hospitals and medical

Figure 1: Hakeem phase 3[21]

B. Hakeem Components. Hakeem is an Electronic Health Record, which is an integration of different types of health information system shown in figure 2. This section briefly explain each components in Hakeem. Administrative Information System: This system contains critical patient information such as patient name, demographics, patient disposition, employer information, chief complaint, unique identification for each patient

SIGMA2012 Symposium on IT Governance, Management, and Audit. College of IT, Universiti Tenaga Nasional, Malaysia

2012

centers do not have the infrastructure for implementation such as Hardware, Software, and IT specialists [1, 15,19,20]. o Maintenance and support cost: Hakeem needs to be supported and maintained after it has been deployed which is expensive. o Training cost: In order for stakeholders to use Hakeem, trainings must be provided [15]. Technology challenges: o Lack of technology infrastructure [12,15,19]. Most public hospitals in Jordan do not even have a computer department. o High change rate in technology [17] also contributes to the problem. o Difficult to support and maintain data due to its huge volume. o Problems with the system such as systems stop working, power off, systems crash, or losing data. Policy and legislation challenge [1]: o Privacy: Privacy is one of the most important policy that must be protected in most countries. However, the policies or regulations for privacy in patient information in Jordan is unclear [17, 18,19]. o Security: Nowadays, different types of threat and attack in the cyber world exist such as hackers and viruses [20]. On the other hand, specific challenges face by Hakeem project are: Stakeholders challenges: Some stakeholders may resist or reject to the changes [7] due to the following reasons: o Stakeholders do not think that they will get any benefits from the project. They believe that only patients will get the benefits, therefore, they do not support the project. o Administrative staff feels that Hakeem project will replace them in future. o The stakeholders refuse to learn because they believe that an expert like them cannot be a novice or a learner. o Workload: doctors, nurses, and pharmacist suffer from high work pressure resulting from high workload. According to Jordan Ministry of Health, in 2010, the population were 6,1113,000 while for every 1000 person, there were 2.65 doctors, 4.19 nurses and 1.5 pharmacists. This is a low number if compared to the number of population. Therefore, this gives an extra workload to them as a result of entering the information and diagnosis of patients. This also lead to decrease in productivity. o Age: There are a number of older staff especially the specialist doctors, who cannot use the technology in that age. o Technology experience: Most of the stakeholders can not use the new technology because they have been using the traditional ways of using paper for so long and some of them think that using computers is too complex.

o Language: Hakeem is developed using English terminologies, which becomes a problem for some staff especially administrative staff. This is because most of the time, the administrative staff speaks Arabic while doing their jobs. o Fear of failure: the leadership in healthcare sectors fears that Hakeem will not succeed. They want to be successful every time. Organizational Challenges: o The turnover of trained employees is high, which results in companies recruiting novice employees. This has caused extra training cost. o External Competitor: There are many competitors outside Jordan who were waiting for Hakeem project to collapse. Most of these competitors are medical factories. GOVERNING THE CHALLENGES The challenges faced in Hakeem implementation may reduce the success rate, but if appropriate methods are used success may be achieved. In this section, recommended solutions and guidelines for all challenges faced in EHR implementation either general or specific to Hakeem are discussed: Government should consider this project as a long and costly project but full of benefits to its stakeholders. Jordanian government should give full support especially in terms of financial support, and a strategic initiative which will encourage and assist stakeholders to move over. Vision, mission, goals, and benefits of Hakeem project must be made known and understood by all stakeholders. Hakeem should implement a clear and understandable work policy. Stakeholders should involve in all Hakeem phases starting from IT decisions and design. The workload for doctors, nurses, pharmacists, and others who works with patients must be reduced. The time spent with patient should be added to the time needed to insert patient data. The workload must be calculated on average, so the doctors do not feel that they are overworking. This can be done by hiring a number of staff to suit the number of patients. Healthcare staff should know that Hakeem is not developed in order to replace certain jobs. Financial, and moral rewards like certificates, to enhance productivity and encourage the staff to use the new system should be given. Enforce laws related to privacy and confidential information and publicized them so that the society will be aware of them. In Jordan, an electronic transaction law has already existed in 2001. EHR must be easy to use, easy to learn, has the capabilities to accommodate changes in technology, and processes.

SIGMA2012 Symposium on IT Governance, Management, and Audit. College of IT, Universiti Tenaga Nasional, Malaysia

2012

Apply the most secure tools and algorithm to safeguard and protect data such as using encryption, watermarking and applying accountability. A mitigation plan should be established for emergency situations to ensure that Hakeem keeps working. To facilitate Hakeem services, it is better to establish an in-house training department, to simplify staff training process. In most research, they found that training is the best solution to decrease the healthcare staff resistances toward changes. Using data warehouse and data mining techniques to deal with huge volume of data. Cloud computing could also be used to store data. CONCLUSION Although there are many challenges exist during Hakeem implementation, we hope that the recommendations stated in this paper will help in overcoming those challenges. Hakeem implementation is expected to provide a modern health information management systems across Jordan. In line with King Abdullah's vision, it is hope that the quality of healthcare in Jordan will be at its highest level in order to provide the best healthcare service to the citizen of Jordan. ACKNOWLEDGEMENT First of all, Thanks Allah is helping us complete this paper, and for any success we have reached. The authors acknowledge COO Eng. Feras Kamal and his entire staff for full support and help. Finally, many thanks our college and Uniten for giving us this chance to start writing. REFERENCES
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