Health Management Information Systems

Why health information system? Good management is a prerequisite for increasing the efficiency of health services. Improved health information system is clearly linked to good management. Information is crucial at all management levels of the health services from periphery to the centre. It is required by policymakers, managers, health care providers, community health workers. “Changing the way information is gathered, processed, and used for decision-making implies changing the way an organization operates.”

Definitions System - Any collection of components that work together to achieve a common objective. Health System - All the activities whose primary purpose is to promote, restore or maintain health. Information - Meaningful collection of facts or data. Information System - Systems that provide specific information support to the decision-making process at each level of an organization. Health Information System - A set of components and procedures organized with the objective of generating information which will improve health care management decisions at all levels of the health system. The ultimate objective of health information system is not “to gain information” but “to improve action”

What is wrong with current health MIS? Irrelevance of the information gathered Poor quality of data Duplication and waste among parallel health information system Lack of timely reporting and feedback Poor use of information The difference in culture between data people and decision makers: Planning and management staff rely primarily on “gut feeling” to formulate ad hoc decisions rather seek pertinent data.

Relations between functions and objectives of a health system Stewardship Responsiveness to people’s non-medical expectation Creating resources investment and training Delivering services (provision) Health Fair (financial) contribution Financing (collecting, pooling & purchasing)

Service delivery functions in health units First level (dispensaries) To provide curative care for the most common health problems To provide prenatal care services To organize under-5 clinics (including immunization) To provide family planning services To provide IEC services in the catchment area Secondary level (First referral level) To organize out-patient referral clinics To provide in-patient services To manage medical, surgical & gynecological emergencies To provide X-ray and laboratory facilities Tertiary level To provide all types of surgical interventions To provide specialized care

Management functions in a health service system The central level (Ministry of Health) is responsible for: Health policy formulation, including policy on intersectoral activities Production of national health plans and guidelines for local planning Advisory role on allocation of resources, particularly capital funds Source of high level technical advice for specific programmes Training and regulation of health personal development Regulation of private profit and nonprofit health organization Control of national health organizations and research institutes Liaison with international health organizations and aid agencies State level is responsible for: State health planning and programme monitoring Co-ordination of all regional health activities Employment and control of the health personnel Budgeting and Auditing the health expenditure Managerial and technical supervision of district health teams Provision of supplies and other logistical support

Management functions in a health service system (contd.) The Districts have the following main functions: Organizing and running the district hospital Managing all other government health facilities Implementing all community-based health programmes Managing and controlling local health budgets Co-ordination and supervision of all government, non-government and private health services within the district Promoting active links with local government departments Promoting community participation in local health service planning Preparing an annual health plan Raising additional local funds In-service training of health workers Supervising and controlling all community health workers in the district Collecting and compiling routine health information and forwarding it to regions and ministries of health

Steps involved in restructuring of Health MIS Step 1: Identifying information needs and feasible indicators Step 2: Defining data sources and developing data collection instruments for each of the indicators selected Step 3: Developing a data transmission and processing system Step 4: Ensuring use of the information generated Step 5: Planning for health MIS resources Step 6: Developing a set of organizational rules for health information system management

Step 1: Identifying information needs and feasible indicators Identifying information needs for follow-up of a pregnant woman in a primary level Identifying indicators to ensure efficient drug management in a referral hospital Identifying indicators to ensure efficient Information, Education and Communication in the community Identifying indicators to monitor the quality of supervision by the district management team

Step 2: Defining data sources and developing data collection instruments for each of the indicators selected Develop an appropriate record form for follow-up of haemo-dialysis in a tertiary care hospital Develop a monthly reporting form for activities performed in a primary level clinic Define data sources for a situational analysis at the district level Develop data sources for monitoring the quality of teaching in a medical college

Step 3: Developing a data transmission and processing system Structure the information flow on pregnant women between the traditional birth attendant and midwife in the health centre Ensure that monthly report forms from health centres are entered in the district computer in a timely and accurate manner Develop a mechanism for reporting of Research done in a research centre

Step 4: Ensuring use of the information generated Develop user-friendly feedback formats for regional mangers on the utilization of inpatient services in the region Train health auxiliaries in follow-up procedures for hypertension patients using a standard record form Develop a curriculum for the undergraduate and post-graduate students depending upon the need in the country Ensure research on the priority health issues for the country

Step 5: Planning for health MIS resources Create positions of computer operators in cases where district level data processing is computerized Submit revised recurrent cost budgets based on proposed new data collection procedures Step 6: Developing a set of organizational rules for health information system management Develop standard case definitions Change the job description of doctors in cases where health information system restructuring involves their active participation in data collection Develop an instruction manual for computer operators

planning and management Information process Data collection Resources Data transmission Management Data processing Organizational rules Data analysis Information for use in planning and management

Knowledge states Processing activities Valuation Weighing option Interpretation Analysis Sorting selection Collection Decision Judgement Understanding Knowledge Information Data

Advice from peers Donors Budget constraints Advice from peers Donors Political parties Unions Community Past experience Religious groups Special interests Media Information Process of decision- making Decision

Ways to enhance the use of information in decision-making Characteristics of the data Characteristics of the problems and the decisions they require Organizational or structural characteristics Cultural differences between ‘data people’ and ‘action people’ The communication between the two

Characteristics of the data Ownership and relevance Validity and reliability Aggregation of data Customizing information to the users’ needs Timeliness of feedback

Different characteristics of the users (action people) and the providers of data (data people)

Sybsystems of Health Information System WHO proposes to categorize the health information system under five interrelated “subsystems”: Epidemiological Surveillance (notifiable infectious diseases, environmental conditions, and risk factors) Routine service reporting Special programmes reporting systems (tuberculosis and leprosy control, MCH, school health) Administrative systems (health care financing systems, health personnel systems, logistic systems) Vital registration systems (births, deaths, and migratory movements)

Communication Communication process within a health team Feedback process Communication products Time comparison Geographical comparison Comparison of actual performance vs. mean performance Comparison of actual vs. planned performance

A framework for defining information needs and indicators Perform a functional analysis at each management level of the health service system Identify information needs and select feasible indicators Patient / Client management Health Unit management Health System management

Indicators Indicators are variables that help to measure changes, directly or indirectly. - WHO Indicators are variables that indicate or show a given situation, and thus can be used to measure change. - Green Input indicator Process indicator Output indicator Outcome indicator Determinant indicator Count indicator Proportion indicator Rate indicator Ratio indicator Index

Helpful questions in selecting good indicators What is the indicator supposed to measure (validity)? What will be the cost of measuring the data to arrive at the numerator and denominator of the indicator? What is the relative importance of the subject matter to be addressed and the decision to be made based on the indicator (relevance)? Does the indicator actually capture the changes that occur in the situation under study (specificity)? Is the change shown by the indicator a true change in the situation under study

Helpful questions for operationalizing the indicator What are the sources of the data (numerator & denominator)? At what frequency should the numerator and denominator be collected? At what frequency should the indicator be processed and analyzed? Who will actually make use of the indicator? What is the target of the indicator that needs to be collected? What is the threshold for the minimum and maximum value of the indicator that should trigger an action? What will be the nature of the action (decision) once the indicator reaches the threshold?

Types of routine data collection methods Health unit data collection Community data collection to monitor activities performed in the community by health unit staff or by community health workers to obtain more representative data on the health status and living environment of the communities served, including data on births and deaths in the community, agricultural and meteorological data, data on education etc. to assist in planning for health services that are more accessible to community Civil registration systems

Data collection instruments Data collection instruments for patient/ client management Preventive Growth cards MCH cards School health card Family registration records Curative Medical records Laboratory forms Referral forms Other issues Content (comprehensive) Record filing (patient-retained vs.. health unit-retained) Layout (self-explanatory) Production form Electronic patient record

Data collection instruments for health unit management Service delivery records Registers Tally sheets (Abstract register Population charts Resource Management records

Data collection instruments for system management Health unit report forms Supervisory checklists ISSUES Layout Computerization

Design & Implementation of routine data collection systems How many and what type of data collection instruments will be needed to respond adequately to the defined information needs? Are existing instruments adequate, or do they need to be modified? If new instruments are needed, how will they be developed? How will the new data collection instruments be introduced to the care providers in charge of data collection? Other issues Relevance Feasibility Burden Layout & Clarity

Nonroutine methods & types of data generated

Health System Model management D E M Burden of A disease N Service delivery organization infrastructure S A T I F Y financing Other factors

Rapid assessment procedures Key elements Short interval for data presentation A methodological pluralism Orientation towards action Methods used Participant observation Individual interviews Focus group Review of reports and other documents Checklists for facilities, equipment etc. (Clinic exit surveys & household surveys)

Computers in MIS Optimization of the scarce resources available for health care, specially in developing countries Information - accurate, comprehensive Retrieval of information - quick Decisions - quick Implementation - rapid Monitoring - adequate Large geographical area can be covered

If computer network is established to cover all the CHCs More speedy communication of data At national, state & district levels, processing can be done for valuable information Obtaining coverage levels for various activities Age-specific & area-specific figures Check suspect data from CHCs Identification of problems requiring research Prompt reporting of results Achieve data standards Data for comparative purposes

Surveillance Active Surveillance Passive Surveillance Helps to assess the incidence and prevalence of diseases so that the magnitude of the problems and their importance can be known Helps to establish priorities and plan preventive programmes Essential to identify high risk groups Helps understand the local epidemiological trends and patterns Useful in monitoring and impact evaluation of control programmes against specific diseases Active Surveillance Passive Surveillance Sentinel Surveillance - A reporting system based on selected institutions or individuals that provide regular, complete reports on one or more EPI target diseases.

Vertical Data Transmission Horizontal Data quality: The degree to which the data or statistics measure what was intended to be measured when the data collection system was designed Inappropriate data collection Failure to report data Unintentional recording and reporting of inaccurate data Intentional recording and reporting of false data Errors in processing data - Editing, Coding, Data entry, Tabulating Vertical Data Transmission Horizontal

What can be done to improve and ensure data quality Keep the design of the information system as simple as possible Involve users in the design of the system Standardize procedures and definitions Design of data collection instruments Develop an appropriate incentive structure Plan for effective checking procedures Training

Population-based community health information systems The five E’s Epidemiology Empowerment Efficiency Equity Effectiveness

Development of community health information systems Determining community health activities PHC-MAP programme Autodiagnosis Iran’s Vital horoscope Community-based maternal records Community-based growth monitoring

Open questions How much equity can be achieved without a population-based community health information system? How much can we streamline population-based community health information system? How can we focus, expand, and refine the target group? What is the relationship between population-based community health information system and research? How do we invert the data collection/data response ratio? Can more communities design, implement, and manage their own information systems?

Health information activities and level Community Promote community demand for health information Map and house numbering Enroll each family Count the population from the enrollment forms, identify age-sex profile Create children’s and women’s rosters, copying their names from enrollment forms Create and distribute the home-based instruments Community health worker Visits homes regularly to promote health behaviours, update records, report pregnancies, births, deaths, migrations

Health information activities and level Health Supervisors Supervise CHWs, Monitor systems outputs, Control information quality Collect vital statistics data Report results of supervision Data transmission to higher levels Coordinator and local management Computerize data Summarize monitoring and supervision reports at periodic intervals and report to all levels with appropriate commentary

Data collection instruments Home-based records: Immunization cards, Growth-monitoring card, Maternal health card Health worker based records: Pregnancy/birth card, death report form, child records, women’s register, workers work form Supervisor’s based: Supervisor’s roster District-based records: Family enrollment forms, birth registers, death registers, health worker’s report, supervisor’s report Home office- and donor-based reports of health project outputs and population health status

Elements of Health information system management Organization rules Data collection standards Case definitions Data transmission Confidentiality Training standards Software design Procurement/ Distribution Quality assurance Private sector Basic Health Services HIS Staff Training HIS Supplies Hardware/ Software Financial Resources HMIS Management Hospital HMIS

Geographical Information System Definition: GIS can be defined as a set of elements that allow the computerized handling of geographically defined data, their entry, storage, analysis, and presentation Process: Linking an already existing, computerized health information system database to a digitized map Core elements: Geographical data & Attribute data Sources of geographical data: Digitizing maps, Surveys using global positioning systems Sources of attribute data: Routine health information system data, Census data, Survey data, Data from other sectors Advantages: Health outcome, Programme planning, Displaying performance indicators, Analytical possibilities, Displaying health care coverage, Intersectoral use of geographical information system

HMIS in context of Health Sector Reforms The more radical and innovative the proposed change is in regard to the information system, the greater the implications for change in the organization Reforms: systemic, programmatic, organizational, & instrumental The objective of producing and utilizing information more effectively will affect the behavior and motivation of all personnel