Critical Success Factors in Establishing the Electronic Health Record. The Experience of ChevronTexaco Hospital, Lagos, Nigeria

Aremo Ade Gabriel, Aeolian Mojirola, Irrechukwu Julia, and Olugbenle Taiwo

Introduction

Developing and implementing a health information management system (HIMS) in a non-health, business-oriented environment is usually a heavy and Herculean task. The nitty-gritty centers on making a compelling business case, gaining the confidence of the stakeholders, and planning and employing basic project implementation strategies. This paper examines the process and the critical success factors that facilitate the deployment of a viable HIMS in the hospitals of an oil producing company in Nigeria.

The electronic health record (EHR) as embedded in the HIMS project of ChevronTexaco Nigeria Limited (CTNL) is a major medical project that predicated its success on these challenges. The business review initiative of 2000 by the medical department of the company resolved that HIMS should be pursued with vigor because of its potential for improving healthcare and cost savings.

This decision was driven by several key business principles that are popularly referred to as the "4 + 1" business strategy. They are:

• Operational excellence
• Cost reduction
• Capital stewardship
• Profitable growth
• Organizational capability

Background

There has been a longstanding desire by the medical department to have a technology-driven healthcare information management system that is accessible and capable of good report generation and statistical representation for data repositories and online practice. Initial efforts were made in the mid-'90s in areas of external medical bills, laboratory, and pharmacy inventories, with little impact. The first major attempt at acquiring a comprehensive application software package to address medical information management needs was in 1996. This attempt was unsuccessful for a number of reasons, such as lack of system flexibility, slow speed of the system, and poor behavioral change management in the process.¹ It focused principally on two operational areas with high data processing requirements rather than global effectiveness of medical services.

Project Description

CTNL is a multinational oil company based in Nigeria. The company provides services to its workforce in the area of clinical, occupational, and community healthcare at five different locations of operation. The medical department, which holds this responsibility, has as its objective, "to acquire a simple, robust and flexible information management system that will facilitate the delivery and audit of quality, integrated and cost effective healthcare service." This led to the setting up of a Project Implementation committee in 2001 and a Guidance Review Team (GRT) to assist in achieving this objective. The company has a distinct process for project execution called CPDEP--ChevronTexaco Project Development Execution Process, which is applicable to any project within the company and its' subsidiaries for successful project management.²

The HIMS project, on completion, was expected to facilitate the following objectives:

• Online access to medical records, irrespective of patient's location
• Real-time drug dispensing and automated labeling and drug interaction alerts
• Online database on external medical bills and services
• Online reports and statistics
• Inventory control and management
• Tracking of equipment maintenance and downtime
• Online processing and reporting of lab and imaging investigations
• Real-time appointment scheduling

Project Implementation and Management

A review of the Business Area Analysis (BAA) was initiated to study the various medical service processes before embarking on the acquisition of any information system. The implementation committee made extensive use of the CPDEP process to select a medical information management system (MIMS) that met those requirements as documented in the reviewed BAA.

Critical to embarking on this path with this methodology, was a disciplined commitment to continually focus on the values and goals of the project. There could be no compromise on critical features and capabilities on any technology. Secondary and tertiary issues have to be weighed and sometimes jettisoned (when necessary) to achieve key objectives. Fundamental to this is the need to differentiate between key and critical success factors, that is, "must have" versus "nice to have."

Critical elements for success included:

• Clear documentation of all processes in the medical department
• Identification of opportunities for IT support in the   delivery of medical services
• Identification of the functional and information requirements of each area unit
• Documentation of the infrastructural requirements to implement a robust and integrated solution
• Examination and selection of most cost-effective alternatives that meet stated requirements
• Identification of gaps between desired and available features as well as strategies for closing those gaps
• Purchase of hardware/software required to implement the selected alternative
• Training for end-users and IT support staff
• Deployment of the selected hardware/software
• Clear understanding of project deliverables
• Identification of show stoppers
• Understanding of the implementing strategies
• Retrospective review after implementation

Good planning implies that there is enough time and resources to fully investigate and analyze project requirements. Variables within the control of the implementation team were largely contained. Policy and budget approval issues that require the attention of the GRT were subsequently referred.

As part of the project implementation strategy, high-level participation was encouraged. A consultant was engaged with several responsibilities that included the review, evaluation, and validation of the BAA, project charter development, request for proposal (RFP), software assessment, cost analysis and assessment of infrastructures and technology requirements, and project implementation facilitation.

A challenge for the project team was to make difficult decisions and manage change reactions and meet overall project goals while maintaining institutional traditions and the needs of each location. To this end, efforts were equally directed toward:

• Standardization of processes, policies, and procedures
• Effective communication with all stakeholders
• Customer relations

Because of the multiple locations where the project had to be implemented, the following structures were established for effective coordination:

• Project Team meetings to maximize time and resources. This was accomplished through standing meetings on a fortnight basis and the use of Net-meeting facilities to ensure participation of members who might not be able to attend the scheduled meetings.
• Creation of an issues bin to harmonize and summarize critical tasks and issues to be completed
• Joint work sessions with the selected vendor were established and regularly held to promote standardization and collaboration between all locations
• A go-live communication plan to inform and guide stakeholders on the activation of MIMS on individual workstations for service delivery
• Establishment of training centers in all locations
• Creation of templates to standardize processes

The Roles of CPDEP in the Project Implementation

The CPDEP served as the roadmap for the implementation process in all five phases. Phase 1 dealt with identifying and accessing opportunities. This entailed prioritizing business objectives, identifying business processes and the risks, and initiating the Business Area Analysis (BAA). Phase 2 involved generating and selecting alternatives with a focus on evaluation and validation of the BAA and benchmarking, and the request for proposal (RFP). Phase 3 concentrated on developing the preferred alternatives, which included documentation, appraisal of prospective vendors, evaluation of the RFP, cost-benefit analysis, defining hardware and software needs, and business process flow. Phase 4 dealt with project execution, and it entailed test system process, training, deployment, and customization of the software. Phase 5 involved implementation and evaluation with a focus on post-implementation support.

The process also encouraged a documentation checklist and metrics that could be used to monitor the health of the project and the probability of success. At different stages of the project, significant activities and deliverables were documented for the GRT that periodically reviews and approves every stage of the project as recommended in the CPDEP process.

Technology Infrastructure

Information is a strategic resource for most industries, and it is essential to the running of day-to- day activities of any organization. Akin to this, are the people that will use the information. Without the people, information is of no value.

Critical to developing an IT strategy is an outline of business case. There is also the need to show how the information system would impact the healthcare delivery, modernize processes and procedures, and bring value to the system. As the project implementation progressed, the Team received approval from the GRT to commence Phase1 with the assessment of IT infrastructures and applications and sourcing of vendors. This phase, as well as succeeding phases, were subjected to GRT reviews and approval before implementation.

Further efforts led to the software selection process. There was also the need to maximize the use of off-the-shelf (OTS) technology that would work on a flexible OTS delivery platform. Some of the system-wide requirements for vendors included: that the application must run in a Microsoft Windows NT 4.0 network environment; that the system should provide data export and import facility; application front-end should be Web browser-based; application should use Oracle or SQL as its database engine; and application should be accessible across a LAN/WAN by multiple concurrent users.

The potential matrix of interconnectivity monitors and distributes data across all locations, which are captured into a single server located in a central place. The database application runs on Oracle database engine. The seamless network structure also contributes immensely to the successful deployment of the software.

The result of this exercise was the installation of a robust, reliable, and easy-to-use integrated system with a heterogeneous, geographically dispersed healthcare network that allows concurrent users (+/-1000) with quick response time. Key issues for success included:

• Know what is important. Differentiate key issues from secondary or peripheral issues
• Continually focusing on making sure the key requirements are met. Secondary issues can be used to serve and support implementation of the critical requirements.

Software Interface

Linking independently developed systems together is an usually a big challenge. The use of the company's interface standards on this project, as well as a methodical development process enabled the vendors to talk a common language and rapidly standardize a messaging system to meet the project objectives.

The deployment of the system involved connecting and integrating some laboratory equipment with the functional software interface. Worthy of mention among the equipment interfaced with the Meditech system are Sysmex 3000 (Haematology Analyzer) and Cobas Mira (Chemistry Analyzer). The data transmission processes between the interfaces were seamless and accurate. The integration engine machine batch was activated so that data transfer could take place. This also ensured that results are sent to the requesting department through the data path transmission technique.

The following are some of the factors that aided the successful implementation of interfacing the software with the equipment:

• Specifications were created to outline the data information needs and their components.
• Regular meetings were held to review requirements and deadlines with each vendor.
• Data paths transfers were tested end-to-end to ensure accuracy.
• When differences in message interpretation were noticed, the vendors made adjustments, where appropriate.
• Acceptance of the successful deployment of the interface system was coded and tested.

Bar Code Technology

The introduction of a linear bar code technology on the project acted as the "key" to the database. It provides a fast, accurate means to access the detailed data necessary to complete the transaction. In this way, the need for slow, inaccurate key entry is eliminated and productivity increased. It also helps the overall process of the healthcare delivery and adds quality to customer service. Although the maximum practical capacity of traditional linear bar codes is restricted to 20 or 30 characters, this is usually more than sufficient to encode the necessary "unique key" that provides real-time access to the required transaction data.

The following areas were identified for the use of bar code scanners in the hospital:

Wireless LAN (WLAN) Technology

The WLAN technology was one of the significant technological features of this project. The project identified the benefits of the implementation of wireless network technology in the hospital environment to supplement and complement a wired LAN, providing user mobility and increase productivity. WLAN allows for real-time access to information. It is a convenient way for healthcares providers to access patient information during a ward round without having to search for a live wire network connection. The following requirements were carefully considered for the Wireless LAN deployment:

• IEEE 802.11b standard as our company-wide deployment standard because it is the most mature standard today
• IEEE 802.11g standard when its products become available and mature
• 802.11b standard with 802.11a for higher productivity
• Use of a single vendor product (Cisco) as a standard and continue to scan for other innovative products

Change Management

Managing change among people of diverse professional inclinations is not an easy task, more so, when people are used to a particular method of operation. At first, the introduction of the Medical Information Management System was seen as an additional burden, as physicians and other medical staff make documentation on the medical records as well as on the system. However, since resistance to change was anticipated in any environment when such change is expected to impact on the operation and responsibilities of the individuals, measures were identified at the beginning of the project to tackle this anticipated resistance. Such measures included:

Management by participation.   Both members and non-members of the project team were brought along on what was being done to improve the healthcare practice through the Medical Information Management System.

Good public relations. Good interaction with key players in the medical department was established to obtain support and cooperation for every stage of the project.

Training. An evaluation of the training needs was carried out in all the locations, and those staff who were not computer literate were encouraged to take training programs with the project committee providing the necessary support.

Communication. A massive awareness program was put in place to educate staff on the value of the Medical Information System to the operation of the medical department, while efforts were also made to emphasize the commitment of the company management to ensure that the project succeeds.

One-on-one interaction . Efforts were also made to identify some would-be difficult personnel, and one-on-one interactive sessions were organized to diffuse their perceptions about the project and to reassure them on the activities and the value of the project.

Retrospective Process

Post implementation meetings were held at each location to establish the success of the project and to adjust the plans and timelines for future rollouts. This was followed by ad hoc committees looking back at each of the modules and their impact on services. The meetings also helped to evaluate the go-live performance and effective utilization of the system, recognize the contributions of team members, and define the next steps for open issues.

Conclusion

A successful rollout of an health information management system in an environment that is not primarily a healthcare environment could be very challenging. This is coupled with other external factors that are likely to impede the progress of the project. In a developing country where there is epileptic electricity supply, a low level of computer literacy, and the problem of funding, it takes a great deal of determination for any company to embark on a project like this that is not only costly, but has its components sourced outside of the country.

However, it is worthy of note that, since the rollout of the system in all the locations, there has been a significant improvement in service delivery. Today, the patients' health information is available at the click of a button; patient appointments are easily facilitated; and online assessment of patients' diagnostic results are now possible. This has the led to the conclusion that the HIMS is no less a means to fast and efficient healthcare delivery.

Endnotes

1. Project Team Charter document--CTNL Medical Information Management System, 2002.
2. CPDEP for Change User Guide document. ChevronTexaco Nig Ltd. 2003.