DEVELOPMENT OF A NATIONAL HEALTH DATA DICTIONARY: A PALESTINIAN EXAMPLE Mazen Skeik, BSc. MPHOct. 5 th 2011

Palestinian Territories: (West Bank, Gaza Strip and East Jerusalem) o Population: o 3.8 million o 42.6% Refugees: o 28.5% in West Bank o 71.5% In Gaza) o Health Care Providers : 1. Gov. (MOH) 2. UNRWA 3. NGO’s 4. Private 5. Military and Police 1.3 M

The Health Data Dictionary (HDD) in Palestine:  Health System Development Project (*HSDP) 1. Creating a HDD 2. Designing and implementing a Clinical Information System (CIS) o To test the HDD 3. Implementing a Health Insurance Information System * Financed by the International Development Association (IDA) MIS Component (Design and Proposed by Dennis Streveler (World Bank Consultant))

 Preparation of data items and definitions (proposed time frame 8-10 months)  Participation in several consultative meetings with representatives from: Policy Makers (MOH) Government Computer Centre Ministry of Interior (MOI) Computer Centre International projects United Nations (UN) agencies NGOs.  Initiation of a National Workshop was supported and attended by the Palestinian Minister of Health 1. Creating an HDD – Preparations:

1.Creating an HDD – Groups Involved in design, implementation, and maintenance:

 Successful HDDs in other countries were investigated, and a template was created:  Data Element Name  Reference ID  Data Element Type  Definition  Data Type  Field Size  Usage and Content  Codes and Values  Technical Comments 1. Creating an HDD – Formatting data elements:

 Collaboration between groups working on related fields:  Senior Medical specialists  Senior Nurses  Health care quality experts  Management information system experts  Allied health professionals  Pharmacists  Computer experts  Statisticians and administrators  Agreements reached between each group involving definition and value of the data 1. Creating an HDD – Involvement of Specialized groups:

1. Creating an HDD – Drafts and finalized HDD:  First draft was introduced in a final national conference  Through video conferencing between WB and Gaza  Final draft was reviewed by the national HDD committee  Endorsed by the Ministry of Health  Version 1 of HDD was published and produced  Distribution of hard copy of HDD in national workshop  Version 2 of HDD was published in 2005  As an online PDF on the Ministry of Health website (

 The Standardized Pharmacy:  The (550) drugs in Gaza and the (700) in West Bank were merged into one list. The formulary is structured on 30 therapeutic groups.  Codes and Values: (Concatenation of)  A Type of healthcare product  NN Name of category  N Name of sub category  N Name of sub-sub category  NN Dosage form  NN Product number When a dictionary can “enforce” accurate drug codes and positively identify the drug(s) being ordered, human errors and mistakes can be reduced. 1. Creating an HDD – Important outcomes to the MOH:  For Example: (E EDL)  06 ANTI INFECTIVE DRUGS  2 ANTI BACTERIALS  1 B-LACTAM DRUGS  11 VIAL  E BENZYLPENICILLIN 10 MILL IU

 Patient Identification Number (ID Number)  A patient's unique number that is given at birth to facilitate retrieval of individual clinical records.  Medical Record Number  The number used by the Medical Records Department to identify the patient's permanent medical/health record file. 1. Creating an HDD – Difficulties:

Decision made by H.E. Minister of Health: In MOH patient ID number and patient medical record number must be the same. 1. Creating an HDD – Difficulties: (Decision Made by Policy Maker)

1. Creating an HDD – International Standard vs. Local Standard :  The diagnosis established after study to be chiefly responsible for occasioning the patient’s episode of care in attendance at the primary health care facility.  The diagnosis established after study to be chiefly responsible for occasioning the patient’s episode of care in hospital (or attendance at the health care facility). Local Standard PHC Diagnosis Code International standard (Principal Diagnosis in Hospital (ICD10)

 The Clinical Information System (CIS)  Registration  Pharmacy  Chronic Patient File i. To demonstrate conformance to standards as defined in the data dictionary ii. Provide ongoing education and training for all staff in the clinic as appropriate to their use of data elements and their definitions 2. Testing the HDD – Implementing the CIS:

 Pre Measurement:  Too many patients at one time (Registration takes too much time)  Shortage of drugs for chronic patients (Unavailable accurate number of patients and schedules to get their treatment)  Post Measurement:  Patient registered one time, therefore resulted in fast retrieve of patient records and insurance checks  Drug supplies now available for chronic patient 2. Testing the HDD – Pre/post measurement Indicators:

Patient Registration at the time of arrival 2. Testing the HDD – Implementation of CIS

2. Testing the HDD – Changing to Computerized System:

 Adoption of the HDD by another health organization  EGH was running under European project  Budget available allowed for the Implementation and Integration of HMIS in the Hospital  HDD was used  Training Conducted NOTE: Key representative from EGH were involved in creating the HDD 2. Testing the HDD – European Gaza Hospital (EGH):

Factors of Success: i. Political  Support from High Level Policy Makers ii. Organizational  Teamwork and close co-operation amongst the key stakeholders and senior specialists. iii. Technical  Easy data module identified priorities to be included in the 1 st HDD. iv. Financial  All stakeholders were working volunteers

Challenges:  Political Situation  Curfew (between and within WB and Gaza)  Implementation  Some un-interest and resistance from health staff to use HDD and change to a computerized system (more work!)  Continuous education of new staff  No commitment from other Health institutions to use the dictionary  Sustainability  Running cost for maintenance and updating the HDD  Redesigning new forms

Future Directions: Developing Countries  Establish priorities and timing  Sustainability (Short and Long Term Financial)  Assign work to appropriate working groups  Electronic Documentation and Publications  Increase adoption of international standard

Palestinian Health Information Centre

Meeting With Health Information Centre Staff

Meeting With Director of Computer Centre in the Ministry of Interior (MOI)

Computer Department – European Gaza Hospital