IST-Africa 2010 Conference Proceedings

Paul Cunningham and Miriam Cunningham (Eds)

IIMC International Information Management Corporation, 2010
ISBN:
978-1905824-19-9

HealthChange: A Change Management

Model for an eHealth Solution in
Developing Countries
Dulindra WIJETHILAKE, Dinusha VATSALAN, Gihan SENEVIRATNE,
1
Keith CHAPMAN , Kenneth THILAKARATNE, Saatviga SUDHAHAR,
Shiromi ARUNATHILAKE, Yvonne WICKRAMASINGHE
University of Colombo School of Computing, NO:
35 Reid Avenue, Colombo 07, 00700, Sri Lanka
Tel: +94 718203810, Email: dulindrawijethilake@gmail.com
1
District General Hospital, Chillaw, Sri Lanka
Abstract: As, Scott R.E. describes in his article A Business Case Approach to
eHealth Sustainability, despite best efforts, many eHealth initiatives still fail to
become sustainable in the long run, even in the developed countries [3]. Reason
behind these failures is the lack of consideration taken in to human factor in these
projects [3]. An eHealth project should address the issues such as, lack of eHealth
readiness, poor change management, etc. This project discusses the factors to be
considered when implementing an eHealth application. Furthermore, the paper
describes the process HealthChange: a change management process and the tasks
carried out to make the project more successful.
Keywords: Change Management, ICT4D, Model, Developing Countries

1.

Introduction

In health care, the most valuable and the most costly resource is considered to be skilled
manpower. Health care is also one area undergoing constant change, driven by new
technologies and innovations. Change management is the process, tools and techniques to
manage the people aspect of change to achieve the most successful outcomes when a new
technology or process is being introduced into an organization or a system.
The objective of using change management in eHealth is to assist people to adapt to and
adopt the desired change and hopefully, provide greater benefit to their clients. The sooner
the change is adopted and fully utilized the better the return on investment will be and the
sooner the program benefits to the client will be realized [6].
Most of the time the projects have been carried out considering only the technical
aspects without taking change management and eReadiness factors into consideration.
Business cases have been used to describe and justify alternative business and healthcare
options. But, when it comes to eHealth applications is the opposite. Hence, it is very
important to have a business model considering all these factors when implementing an
eHealth initiative to be sustained in both developed and developing countries.
When considering the human factor in this context, it is important to consider the seven
eDistinctive components, considered to be missing in most of the projects. The seven
eDistinctive components are as follows:
x Need Assessment
Copyright 2010 The authors

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x eHealth readiness assessment

x Integration
x Change Management
x Policy
x Rigorous pre-planned evaluation
x Privacy impact assessment
According to Prof. Peter Drurys eHealth in Developing Countries: a framework, there
are five vital components to be addressed when implementing an eHealth solution in the
developing countries called 5Cs framework [2]. It is very important to address every
component in the framework in order to make this effort successful. Each component
carries a significant role in the society and if one fails, the whole project will fail.

Fig. 1. 5C Framework, [2].

1.1 Need for Change Management

According to Bashshur R., Legal & Regulatory Constraints along with human dimensions
should be considered when implementing a telemedicine project [4]. Legal & Regulatory
Constraints may vary depending on the country and it may become quite obscure when
crossing boundaries including;
x Individual autonomy
x Privacy
x Confidentiality and informed consent
x Legal liability issues such as jurisdiction and venue in cases of litigation
x Constraints related to intellectual property rights
Although increased interaction and integration of different communities had led to
materialize the Global Village concept, various diversities among deferent individuals
persist. Existing and emerging telecommunication-technologies have brought the isolated
parts of the world together, it is believed that through telemedicine the anomalies that exist
within the healthcare industry would be chased away. Yet, cultural, linguistic, and other
differences in human factors from place to place will hinder the development of true global
telemedicine programs [1].
1.2 Peoples Considerations
When it comes to keeping records in digital format, culture and life patterns have a direct
influence. People are more cautious in sharing their medical information and they find it
very much uncomfortable [5]. Particularly in developing counties, where there is limited
infrastructure and little or no policy being prepared to address personnel health information
and how it can be transferred. The level of access given to the hospitals regarding the
medical records is also an ethical concern among both medical practitioners and patients.

Therefore, the infrastructure of the eHealth solution should encompass medical data
protection. This would consequently convince patients in providing their consent to store
their medical data in an eHealth solution.
Consideration should be given to make the people more aware of and receptive to the
eHealth solution. The focus should be on user requirements and process in the community
as if the process differs from the usual it will be difficult for people to get used to the new
system. Therefore, IT should strengthen the process and add functionalities and features but
not to change the process completely. Managing operations and capacity maintenance is
another factor to be considered carefully because if not the system will not be sustainable.
A successful change management practice for an eHealth initiative would produce the
following benefits to the system users and the patients. If change management practices are
adhered to correctly, these benefits should be accomplished [10].
x Clinical benefits
x Impact to patient safety
x Impacts to health system outcomes
x Impacts to access to services
x Impacts to provider efficiency
x Impacts to patient satisfaction
x Information Management, Technology, Reporting process improvements
It is equally important to monitor and evaluate the effectiveness of change management
activities as well. Therefore, the evaluation analysis could include the following areas:
x Staff satisfaction
x Client feedback
x Speed or degree of adoption
x Rates of utilization
x Staff proficiency and productivity
x Sustainability of change over time
x Rate of Return on Investment
1.3 Design-Reality Gap
One of the main reasons for eHealth projects to fail is that there is a significant gap between
the design assumptions/requirements and the reality of the client health organization [11].
The larger the gap between reality and design, the greater the risk of failure. Therefore, it is
vital to identify the real requirements of the organization. Identification of requirements at
an earlier stage of a project would minimize the chances of a project-failure.
There are two steps in assessing the difference in the design-reality gap; first, the
individual gaps on each of seven ITPOSMO dimensions: information, technology,
processes, objectives & values, staffing & skills, management systems and structures and
other resources. Second, the total design-reality gap (obtained from adding the seven
individual gaps). Bellow listed some of the dimensions that can be considered under
technology and process, in an eHealth initiative.
x Technology Dimension:
o Investigate ways in which healthcare reforms could be delivered without ICTs
o Investigate ways in which healthcare reforms could be delivered using the
existing ICT infrastructure
o Avoid leading-edge technologies in the design
x Process Dimension:
o Keep doing things the same way, only with the addition of some new technology
(see generic point above about automation).

o Avoid business process reengineering; instead, look at optimization or minor

modification of existing healthcare processes within the e-health application design.
x Consider a two-stage approach:
o In the first stage, processes are optimized without any change to ICTs;
o In the second and later stage, new ICTs are brought in

2.

Objectives

The objective of this paper is to demonstrate how an eHealth solution could be effectively
introduced the people of an emerging country. It thus explains issues, challenges and
opportunities to be considered when implementing an eHealth solution.

3.

Methodology

This effort is in accordance with the pilot study: ViduSuwa done in Base Hospital
Maarawila and District Hospital, Dankotuwa under the patronage of Information and
Communication Technology Agency (ICTA), Sri Lanka [24]. This process has being used
to change the attitude of the users towards the new system and the changes of the attitude
towards making the system more user friendly and more acceptable.

4.

Technology Description

The project was developed using open source technologies making it more practical and
affordable for a developing context. Hardware cost will be the only major. Programming
language used in ViduSuwa is J2EE, JBoss Server. A Database was developed using
mySQL. Technologies such as AJAX, Struts, SSL are being used to increase the quality and
security. Furthermore, the system is developed in such a way that medical professionals
find it easy to use even without prior IT knowledge.

5.

Developments

Even though there are many concepts discussed with respect to eHealth Change
Management in developed countries, there had been little research, carried out in the
developing world. Hence, a study was carried out in relation with the eHealth pilot project,
ViduSuwa: An eHealth System for Patients living in Emerging Countries.
This pilot project was implemented in two Sri Lankan hospitals: Base Hospital,
Maarawila & District Hospital, Dankotuwa that stresses enhancing the mobility of Health
Care Services. ViduSuwa is designed to make specialized healthcare services available in
rural areas in emerging countries by connecting a medical Consultant geographically
located in a place of his choice, with a patient in a rural area assisted by a doctor.
The solution is comprised of a Business Model, an Electronic Medical Record (EMR)
System along with Mobile Communication System and a Change Management Model.
Moreover, the solution is designed and developed in a way it can be deployed in a mobile
vehicle to reach people who have no access to specialized consultancies.
Even though Sri Lanka has the highest literacy rate of 90.7% in the Southern Asian
region, its computer literacy rate is only 27% [19],[20]. Among them most of the
Information Technology (IT) literate people live in the major cities. Hence, it is vital to
instigate counter measures such as conducting relevant computer training programs when
implementing such projects.
Change management has become a decisive factor in this project, as the project is to
connect patients in rural areas to consultants in urban areas. Significant effort should
therefore be taken to identify the knowledge gap between the urban and rural area. Hence, it
is challenging to implement such a system in a rural area of a developing country.

After carefully analyzing the efforts put in change management in both developing
countries and developed countries, we came up with the following model to carry out the
change management efforts in the project.

Figure 2. HealthChange: Change Management Process

The Change Management Process has three phases; Change Management Readiness,
Application of Change Management & Re-assessing Change Management efforts.
5.1 Change Management Readiness
Before initiating any Change Management practices, it is essential to identify the
organization and the changes that will take place in the organization. Hence, the business
model crafted in the project is used to identify and analyze the organizational readiness with
the 7S model being used to identify the factors of change in the organization [21].
The Business Model of ViduSuwa checks the organizations readiness in the areas of;
Organization Readiness, Integration, Policies and Evaluation. These cover the
organizations technical capabilities as well as the organizational provisions with respect to
integration, policies, evaluation.
Organizational readiness is the step where we identify existing resources and the
measurement of resource utilization levels in two hospitals. This included the analysis of
the hospital staffs IT knowledge and an evaluation of the existing resources. IT knowledge
was captured through carrying out a survey in both Marawila and Dankotuwa hospital.
Integration is used to study how the two hospitals communicate with each other and to
identify if there are any specific protocols or processes being followed. It is crucial to
identify the communication channels and practice and to make sure it would not change
drastically, the changes should be captured, and measures should be taken to provide easy
way for the people to adapt to the change.
Sometimes there are policies used throughout the organizations, which would lay
limitations on taking certain strategic decisions. For example, in a Sri Lankan hospital there
would only be a maximum of 5000 SLR as petty cash. Hence, a study is required to identify
certain obligations and which should be addressed during the planning stage.
The layout of an organization structure and how they delegate responsibilities, differs in
each organization, department, sector and country. Therefore, a study should be conducted
to identify skilled people in realizing the HealthChange. Furthermore, identifying the

evaluation criteria and the people who would be authorized in decision making with respect
to the information system is important. After analyzing change management readiness, the
next phase is the application of change management
5.2 Application of Change Management
Next change management strategy should be formed based on the outcome of Change
Management Readiness. We used a participatory approach throughout the project where
selected medical staff from both hospitals got involved in decision making from the
initiation to the end of the project. This group formed the change management team.
The group consisted of a medical consultant, a surgical consultant, two heads of the
hospitals, doctors and nurses, who would act as change agents and SMEs where they would
provide others with necessary expertise. The Team was backed up by providing them the
content that will create the Awareness, Desire, Knowledge, Ability and Reinforcement with
respect to eHealth solution.
Awareness programs, training programs were carried out to strengthen the
changemanagement team (Figure 1). An awareness program was conducted to form
awareness among the team and then to generate a desire towards the new system. Once the
team has faith in the system, they will feel the ownership and the empowerment, which will
create ability for them to use the system, to create knowledge among them, and to spread.

Figure 1: IT Awareness and Training Structure

Table 1: IT Training & Awareness Schedule
Program
Awareness program

Training Program
Town Hall Meetings
Public Addressing

Participant Category
Hospital Administration
Hospital Staff
Patients
IT Training
Systems Training
Hospital Staff
General Public

No of
Participants
10
35
30
30
30
-

Notes
Conducted to hospital authority and figure heads
System overview
Launch, Brochures, Television Programs, Radio
Programs, Newspaper articles, Newsletters

After successfully launching ViduSuwa by the Honourable Minister, Health &

Nutrition, Sri Lanka: Mr. Nimal Siripala De Silve, its service of provisioning Specialized
consultations to rural patients is occurring at a positive pace.
5.3 Re-assessing Change Management Efforts
The Final phase is to re-assess the change management efforts and to identify certain
bottlenecks or drawbacks if any. This was carried out by a series of surveys, which were

collected at the beginning of the project as well as at the end of the project. Furthermore, a
set of interviews conducted with medical specialists, system users, and patients to get their
feedback on how they feel about the new change of the traditional health system. Feedback
was collected and analyzed for the re-assessment of change management effort.
Suggestions and modifications were documented and required system changes amended.

6.

Results

The effort was successfully implemented at the Base Hospital, Marawila and District
Hospital, Dankotuwa in the form of an action research with a participatory approach giving
remarkable results in terms of Cost Reduction ( by 89.5%), Time-to-travel Reduction (by
67.6%) and Travel Distance Reduction (91.6%) in ePatients receiving eConsultation
through the system. Moreover, it was determined that patients were feeling much relaxed in
receiving Consultation through this System.
Pre and post surveys were carried out in order to calculate the efficiency and the
productivity of the new system. Pre survey was carried out under the span of four weeks
within the medical and surgical clinics [Figure 2: Pre-Survey Span]. Stratified sampling
techniques were used in selecting the sample. Afterwards, average values were been
compared with average values of the post survey results. Hence, the conclusions stated in
bellow were derived using the outcomes of the survey [Figure 3: Time Efficiency
Comparison between eConsultation and Conventional Consultation].

Figure 2: Pre-Survey Span

(Tw >> Tw)

(Tc < Tc)
(Tt >>> Tt)
?(Tw + Tc + Tt ) << (Tw + Tc + Tt)

Tw - Time-to-waite in the conventional system

Tc - Time-to-consult in the conventional system
Tt - Time-to-travel in the conventional system
Tw - Time-to-waite in the eHealth system
Tc - Time-to-consult in the eHealth system
Tt - Time-to-travel in the eHealth system

Figure 3: Time Efficiency Comparison between eConsultation and Conventional Consultation

7.

Business Benefits

Methodology described in the paper is being used in the pilot project which was carried out
between the two hospitals at north western province of Sri Lanka. ViduSuwa is being
launched between Marawila Base Hospital and District Hospital Dankotuwa. The process
has proven to be a very successful. Hence, it could be used as a process to be used in any
eHealth application in any developing country as a best practice.

8.

Conclusions

ViduSuwa was awarded as the National Best eContent Award in the Health & Environment
category, which was organized by Information & Communication Technology Agency of
Sri Lanka (ICTA) [22]. The HealthChange, the change management process that was
adhered in ViduSuwa has proven to be a successful one. The system-users showed a
significant attitude change towards the new system before and after the change management
process. After the process the users have taken the ownership of the system and even
suggesting the future changes of the system and have become the driving force behind
ViduSuwa. Hence, the process can be used in eHealth applications successfully.

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