-
Descriptive Approach: covers the theoretical background for the development and administration of Kuwaiti health services and residential area based geographical distribution.
-
Statistical Analysis Approach: covers medical services using Geospatial factors; quantitative population distribution among health areas; quantitative evaluation of service level, and client satisfaction.
-
Applied Technical Approach: based on computer programming and simulation to propose computer-based models to optimize Geospatial metadata errors. It utilizes advanced Geo-information technology systems to structure accurate databases with reliable outputs needed by decision makers.
This study’s above-mentioned research methodology will be implemented by:
-
Designing a residential database according to different residential areas vs. health centers.
-
Designing a digital map using GIS based on residential districts compliance with residential health center distribution, and geographical distribution of health centers per residential district.
-
Programming a Visual Basic simulation system to rectify geospatial metadata errors, especially in medical records.
-
Designing an applied model for specific areas of Health Services Management, using geo-databases to produce decision making user-friendly out-put.
Because Kuwait has approximately 74 districts within 6 different governorates, this large study framework would impact the sheer volume of the final analysis. Therefore, this study limits its focus to those districts in the capital governorate (Fig. 2) representing 20 areas with 20 health centers, in addition to a number of clinics and specialized hospitals. It is recommended that the results of this study serve as a model for other governorates, in the State of Kuwait [17–20].
In analyzing the questionnaire (Appendix A), it is evident that numerous administrative problems warrant attention, as follows:
-
Loss of health files, especially expatriate files in about 85% of all health care centers.
-
Similarity in names within 71.4% of all health files necessitates a computer system linking names with other personal data such as date of birth and civil identity number.
-
47.6% shortage in medical record data because doctors have insufficient time to complete records of diagnoses and other pertinent information.
-
47.6% data deficiency is primarily due to lack of basic information (i.e. civil identity number, family/tribe name, address, date-of-birth etc.), resulting from lax medical record employees failing to record complete data upon first opening health files for new patients.
-
Keeping active patient health records for patients who have moved to other residential areas creates major problems caused patient carelessness in transferring health files to the new clinic. This leads to two-or more–sets of active files at different clinics, a situation requiring a nationwide administrative system preventing such duplication.
-
Administrator absenteeism is remedied by holding administrators accountable for carrying out their duties by creating a system that organizes and supervises daily work hours.
-
The current study has depended on the latest statistical data published 1999, thus indicating a lack of current data. This reflects a statistical dysfunction in the health care system.
Analysis of the Percentage of Concentration in Health Care Services
In studying Fig. 3, which shows the location distribution of quantitative health care services represented in the number of doctors, nurses, and administrative staff, the following characteristics from Fig. 4 can be extracted as follows:
-
There is an imbalance in location distribution in health care services factors represented in doctors, nurses, and administrative staff. This is due to the difference in the numbers of doctors, especially in Khaldiya, Faiha’, De’eiya, and Doha health care centers. The number of doctors is three times that of doctors in Mansouriya, Shuwaikh, Shamiya, and Granada’s health care centers. This is primarily due to the presence of additional specializations in the above-mentioned area centers. The Ophthalmology Center in Khaldiya serves all areas in the Capital Governorate, while Faiha’s Dentistry Center extends its services to nearby areas. The remaining areas with disproportionately high numbers of doctors reflect administrative deficiencies in allocating medical personnel. This is especially the case when the areas that have a higher number of doctors do not have additional health care services such those in Faiha’ or Khaldiya.
-
There is an imbalance in distribution of nursing staff and assistants. The differences in distribution among health care centers is clear since there are equal numbers of doctors and nurses in health care centers such as Granada, Shamiya, Dasman, and Sulaibikhat, but unequal numbers of doctors and nurses in other areas. This represents a shortage in health care services since the number of nurses is noticeably less than the number of doctors in Doha, Qadsiya, Yarmouk, Surra, Rawdha, and De’eiya health care centers, while there are more nurses than doctors in Abdulla Al-Salem, Murqab, Dasma, and Shuwaikh. This disparity confirms the lack of a proper administrative system that would ensure balanced distribution of assistant health care personnel [21].
Table 1
The percentage of concentration of health care services, doctors, nurses, and administrative staff, along with the percentage of referring patients.
No.
|
Health Care Center
|
Doctors
|
Nurses
|
Admin. Staff
|
Referrals #
|
No.
|
%
|
No.
|
%
|
No.
|
%
|
No.
|
%
|
1.
|
Dasman
|
3
|
2.8
|
3
|
3.9
|
5
|
5.3
|
42466
|
2.7
|
2.
|
Dasmah
|
2
|
1.8
|
4
|
5.3
|
4
|
4.2
|
27838
|
1.8
|
3.
|
Sawaber
|
3
|
2.8
|
4
|
5.3
|
3
|
3.2
|
33030
|
2.1
|
4.
|
Mansouriya
|
2
|
1.8
|
5
|
6.6
|
5
|
5.3
|
18411
|
1.2
|
5.
|
Abdulla Al-Salem
|
3
|
2.8
|
6
|
7.9
|
7
|
7.4
|
30177
|
1.9
|
6.
|
Qadsiya
|
5
|
4.6
|
3
|
3.9
|
4
|
4.2
|
54224
|
3.5
|
7.
|
De’iya
|
11
|
10.1
|
4
|
5.3
|
3
|
3.2
|
173198
|
11.2
|
8.
|
Faiha’
|
12
|
11
|
5
|
6.6
|
6
|
6.3
|
253861
|
16.4
|
9.
|
Nuzha
|
3
|
2.8
|
4
|
5.3
|
5
|
5.3
|
21060
|
1.4
|
10.
|
Shuwaikh
|
2
|
1.8
|
3
|
3.9
|
5
|
5.3
|
9914
|
0.6
|
11.
|
Granada
|
2
|
1.8
|
2
|
2.6
|
2
|
2.1
|
8224
|
0.5
|
12.
|
Sulaibikhat
|
9
|
8.3
|
2
|
2.6
|
5
|
5.3
|
220595
|
14.2
|
13.
|
Khaldiya
|
4
|
3.7
|
3
|
3.9
|
5
|
5.3
|
40300
|
2.6
|
14.
|
Hamas Al-Saqer
|
6
|
5.5
|
7
|
9.2
|
7
|
7.4
|
84148
|
5.4
|
15.
|
Rawdha
|
8
|
7.3
|
3
|
3.9
|
4
|
4.2
|
87694
|
5.7
|
16.
|
Doha
|
6
|
5.5
|
4
|
5.3
|
3
|
3.2
|
116626
|
7.5
|
17.
|
Yarmouk
|
8
|
7.3
|
3
|
3.9
|
4
|
4.2
|
117278
|
7.6
|
18.
|
Surra
|
7
|
6.4
|
3
|
3.9
|
4
|
4.2
|
74789
|
4.8
|
19.
|
Kaifan
|
7
|
6.4
|
2
|
2.6
|
5
|
5.3
|
71585
|
4.6
|
20.
|
Shamiya
|
4
|
3.7
|
4
|
5.3
|
6
|
6.3
|
41748
|
2.7
|
21.
|
Industrial Shuwaikh
|
2
|
1.8
|
2
|
2.6
|
3
|
3.2
|
22566
|
1.5
|
|
|
109
|
100
|
76
|
100
|
95
|
100
|
1549632
|
100
|
Source: The Questionnaire Data appendix (1), in addition to the calculation of percentages by the researcher.
|
The implemented methodology for improving the Capital Governorate’s health care administrative system is as follows:
-
Establish an administrative database.
-
Establish a health database for patients.
-
Establish a population database in areas affiliated to health care centers.
-
Establish a statistical database for severe medical cases.
-
Establish a location database (maps).
-
Design an information system to link the different databases.
-
Enter location analysis functions to the comprehensive information system.
-
Add a report preparation system for current, daily, monthly, and yearly reports-as needed.
-
Add an opinionative system asking for patients and population’s views.
-
Add a performance evaluation system for administrative and medical performance.
The specifications of each sub-system of the above ten systems can be determined as well as their assigned tasks and linkage to other systems as follows (Fig. 5):
Administrative Database
This consists of the administrative hierarchy, medical workforce, and doctors and nurses’ personal data, position, work history, specialization, work hours, grants, penalties, violations, etc. [22].
Population Database
This includes detailed and demographic data about the population in residential areas affiliated to the health care center (i.e. name, gender, nationality, civil ID number, home address, telephone number, date of birth, place of birth, occupation).
Patients’ Database
Consistent design of the health file contains the following data: name, civil ID number, date of birth, home address, telephone number, nationality, gender, occupation, health status, date of referral, treatment, and doctor’s remarks.
Critical Health Statistical Database
Comprises critical health cases and includes: name, civil ID number, home address, telephone number, critical health cases, date of referral, follow-up date, treatment, and doctor’s remarks.
Spatial Database
It includes a detailed map of the blocks in a residential area affiliated to a health care center, roadmap, and significant area landmarks (i.e. schools, government buildings, and private buildings). Also included is geo-coding address data pertaining to plot number, street, block, and area name, and name of governorate.
Health Management Information System
All databases and sub-systems–such as GIS, the daily work system, and performance evaluation system–are linked in the interface window on the user’s monitor. Through this window, one language, either Arabic or English, can be chosen [23].
Spatial Analysis System
This consists of many analytical functions through links with population database, referrals information database, critical health cases database, and the map or the spatial database. The following analytical functions are performed:
-
Spatial distribution of certain health cases.
-
Allocating coverage area of health care center.
-
Ability to rearrange coverage area by using the rezoning system.
-
Searching for referral distribution in a certain time period.
-
Other duties.
Health Reporting System
This can extract health or statistical reports based on health cases, age group, nationality, gender and time period (i.e. current, daily, weekly, monthly, and annual reports). This system contributes to overcoming statistical problems encountered by the current study, and represented in the old statistical published data. The latest published statistics go back to 1999, a five-year time period that would influence validity of research and queries dependent on these statistics.
Feedback of Patients and Population System
Placing computer monitors in waiting rooms (for men and women) would obtain patient feedback to help evaluate health administrative system performance.
Evaluation System
This system serves as a mirror that reflects health and administrative shortcomings derived from referral feedback, regular administrative and organizational remarks, and different reports about doctors, nurses and administrative personnel.
GIS Procedures
The requirements of establishing a GIS system for the study include:
-
Software: The ARC/GIS software will be used–with extensions such as spatial analyst and geo-statistical analyst, where both accomplish the study’s required analytical functions.
-
Database: Dependent on the Access Database because it is the best database that deals with GIS programs. It will be used to design administrative, population, referral, and critical health case databases.
-
Programming language – Visual Basic is used to design a usage window linking the different databases, and to design sub-systems, such as health reporting, referral, population feedback, and performance evaluation systems.
-
A base map of the study area will contain: location data regarding blocks, ownership, addresses, number of families, and number of residential units. It also has a network of main and side roads, and area geographical characteristics (i.e. schools, health care centers, governmental and private buildings, parks, etc.).
-
Population and statistical data including demographic data about a residential area population affiliated with a health care center, including addresses–to facilitate linking with the base map (i.e. Geo-coding Addresses).
-
Selecting a computer network connected to a main server with high specifications, initially serving all network parties only. This will establish a central unit of health information systems affiliated with the Ministry of Health, serving all medical installations in the State of Kuwait. Monitors will be distributed to all health care center work stations (i.e. reception, doctors, pharmacy, dressing rooms, administration, and men’s & women’s waiting rooms). There must be a future plan to set a monitor for the high level administration in the Ministry of Health to supervise daily performance while printing current reports, as needed [24–26].
According to Fig. 6, the phases of executing the GIS system can be explained as follows:
System Creation/Configuration Phase
This phase consists of selecting a hardware network including server, clients, and local network based on the Internet. It includes selection of specialized programs in GIS and aforementioned extensions.
Database Creation Phase
It includes three types of databases–the base map (the Kuwait Municipality map can be approved for the purpose), the population database (the data from the statistics sector in the Ministry of Planning or the Civil Identity System), and the referral information database, which converts patient health files from paper to digitally based files.
Data Integration and Linkage Phase
In this phase, integration among the three databases is completed:
Data Manipulation Phase:
This is an important phase since the data in the three databases needs many updating and error correction possesses resulting from linking databases together.
Data Analysis Phase
A spatial and statistical analysis of information from above mentioned databases involves: isolating and identifying location distribution of certain health cases; distributing coverage range of health care centers, and re-planning coverage range through Rezoning System.
Final Reporting & Output Phase
Current, daily, weekly, monthly, and yearly reports are determined in this final phase, based on health system performance, population statistical data, medical cases, etc. This is a very important phase for decision makers to make the right decisions and avoid errors that have hindered development of health services (Fig. 7).
The stages of geo-statistical procedure can be described as follows:
-
Representing data; adding layers and display in the GIS.
-
Exploring data: investigate statistical and spatial of database properties.
-
Fitting a model: choosing a model to create a surface.
-
Performing diagnostics: assessing quality of output surface using cross-validation and validation tools to implement the model in order to predict values at unmeasured locations.
-
Comparing models: after creating multi-surfaces, cross-validation statistics can be compared [27, 28].
Practical Implementation of the Proposed System
The practical implementation process takes several applied stages as follows:
Prefatory Stage
In this stage, a name is selected for the applied topic while determining the dimensions and specifications of the area being studied. Determining technical and data requirements to execute proposed implementation is done as follows:
-
Name of implementation topic: “Application of GIS and Spatial Statistics on the development of the Health Management System.”
-
Study Area: select precise characteristics and specifications of the study area in a manner satisfying the spatial framework, consisting of a network of health care services. The applied area is the Capital Governorate in the State of Kuwait, comprising 28 residential areas, classified according to land usage, as follows:
-
Investment and Residential Areas: Qibla, Murqab, Sharq, Dasman, and Bneid Al-Qar.
-
Model Residential Areas: Dasma, Mansouriya, De’eiya, Qadsiya, Nuzha, Rawdha, Abdulla Al-Salem, Faiha, Shamiya, Shuwaikh, Kaifan, Khaldiya, Odailiya, Granada, Sulaibikhat, and Doha.
-
Industrial Areas: Shuwaikh Industrial Area.
-
Health Areas: Shuwaikh Health Area where the main hospitals and specialized centers are.
-
Educational Areas: Shuwaikh Educational Area.
-
Commercial Areas: Shuwaikh Commercial Area and Shuwaikh Port.
-
Unused Areas: Doha Port Area.
The hierarchical plan of the areas in the State of Kuwait follows a pattern whereby the State is divided into 6 governorates, mainly: The Capital Governorate, Hawalli Governorate, Ahmadi Governorate, Mubarak Al-Kabeer Governorate, Farwaniya Governorate, and Jahra Governorate. A governorate is divided into a certain number of areas based on the governorate land-area. Each area is divided into a certain number of blocks–as is the case in other countries– and the number of blocks varies, depending on the land-area of the area itself. The blocks are divided into parcels (plots), which are allocated for a single building with its annexes. In some cases, parcels are divided into smaller areas to be allocated for small residential buildings.
The study area “Capital Governorate” includes 21 health care centers distributed throughout the model residential areas, so that each residential area has a health care center. There are also health care centers in both industrial and commercial areas (Fig. 2).
-
Data and Technical Requirements: Implementation necessitates technical requirements represented in a computer network, server and monitors, along with different programs.
Technical requirements of computers in the instance of current implementation are limited to one computer machine and a Printer. The required Software Programs to be used for implementation:
a. ARC/GIS
b. MS Access
c. Visual Basic++
d. SPSS
Data Requirements
-
Residential data about the study area, which are residential statistics published by the Ministry of Public Health – the Health Record Supervision entitled “the Health Care Centers Registration Statistics in the State of Kuwait based on the health map” published in July 2001. It comprises a number of statistical tables with divisions based on population number, gender, and nationality in each block. A block is not the smallest residential unit since a unit can be divided into a number of plots. However, the residential data based on the plots is not permitted to be obtained. For the purpose of the current study, residential data was sufficient based on blocks in each residential area. The other advantage of available residential data is that it is divided based on the governorate–then the area, and suitably categorized according to its affiliation to a health care center in the coverage domain of health care services.
-
Referral data for 1999 (based on health care centers’) from the Ministry of Health’s Central Department for Initial Health Care entitled “The Annual Report Appendix for Initial Health Care Services of Health Areas,” should be the latest information, published to date. It consists of a number of tables that include categorization of referrals according to health care centers, nationality, gender, and age group.
-
Data about health care centers was largely derived from the questionnaire (which contained a number of inquiries about the health care center: number of medical staff and medical specializations; coverage domain; inquiries about administrative problems (especially health files), and suggestions by the medical staff. This is in addition to a questionnaire about patients, which inquired about number of referrals, degree of satisfaction with the level of health care services, waiting time, and types of services offered. The questionnaire was tabulated using SPSS to interpret the current situation at the administrative level of health care services [29, 30].
-
Mapping data, which is the Base Map, accounted for the implementation. It was obtained from Openware Company, which is the local agent for the global company ESRI specialized in GIS. The map consists of the following mapping layers (Fig. 3). The governorates’ boundaries in the State of Kuwait including the study area–the Capital Governorate:
-
Area boundaries.
-
Blocks boundaries.
-
Main roads, side roads, and local roads network.
-
Attribute data for each of the above layers.
-
Geographic coordinates and national coordinates (KTM).
Data Entry Stage
The above data, obtained in the initial stages, is analyzed as follows:
-
Reading the base map in ARC/GIS Software.
-
Reviewing and making attached attribute data identical with the mapping layers.
-
Completing attribute data by entering population, and patient data, medical staff data (i.e., doctors, nurses, number of administrative subjects) and data about the number of medical specializations offered. This is done through adding more columns in the attribute data, to agree with type of mapping layer.
-
Entering questionnaire data (appendix 1) into SPSS program for analysis, while obtaining percentages of questionnaire topics (i.e. degree of satisfaction with the health care services and other). The most important of these is the problem with health files based on the study’s questionnaire results.
-
Entering location of health care centers by developing a new mapping layer, in addition to completing attribute data of this layer with data associated with each center (i.e., number of people affiliated to the center; number of referrals, doctors, nurses, administrative subjects, and medical specializations or services on offer).
Data Tabulation Stage
In this stage many data analysis methods were carried out as follows:
- Spatial Analysis: a data analysis to conclude the following:
- Coverage domain of every health care center
- Quantitative comparison between number of referring patients and population statistics in each health care center
- Quantitative comparison of the numbers of medical staff : doctors, nurses, administrators
- Statistical analysis on questionnaire findings using SPSS to reach the following results:
- Percentage of health care centers experiencing administrative problems
- Percentage of health care centers with health file problems
- Types of common problems
- Suggestions from medical staff
- Suggestions from patients.
User Interface Programming
Visual Basic is approved as the language to be used to reach the following:
- Initial user interface that includes the following:
- Name of ministry (Ministry of Health).
- Name of health department (Health Department in the Capital Governorate).
- Ministry logo (Ministry of Health).
- Two buttons to choose between Arabic and English.
- Small window to enter the user name and password (Figure 8).
- Second User Interface (Main Menu) (Figure 9) which includes the following data in the form of a button:
- Administrative Database.
- Patient Database.
- Population Database.
- Critical Health database.
- GIS Base Map.
- Health Reporting.
- Work Schedule.
- GIS Interface (Figure 10):
When the GIS button is chosen, the GIS user interface is opened. It is suitable for the regular user to access any of the following data:
- Review of the Base Map.
- Review areas within health care center coverage domain (Buffer Area).
- Review areas with highest number of referring patients (Patients Area).
- Review areas with a number of patients from . . . to . . . (Patients Statistics).
- Review areas with certain types of diseases (Disease Statistics).
- Review areas with a certain age group frequency (Age Statistics).
- Others . . .
- Administrative Menu Interface (Figure 11):
This interface consists of the following attribute data:
- Doctors – doctors assigned to the health care center.
- Pharmacy – details about medicines.
- Reception – health files storage.
- Administrators – administrators assigned to the health care center.
- Nurses – nurses assigned to the health care center [31].
- Referring patients database interface (Figure 12):
This interface menu consists of the following details:
- Patient’s civil ID number.
- Patient’s name.
- Residential area (district).
- Block number.
This interface is where reception starts to organize the waiting sequence of patients. Patients are handed waiting numbers and then distributed to different doctors based on individual case requirements [32,33].
When pressing the continue button of this interface, a patient’s health file is opened in the form of a stable interface for all cases. Its contents are as follows (Figure 13):
- Patient’s personal data: civil ID number, name, date of birth, nationality, gender, and address.
- Date of last visit, case diagnosis, and type of treatment.
- Health history of patient based on number of visits in terms of date, diagnosis, type of treatment, and doctors handling the case.
- Date of current visit: . . . . . . . . . . . . . . . .
- Diagnosis: . . . . . . . . . . . . . . . .
- Treatment: . . . . . . . . . . . . . . . .
- Doctor’s remarks: the doctor can write remarks associated with critical cases or medical referrals to other health care centers or hospitals.
- Storing data: above-mentioned data is stored in the patients’ database, and then the file is closed.
- Daily working schedule interface (Figure 14):
This interface enables inquiry into work schedules for medical and administrative staff, and contains following:
- Doctors’ schedule: posts doctors’ names; working hours, and doctors on call.
- Nurses’ schedule: posts nurses’ names; working hours, and nurses on call.
- Administrators’ schedule: posts names of administrators; working hours, and administrators on call.
- Pharmacy schedule: posts names of pharmacists; working hours, and the pharmacists on call.
- Medical report interface (Figure 15):
This interface is extremely important since it wraps up the whole administrative system, health care services, performance evaluation, and other. The interface includes the following details:
- Real Time Report: lists the case and the time of reporting.
- Daily Report: consists of all completed duties in all departments.
- Weekly Report: lists duties completed by all departments.
- Monthly Report: lists duties completed by all departments.
- Annual Report: lists duties completed by all departments.
Operating Stage
The operating stage is the final stage to implement the application of using modern technology, such as GIS and spatial statistics in developing health administration services and treating problems and errors through a completely updated system. The system will initially be applied in health care centers of the Capital Governorate. This is the practical result of the dissertation, after which it will be developed and implemented in other Kuwaiti governorates [34-37].