2. District hospitals provide a significant proportion of health services in a district District hospitals consume a high % of the district health budget District hospitals report on communicable and non- communicable diseases District hospital reporting largely neglected District reports are thus under-reporting in relation to services provides Strengthening district hospital information systems urgent priority

3. Syntactic / technical level: Data transfer and interoperability. Example - SDMX-HD Semantic level: Meaning and shared understanding. Example ICD10 Pragmatic – organizational, political level: Decision making power deciding on what standards, and how should it be enforced

5. 1.Bottom up evolution, based on practice, while adhering to global and national definitions and guidelines. 2.Hierarchy principle, where the lowest level requires most detailed standards and levels above increasingly abstracted. 3.Flexible standards, to address the paradox of control and coordination

6. 20 hospitals in Himachal Pradesh, India Started with one hospital in May 2010 HISP India set up a team of 11 people to execute the project The hospital domain new for HISP India OpenMRS the development platform Scope: 10 modules (registration, billing, lab, radiology, OPD, IPD, Pharmacy, Inventory, blood bank, finance) Further, this application to be integrated with DHIS2

7. Routine Patient Flow at DDU

8. Hospital System Overview: Module Connectivity

9. Module level – what to collect, how, formats, mix between paper and electronic Inter-module level. For example, billing central, example it triggers medical services like Blood Bank, Lab and IPD. Creation of the Core module to manage communication. Hospital system level – combining with semi- permanent data Inter-hospital level – 20 district hospitals

11.  The setting  Doctors see about 100 OPD patients a day  In general, not comfortable with computers  “Care versus administration”  Doctors incentive?  Our approach:  Combining bottom up with global standards  Making it voluntary and not mandatory  Focusing on chronic and IPD patients  Getting doctors to provide solutions

12. Now 10 modules under implementation Standards help to deal with complexity Standards help tp enforce interoperability Flexibility allows adjustment of standards to local realities Flexibility key for scaling