Towards a Smart GIS Public Health Record System for the Capital Governorate, State of Kuwait

Health care services are considered the sign of a contemporary civilized society, reecting its level of modernity. A study of the developmental stages and location variables of health care services can facilitate understanding location characteristics for a progressive perspective to achieve optimal standards of health care service. This study focuses on the 17 public health centers located within the districts of the Capital Governorate, State of Kuwait. The scientic methodology that is used in this study is based on a spatial and geo-statistical analysis of public health centers. The results of this applied analysis highlight the inadequacies of the current management system running public health facilities in the State of Kuwait. The study seeks to create a new system based on GIS technology dubbed “Public Health Record Information System”. The proposed system would not only rectify patient health record errors, but also improve the overall health management process.


Introduction
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The State of Kuwait is made up of six governorates ( Fig. 1) consisting of approximately 70 districts constituting the narrow, inhabited coastal area along the Arabian Gulf. Dependent upon the design of ideal land area usage, each district contains basic infrastructure and services, including that of health care. Accordingly, health centers were established within all districts so that each area had a clinic offering services to families based on a system of health le records for each person living in that area [6].
Since health records include patient health history and address data, they are an important source of information easily impacted by human or other error. For example, the existence of duplicate les for a single individual, or an additional health record le in a clinic outside a patient's residential area both result in multiple, patient records. In additional, similarities in different individuals' full names constitute another problem due to errors in health follow-up caused by incorrect medical histories of presenting patients. The problematic associated with recording health information creates a major obstacle in the administrative and follow-up systems of any health department. Misdiagnosis or mistreatment of a patient based on another person's health history can potentially lead to serious iatrogenic conditions. This study focuses on the 17 public health centers located within the districts of the Capital Governorate ( Fig. 1). The scienti c methodology that is used in this study is based on a spatial and geo-statistical analysis of public health centers. The results of this applied analysis highlight the inadequacies of the current management system running public health facilities in the State of Kuwait. The study seeks to create a new system based on GIS technology dubbed "Health Management Information System". The proposed system would not only rectify patient health record errors, but also improve the overall health management process [7,8].

Description Of The Research Problem
The importance of studying health care services comes with government efforts to realize programs that achieve social and economic goals. Although their importance has largely been limited to civilized societies in developed countries, health care services are gaining special attention in the policies of developing countries as growth and planning tools with which to uplift people and their societies.
The State of Kuwait was the rst GCC country to found health care services with the establishment of the Health Department in 1936. The rst government health clinic was also established, followed by the old Amiri Hospital (1949), along with specialized hospitals such as the Contagious Diseases, Psychiatry, and Chest Hospitals, all supervised by the Health Department a liated with the Municipality.
After Independence in 1961, the Health Department was converted into the Ministry of Public Health, and the Maternity Hospital was opened, and a year later Al-Sabah Hospital (1962) opened its doors to the people of Kuwait. A system of health records was initiated while expanding the number of hospitals and health complexes. During the 1980s, ve new hospitals were opened: Mubarak Al-Kabeer; Farwania; Jahra; Ibn Sina Specialized Hospital, and a renovated Amiri Hospital. This is in addition to specialized health facilities such as the Center for Islamic Medicine; Heredity Diseases Center; Kuwait Cancer Center; Razi Hospital for Osteology; Kuwait Center for Allergic Diseases, and Hamad Al-Issa Center for Organ Transplant.
The most important component of the health eld's administrative phase was instituting a system of health areas in the State of Kuwait. A 3-tiered system (initial, secondary and tertiary health care levels) was designed and applied in the 1980's. However, the Iraqi invasion and its aftermath had a profound negative impact on the efforts and infrastructure of Kuwait's health care system. Wholesale destruction, plunder, and deportation all health care personnel caused the health care system to suffer enormous setbacks. Despite this, the State of Kuwait exerted tremendous effort to restore and restructure the health care service network in all its governorates.
Because health care services are an essential function of any society, many geographic researchers have contributed to studying problems associated with providing them. However, it is notable that health care services in the State of Kuwait have elicited little interest among geographic researchers-excluding Sultan's study (1998) which focused on the nature of health care in the State of Kuwait as compared to that of other countries. The study also touched upon regional distribution of these services in different areas of the country. Alzaher's (2004) study emphasized a characteristic analysis of health centers in the Jahra Governorate in the State of Kuwait [9].
The current study's methodology is to apply Geographical Information Systems (GIS) in analyzing the level of health care services offered in Kuwait. It focuses on the Capital Governorate as the object under consideration-since similar studies are scarce. The current study represents a serious attempt to uncover administrative errors in the existing system of health care services with respect to registration and followup. There are numerous instances of health le duplication, patient name mix-up and other issues hindering organized health care provision at any given location, based on actual population distribution [10].

Previous Studies
Health care service studies vary in type at the international level and can be classi ed as follows: Studies tackling geographical distribution of health care service dependent on statistical techniques, the most important being-Schneider (1967); Abernathy et al (1972); Hertzel (1978), and Philips (1990). These studies sought to improve development of health care services through better understanding: location planning; characteristics of bene ciaries, and factors affecting competent delivery of health care services.
Studies focusing on location distribution of health care services based on population growth rates; development of health care service centers' numbers, and workforce volume. The most important of these being Taylor's (1982), which emphasized the problem of public services distribution, especially in rural areas. The importance of location distribution studies is con rmed by Shannon & Dever (1974) who posited that quantitative and qualitative location distribution of health care resources is basic to providing effective health care [11].
An international study tackled the technology of Geographical Information Systems (GIS) in the eld of health care services. Gesler (1986) emphasized using location analysis in medical geography to monitor the spread and location of diseases versus location of health care centers and hospitals. Lam (1986) determined location distribution patterns of cancer cases in China using geographical information systems. Jacoby (1991) examined using modern techniques to detect geographical distribution of physiotherapy cases, and distances between people and health care centers. Sanson, Pfeiffer and Morris (1991) used GIS to pinpoint areas where animal disease spread. This study is diverse in methodology since it depends on the means of allo cating cases, gathering, storing and analyzing data to present ndings in order to support environmental and civil planning. Kitron et al (1994) monitored Malaria cases in Palestine using GIS. Oranga's (1995) study depended on geographical information systems to locate population distribution around health care centers in certain African countries, especially those souths of the desert. Rushton et al (1997) used GIS in addressing concerns related to improving public health care services. Reissman et al (2001) used geographical information systems in the area of initial services to organize preventative pediatric health care follow-up. In addition, there are many studies, publications, and conferences periodically being held in the use of geographical information systems to improve health care services [12][13][14][15].
Developing countries have not been far behind with similar studies related to health care services. This is especially true in evaluating service status and drawing comparisons with developed countries, while identifying hindrances and providing solutions for upgrade. Some of the most important studies include Gestler's (1984) which emphasized the characteristics of developing countries' health care services; Annis's (1981) which focused on health care in Guatemala, and Siddiqi's (1980) which examined health service policies in relation to the development of Pakistan's health workforce.
As concerns the Arab region, there have been a number of geographical studies in the area of health care-especially in Egypt and the Kingdom of Saudi Arabia. The most important of these was Gomaa's (1978) regarding health care planning and development in Communist society. Also notable are Al-Zahrani's (1989) study dealing with health care services in Makkah, and Al-Kahtani's (1991) work on Saudi Arabian patterns of location distribution. Also noteworthy are Al-Ribdi's (1990) look at the geography of health care services in Saudi Arabia, and El-Bushra's (1980) study of the geographic distribution of Saudi Arabia services. El-Bushra also did a study (1985) on geographical population distribution and health care services in Yemen. A third study by the same author (1989) focused on Saudi Arabian patterns of geographical distribution and health care planning planning. Al-Walai's (1986) work focused on geographical distribution of diseases in Saudi Arabia, with special emphasis on location factors.
Geographical studies of Saudi Arabian health care have been extended to location modeling of services in the Baha area such as Al-Ghamdi et al's (1991) study. There were other studies analyzing regional distribution of services, which provided reasons for problems related to geographic distribution. These include studies conducted by Al-Kahtani (1994), and Al-Garallah (1997).
Locally, however, the efforts of geographic researchers in the State of Kuwait have been limited to just a few studies. These include the work of Sultan (1998), who presented a geographic and analytical study of Kuwaiti Kuwait health care services, and Al-Hamra and Al-Zaid's (1999) comparative study of patient referral satisfaction and level of service in initial health care centers. This is in addition to a number of specialized reports based on the most up-to-date study issued by Kuwait's Ministry of Health in 1999. Al-Jarallah (1996) focused on the development of health care services in the State of Kuwait since Kuwait's independence in the early sixties. Finally, Alzaher's (2004) work, the latest effort associated with the topic of this study, differs from it because its focus is on analyzing the characteristics of initial health care centers in the Jahra Governorate in the State of Kuwait [16].
Prior studies clearly indicate that there has been no serious Arab research to analyze health care service administration. Previous studies were lacking in the areas of hierarchy, supervision & guidance, and archiving of patient records-major factors in successful provision of health care. Therefore, the current study emphasizes these aspects while fully bene ting from GIS with respect to location and statistical analyses of administrative systems of health care service in Kuwait. The study uses the Capital Governorate in the State of Kuwait as an applicable model that can be generalized to other Kuwaiti governorates.

Methodology
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 computerbased 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: 1. Designing a residential database according to different residential areas vs. health centers.
2. 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.
3. Programming a Visual Basic simulation system to rectify geospatial metadata errors, especially in medical records. 4. Designing an applied model for speci c 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 nal 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][18][19][20].
In analyzing the questionnaire (Appendix A), it is evident that numerous administrative problems warrant attention, as follows: Objectives: This study proposes to achieve the following objectives: Develop methodology to reduce medical record errors.
Optimize health center allocation.
Improve the system health care administrative.
Create an automated control system for health services and management.
1. Loss of health les, especially expatriate les in about 85% of all health care centers.
2. Similarity in names within 71.4% of all health les necessitates a computer system linking names with other personal data such as date of birth and civil identity number.
3. 47.6% shortage in medical record data because doctors have insu cient time to complete records of diagnoses and other pertinent information.
4. 47.6% data de ciency 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 rst opening health les for new patients.
5. Keeping active patient health records for patients who have moved to other residential areas creates major problems caused patient carelessness in transferring health les to the new clinic. This leads to two-or more-sets of active les at different clinics, a situation requiring a nationwide administrative system preventing such duplication.
6. Administrator absenteeism is remedied by holding administrators accountable for carrying out their duties by creating a system that organizes and supervises daily work hours.
7. The current study has depended on the latest statistical data published 1999, thus indicating a lack of current data. This re ects 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 re ect administrative de ciencies 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 con rms the lack of a proper administrative system that would ensure balanced distribution of assistant health care personnel [21]. 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: 1. Establish an administrative database.
2. Establish a health database for patients.
3. Establish a population database in areas a liated to health care centers.
4. Establish a statistical database for severe medical cases.

Establish a location database (maps).
6. Design an information system to link the different databases.
7. Enter location analysis functions to the comprehensive information system. 8. Add a report preparation system for current, daily, monthly, and yearly reports-as needed.
9. Add an opinionative system asking for patients and population's views. 10. Add a performance evaluation system for administrative and medical performance.
The speci cations 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 a liated to the health care center (i.e. name, gender, nationality, civil ID number, home address, telephone number, date of birth, place of birth, occupation).

Spatial Database
It includes a detailed map of the blocks in a residential area a liated to a health care center, roadmap, and signi cant 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 ve-year time period that would in uence 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 re ects 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 geostatistical 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 a liated 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 speci cations, initially serving all network parties only. This will establish a central unit of health information systems a liated 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][25][26].
According to Fig. 6, the phases of executing the GIS system can be explained as follows: System Creation/Con guration 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 les from paper to digitally based les.

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.

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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 nal 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: 1. Representing data; adding layers and display in the GIS.
2. Exploring data: investigate statistical and spatial of database properties.
3. Fitting a model: choosing a model to create a surface.
4. 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.

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 speci cations of the area being studied. Determining technical and data requirements to execute proposed implementation is done as follows: 1. Name of implementation topic: "Application of GIS and Spatial Statistics on the development of the 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).
A. Data and Technical Requirements: Implementation necessitates technical requirements represented in a computer network, server and monitors, along with different programs. 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].
When pressing the continue button of this interface, a patient's health le is opened in the form of a stable interface for all cases. Its contents are as follows ( Figure 13): e. Annual Report: lists duties completed by all departments.

Operating Stage
The operating stage is the nal 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 2. Create a core data base for the health services, and publish annually reports supporting research. we had submitted the same research early October 2020 to the Gavin publishers to be published in their Journal entitled "International Journal of Community medicine and public health. After I received an acceptance letter within 3 weeks, I got the impression that they are not a real publisher. I search on the internet and discovered that the Gavin publisher is on the predatory list. I asked them to withdraw my research. from their website. After they received the full fee of 760 US$, I removed it. They send me this link to ensure that the research is not on their website anymore. We do con rm the right to resubmit the research to another Journal Declarations Ethics approval and consent to participate 'Not applicable' Consent for publication ' we had submitted the same research early October 2020 to the Gavin publishers to be published in their Journal entitled "International Journal of Community medicine and public health. After I received an acceptance letter within 3 weeks, I got the impression that they are not a real publisher. I search on the internet and discovered that the Gavin publisher is on the predatory list. I asked them to withdraw my research. from their website. After they received the full fee of 760 US$, I removed it. They send me this link to ensure that the research is not on their website anymore. We do con rm the right to resubmit the research to another Journal' Availability of data and material 'Not applicable' Competing interests 'Not applicable' Funding 'Not applicable' Authors' contributions "Aziz analyzed and interpreted the data regarding the geographical distribution of Public health Centers and was the major contributor in writing the manuscript. Al-Helal was involved in data capturing, classi cation, and achieving the data entry phase. Both authors read and approved the nal manuscript."