A Strategic Roadmap for Achieving the Potential Benefits of Electronic Health Record System in the State of Kuwait Bashair Almutairi Thesis submitted in accordance with the requirements of the University College London for the degree of Doctor of Philosophy University College London July 2011 tcaAtsbA This research investigates the desired benefits of using an Electronic Health Record (EHR) in Kuwait Primary Health Care Centers and the perceived barriers to its successful adoption. From this, a set of key strategic capabilities are proposed, ranked for priority and urgency as a roadmap for EHR adoption in the State of Kuwait. This thesis examines the organization of the health care system in Kuwait and important issues related to primary health care, including the implementation and current use of the EHR system at Kuwait primary health care centers. International evidence of the EHR system benefits, barriers and capabilities such as interoperability, confidentiality and security were used as the basis for user surveys. The research applied domain theory and research-based improvement strategy as a means of identifying the stakeholders and the priorities area of investigation. The research utilized a quantitative research design focusing on multiple case studies as the survey methodology. Two case study surveys were conducted to identify the main benefits and barriers that affect the adoption of the EHR at international and national (Kuwaiti) levels. The first survey involved international and national decision makers. The second survey involved healthcare professionals working in Kuwait primary health care to assess their view regarding the features of the current system, the benefits and barriers of more complete EHRs. The results of first and second surveys were used to develop a list of key EHR system capabilities and adoption requirements relevant to Kuwait primary care. This list was used for the design of a third survey, for senior stakeholders at the Kuwait Ministry of Health, to identify their strategic roadmap priorities. This research, drawing on the literature of the EHR design and implementation, a study of international initiatives of the EHR adoption and outputs of three case studies, has emphasized the importance of developing a strategic roadmap for Kuwait to achieve the potential benefits of EHRs. 2 Acknowledgements I would like to express my sincere thanks to my supervisor Professor. Dipak Kalra, the Director of Centre for Health Informatics Multiprofessional Education at UCL, for his supervision, guidance, encouragement and interest throughout the last four years. Many thanks are extended to Dr. Henry Potts for his continuous help and support. Since the respondents were guaranteed confidentiality, I cannot thank them by name, but nonetheless wish to express my gratitude to them for devoting time and efforts to the success of this research. In fact, the research could not have been done without their generosity. Also, special thanks also go to all member of research community at Kuwait Ministry of Health for their support and guidance. None of my academic success would have been possible without the love and support of my mother and father. I also extend my gratitude to my sisters and brothers. Finally and most importantly, I am also deeply indebted to my husband, Mishari Al-Otaibi, for his support. Also special thanks go to my son, Fahad, who helped me give of myself. With you I am anything I want to be, without you I am nothing at all. 3 Table of Contents Chapter One: Introduction 25 Chapter Two: Health 27 2. Introduction 27 2.1. Health Concept 28 2.2. Determinants of Health 30 2.2.1. Genetic Inheritance 30 2.2.2. Physical Environment 30 2.2.3. Social Environment 31 2.2.4. Health Behaviour 31 2.2.5. Healthcare as a Determinant of Health 32 2.2.6. Summary 33 2.3. Values and Goals of Healthcare 34 2.4. Healthcare System 35 2.4.1. Healthcare System Definition 35 2.4.2. Goals of Healthcare System 36 2.4.3. Health System Building Blocks 37 2.4.4. Healthcare Services 38 2.4.4.1. Characteristics of Healthcare Delivery 38 System 2.4.4.2. Utilisation of Healthcare Services 38 2.4.4.3. Types of Healthcare Services 39 2.4.4.3.1. The Primary Healthcare 39 2.4.4.3.2. The Secondary and Tertiary Healthcare 40 2.4.5. Health System Challenges 40 2.4.6. Summary 41 2.5. Measurement of Healthcare System 42 2.5.1. Health Indicators 42 2.5.2. Health Status Framework 44 2.5.3. Determinants of Health Framework 45 2.5.4. Health System Performance Framework 46 2.5.5. Summary 48 4 Chapter Three: Primary Health Care 49 3. Introduction 49 3.1. Definitions, Context and Features of 52 Primary Health Care 3.1.1. Definitions 52 3.2. Context 53 3.2.1. Socioeconomic Development 53 3.2.2. Strategic Approach 55 3.2.3. Political Climate 55 3.3. Features 56 3.4. Functions 58 3.5. Core Values, Principles, Objectives, 59 and Elements of a Primary Health Care System 3.5.1. Core Values 59 3.5.2. Principles 60 3.5.3. Objectives 60 3.5.4. Elements 61 3.6. Models of Primary Health Care 62 3.7. Implementation of Primary Health 63 Care 3.7.1. Primary Health Care Approaches 63 3.7.2. Summary of Primary Health Care 63 Approaches 3.8. The Primary Health Care Team 65 3.8.1. Composition 65 3.8.2. Teamwork 65 3.8.3. Patient Outcomes 66 3.9. Benefits of a Primary Health Care 67 Team 3.9.1. General Benefits 67 3.9.2. Specific Benefits 68 3.9.3. Longitudinality 68 3.9.4. The Early Management of Health 68 Problems 3.9.5. Integrated Care 69 3.9.6. Improving the Quality of Clinical Care 70 5 3.9.7. Primary Care as the First Point of 70 Contact 3.9.8. Comprehensiveness 71 3.10. Primary Health Care Challenges 71 3.10.1. Demographic Changes 71 3.10.2. Economic Growth and Crisis 72 3.10.3. Globalisation 72 3.10.4. Worldwide Health 73 3.10.5. Primary Care Practice 73 3.10.6. Environmental Changes 73 3.10.7. Civil Society's Role and Contribution 74 3.11. Summary 74 Chapter Four: The History and Characteristics of 75 the State of Kuwait 4.1. Introduction 75 4.1.1. Facts 75 4.1.2. Demographics 76 4.1.3. Education 76 4.1.4. Economy 78 4.1.5. Welfare Regime 78 4.1.6. Summary and Conclusion 79 4.2. Development of Kuwait’s Information 80 Technology 4.2.1. National Information Technology 80 Strategy 4.2.2. Information Technology Infrastructure 80 4.2.3. Accessibility and Usability of 82 Information Technology 4.2.4. Training 83 4.2.5. Information Technology Security and 83 Privacy 4.2.6. Examples of Information Technology 84 Applications 4.2.7. Summary 85 4.3. Development of Kuwait's Health Care 87 Delivery System 4.3.1. Health Care Legislation 88 4.3.2. The Ministry of Public Health 89 6 4.3.3. Health Care in Kuwait 89 4.3.3.1. Health Regions 89 4.3.3.2. Health Care Facilities 90 4.3.3.3. Health Care Expenditure 91 4.3.3.4. Demographics of Ministry of Public 92 Health Professionals 4.3.3.5. Health Indicators 93 4.3.3.5.1. Health Statistics 93 4.3.3.6. The Health Information System 94 4.3.3.6.1. Previous Health Information System 94 Applications 4.3.3.6.2. Current Health Information System 97 Applications 4.4. Kuwait Health Care System Challenges 99 and Barriers 4.4.1. Public Awareness and Health Education 99 4.4.2. Public Expectations 99 4.4.3. The Health Economy: A Burden of 100 Costs 4.4.4. Demographic Changes 100 4.4.5. Burden of Chronic Diseases 100 4.4.6. A Shift from a Curative Approach to 101 Improve Health 4.4.7. Shortage of Medications 101 4.4.8. Poor Infrastructure of Government 101 Hospitals 4.4.9. Manpower Development 102 4.4.10. External Health Care Market 102 4.4.11. Health Service Management and Quality 102 4.4.12. Management Structure 103 4.4.13 Lack of a Strategic Plan 103 4.4.14. Code of Ethics and Medical Law in 103 Kuwait 4.5. Summary 104 7 Chapter Five: Electronic Health Record System 106 5.1. E-health: An Introduction 106 5.1.1. Definition of E-health 106 5.1.2. Essential Elements of E-health 107 5.2. The Development of E-health 109 5.2.1. Historical Overview 109 5.2.2. Definitions of an Electronic Health 114 Record System 5.3. The Motivation to Adopt an Electronic 119 Health Record 5.3.1. Limitation of Paper-based Medical 119 Records 5.3.2. The Need to Adopt an Electronic Health 121 Record System 5.3.2.1. The Overall Challenges, Drivers, and 122 Applications of Electronic Health Record 5.3.2.2. The Categories Benefits of Electronic 126 Health Record 5.3.3. Data Management 126 5.3.3.1. Data Accuracy 128 5.3.3.2. Data Availability 128 5.3.4. Advantages of an Electronic Health 129 Record System 5.4. The Characteristics and Role of 131 Electronic Health Record 5.4.1. The Characteristics of Electronic Health 131 Record 5.4.2. The Role of Electronic Health Record 131 5.5. Key Capabilities and the Adoption of 133 Electronic Health Records 5.5.1. Key Capabilities 133 5.5.2.