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Challenges & achievements in strengthening
Health Information Systems in
India: A historical
perspective T. Sundararaman.
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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.
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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
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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.
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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.
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• 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
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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
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“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
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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.
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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.
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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
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Availability and Design of Primary registers
• Manual / Printed registers
• Missing data elements
• Computation feasibility
• Tracking / Follow up function
• Portability
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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
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• 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:
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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.
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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 ???
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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….
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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.
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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
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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.
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Other Challenges
• Technical Inter-operability.
• Institutional Capacity:
• Institutional Designs- rule setting, authority, power
• People and Provider friendly
• Keeping Communities informed and involved.
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THANK YOU