Digital Health in

Sri Lanka

‘Sustainable Implementation of Digital Health Solutions through

Local Capacity Building’

1998-2017

Digital Health in Sri Lanka

The development of Digital Health in Sri Lanka is a joint effort of the Ministry of Health (MoH); Information and Communication Technology Agency (ICTA) of Sri Lanka; the Specialty Board in Biomedical Informatics, Postgraduate Institute of Medicine, University of Colombo (PGIM); and the Health Informatics Society of Sri Lanka (HISSL).

This booklet was compiled and published by the HISSL to showcases some of the key Digital Health initiatives in Sri Lanka. Sri Lanka would be happy to share its experience and expertise in implementing these systems with other countries.

This Booklet was compiled by the Health Informatics Society of Sri Lanka

http://www.hissl.lk info@hissl.lk

Table of Contents

The Health Informatics Society of Sri Lanka ............................................... 1

Human Resources for eHealth in Sri Lanka ................................................. 3

Strategic Planning for eHealth in Sri Lanka................................................. 7

PHN and MPI Personal Health Number & Master Patient Index ........ 9

eIMMR Electronic Indoor Morbidity and Mortality Register ............ 10

HHIMS Hospital Health Information Management System................ 13

HIMS Hospital Information Management System ................................. 15

DNMS District Nutrition Management System ....................................... 19

Electronic Patient Information Management System of the National

Programme for Tuberculosis and Respiratory Disorders .................. 21

eRHIMS electronic Reproductive Health Information Management

System ..................................................................................................................... 22

eNCD electronic Non Communicable Diseases System ....................... 24

Registering and Verification of the Electronic Health Information

Systems in Sri Lanka .......................................................................................... 25

"Suwasariya" Telehealth Programme ......................................................... 27

Sri Lanka Stroke Clinical Registry ................................................................ 30

Essential Drug Stock Alert Tracker .............................................................. 32

SLJBMI Sri Lanka Journal of Bio-medical Informatics .......................... 39

A Short History of Health Informatics in Sri Lanka and the Health

Informatics Society of Sri Lanka (HISSL) .................................................. 40

1

The Health Informatics Society of Sri Lanka

The Health Informatics Society of Sri Lanka (HISSL) [http://www.hissl.lk] is the professional association of all those in the field of eHealth in Sri Lanka. The inaugural meeting was held on 15th November 1998 at 0900 hrs at the Lionel Memorial Auditorium of the Sri Lanka

Medical Association with Dr. Shyam Fernando in the Chair and Prof. Tissa Vitharana, Advisor to the Minister of Science and Technology, as the Chief Guest. The meeting was attended by 75 people. The constitution of the Society was adopted.

The picture shows from left to right Dr. Vajira H. W. Dissanayake (Founder Secretary), Prof. Tissa Vitharana, the late Prof. MTM Jiffry and Prof. Shyam Fernando (Founder President) lighting the oil lamp at the start of the inaugural meeting.

The primary objectives of HISSL are:

1. To promote the use of computers and

2

information technology in teaching, learning, research and delivery of care in the field of health.

2. To improve computer and information technology literacy of health care professionals.

3. To improve the access by health care professionals to computer hardware, software and information technology services.

4. To improve and facilitate continuing professional development of members.

5. To improve and facilitate research and development in health informatics.

6. To foster collaboration with national, regional and international medical, informatics and professional associations.

7. To foster fellowship among members.

The picture shows a section of the audience at the inaugural meeting held at the Lionel Memorial Auditorium of the Sri Lanka Medical Association on 15 November 1998. In the front row from right to left are three Presidents of HISSL – Prof. Vajira H. W. Dissanayake (Current President), Prof. Resvi Sheriff (Immediate Past President) and the late Prof. MTM Jiffry.

3

Human Resources for eHealth in Sri Lanka The strategy of developing Human Resources for eHealth in Sri Lanka is two-fold. The first strategy is the creation of a group of ICT competent doctors who can work as the interface between the medical and ICT profession to spearhead the planning, development, implement, monitoring and evaluation of ICT projects in the Health Sector in Sri Lanka working in close collaboration with Medical Administrators.

This is done through the MSc course in Biomedical Informatics of the Postgraduate Institute of Medicine, University of Colombo (PGIM). The curse is aimed at producing a generation of leaders in eHealth in Sri Lanka who can spearhead the implementation of ICT in the health sector in Sri Lanka working hand in hand with the administrators and policy makers at the highest level.

The stakeholders of the MSc and MD courses

The course was initiated in 2007 as a joint project

between the University of Colombo, Sri Lanka and the

4

University of Oslo, Norway by Prof. Vajira H. W. Dissanayake, the current President of HISSL, and Prof. Sundeep Sahay, Professor, Department of

Informatics, University of Oslo with the support of Prof. Resvi Sheriff, the Director of the PGIM, who was at that time also the President of HISSL.

The first batch of MSc graduates with the Members of the Director PGIM and the Members of the Specialty Board in Biomedical Informatics

The course was supported by a NOMA grant funded by Norad and managed by the Norwegian Center for International Corporation in Higher Education (SIU). How the stakeholders partner to produce specialists for Sri Lanka is shown in the figure in the previous page. So far 90 graduates have graduated from the course. They are deployed across the public health sector in Sri Lanka both at central and regional level. The PGIM commenced the MD in Health

Informatics course in January 2017. This would enable the successful graduates to become board certified as specialists in Health Informatics in Sri Lanka. This would make Sri Lanka one of the few countries in the world to have such specialists. The second strategy is the development of ICT awareness and literacy among the health workforce. This is done through various workshops, seminars and conferences organized by the HISSL and the Ministry of Health. The

5

Major eHealth Conferences organized by the HISSL in the past few years include the

ones listed below.

2010: eHealth Sri Lanka 2010 Conference [http://www.hissl.lk]

2012: eHealth Symposia were held in Colombo, Galle, Kandy, and Jaffna as part of the 125th Anniversary Celebrations of the Sri Lanka Medical Association

2014: eHealth Sri Lanka 2014 Conference [http://www.hissl.lk]

2015: eHealth Asia 2015 Conference [http://www.ehealthasia.org] with the Minister of Health Honorable Dr Rajitha Senaratne as the Chief Guest.

2016: 24th Triennial Conference of the Commonwealth Medical

Association 2016 on Digital Health for Health and Wellbeing [http://www.cma2016.org] with the President of Sri Lanka His Excellency Maithripala Sirisena as the chief guest

6

The following upcoming conferences will be hosted by HISSL in Sri Lanka:

2017: 2nd Commonwealth Digital Health Conference – 10 to 12 October 2018: Asia Pacific Association of Medical Informatics 2018 – 9 to 12 October

7

Strategic Planning for eHealth in Sri Lanka Strategic planning for eHealth in Sri Lanka began with the establishment of the National eHealth Steering Committee in the Ministry of Health in June 2010. Working under the directions of this committee and Dr. S.R.U. Wimalaratne, Director (Information), Ministry of Health, and Dr.

Champika Wickramasinghe who succeeded him in 2013, the National eHealth Technical Committee has developed the following national eHealth Base Documents. - National eHealth Policy - National eHealth Standards

and Guidelines - National eHealth Strategy

The national eHealth Policy articulates the guiding principles for eHealth in the healthcare sector of Sri Lanka. Its vision is to streamline the adoption and use of ICT in the Healthcare Sector of Sri Lanka.

Its mission is to facilitate adoption of ICT solutions appropriately in the healthcare sector of Sri Lanka to improve the quality, efficiency, patient safety, and cost effectiveness of health

8

care thus contributing to achieve the goals set out in the National Health Policy. The Standards and Guidelines and the Strategic Plan are aimed at achieving this vision and mission. A parallel process

is the acceptance of a uniform personal health number (PHN) to be used across the health care services to identify patients. The PHN has now been officially endorsed.

9

PHN and MPI Personal Health Number & Master Patient Index

The Health Ministry is in the process of implementing the National Healthcare Recipient Identification System to enable it to consolidate all the interactions of a particular person with the healthcare system to his/her Personal

Health Number (PHN). This will allow the Ministry to capture the true disease burden of the country as opposed to the individual incidences that are being captured now.

The format of the PHN

The MoH has also taken steps to introduce a Master Patient Index (MPI) at district level initially with the intention of scaling it up to national level. This would further enhance the development and use of Personal Health Records in the future, which would be a great

benefit to the healthcare recipient, where all his/her medical records are in one place. These initiatives are aimed at ensuring interoperability among electronic health record systems within the country.

10

eIMMR Electronic Indoor Morbidity and Mortality Register

The first system approved for country wide implementation in the Health Sector in Sri Lanka

Collection of nationwide real time data on indoor morbidity and mortality (IMMR) is challenging. The eIMMR system developed by Dr. Nadish Kariyawasam and Dr. Buddika Dayaratne is now making this possible in Sri Lanka. Initially developed as an MSc student project in 2009 with a grant of Rs. 50,000/- from the HISSL. It has now been taken over by the Ministry of Health. It is the first software tool approved by the Ministry of

Health for nationwide deployment. It is currently implanted in over 400 (63%) health care institutions (out of a total of 635 secondary and tertiary care institutions). These institutions account for approximately 70% of the total nationwide hospital admissions in Sri Lanka. There are 1738 user accounts. The database now contains over 15 million records. It is hoped that all institutions will use the eIMMR system for reporting their statistics by the end of 2017.

Web interface of the eIMMR

11

13

HHIMS Hospital Health Information Management System

Many developed and developing countries around the world have realized the advantages of incorporating Information and Communication Technology (ICT) into the health sector. Sri Lanka is also looking into development of electronic health solutions for the preventive and curative healthcare sectors of the country. The Information and Communication Technology Agency of Sri Lanka (ICTA, currently operates under the Ministry of Telecommunication and Digital Infrastructure) with the intention of making Digital empowered nation, initiated “Digital Health Project” collaboration with Ministry of Health.

The Main objective of this government funded project is to improve quality, safety, efficiency and patient centeredness in service delivery of the Sri Lankan state health sector using ICT. This focuses on improving the quality and efficiency of the health care services provided by the government hospitals in Sri Lanka by implementing electronic medical records systems in 300 government hospitals covering the National Hospital, Teaching Hospitals, Provincial and District General Hospitals, Base Hospitals and selected divisional hospitals throughout the country by the end of 2018. The Digital Health project promotes Electronic Health Records (EHR). EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and doctors. The data, the timeliness and its

13

availability will enable providers to make better decisions and provide better service to the Sri Lankan health sector stakeholders including decision makers. The ICT Agency of Sri Lanka, developed the ‘Hospital Health Information Management System’ (HHIMS) on the request of medical practitioners and administrators of the government health sector back in 2010. It is a free and open source software solution (FOSS). It includes an Electronic Medical Record, Patient Admission, Appointment and Queue Management, Clinic Management, Laboratory Information System (LIS), Pharmacy Stock management, Notification, OPD Management, Questionnaire, Report, Ward Management, User Management, Permission and PACS modules and other modules as in the figure below. Performance management dashboard is also included in HHIMS. HHIMS is a web based

software solution. It was developed in PHP 5.5.9 with Codeigniter v2.0.1 framework which requires Apache 2.4.7 environment. If it is a local deployment ICTA propose a server with 8 GB memory and 1 TB hard drive in latest Ubuntu server distribution. HHIMS software is being used successfully in several state sector hospitals like National Hospital of Sri Lanka-Accident service (premier trauma care institute in Sri Lanka), Base Hospital-Avissawella , District Hospital Dompe, Base Hospital-Panadura and General Hospital-Ampara. HHIMS was implemented in Karawanella BH in 2011 as HHIMS version 1.0 where ICTA took the initiative to fund and proceed with the project with all aforementioned features. Then HHIMS was implemented in Dompe DH (2011, V1.1), Avissawella BH (2013, V1.3 customized) and Panadura BH (2014, V1.3). ICTA has selected 3 major government hospitals - Homagama BH, Horana BH and Galagamuwa BH to

14

implement and pilot the latest version (v2.7) of HHIMS with facilitating Wi-Fi enabled network infrastructure. Homagama and Horana BH systems were started in mid of 2016 which currently operational in all sections of OPD setup with enhanced usability and user friendliness from the lessons learnt from initial implementations and resource personnel. This project aims to increase the EHRs coverage of the selected hospitals up to 80% from the total patients who access the health services

from government health sector. Final outcome of this project is to improve quality and efficiency in service delivery, governance, accountability and effective use of resources of the government hospitals. As result of that availability of updated, accurate information for patient care will be found. That helps improve the capacity of health authorities to detect emerging and re-emerging diseases and take necessary preventive actions in future.

15

HIMS Hospital Information Management System

Development and implementation of Hospital Information Management System (HIMS) for the large hospitals in the state health care was initiated in 2013. The solution focused on enhancing service delivery, streamline the information management, sustainability and cost effectiveness. Requirements of key stakeholders were taken into consideration in the development process and the solution adopt agile development methodology enabling accommodating end user needs. The scope of the HIMS project includes development of Hospital ICT infrastructure, improvement of end user ICT literacy and implementation of the HIMS. Further, improvement of software system, building hospital capacity to maintenance the system and ICT infrastructure were also considered. Core modules of the HIMS (Master Patient Index, Ward Management Module & MRO module) were

implemented in four hospitals at the moment. The laboratory module of the HIMS is deployed at the National Cancer Institute Maharagama and it is in initial stages of implementation in other hospitals. Computer resource centres (IT training centres and Computer maintenance units) were established with capacity to provide the necessary training to users and maintenance of equipment to ensure smooth operation of the system. Its mandate is to maintain the LAN and end user training to improve the ICT literacy. The developers who are stationed at the National Cancer Institute Maharagama carry out further improvement of the software and perform maintenance. The software development was a collaboration between the Ministry of Health and the University of Kelaniya. The software was designed in a

16

modular way and initially focused on inpatient care at the hospital. Admission/ discharge and clinic registering module was developed initially and implemented as the base module. HIMS is capable of issuing unique patient identifier, Personal Health Number (PHN), and it can

capture a PHN issued from other hospitals. The system is completely interoperable with the eIMMR system, the official indoor morbidity and mortality reporting system of the Ministry of Health, thus allowing automatic transfer of IMMR data from HIMS to eIMMR.

. The components of HIMS

Three developers provide around the clock maintenance service of the HIMS. They are also involved in development of other modules. They are being stationed at the IT laboratory of the National Cancer Institute Maharagama. The Ministry of Health and two international donors provided the funds required for the project. Minor customizations

required by different hospitals are also being addressed by the same developers. Implementing hospitals are not bearing any cost for the software and the source code of the software is the property of the Ministry of Health. Knowledge of the end users to adopt a computer based system and proper change management are very

17

important aspects in HIMS implementation and sustainability.

A nurse updating clinic records

All hospitals adopted gradual implementation process allowing users to familiarize with the software. After period of successful parallel running of both systems, manual and digital system, a compressive evaluation was carried out before shifting to the digital system. The Ministry of Health’s requirement to keep paper base documents was replaced with printouts generated from the system. Training programmes are being carried out on basic computer skills covering all categories of staff and software specific training is

provided to the direct users of the system. Implementing HIMS is having many positive impacts on the health system. With the implementation of the Master Patient Index time taken for patient registration will be minimized and patients who are already registered in the system need not submit personal details on subsequent admissions. At the end of the care process an indoor mortality and morbidity report (IMMR) is generated for each and every inward patient at the Medical Records Office (MRO). With the implementation of MRO module of the HIMS the system utilises the patient information entered at various care points to generate the IMMR. The IMMR generated with the ICD 10 code can be automatically transferred to the eIMMR system of the Ministry of Health. In the future the Ministry of Health is gearing up to adopt using the PHN to identify IMMR records thus minimizing errors and duplications. With the introduction of the laboratory

18

management module patient investigation reports will be saved to the patient profile. Sri Lanka spends about 2% of the GDP on Health. The government absorbs a huge cost to provide free health care services. The software development model that was adopted has saved millions of rupees to the government. For the last three years the cost of software development was only Rs. 3.5 million rupees. Since the source code belong to the Ministry of Health any government hospital that is willing to implement the software will get it free of charge and the necessary modifications and maintenance support will be provided free of charge.The method adopted to develop trained personal to maintain the network and the hardware is unique. The Ministry of Health with the help of University of Moratuwa trained selected staff from the hospitals to carry out above functions and the necessary tools were also provided. Training of hospital staff is

being carried out at the implementing hospitals. This sustainable model adopted by the project team allowed the Ministry of health to own a Hospital Information Management System with a very minimal cost. The Ministry need not fund each and every hospital to purchase software. Furthermore maintenance is carried out by staff members who are already in the health sector with no additional burden to the national health budget.

19

DNMS District Nutrition Management System

Sri Lanka is seen as a model for delivery of high quality health care in a low resource setting. The nutrition indicators of children however give a different picture. The government of Sri Lanka decided to address this issue with a national action plan coordinated at the highest level of government – the Presidential Secretariat. The Health Informatics Society of Sri Lanka (HISSL) was invited to develop the District Nutrition Monitoring System to support the multi-sector action plan for nutrition. The system consisted of three components. The first component was a smart phone app to be used by public health midwives that enable them to track and

monitor children in their areas. The second component was a web application to enable healthcare managers to monitor the nutrition status of children across the country. The third component alerted different government agencies in the health sector, social services sector, and agriculture sector to take personalised interventions aimed at households that had malnourished children using risk factor data gathered by public health midwives, and enabled them to monitor the effectiveness of the interventions. The software backbone of the system was DHIS 2. The financial support came from Unicef. The first phase of implementation commenced in June 2016. This involved

20

deploying the system in 3 districts – Nuwara Eliya, Matale, and Polonnaruwa. 604 public health midwives were trained and they commenced using the system. A post implementation evaluation and a field level review is currently underway to further strengthen implementation activities. The Project Team lead by Dr. Roshan Hewapathirana and Dr. Pamod Amarakoon won the award for the best early stage app in South Asia at the mBillionth awards of the Digital Empowerment Foundation in New Delhi, India in July 2016; the Commonwealth Digital Health Awards in October 2016, the eSwabhimani National ICT Awards in November 2016, and the World Summit Award 2016 after having been placed first among entries from 178 countries at the World Summit Awards (WSA)2016. [https://www.worldsummitawards.org/winner/district-

nutrition-monitoring-system-dnms/]. WSA has been initiated in 2003 in the framework of the UN World Summit on the Information Society (UN WSIS). It contributes to the UN SUSTAINABLE DEVELOPMENT GOALS AGENDA by recognizing local digital content with an impact on society, demonstrating the richness and diversity of innovative applications.

. The team accepting the

mBillionth Award

21

Electronic Patient Information Management System of the National Programme for Tuberculosis and

Respiratory Disorders The Electronic Patient Information Management System for Tuberculosis is a successful programme-wide DHIS2 implementation. The National Programme for Tuberculosis Control and Chest Diseases (NPTCCD) commissioned the implementation in 2013 for Tuberculosis aggregate reports. Currently it has evolved into both aggregate and individual records and has been designed to encompass TB and other respiratory diseases such as COPD/Asthma and Lung Cancers. Data is captured through the chest clinics and at field levels. With the emergence of multi-drug resistant TB, the WHO and the Global Fund (GFATM) have highlighted the importance of

TB case surveillance. Hence, funded by the GFATM, the system is moving towards being developed into a comprehensive, integrated solution for respiratory disease management and reporting. The project is coordinated by Dr. Pramil Liyanage and it received the Commonwealth Award for Application of eHealth to Reach SDGs with Special Jury Mention at the Commonwealth Digital Health Awards in 2016.

22

eRHIMS electronic Reproductive Health Information

Management System

The Reproductive Health Management Information System (RHMIS) is the main source of data for national health indicators in maternal and child health, family planning, adolescence and women’s health. The electronic Reproductive Health Management Information System (eRHMIS) was designed to replace the paper-based system which consists of nearly 25 data collection formats. The system is planned to be developed and implemented in a phased out manner. During the phase 1, Maternal and Child Health (MCH) data will be captured at Medical Officer of Health (MOH) level in aggregated format. It is planned to capture data at Public Health Midwife (PHM) level where the services are provided as disaggregated data of individuals. eRHMIS

will be expanded to capture all public health information required by the Family Health Bureau, the main government agency involved in coordinating maternal and child health care in Sri Lanka. System will be expanded to capture other public health data such as special surveillance data. eRHMIS has now been fully implemented island wide with all MOH offices in the country reporting their statistics electronically.

23

The Data Entry Screen of eRHMIS

An eRHMIS User Training Workshop

24

eNCD electronic Non Communicable Diseases System

This DHIS2 based system implementation was implemented to support the Non-Communicable Disease Unit of the Ministry of Health. From 2014 to 2016 the system was able to replace the paper based data gathering on Diabetes, Hypertension and Cardio-Vascular Diseases in the community. The data

capturing is done at Mobile NCD Clinics, Healthy Lifestyle Clinics and NCD clinics in preventive care institutions. The next phase of the project is expected to incorporate Road Traffic Accidents Surveillance. It is also planned to enable mobile supported data capture at mobile NCD clinics.

Handing over of the system by the development team to the Minister of Health Honorable Maithripala Sirisena (the current President of Sri Lanka) on 24 January 2014 by Prof. Vajira H. W. Dissanayake. Dr. Deepal Wijesooriya who led the team that developed the system is also in the picture.

25

Registering and Verification of the Electronic Health Information Systems in Sri Lanka

Most of the Health Information Systems in Sri Lanka are currently being computerized. This is meant to improving the efficiency, reliability and meeting expectations of the stakeholders. Many software are being developed, piloted and implemented in the state healthcare sector. Sometime there is duplication of effort. The “National eHealth Guideline & Standards (NeGS)” which is applicable for electronic Health Information Systems of both the state and private healthcare sectors is now in effect. The state healthcare sector has now recognized the requirement for a mechanism to ensure adherence of the electronic health information systems to the NeGS and other legal and ethical requirements to ensure interoperability, legality and sustainability of these systems. The scope of this initiative is to create a registry of the

electronic Health Information Systems of the State Healthcare Sector that covers one or more of the following areas: ● Systems that manage

Personally Identifiable Data of healthcare recipients.

● Clinical information systems.

● Systems managing medical equipment and/ or medical supplies.

● Systems handling aggregated data of one or more medical conditions including risk factors and outcomes of the condition(s).

The process will address the issues arising in emerging electronic health information systems early in their life cycle, ensure that the systems cater to the requirements, and identify overlapping systems catering to the same scope and facilitate comparing such systems which in tern would

26

facilitate the implementation of the NeGS. The processes and the formats were presented at technical level forums for suggestions and critical analysis. The way forward include the further improvement to the formats/ processes according to the suggestions, the recommended version to be National eHealth Steering committee for approval, pilot testing of the process, development of the web based system to enable the proposals

to be accepted and to responded online. Furthermore the paper based system will be continued in parallel till the web based mechanism is streamlined. A hand book will be prepared on the process to guide the researchers, developers, implementers and other stakeholders of electronic health information systems.

27

"Suwasariya" Telehealth Programme Instantaneous access to free medical advice or health information on disease details as well as disease prevention from qualified medical professionals or from a recognized institute is a vital factor in community health promotion. Electronic media is now frequently used as a tool for health-related information and communication in recent years. Sometimes medical care seekers appear to be using the Internet to enhance their own medical care by using the information online to diagnose a problem. Identifying above situation and needs, Suwasariya (Healthnet) was designed and developed as a national programme to educate and promote health of Sri Lankan people by Health Education Bureau (HEB) which is the center of excellence in Sri Lanka for health education, health promotion and publicity of health

information. Its services aimed for empowering and mobilizing communities for the improvement of their quality of life through health promotion principles. Implemented as a tri-lingual health education information, advice and guidance service by the Health Education Bureau from which Sri Lankans within the country and abroad can access and seek help in the language of their choice. Suwasariya has two main components, a health educational web site (http://suwasariya.gov.lk/) and a 24/7 health related help seeking call centre (Hot line-+94710107107, email and SMS). Following types of health educational services are provided by Suwasariya web site and call center. ➢ Provide guidance to

resolve non-emergency medical issues.

➢ Education on personal conditions needing

28

discussion with a doctor. ➢ Providing information

about disease prevention and treatment.

➢ Provide clarifications on health publication and other communications .

➢ Personalized advice on Nutrition, Healthy Lifestyle, and Personal Hygiene.

➢ Education and guidance on Sexual problems difficult to discuss face to

face with a doctor. ➢ Provide services to who

are abroad working or travelling and in need to discuss health issue with a Sri Lankan doctor in his or her mother tongue.

Services are provided by consultant community physicians and medical officers who are well experienced in preventive and curative sectors in Sri Lanka. It is supported by a group of other government health institutes.

29

30

Sri Lanka Stroke Clinical Registry Stroke is the third leading cause of hospital death worldwide. It is the main cause of adult disability. Effective management of strokes is hindered by many factors and one of the most important issue is lack of reliable epidemiological data, indicators, prevalence pattern leads to reduced quality of care given in acute, chronic and rehabilitative phases of the affected patients. Therefore the need to develop a Stroke Clinical Registry was crucial to improve the management, treatment, and rehabilitative care. Hence the objective of this initiative was to design, develop and pilot the web based Sri Lanka Stroke Clinical Registry (SLSCR) for the management of Stroke patients. The project was funded by World Federation of Neurology and World Stroke Organization through Ministry of Health. The core team included professionals from the National Stroke

Association of Sri Lanka, Association of Sri Lankan Neurologists, Ministry of Health, Health Informatics Society of Sri Lanka and other healthcare providers. The SLSCR provides individual and health related information of patients, generates real-time data from the patient records for health management at various administrative levels, and facilitate clinician to access accurate patient information. The implementation commenced with a detailed requirement analysis and an architectural design for the electronic Health Information Management System and creating data components. The system was developed using Free and open source software such as PHP and MySQL in order to minimize cost and was piloted at Stroke Unit of National Hospital, Sri Lanka. During the pilot phase software underwent testing

31

for any issues of system functionalities, Graphical User Interphase, data entry and analysis reports were documented and resolved. After successful implementation at the Stroke Unit of the National Hospital of Sri Lanka, the system was introduced to the Teaching Hospital (TH) Kandy, TH Karapitiya, TH Jaffna and District General Hospital (DGH) Chillaw. Nursing officers were trained to enter

data. The system was introduced to the Colombo South Teaching Hospital (Kalubowila), Mulleriyawa Base Hospital, and the Teaching Hospital Batticaloa. Upto February 2017, data of more than 5300 stroke patients were captured in to the system. It is planned to introduce the system to all the Stroke units, Tertiary Care Hospitals and all District and Provincial General Hospitals by the end of 2017.

32

Essential Drug Stock Alert Tracker The health status in Sri Lanka is well above the regional health indicators and it clearly reflected in the heath indicators. However lack of pharmaceutical supplies in government healthcare institutions is a major complaint from the general public. The Medical Supplies Division (MSD) issues pharmacy items for the region to their Regional Medical Supplies Division (RMSD). Ministry of Health institutions receive pharmacy supplies directly from the MSD. Provincial health care institutions receive their pharmacy supplies from RMSD and there is a Divisional Pharmacist in the RDHS office to monitor and regulate this process. Each health institution maintains their drug stock within their own drug store. However with the present manual system, real time drug stock status information of

each institution is not available at the RMSD or at the regional and provincial health offices. Therefore they are not able to take steps to replenish stocks in a timely manner. As a result most of the shortages of pharmacy items in health care institutions are not due to the shortage of drugs at RMSD or MSD but due to this poor communication between RMSD and health institutions or unequal distribution of the items from the RMSD. As drug stocks are maintained in a manual drug stock register, there is no active alert mechanism to make alert the head of the institution or officer in charge of the drugs store to low stock early and inform the RMSD to supply stocks in a timely manner. To overcome these problems a simple web based application was developed to establish a timely information flow. This Essential Drug stock alert tracker was developed and integrated to the Provincial

33

Health information System (PDHIS). Each health care institution was given a user name and password to log into the system. The Officer in charge at the drug store can log into the system and enter the pharmacy items received from the RMSD and items issued from the drug store to the wards, clinics and OPD during the week. Each institutions average daily usage is entered into the system and from that their reorder level is calculated. There is a color code system implemented and the user dash board visualize the available stock with the color code. This system was deployed in all regional hospitals in the Colombo district (2 base Hospitals and 9 divisional hospitals) from August 2015. It was extended to the hospitals in the Gampaha and Kalutara districts in October 2015. Currently there are 42 health institutions in the Western Province using the system. At the commencement of the

system in the Colombo district (2015/8/21) 16.24% of items were at zero stock level and only 55.56% items were at satisfactory stock level. By January 2017 zero stock level had reduced to 0.4% and satisfactory stocks level had increased up to 85.4%. The Zero stock level in Kalutara district showed a decline of 23.42% which was the highest reduction compared to the other two districts. However satisfactory stock level had only indicated an increase of 19% by January. The success of the system was recognized by the Commonwealth Medical Association (CMA) and the South Asian Digital Empowerment Foundation (DEF) by awarding this system a Commonwealth Digital Award and Manthan Award respectively in 2016. The team: Dr A L Fareed - Provincial Director of Health Services, Western Province, Dr Anil Samaranayake - Deputy Provincial Director of Health Services, Dr Vajira Nanayakkara – Consultant

34

Community Dental Surgeon, Dr Lasantha Ranwala - Chief Designer and (now Registrar in Health Informatics and formerly) Medical Officer Health Informatics, Office of Regional Director of Health Services, Colombo, Dr

Mohamed Rikaz Sheriff – (Formerly) Medical Officer Health Informatics, Dr Sandun De Silva – District Registered Medical Officer ,Office of Regional Director of Health Services, Colombo

39

SLJBMI Sri Lanka Journal of Bio-medical Informatics

The Sri Lanka Journal of Bio-medical Informatics (SLJBMI) published jointly by the Postgraduate Institute of Medicine of the University of Colombo and the Health Informatics Society of Sri Lanka is the only Sri Lankan journal in the field of Biomedical Informatics. The fist issue of the Journal was published in January 2010. It is published quarterly. The Editor in Chief of the Journal is

Dr. B. J. C. Perera with Prof. Vajira H. W. Dissanayake, Prof. Jayantha Weerasinghe, Dr. Rohana Marasinghe, and Dr. Roshan Hewapathirana serving as Executive Editors. It is a peer-reviewed open access journal available freely on the Sri Lanka Journals online platform at the URL: http://www.sljol.info/index.php/SLJBMI

The journal ceased publication after its second issue of the fourth volume in 2013. It is expected to be revived soon.

40

A Short History of Health Informatics in Sri Lanka and the

Health Informatics Society of Sri Lanka (HISSL) In January 1997, a group of doctors met at the head quarters of the Sri Lanka Medical Association (SLMA) to discuss the formation of a committee on medical informatics. The meeting ended with the appointment of a committee with Dr. Shyam Fernando as the Chairperson and Dr. Vajira H. W. Dissanayake as the Secretary. The objective of the committee was to increase awareness about medical informatics among doctors. The main activity of the committee was the publication of an electronic newsletter called MediInfo that was emailed to members of the SLMA. The archive of this electronic newsletter, which can be accessed at http://www.infolanka.com/org/mediinfo/, provide interesting insights in to the medical informatics scene in Sri Lanka at that time.

HISSL was incorporated as a nonprofit company in Sri Lanka in the year 1999. HISSL became a member of the Asia Pacific Association of Medical Informatics (APAMI) in 1999 and a member of the International Medical Informatics Association (IMIA) in 2011. Dr. Vajira H. W. Dissanayake attended the APAMI meeting in Hong Kong in 2000 and read a paper, Dr. Kumara Mendis served in the steering committee of the APAMI meeting in 2003 in South Korea, and Dr. Roshan Hewapathirana represented HISSL when it was admitted as a member of IMIA at the IMIA General Assembly in Oslo on 28 August 2011. The main activity of HISSL during its first decade of life was scientific meetings that it organized on its own and in collaboration with other

41

professional medical colleges and associations. The inaugural scientific meeting of the HISSL was held on 4 April 1999, and thereafter meetings were held in March 2003 and in June 2004. In between many smaller meetings and symposia were held in collaboration with other professional medical colleges and associations. The Presidency of HISSL passed on to the Late Prof. M.T.M. Jiffry in 2003 and to Dr. Kumara Mendis in 2004. In these early years some of the prominent personalities who visited Sri Lanka and helped and encouraged us were Prof. Ian Purves from the UK, Prof. K. C. Lun from Singapore, Prof Yun Sik Kwak from South Korea, and Prof Yu-chuan Jack LI from Taiwan. Among them, Prof. Lun’s influence on HISSL was very prominent. In January 2008, Prof. Rezvi Sheriff was elected President. He held this position until September 2009 when Dr. Vajira H. W. Dissanayake was elected President, a position

that he continues to hold up to date. Under Dr. Vajira H. W. Dissanayake’s leadership, HISSL has grown from strength to strength. The foundation for this success came in the form of a chance introduction of Prof. Sundeep Sahay, Professor, Department of Informatics, University of Oslo, Norway to Dr. Dissanayake by Dr. Rohan Jayasuriya of the University of New South Wales, Australia in 2007. Prof. Sahay who has been involved in developing health informatics in many countries offered his support for Sri Lanka to do so. In June 2007 Prof. Sahay visited the University of Colombo and at a meeting at the Postgraduate Institute of Medicine (PGIM) of the University of Colombo, facilitated by HISSL, at the office of Prof Rezvi Sheriff, who at that time, in addition to being the President Elect of HISSL, was also the Director of the PGIM, it was decided to start a Masters Course in Biomedical Informatics. After the meeting Dr. Dissanayake and Prof. Sahay worked on

42

submitting a grant application to the Norwegian Center for International Co-operation in Higher Education (SIU) for funding to start the course. They were successful in securing a grant of over a million dollars that supported the course until 2014. Today the course has become self-financing and annually upto 30 students are taken into follow the course. The grant, in fact, came from Norad under its Norwegian Masters (NOMA) programme that was managed by SIU. Dr. Dissanayake was requested to spearhead this project at the PGIM. By August 2008, curriculum development was completed, a specialty board in Biomedical Informatics was set up to administer the course with Dr. Dissanayake as Founder Chairperson and Dr. Roshan Hewapathirana as the Course Manager, and advertisements had been placed to recruit students for the course. The first batch of students started their training in May 2009. The commencement of the course

laid the foundation to creating a generation of leaders in health informatics who would work with medical administrators hand in hand to spearhead the deployment of health informatics in Sri Lanka. The Ministry of Health granted two years paid leave for medical doctors and dental surgeons to follow the course. As a result, the course was very popular. So far there have been 89 Sri Lankan graduates from the course in 5 batches and 50 more are currently following the course. One of the graduates was a Vietnamese student who went back to Vietnam after graduation. The graduates have been appointed as Medical Officers/Dental Surgeons in Health Informatics in various institutions of the Ministry of Health and have been spearheading the development of health informatics in their institutions. This has resulted in rapid development of health informatics in Sri Lanka with

43

exponential growth expected in the next few years. The success of the course and the impact it has had on the health sector in Sri Lanka resulted in Health Informatics being recognized as a board certifiable medical specialty in Sri Lanka in 2015. The graduates of the masters course can now follow a two-year Doctor of Medicine (MD) course in health informatics and after two more years of post MD training, of which one year is in an overseas country, they become eligible to be Board Certified in Health Informatics. The entire programme is funded by the Ministry of Health. MD students, like the MSc students, are granted paid leave to follow the course full time. The first batch of twenty-two MD students was selected in November 2016, and they will go on to become the first batch to be board certified in the year 2020. In this background HISSL has been showcasing its activities and the achievements of the

graduates of the masters course at its annual conferences that have now taken an international dimension. The first in this series of conferences - eHealth Sri Lanka 2010 was held in October 2010; thereafter the conferences have been eHealth Sri Lanka 2013; eHealth Asia 2015 (ehealthasia.org); and Digital Health for Health and Wellbeing in collaboration with the Commonwealth Medical Association in 2016 (cma2016.org). These conferences have resulted in Sri Lanka becoming a hub for eHealth/mHealth and Digital Health activities. In recognition of this fact the Commonwealth Medical Association (CMA) invited Prof. Vajira H. W. Dissanayake to take on the Presidency of the CMA with the view to leading a Commonwealth wide Digital Health initiative. This resulted in the launch of the Commonwealth Digital Health Network and the Annual Commonwealth Digital Health Awards in October 2016 in

44

Colombo. These initiatives are being driven with the technical assistance of HISSL. In January 2010 HISSL joined up with PGIM to launch the Sri Lanka Journal of Biomedical Informatics as an outlet for showcasing Sri Lanka case studies in the field of Health Informatics. It was a peer reviewed open access journal published quarterly online (http://sljbmi.sljol.info). Dr. BJC Perera served as its founding editor in chief. The journal has had many challenges and ceased publication in 2013. It will be re-launched in 2017. Today HISSL is the major technical partner of the Ministry of Health, Sri Lanka for ICT implementation in the country. The Sri Lankan government has recognized the role played by HISSL. HISSL is represented in the national eHealth Steering Committee of the Ministry of Health and the Country Coordinating Mechanism of the Global Fund. In fact in

November 2013, when the World Health Organisation’s South East Asian Regional Office (SEARO) adopted a Regional eHealth Strategy at a High Level Ministerial Meeting in Bangkok, Thailand, President of HISSL, Prof. Vajira H. W. Dissanayake was requested by the government of Sri Lanka to represent the country and be the signatory for Sri Lanka. HISSL has also been working as partners with international development organisations such as such as the UNICEF and Bloomberg Philanthropies to implement major health informatics projects in Sri Lanka. The District Nutrition Monitoring System App developed by HISSL with funding from UNICEF, which is used by field level public health staff in Sri Lanka to monitor the nutrition status of children, won the prize for the best early stage app in the South Asian region at the mBillionth Awards Ceremony in New Delhi in July 2016. This has been one of the major milestones in the transformative process that

45

the Health Informatics sector in Sri Lanka has been undergoing as a result of the work that HISSL has been doing since 1998. It is noteworthy that the driving force for this change has been the medical professionals themselves. In November 2016 the government of Sri Lanka took a major step forward for Digital Health in the country when the Cabinet of Ministers accepted a proposal by Prof. Dissanayake to set up a Sri Lanka Institute of Digital Health. The institute will be established within the next two years. The opening of the institute in 2018 would be the culmination of a 20-year long journey by HISSL to promote and facilitate Medical Informatics, Health Informatics, eHealth, mHealth and now Digital Health in Sri Lanka and the region

Published by the Health Informatics Society of Sri Lanka