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Creating continuity of care for population health management

A single health record provides streamlined and preventative care opportunities for Abu Dhabi’s public school system.

Dr Bakr Ismael, Dr Najah Mustapha, Dr Haitham Mohamed, Hiede Reginio RN

5 June 2019

One person, one record is one of the primary goals of electronic health records (EHR), and one that can dramatically improve the patient experience and providers' abilities to provide high quality, effective care.

A single, continuous health record is particularly useful when managing patients with chronic conditions. Globally, an estimated 41 million people die each year from a chronic disease, which represents 71 percent of all annual deaths, and 15 million of those deaths are people between the ages of 30 and 69. In the United States, the Centers for Disease Control and Prevention estimates that six out of every 10 Americans live with at least one form of chronic disease, and chronic diseases account for 90 percent of the country's annual health care expenditures. Because chronic disease is an ongoing event, episodes of care are likely to take place at different venues with different providers, across long intervals of time. The ability for different providers and health care organizations to freely share health data helps give a complete picture of a patient's disease history and makes it easier to track and manage a patient's chronic condition.

Sharing patient data across providers and venues is also beneficial for the view it gives into population-level health issues and the insight it can provide into population health management. Understanding how chronic diseases like diabetes, hypertension and addiction affect a given population can help with early intervention and management of those conditions, while sharing data can help providers coordinate care in a way that isn't possible when data is siloed.

The Middle East has experienced a dramatic upswing in the incidence of chronic disease in recent years, in the form of obesity. Eight Middle Eastern countries, including Qatar, Kuwait and the United Arab Emirates, report the highest global ratio of obesity among adults at 27 percent. Obesity is a risk factor for diabetes and projections indicate that the number of diabetic patients in the Middle East and North Africa region is expected to rise from 39 million people in 2017 to 82 million by 2045 – an alarming 110 percent increase. The so-called "diabesity" epidemic is prompting governments and organizations to devise strategies and programs to track and improve public health.

A plan for population health

The United Arab Emirates (UAE) has been a leader in modernizing its health care system and creating a world class health care experience for its citizens. As part of its ambitious Vision 2021 project, the UAE seeks to make the one person, one record idea a reality in the country by connecting the health records of every citizen and creating better outcomes through population health management.

In the emirate of Abu Dhabi, Ambulatory Health Services owns and operates health clinics across the emirate. Their parent company SEHA (the name "SEHA" is a phonetic rendering of the Arabic word for health) is the largest health care network in the UAE and owns and operates 12 hospitals, 46 health care centers, two occupational centers, 11 disease and screening centers, nine dialysis centers and 256 school clinics. Its mission since its founding in 2007 has been to improve health care delivery to the public across the Abu Dhabi emirate. The SEHA Health System's hospitals, clinics and doctors' offices are connected by a single electronic health system named Malaffi, which means "my file" in Arabic.

In alignment with the Vision 2021 country-wide initiative and in order to gain insight into the overall health of the student population, in 2010, the Abu Dhabi Department of Health (DOH) mandated that public school students enrolled in grades 1, 5 and 9 undergo comprehensive school screening including a scoliosis examination, visual acuity test, audiometry screening, dental screening with fissure sealant and blood screening for anemia. In addition, DOH mandated that all students enrolled in public schools undergo annual screening by the school nurses which entails height and weight measurement, blood pressure measurement and vision acuity testing. School nurses are expected to conduct annual screening, administer vaccines, provide first aid and chronic disease management in addition to the control and reporting of communicable diseases and follow up of all students with health issues.

The public school system is comprised of 256 schools and serves approximately 138,000 students, with a nurse to student ratio of 1:750. When the program was enacted, Malaffi did not extend into Abu Dhabi's public schools. All student health records were kept in paper format, and school nurses had no way to connect to SEHA's EHR and efficiently relay student health information to the DOH. In addition, there were issues with compliance and consistency.

"We did not have a structured approach of follow up," said Dr Najah Mustapha, school health director with SEHA. "We were missing vital information because parents were not always compliant, and we had a lack of proper documentation due to a lack of compliance with documentation guidelines."

Creating the connection

When SEHA implemented the Malaffi electronic health record across the entire Abu Dhabi public school system, it allowed school care providers to connect directly with SEHA's system and create a centralized source for all student health data. It also allowed school nurses to follow up on referrals within SEHA care facilities and ensure students received additional care when needed.

"Having a single EHR enables us to ensure continuum of care for students," said Dr Bakr Ismail, acting health informatics director in Ambulatory healthcare services – SEHA. "We are now able to follow up directly with what is going on with a student, which has improved nursing care in the school. Any nurse can get insight into allergies, medications, and can get feedback on whether a student attended an appointment because of a referral and what the results were."

The EHR has also helped officials gain valuable insight into health issues in the student population and they have been able to implement programs targeted at addressing them. Noting that student overweight and obesity rates were on the rise, several health initiatives were designed to increase awareness of healthy lifestyle choices, including a fast food initiative, a physical activity initiative and a diabetes initiative. School nurses can also use Malaffi to follow up on the health records of individual students to ensure that referral appointments to pediatricians have been completed.

The single connected EHR has also allowed schools to provide better follow up and management for cases of scoliosis and asthma. The DOH-mandated screening program has helped identify a higher number of cases of suspected scoliosis – in the 2015-2016 school year there were 442 suspected cases of scoliosis, compared with 392 cases in the 2014-2015 school year and 266 cases in the 2013-2014 school year. With the school system's ability to follow up with referrals to primary care doctors through the EHR, more students are now getting the treatment and therapy they need for scoliosis.

In the case of asthma, in the 2017-2018 school year, an inventory of student medical forms revealed 85 cases of asthma, with 49 percent identified as active asthma. Because parents do not always accurately and completely fill out school medical forms, nurses did not have an up to date status of all reported asthma cases. With the ability to connect to the SEHA EHR, school nurses are now able to view information on students' recent attacks, hospitalizations and medications. As a result, nurses have been able to identify that 71 percent of reported cases are active asthma and provide needed support to those students.

The progress that schools have made on student health issues has affirmed the value of having an integrated EHR.

"Making student clinical data available for school health care providers was a huge challenge that turned out to be the best decision we ever made," said Dr Haitham Mohamed, health information system site manager at SEHA. "The results we have seen so far are very encouraging."

Administrators are still working on customizing school health forms to identify more chronic health problems within the student population. Based on the improvements they've seen as a result of implementing the EHR, they are setting their sights on the future – connecting the emirate to truly create one patient, one record.

"Having the feedback of the physician and the feedback of the school nurse available in one system enables us to provide a huge benefit to the population," said Dr Ismail. "We are now developing a health information exchange (HIE) and hopefully by the end of 2019 we will be able to be connected to all providers within the emirate of Abu Dhabi."