Challenges & achievements in strengthening

Health Information Systems in

India: A historical

perspective T. Sundararaman.

Health Sector Reforms

• Malaria Control

• State Health Management Information Systems- In 7 States as part of WBHSDPs

• Routine Immunization Management Program

• Sporadic use in Medical College Hospitals- eg AIIMS

The 1st Generation Systems (1993–2005)

The first generation IT systems are characterized by low expectations, low effectiveness and complexity.

HMIS as part of World Bank Funded

HSRsState From Budget

(US M.$)

% HMIS allocation

Uttar P 2000 4780 77 1.6

Uttaranchal

2001 -- 11 --

Orissa 1998 82 10 11

Rajasthan 2004 159 20 19

Maharashtra

1999 138 12 9

Andhra P 1995 136 4 3

Karnataka 1996 78 9 12

Tamil Nadu 2005 132 26 20

Evaluation of phase 1 HMIS

( Study by EPOS-2004)

• Totally 15 states were funded by WB, DFID, USAID or NORAD.

• In three states only manual HIS could be strengthened; Optical mark reader in TN, Use of PDA in Andhra & Web-based system in Maharashtra.

• Uniformly Poor results: Maharashtra had some limited success:

• Problems due to changing requirements, poor infrastructural and HR capacity, poor ownership and change management, problems of integration, and need for policy.

Two Bold Andhra Experiments

1. India Health Care Projects: 3 districts of Nalgonda, 200 staff given PDAs( personal digiital assistants): for generating schedules, transmitting data, enable tracking: replace registers: insufficent hardware, problems of uploading into data-base, data-base used did not match names/services users; poor technical support, staff afraid to lose/use them.

2. Family Health Information Management Systems- mega spend of over 50 crores: name based follow up of FW services:scheduling, tracking, scaled up to whole state after a pilot in one dt., staff appointed in every PHCs: borrowed data base did not match, Bugs in software, incomplete data entry, poor use of informatio, schedules were handed down, but no demand for the same, poor ownership.

• The National Health Information Management Systems:

1. National HMIS Web-Portal: 2. Disease Surveillance Systems3. Pro-MIS ( drug procurement & Logistics)4. Mother and Child Tracking Systems5. Financial Transaction Recording Systems6. The RSBY support systems.

2nd

GenerationSystems

National Rural Health Mission

Catalyzed

States begin developing a number of Systems-

1.Human Resource MIS

2.Hospital Information Systems

3.Drug Logistics and Inventory Systems

4.E- Tendering and Procurement Systems \

5.Clinical Establishments Lregulation

6.Emergency Call Centre and Ambulance

7. Tele-medicine;Mobile Health,Insurance etc

2nd

GenerationSystems

National Rural Health Mission

Catalyzed

“Study of Functional Specifications of

Public Health IT Systems” nine IT systems.

Systems Studied: 1. Web Portal 2. DHIS 3. MCTS 4. NACO- SIMS 5. IDSP 6. Malaria-NAMMIS 7. Gujarat- eMAMTA, 8. Tamil Nadu- State HMIS (TCS)

LEARNINGS:On positive side there is an increasing commitment to use of electronic IT systems. Growing degree of complexity and sophisticationProblems related to DATA QUALITY; TECHNOLOGY & INSTITUTIONS

1. Andhra Pradesh – Historical HMI S Development

Completeness of data

reporting• Absence of private sector data. Private

clinics

and nursing homes do not send in data.

• Geographic areas like city corporations or company townships or some facilities get missed out.

• Some of the public facilities that are expected to report- fail to do so.

Timeliness and Adequacy of

reporting

• Delayed reporting effects the aggregation process adversely- data gets excluded from aggregation.

• Large number of zeros in the report leads to in - adequate reporting.

Errors in reporting and

aggregation

• Data definitions and misinterpretation, consistency of terms used

• Data duplication- Area v/s Service reporting

• Data aggregation problems -both random and systemic

• Data entry errors

Availability and Design of Primary registers

• Manual / Printed registers

• Missing data elements

• Computation feasibility

• Tracking / Follow up function

• Portability

Findings: Institutional

learnings: Limited Capacity building and No Change management- except in early part.

Local Data Analysis: Limited to data entry assessment. If available limited to higher levels, no analytics for local users.

User Friendly Reports and OLAP: fixed predefined report formats, no flexibility for users to define their own reports. User can’t slice, dice, drill down or drill-up. Although SAS is available in some systems but not used to help analysis.

Data Privacy & Security: Systems don’t follow common data security norms and have not been built with a purpose to ensure confidentiality, security & privacy of public health data.

Hardware and Network issues: Limited support to end user infrastructure

• Poor System Design: Poorly designed systems haven’t achieved desired objectives. Developed as Application for single purpose not at product which can be used in multiple programs. Inflexible, Lacking integration, Poor & Heavy form design, Limited data entry options.

• System in flux: System requirements are never frozen and are constantly changing, confusing for user as well as for designer.

• Product life cycle and procurement: Procurement is insensitive to software lifecycle and technology obsolescence. No evidence of product life cycle management, configuration management and release management- requirements document, functional and technical design documents, test plans and test reports not available for most systems.

• Lack of Standards- every system has done their own thing leading to data silos. Lack of Technology architecture, Data standards, Disease and procedure codes and Interoperability standards.

Findings: TECHNOLOGY LEARNINGS:

BUT the problem : All Public Health IT Systems in silos

Nutrition

Block

Facility

MCTS –

Reprod.& ChildHealth System

at National

Level

NACO National Disease Progra

mHospital Informa

tion Systems, EMR

State Health Programs e.g. EMRI,

eMamta, HMIS, DHIS

Birth &

Deaths

Private

Sector

MOHFW

District Admin

State HQ

Directorates e.g. Malaria, IDSP, NACO

IDSP National Disease Progra

m

Malaria National Disease Progra

m

RNTCP National Disease Progra

m

Web portal –

Reprod.& ChildHealth System

at National

Level

o Every program/ state develops own IT solutions. States have 10 to 30 systems

o No help to integrated decision making for Public Health management.

o State to central exchange very poor- and even at the same level.

o Systems a struggling with poor design and falling short of objectives.

o Private Providers not participating in information exchange.

Rapidly accelerating

expectations.

• From 600 district reports (2008),

• to 5000 block block reports ( 2011)

• to 2 lakh facilities( 2012), & 60 million mothers and children (2012), below 2

• to every health encounter ???

A larger more universal role for health information:

• In Public Systems:• Reduce work load of data recording • To support decentralized; integrated

decision making. • To improve morbidity and mortality

understanding.

• For Providers AND Patients• to improve quality of care

• To enable continuity of care

• For Insurance Payers• access to patient records for claims

settlements:

3rd Phase-

(2012 onwards):

From IT Systems to

IT Architectur

e….

The Digital Challenges- 1

The Primary Care Register

• A hand held device where services being delivered can be entered and the data base on population serviced can be stored and which will have 3 fns

1. Which will retrieve and display information/ record of any specific person- for better patient care

2. Will aggregate population based statistics and report it.

3. Which will be documentation of services delivered and a work organizer for the service provider.

Digital Challenge-2

The Hospital Information System:

1. Allow case-sheets to be stored and recalled when needed for patient care and patient information- without making case-sheet writing mandatory.

2. Allow administrative functions and enable administrative decision making

3. Generate aggregate data and epidemiological data- for reporting and public health

Digital challenge- 3

Public Health Management

• Generate public health information in terms of morbidity, mortality and if possible the cost of care

• Be able to allocate resources, reward quality of care, identify performance gaps.

• Ensure continuity of care across primary, secondary and tertiary levels and across geographies and providers.

Other Challenges

• Technical Inter-operability.

• Institutional Capacity:

• Institutional Designs- rule setting, authority, power

• People and Provider friendly

• Keeping Communities informed and involved.

THANK YOU