THE EVALUATION OF THE HOSPITAL INFORMATION SYSTEM (HIS) AT

DISTRICT HOSPITAL, SHIMLA, HIMACHAL PRADESH

Submitted by:Dr. Isha Jain

PG/11/032

CONTENTS Organization profile Introduction to HIS Rationale of the Study Objectives of the Study Methodology Results and Outcomes Discussion and Conclusions Limitations of the study Recommendations Case study- Challenges faced during

Mobile Training at Shimla district References

ORGANIZATION PROFILE- HISP INDIA

HiSP India is a not for profit NGO specializing since more than a decade in designing and implementing solutions in health informatics for the public health sector in India, and also recently in Bangladesh and Sri Lanka.

In India, it has worked in at least 90% of the states, and currently has a presence in about 20 states.

To enable networks of collaborative action with like-minded actors who aspire to the ideology of open source software, open standards and decentralized decision-making to create complementary strengths in providing integrated and public health friendly health information systems.

MISSION

VISIONIt works with a Vision “to enable and coordinate a network of excellence in public health informatics, specializing in integrated health information architectures, with a geographical focus on South-East Asia.” HiSPIndia has a registered and head office in New Delhi, and project offices in Kerala, Himachal Pradesh, and Punjab

It is an old heritage hospital and was opened in 1885.

There is an average of about 1200 out- patient (OPD) visits per day.

It is the first district hospital of Himachal Pradesh where HIS is implemented by HiSPIndia.

It is the most established and functional government hospital.

It is a 150 bedded hospital with all functionalities.

ABOUT DISTRICT HOSPITAL

INTRODUCTION

HIS (HOSPITAL INFORMATION SYSTEM)

Health Information System (HIS) is a system that integrates data collection, processing, reporting, and use of information necessary for improving health service effectiveness and efficiency through better management at all levels of health services [Lippeveld et al., 2000].

HIS is a collection of tools, systems, users, routines, that together seek to improve health services

Primary hospitals

Secondary hospitals

Tertiaryhospitals

Hospital information system (HIS)

Health management information system (HMIS)

RATIONALE OF THE STUDY Evaluate the system efficiency under various

parameters. The chief criterions under consideration are system

acceptance and satisfaction amongst end users and patients.

This will help in assessing effectiveness of HIS along with the current shortcomings in the deployed system.

As NRHM funded HiSP project is in the process of implementing the HIS in 21 government hospitals of Himachal Pradesh, the results of this study will be useful for improving the existing system.

GENERAL OBJECTIVES

•“Evaluation of Hospital Information System (HIS) in Hospital, Shimla” is to analyze the impact of the implemented system at the hospital by knowing the user satisfaction of the stakeholders. •Also, to attain feedback onto the implemented system and to improvise on the drawbacks of the same.

SPECIFIC OBJECTIVES•User satisfaction towards HIS by the Study Population or Stakeholders•Technological glitches (if any) in DDU Hospital after implementation of HIS•Impact of eliminating paper based records on the Study Population or Stakeholders

METHODOLOGY

Implementation of the HIS application: September 2010

Tenure of implementation till date: 1.5 Years

Evaluation of the HIS: April 2012

No. and Names of the Modules implemented: 09

(Registration, Billing, Radiology, Laboratory, Blood Bank,

Inventory, Pharmacy, OPD and IPD)

No. and Names of Modules in use : 07

(Registration, Billing, Laboratory, Inventory, Pharmacy, IPD

and OPD)Study site: Deen Dayal Upadhyay (DDU) Hospital, Shimla (HP)

Tools for the Study:

Questionnaires for Administrators, Doctors, Nursing Staff,

Laboratory Technicians, Radiology Technician.

FGDs for Nursing Staff, Laboratory and Radiology Technicians and Patients.

Interviews for Data Operators of Registration and Billing, JAS, Inventory and Patients

Type of study: Descriptive/cross sectional study Study population (Stakeholders Identified):

Stakeholders NumberAdministrator 1

Operators for Registration and Billing 3Data Entry Operators 6

Doctors 23Pharmacist/ JAS 2

Radiology Department 2Laboratory Department 4

Nursing Staff 40Patients 200

Total Sample Size 281

RESULTS &

OUTCOMES

Types Of Users

Note : All the values are in PercentagesTotal No. of Clinicians = 23 Total No. of Nursing Staff = 40

No. of Clinicians = 8 No. of Data Entry Operators = 6 No. of Nursing Staff = 16

No. of Clinicians = 8 No. of Data Entry Operators = 6 No. of Nursing Staff = 16

Most of the users have technical issues like Computer hangs and Server problems but only the data entry operators also have printer related issues.

No. of Clinicians = 8 No. of Data Entry Operators = 6 No. of Nursing Staff = 16

Does the Procedures and Diagnosis Comply (Match) with your re-

quirements

00.5

11.5

22.5

33.5

44.5

5

5 3

Clinicians

To Some ExtentYes

Only 3 out of 8 Clinicians said that the procedures and diagnosis comply with their requirements

Has HIS decreased your Time & Ef -fort

0

2

4

6

8

10

12

14

16

16

Nursing Staff

No

All of the Nursing staff said that HIS has in turn increased their time and effort because they have to maintain both the registers as well as the electronic records at the same time.

00.20.40.60.8

11.21.41.61.8

2

12

4

Nursing Staff

As and when Pa-tient comes

When are the Patient Entries made on the HIS Application

Most of the i.e., 12 out of 16 Nursing Staff make the patient entries by the end of the day and only 4 out 16 Nursing Staff makes them as and when patient comes

REASONS FOR NOT USING HIS APPLICATION

BY PASSIVE AND NON-USERS

NUMBER OF PASSIVE USERS:

CLINICANS: 9 NURSING STAFF: 9

NUMBER OF NON- USERS:

CLINICANS: 6 NURSING STAFF: 15 TECHNICIANS: 7

NURSES

CLINICANS

TECHNICIANS

0 1 2 3 4 5 6 7 8 9

9

3

0

DID NOT GET TRAINING

DID NOT GOT TRAIN-ING

All the technicians said they got training3 out of 15 doctors said they did not get the training9 out of 24 nurses also did not get the training

NURSES CLINICIANS5.45.65.8

66.26.46.66.8

77.2

7

6

WORK LOAD

WORK LOAD

WORK LOAD here means,FOR NURSES(24) : They have to attend to patients as well as clerical work.FOR CLINICIANS(15): patient consultation at OPD7 Nurses and 6 clinicians stated workload as a reason for non-usage of application

Most of doctors i.e. 8 (non-users and passive users) also pointed out that diagnosis and procedures were incomplete and inadequate as a reason for non-usage of application.

NON- USERSPASSIVE-USERS

0123456

2 6

INCOMPLETE AND INADEQUATE DIAGNOSIS (IN HIS APPLICATION)

INCOMPLETE AND INADEQUATE DIAGNOSIS

When asked from nurses i.e., 24 (non-users and passive users) while doctors said they did not require any training.

34%

8%

75%47.8%26%

25%21%2%24%

39%

Satisfaction Level of the Users/Stakeholders with the Training provided by the HIS Team

75% of the others Stakeholders, 35% of the Nursing Staff and 25% of the Clinicians were satisfied with the training and support provided by the HIS Team.

CliniciansNursing Staff Others

ADMINISTRATOR’S FEEDBACK •Inefficient and Ineffective

•Not being used properly by clinicians, nursing staff and

inventory

• Staff is not confident about the utility and efficiency of HIS

application.

• Further training is also required for all the departments.

•Require data-entry operator

BENEFITS OF HIS Records are easy to maintain for BPL and RSBY patients Patient receives a compiled report for all the

laboratory tests. Feedback was received on interviewing JAS,

registration and billing as they were satisfied with the

time taken and efficiency of system even at rush hours

FEED BACK OF PATIENTS REGARDING HIS BPL and RSBY patients were not satisfied because of

long waiting time for registration.

Delay in receiving the laboratory reports due printer

issues.

Patient favoritism in Government hospitals.

Patients, only from Medicine, Dental and Surgery

OPDs were aware of some kind of application being

used by the clinicians.

REASONS OBSERVED FOR UNDER UTILIZATION OF HIS lack of motivation of clinicians

Limited staff at DDU

Heavy patient load

HIS is not properly implemented, as they are using same

old slip system during admission and discharge process of

IPD patients.

LIMITATIONS OF THE STUDY The sample population for study was taken on conveniences

basis.

The Patients were not aware of the HIS application,

therefore had lesser interest in participating for the

interviews and FGDs..

The HIS application is not fully functional in most of the

IPD/OPD departments of the hospital.

The sample was taken from single hospital; therefore a

generalized inference could not be obtained for the study.

RECOMMENDATIONS

CONT… Firm policies are required for proper usage of the

system by the government

Monitoring team should be constituted

Behavior change management of staff is required.

Data entry operators are required to reduce the

burden of staff

Training and follow up is required

CONT… Onsite support will be good for staff having different computer

skills

Regular updating of system in terms of procedures and diagnosis is

required.

Proper hardware support for all the departments.

Help desk should be constituted

Also, in spite of provision of referral system in the application it

was seen that clinicians were not using this application leading to

unnecessary inconvenience for patients as a result management

should promote proper and complete usage of this application.

CASE-STUDYCHALLENGES FACED DURING MOBILE

TRAINING AT SHIMLA DISTRICT.

Mobile services are emerging, making it accessible and citizen-centric by

extending the benefits of remote delivery of government services to those

who are unable or unwilling to access public services through the Internet

Governments are expressing interest in m Health as a complementary

strategy for strengthening health systems and achieving the health-related

Millennium Development Goals (MDGs) in low and middle income

countries.

M Health is being applied in maternal and child health, and programmes

reducing the burden of the diseases linked with poverty, including

HIV/AIDS, malaria, and tuberculosis (TB).

Primary Health Care Services using Mobile ensures improved access to

healthcare

INTRODUCTION

METHODOLOGY:Study design:Observational study

The team interacted with various health workers during mobile training at various training centers and issues that came from health workers were noted and addressed.

Study site:

Study population:

There were about 201 health workers (ANMs).

State Himachal Pradesh

District Shimla

Block Masobhra, Basantpur, Rampur, Narakanda

VARIOUS IMPLEMENTATION CHALLENGES FACED ARE DISCUSSED UNDER FOLLOWING HEADINGS: User end challenges Challenges with user phones Administrative challenges

USER END CHALLENGES Most of Health workers had compatibility issues which

resulted in

Reluctance in reporting.

Lack of interest to undergo training.

Also many of health workers demanded money for

sending SMS’s for reporting.

Lack of knowledge, awareness

Not all health workers present for training.

CHALLENGES WITH USER PHONES: DHIS2 mobile compatibility issue: Application could be installed

on only 42 % user phones. Remaining 58 % phones were in-compatible. These phones were either:

1.1 - not java based 1.2 - were black and white phones 1.3 - were not Bluetooth enabled 1.4- some mobile phones got hanged while using the application

(local and Chinese brands) 1.5- some phones had memory issues and hence ‘jar’ files could

not be installed Accountability issue: Using the health workers personnel phones

for training and reporting makes them less accountable for sending reports on timely basis.

42%58%

Compatible PhonesNon-Compat-ible phones

ADMINISTRATIVE ISSUES Timely information not given to health workers and other officials: In

many blocks the health workers are not given timely information

about the training schedule or the training dates are kept in such a

way that it clashes with their other day to day work.

State not sure about which technology to go for and whether to

provide phones to health workers or not: Before the start of state

wide implementation the state should be sure of which technology

(sms or gprs) to go for. This not only helps in better training plan but

also prevents wastage of time, money and human resources.

CONCLUSIONS AND RECOMMENDATIONS: State should provide mobile phones to health workers: This has

following advantages : No need to depend on mobile phone of health worker. No issue of application in-compatibility. Training becomes easy and fruitful. Any technical or user issue can be solved quickly A sense of encouragement and motivation to learn new technology is

there. Health workers can learn and share their user experiences with each

other since all would be having same kind of phones. Any up gradation or change in the application can be made quickly. No issue of phone being used by family members of health worker.

Training should be started only when the use

of technology is decided: Once the

implementation is started there should be least

changes in things. Browser based training has already

been given to Syri block of Solan district and Shahpur

block of Kangra district. And now SMS based training

has to be given. We cannot ensure sustainability in

mobile health implementation if we keep on changing

our technology use.

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