Knowledge Brief Health, Nutrition and Population Global Practice STAKEHOLDER PERSPECTIVES ON E-HEALTH IMPLEMENTATION IN ARMENIA Adanna Chukwuma and Marianna Koshkakaryan June 2018 KEY MESSAGES: • There is general recognition across stakeholders in Armenia that the e-health system can facilitate exchange of clinical and non-clinical information, transparency and accountability in service provision, and support for monitoring and evaluation. • By tracking patient movement across health facilities, the e-health system links budgetary allocations to service use, enabling efficiency and supporting performance-based financing. • However, scale-up of the e-health system has presented financial, technical, and organizational challenges that have negative implications for the sustainability of the system, efficient health care delivery, and the system’s ability to meet informational requirements for health decision-making. • There are opportunities to iteratively adapt the e-health system in Armenia through a systematic assessment of the e-health system scale-up experience and through regular and structured interactions between the private operator of the e-health system, key stakeholders involved in the implementation of the e-health system, and policy makers that can facilitate the adoption of needed changes. Introduction A health information system that provides relevant, timely the implementation of the Integrated Health Information and high-quality data is essential for decision-making, System of Armenia (IHISA), an electronic health (e-Health) monitoring policies and programmes, and undertaking system.2 IHISA aimed to modernize health information research in health systems. Ideally, health information systems in Armenia using technology. systems should also be interoperable, allowing communication between databases and aggregating data Between October and December 2015, a pilot was into meaningful information within a global information implemented in six medical institutions to study the system.1 Thus, in December 2010, the Ministry of Economy performance of IHISA given variation in key factors across and the Ministry of Health of the Republic of Armenia (RA) facilities including patient flow and business processes. signed a Memorandum of Understanding, appointing The pilot sites were Heratsi and Muratsan Medical Centers EKENG CJSC to coordinate and execute in Yerevan, Balahovit and Abovyan Medical Centers in Kotayk Marz, Goris Medical Center in Syunik Marz, Page 1 HNPGP Knowledge Brief • Stakeholder Number Vanadzor Polyclinic in Lori Marz and Ingo-Armenia insurance Company.3 More than 60 health workers and Head medical doctor, Hospital 2 administrative staff were trained, entering over 100 patient records into the system during the pilot. Following the pilot, Head medical doctor, Primary Health Care 1 IHISA was rolled out to the 480 medical institutions that facility receive state insurance funding, supported by the World Head, Therapeutic department 1 Bank through the Second Public Sector Modernization Project (PSMP-2). By May 2017, the system included Financial manager 2 information on over 32000 personnel, including 22000 E-health system operator in Health Care 4 doctors and nurses. The scale-up included training of over Facility 600 health workers, administrative staff, and trainers in the Ministry of Health. This component was introduced into the General practitioner, Primary Health Care 2 PSMP-2 Project, through restructuring two years after facility approval, at the Prime Minister’s request, as it offered General practitioner, Hospital 2 opportunities to strengthen accountability in the delivery of health services, improve efficiency in resource use through Ministry of Health representative 1 targeted allocation of state funding, and encourage Private sector practitioner representative 2 comprehensive and real-time exchange of medical and administrative information.4 It is anticipated that IHISA will Member, Health Project Implementation 1 be extended to all health facilities, including dental clinics Unit, World Bank-Supported Project and diagnostic centers, and will allow for further integration National Institute of Health representative 1 of information with other state agencies.5 Private insurance company representative 1 The adoption of an integrated electronic health information system was novel for Armenia, and at the time, for World Patients, only one of whom had access to 2 Bank Projects in Europe and Central Asia more broadly. the e-health system. Understanding the perspectives of key stakeholders on the successes and challenges in the implementation of the e- Total 22 health system provides lessons that are relevant for Armenia and other countries in the region that aim to adopt Study Findings similar systems. Thus, through key informant interviews 1. There is a general recognition across stakeholders with 22 purposively-selected stakeholders, this knowledge that the e-health system can facilitate exchange of brief explores the perspectives of stakeholders who were clinical and non-clinical information, transparency involved in the implementation of the e-health system or and accountability in service provision, and have been beneficiaries of its implementation. support for monitoring and evaluation . The interviews highlighted that physicians recognized the The key informant interviews aimed to understand the need for efficient communication between providers perspectives of each stakeholder on the rationale for and with patients, that could be facilitated by introducing e-health system; positive and negative technology. Also, insurance companies recognized experiences following the system’s introduction; and that an e-health system may allow easy potential improvements that could be made to the e-health communication with health care providers system. Stakeholders were purposively selected based on electronically and access to the medical records of their influence over and/or interest in the design and consumers. However, interviewees noted that these implementation of the e-health system. In addition, gains were conditional on national adoption of an e- stakeholders that might have been affected by design and health system that was comprehensive in terms of implementation choices were also interviewed. Responses inclusion of information needed by key groups: of stakeholders were summarized and anonymized. A brief physicians, diagnostic staff, researchers, insurance description of the stakeholders interviewed is below: providers etc. The current e-health system still requires extensive paper-based recording and is largely limited to financial reporting as discussed further below. 2. The e-health system has supported improvements in resource allocation in the health sector. As the system is integrated with the state register, Page 2 HNPGP Knowledge Brief • administrative staff and system operators can verify c) The e-health system does not prevent case patient identity and track patient movements across duplication. Integration of the e-health system with facilities. This enables health care providers and the state register was to allow for unique individual private insurers to better manage patients who are identifiers and to prevent case duplication. However, beneficiaries of the benefits package. Given the clarity there are technical problems with the linkages between of patient flow, special requests to calculate patient databases, such that the e-health system does not enrollment are no longer needed, and resources follow control for double entries effectively. Thus, elimination the patients more efficiently. The yearly state budget of duplicate cases is done manually. allocation via the e-health system is also calculated automatically, and the system supports ongoing d) Health care providers perceive the skill and time initiatives to reward facilities for performance. The requirements for implementing the e-health capacity of the system to track patient movement has system as high and preventing efficient reduced the probability of fraud via claims for patients interactions with patients. The scale-up of the e- who were not served. Case duplication may still occur health system has involved training for health facility as discussed below. staff on data entry and management, which will be completed in 2018. However, aptitude for learning these skills vary with age and prior use of technology. 3. Scale-up of the e-health system has presented Aside from the initial training experience, there are no financial, technical, and organizational challenges user manuals to support interaction with the e-health that have negative implications for the system. The e-health program requires up to 25 sustainability of the system, efficient health care minutes to enter a single case and is time-consuming. delivery, and the system’s ability to meet Given these constraints, providers were more inclined informational requirements for health decision- to arrangements where a dedicated e-health system making. operator in the health facility supported entry of paper- based consultation data into the system, re-introducing a) Facilities face high recurrent expenditure to inefficiencies in data collection. maintain the e-health system, as implementation requires a steady power supply, internet e) The integrated e-health system is unable to provide availability, licensed software, and administrative the full range of functionality supported by the staff. The subsidies for administrative costs provided prior, decentralized electronic systems for by the State – 100% for Primary Health Care (PHC) hospitals and PHCs. The prior systems focused facilities and 70% for hospitals – will be discontinued in solely on collecting data to support performance-based 2019. The estimated average cost of power supply and financing, aggregated from paper-based records internet to support implementation in each facility is (N001 and N002) filled by physicians and uploaded into one million AMD. These costs place a high financial the system by operators. Each entry took an average burden on already-strained facilities and jeopardize the of 4 minutes. These decentralized systems continued use of the e-health system. automatically generated a set of reports on performance indicators and funds that informed b) The e-health system does not support the decision-making in health facilities and by the State generation of epidemiological and service Health Agency. While the current e-health system coverage data for health system performance allows providers to enter data encompassing the prior management. It was envisaged that the e-health paper-based records, it does not automatically system would integrate the different paper-based data generate reports or identify errors in data entry. Thus, collection systems for health data in Armenia. system operators, physicians, and financial However, the health statistics on morbidity and administrators must manually fill in these gaps in data mortality collected via the National Institute of Health entry. There is still no provision to directly input patient (NIH) have not been integrated into the e-health history, examination, test results, and other system, and facilities continue to collect separate management. Currently, paper-based records with this paper-based statistics. The e-health system also does information is scanned to the patient’s e-health entry. not automatically generate facility-level indicators currently supported through results-based financing, f) Continuous interaction between the private such as the cervical cancer screening coverage. operator coordinating the implementation the e- health system and users has informed improvements in functioning. Users recognized that Page 3 HNPGP Knowledge Brief • negative implementation experiences presented Given the purposive sampling for this qualitative opportunities to identify and correct system flaws. The assessment, our findings may not reflect the universe of private operator responded quickly to problems, and constraints to the e-health system use in Armenia, cannot worked with facilities to identify potential solutions to account for the relative frequency of the identified bottlenecks. However, improvements were slow, in constraints across all facilities, and may not be part because interactions between the private operator generalizable to the entire country. A systematic survey of and health facilities were ad-hoc rather than e-health system implementation, using a randomly- systematic. selected sample or involving all facilities, is needed to fill these quantitative gaps. There is broad recognition across stakeholders, that Conclusion despite the difficulty in implementing the e-health system it The Armenian experience of implementing an integrated can facilitate improvements in health system performance health information system provides useful lessons for through providing information for research and decision- improving the functionality of the current system and for making. There are opportunities to iteratively adapt the e- adopting technologies to improve health systems more health system in Armenia through a systematic generally. To encourage facilities to continue to use the e- assessment of the e-health system scale-up experience health system, there is an immediate need for financial and through regular and structured interactions between support for the associated recurrent costs for maintaining the private operator of the e-health system, key the e-health system and technical assistance, including stakeholders involved in the implementation of the e-health training and user manuals, to guide everyday use by system, and policymakers that can facilitate the adoption medical practitioners. of needed changes. Several constraints to implementation could have been diagnosed before program launch or during the pilot, such as the lack of financial resources in facilities to support End Notes 1 Jardim, Sandra V.B. 2013. "The Electronic Health recurrent expenditure to maintain the system and the Record and its Contribution to Healthcare Information inefficiencies introduced into the provider-patient Systems Interoperability." Procedia Technology 9 (2013): interaction by using the system. A systematic diagnostic of 940-948. health system needs for the adoption of the technology 2 EKENG. 2015. “E-health”. Accessed at: would have assessed the requirements at the provider, https://www.ekeng.am/en/ehealth/ facility, operator, and government level to fully implement 3 _____. 2015. “Pilot of the Armenian e-Health System an integrated health system. This diagnostic would also Has Been Implemented”. Accessed at: have explored potential behavioral constraints to adopting https://www.ekeng.am/en/news/2015/12/23/Pilot%20of%2 the technologies and informed a comprehensive approach 0the%20Armenian%20e- to introducing the e-health system that addressed these Health%20System%20Has%20Been%20Implemented/3. constraints. Feedback from stakeholders illustrates the 4 World Bank Group. 2017. Implementation Completion need to plan the sequencing of activities related to the and Results Report. Second Public-Sector Modernization adoption of similar technologies. For example, pre- Project. Report No: ICR00004207 requisites for the adoption of e-health in facilities should 5 Communication with Ministry of Health Representative. have been addressed ahead of the national launch including training of all staff, ensuring the supply infrastructure needed for the e-health system, addressing staffing needs for system functioning, and development of This HNP Knowledge Note highlights the key findings from a rapid user manuals and other guidelines. qualitative assessment by the World Bank of stakeholder perspectives on constraints to the implementation of the integrated health information system in Armenia. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4