South Caucasus Health Information Project

Activity Summary

September 2001 - June 2005



Introduction

Since 1999, the Canadian International Development Agency (CIDA) has funded the work of the Canadian Society for International Health (CSIH) in the South Caucasus region. Following the completion of a successful first phase project (June 1999 - September 2001), the South Caucasus Health Information Project, began its second phase in September 2001 and will continue to work with its three partner countries, Armenia, Azerbaijan and Georgia, until the end of June 2005.


The goal of the South Caucasus Health Information Project (Phase 2) is to strengthen health reform in Armenia, Azerbaijan and Georgia through the appropriate application of health information technology and information management strategies.

Specifically, the Project’s objectives are to:
  1. Assist in the development of national health information management plans and strategies for sharing health information within and among the three South Caucasus countries;
  2. Build capacity for health information management through the training of professionals and the integration of health information modules into academic curricula in the health sector;
  3. Enhance the capacity of stakeholders to use health information for better decision-making in health and other sectors, while identifying gender-specific health issues; and
  4. Move from isolated to integrated health information systems focused on better health outcomes.

The main activities designed to meet these objectives include:
  1. Health Information Systems (HIS) Certificate Course &ndash This 150-hour (five weeks over two years) participatory course was designed to train specialists in the development and management of an integrated HIS.
  2. HIS Demonstration Projects &ndash A model HIS was installed in each country to support an electronic patient record for a set of closely associated institutions and programs within a small geographic area. Each of the systems was tailored to its respective nation’s priorities.
  3. Curriculum Development &ndash This activity focused on the development of Health Informatics curricula, which can be incorporated into existing undergraduate and post-graduate programs for physicians and other health professionals.
  4. Regional HIS Initiatives &ndash CSIH supported opportunities for the discussion of HIS issues among the three countries by way of regional conferences where experiences and information could be shared.
  5. HIS and Population Health Issues &ndash The role of health information systems in addressing priority population health issues, for example in monitoring poverty reduction strategies, was addressed throughout the various other activities, such as regional conferences and presentations.

Project activities also included the dissemination of health information, study tours and official visits, as well as coordination with donors (WHO, World Bank, UNFPA, DFID, USAID).

Partners

The implementation of the South Caucasus Health Information Project (SCHIP) began with Memoranda of Understanding signed by CSIH and the Ministers of Health of Armenia (February 2002), Azerbaijan (June 2002), and Georgia (February 2002) and serve as the basis for project activities. Within the framework of these agreements, work began with various institutions in each country.

Armenia
  • Ministry of Health
  • National Institute of Health
  • Centre for Perinatology, Obstetrics and Gynecology
  • Artashat Maternity Hospital
  • Yerevan State Medical University
Azerbaijan
  • Ministry of Health
  • Department of Health, Ganja City
  • Azerbaijan State Medical University
  • Azerbaijan State Advanced Training Institute for Doctors
Georgia
  • Ministry of Health, Labour, and Social Affairs
  • Centre for Disease Control and Medical Statistics
  • Public Health Department, Shida Kartli Region
  • Georgian State Medical Academy
  • Tbilisi State Medical University


Project Coordination and Implementation

Focal points have been designated by each Ministry of Health to coordinate the implementation of project activities in their respective countries:
  • Dr. Vladimir Davidiants, Chief Sanitary Doctor, Armenia
  • Manana Tsintsadze, Deputy Director, Centre for Disease Control and Medical Statistics, Georgia
  • Dr. Alexander Umnyashkin, Advisor to Minister of Health, Azerbaijan
Project implementation was further assisted by CSIH offices in each country, staffed with part-time field coordinators:
Dr. Ruben Hovhannisyan, Armenia
Zarema Ahmadova, Azerbaijan
Marina Pochkhua, Georgia.


In addition to CSIH staff based in Ottawa, numerous Canadians contributed to the successful implementation of the various components of the project. A Canadian Advisory Committee comprised of CSIH members provided invaluable advice and support in the design of the project on a volunteer basis. In Canada, partnerships were established with the University of Ottawa, Dalhousie University, and University of Victoria for the implementation of activities. Several Canadian consultants and volunteers traveled frequently to the South Caucasus to work with local partners on the project.



Project Activities

1. HIS Certificate Course
The HIS Certificate Course was designed to educate those health system personnel who will be responsible for building and operating health information systems in each country. The course supplied the training necessary for people to become health information system managers in diverse organizational units within the health care system, such as clinics, hospitals, and government. The five course modules were designed to provide participants withan integrated learning path starting with basic computer skills and ending with a consideration of health policy and health care system management from an information management perspective.

The HIS Certificate Course was delivered in five sections totalling 150 hours of instruction:

The demonstration projects (described below) have been integrated into the HIS Certificate Course in each country to ensure that there are qualified people available to make use of the new HIS. Throughout the Certificate Course, the demonstration project was used as a case study for network and database design, project planning, computer system operation and system maintenance.


The HIS Certificate Course training was held in training facilities at the National Health Management Centre in Tbilisi, Georgia and within the Ministry of Health of Azerbaijan. In Armenia, CSIH has helped to upgrade the computer training lab at the National Institute of Health, which hosts the HIS Certificate Course in Yerevan. Course materials and assignments are posted at www.csih-schip.com in English, Armenian, Georgian, Azeri and Russian.



The HIS Certificate Course was completed, with a final exam administered in April 2004, and graduation ceremonies were held with certificates presented by their respective Ministries of Health. The individuals achieving the highest results on the exam were invited to take part in a two-day training-of-trainers course and select individuals were then chosen to take part in an HIS study tour to Canada.

The HIS Study Tour took place from June 26 &ndash July 11, 2004, with eleven participants from the Caucasus taking part in visits to various health facilities and health information agencies in Toronto and Ottawa.

As a final assignment for the selected top graduates who came to Canada, each national group prepared a workshop outline to pass on their knowledge and experience on the uses of HIS and the demonstration project to their peers. These workshops were conducted successfully by local trainers the fall of 2004.
The lead trainer for the HIS Certificate Course, Dr. Paul Fisher, has compiled a monograph based on the Certificate Course materials to share with MOH partners and course graduates.

2. Demonstration Health Information Systems Projects

SCHIP focuses on the development of long-term, sustainable tools for health reform, including the development of a computerized health information system (HIS). This demonstration project comprises software development, short-term training programs for the participating institutions, equipment and telecommunication networks where appropriate. It shows how health information concerning the catchment population can be used for health planning and governance. The experience gained can be transferred to other modalities of health care and the HIS can be replicated at additional institutions.

HIS application software is a database system built for modern information requirements, which also accommodates existing forms and procedures. The system is conceptually based on an electronic health record; it supports the collection of data that describe patient health care events, demographics and social status. The software uses international standards to code signs, symptoms, diseases and procedures. The system captures data about hospital stays and outpatient visits, which include diagnoses, medications, procedures, diagnostic tests, immunizations, consultations, pregnancies, deliveries and reproductive health counseling.

The CSIH demonstration system is currently running at the following sites in three South Caucasus countries, including:
Software Licensing, Copyright and Distribution
The HIS is built on an open source platform. The Linux operating system, standard Linux tools, a high performance database engine and a web service are used. Consequently, the platform is far less expensive to implement than other proprietary systems such as Microsoft® Windows™. The application software itself has a copyright that is held by CSIH and Dr. Jim McDaniel, the software designer and developer. At the end of the project, copies of the software will be donated to the partner organization of each country with an agreement that permits the organization to distribute the software to not-for-profit institutions within the country. Further development and software maintenance will become that organization's responsibility.

Database Characteristics
The HIS database has been designed to accommodate multiple facilities of varying types. Data can be imported from several servers into a single central database for redistribution. Consequently, a patient's encounters are compiled into a single electronic health record and comprehensive patient histories and summary management reports can be produced. Where facilities are geographically close such as co-located ambulatory clinics and a hospital, itis possible for the facilities to share a single database server. This substantially reduces the operational overhead of the HIS.

Although personal identifiers simplify data entry and substantially improve health record integrity, the HIS does not require a personal identifier for each patient or client. A person can be identified by a wide range of personal attributes, which include but are not limited to name, date of birth, gender, passport number, and family relationships. As well, the application software provides tools to identify and consolidate fragments of patient health records.

A patient catchment area is classified by its health region and health district. It can be assigned arbitrarily to either, as health regions and health districts are independent of each other. Consequently, summary reports can be defined for geographical areas that may or may not be overlapping or hierarchical. The following international standard coding systems are used in the CSIH system: The ICD-10 diagnosis coding subsystem is sophisticated; a user can enter one or more phrases to search an electronic code book. The code book can be viewed as a web page and references between codes can be followed by clicking on relevant links. Two code books, which are available in the English, Russian, Armenian and Georgian, can be installed and so that a user can switch from one language to another.

The application screens are displayed in the language that is native to the participating country. Currently there are translations from English to the Armenian, Georgian and Azerbaijani languages. The HIS has application programs to install the translations. This feature also increases the flexibility of the database by allowing some data elements to be renamed. If, for example, there were no need for “patient occupation”, this element could be used for some other data.

Users can design their own reports using a report writer tool that is integrated into the HIS. There are also 16 predefined reports that show clinical, operational and management information. These reports can be modified using the report writer tool.


Human Resources
Beyond the technical requirements of the project, CSIH has made a significant investment in developing human resources in each participating country. The Certificate Course, covered topics ranging from computing basics to elementary biostatistics to project management, and used the HIS as an example. System administrators and trainers attended a Linux training course and various application workshops. The designated system administrators and trainers have been encouraged and supported in their own efforts to train other stakeholders, including administrators, doctors, nurses and clerical staff. To facilitate on-site training, small training centers have been established by CSIH in Yerevan and Tbilisi.

Most recent training activities, held In 2005, included report-writer workshops, fine-tuning and final installation of software, continued user training for system administrators and operators, and the development of User and System Administrator documentation and dissemination.


3. Health Informatics Curriculum Development

CSIH has been working with the medical universities and post-graduate training institutions in each country to integrate key concepts of health information into existing educational programs.
Integrating health information training into medical school curricula will provide physicians and other health professionals with an understanding of the role of data and health information for clinical decision support as well as a general understanding of the role of health information for policy-making and health planning. The health informatics training will also build the capacity of health planners and administrators, as well as physicians returning for additional training, to use information as the basis for managing facilities, designing programs, and developing policies focusing on management information systems.

Through partnership with the Faculty of Medicine, University of Ottawa, and the School of Health Services Administration, Dalhousie University, CSIH developed a modular curriculum incorporating undergraduate and post-graduate materials in the following topics:
  • Computer Literacy
  • Literature Searching
  • Basic Biostatistics/Epidemiology
  • Evidence-Based Medicine/Critical Appraisal
  • Hospital/Practice-Based Applications of Medical Informatics
  • Population Health Databases and Health Information and Database Management

The curriculum material in English and Russian was distributed to the partners in the South Caucasus in CD-Rom format in 2004. Instructional labs, consisting of at least ten computers and an instructor workstation, were set-up at the participating academic institutions to support the delivery of HIS content to students.


Local partners are now focused on adapting their teaching practices and the developed curriculum materials into local context (such as the recertification of practicing doctors). Follow-up training in Evidence-Based Medicine (EBM) for university instructors was conducted in February 2004. EBM and Cochrane Library training continued in January 2005 with the participation of Dr. Vassily Vlassov, Director of Russian Cochrane Collaborating Center.

In response to requests from the local partners, health administration workshops entitled, “Health Outcomes and Performance Indicators: Tools for Health Administrators” were also held in April 2004. The workshop was based on Module Five of the Health Informatics curriculum and lead by its author, Dr. David Persaud from Dalhousie University. The workshop took place in Armenia, Georgia and Azerbaijan and focused on practical hospital applications, including clinical practice guidelines and performance indicators for measuring health outcomes, which was especially useful for the hospital managers, as well as for the selected staff of the Medical Universities and the Medical Academies in attendance.

From September 28 - October 9, 2004 a health second informatics study tour was held for six selected representatives from the undergraduate and post-graduate medical educational institutions in Georgia, Armenia and Azerbaijan. This study tour coincided with the Cochrane Library’s 12th Annual Colloquium held in Ottawa October 6-9th. During the study tour, participants attended EBM sessions and met with senior staff at the University of Ottawa, and visited a number of hospital and community care facilities.

To help celebrate their jubilee, Tbilisi State Medical University hosted a conference on “New Perspectives on Georgian Health” from January 20-24th 2005, and CSIH supported the attendance of invited colleagues from Azerbaijan and Armenia.

4.  Regional Cooperation

CSIH is committed to promoting regional cooperation in the area of health information systems among the three South Caucasus countries. Regional consultation provides opportunities for the three countries to come together to discuss issues and obstacles to the development of effective health information systems and explore opportunities for collaboration.

An initial planning meeting was held in Tbilisi, Georgia on September 27, 2002, with a total of twenty-five participants representing all three countries, CSIH and other donor organizations. The first HIS Policy Conference, with a focus on standardization of data, was held in Tbilisi, Georgia, May 27 &ndash 28, 2003 with approximately 50 participants from the three countries, and was co-hosted by the UK partners of the Department for International Development (DFID) Primary Health Care project. Topics included Poverty Reduction Strategies, Reforming Health Care, Standardization of Data, Unique Identifiers and Privacy issues.


The second regional conference for Ministry of Health officials from the three countries took place April 21-22nd, 2004 in Tbilisi. The two-day conference, hosted by CSIH and the Ministry of Health, Labour and Social Affairs (MOHLSA) in Georgia, brought together approximately 60 participants to discuss the development of health information systems in the South Caucasus. Dr. Nikolaz Pruidze, Deputy Minister of MOHLSA, made opening remarks at this event, followed by an assessment of each country’s developments in HIS by representatives from the Armenian Ministry of Health, the Primary Health Care Management Committee of Georgia, and the WHO Liaison Office in Azerbaijan. The conference focused on data quality, health indicators, and how to use information to improve the quality of health care. Background information on each topic was provided and the larger group was split into three working groups to discuss the challenges of improving their national HIS, the need for greater capacity and training for human resources.

Following consultations with the Ministry of Health, Labour, and Social Affairs of Georgia, the Primary Health Care Management Committee, and representatives of the Oxford Management Group (OPM) in charge of the HMIS component of the Primary Health Care Reform Project, CSIH hosted an HIS Policy Workshop specifically for MOHLSA personnel in the October 2004.

Discussions with the WHO liaison office in Azerbaijan after the Conference focused on the WHO-supported health reform consultations. Efforts were made to coordinate with the WHO to effectively integrate HIS policy in Azerbaijan’s national health strategy.

A final regional meeting is being held in Tbilisi in the spring of 2005 to discuss project achievements, HIS sustainability and future policy implications.




5. HIS and Population Health - Policy

The South Caucasus Health Information Project has kept a strong focus on its operations to ensure they are within the health policy reform frameworks of the Ministries of Health. New interests and concerns have also emerged and been given priority that has affected the health sector and placed further demands on health information systems.

It has been universally recognized that poverty and health are inextricably linked in a vicious circle. Thus, concerns about poverty have led to the production of Poverty Reduction Strategy Papers (PRSPs) that are expected to lay out a cross-sectoral strategy to address reductions in poverty levels, which have increased in all three countries since the collapse of the Soviet Union.

The PRSP framework will help to focus efforts by looking at health outcomes cross society.
Although articulated on different occasions and under different auspices, the interest in poverty reduction and the introduction of the Millennium Development Goals (MDGs) intersect. The MDGs of special significance to the health sector are those that seek to reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria, tuberculosis, and other diseases. It has been argued that for middle-income countries the approach may not serve their interests as well as for low-income countries since their more important requirements revolve around financing and management issues rather than focusing on infant and child mortality. The MDGs do not necessarily reflect what is most important in any particular country especially with changing demographics and an increased proportion of the population in older age groups.

Certainly, current and future development assistance from the international community is adopting the PRSP framework as their principal concern in making decisions about allocating resources across programs and activities. As a consequence there is an ever-increasing interest in accurately monitoring progress. With poorly developed health information systems, alternative means of accurately determining health status have had to be deployed such as multiple-indicator cluster surveys, household surveys and demographic and health surveys. Conduct of these surveys has revealed the inadequacies of existing health information systems. These surveys are expensive so it is in the general interest to develop functioning and accurate Health Information Systems.

Health information systems play a key role in the monitoring and evaluation of health status of populations. Through consultation with partners, CSIH has highlighted the role of health information systems in health policy decision-making and monitoring poverty reduction.

In April 2002, CIDA asked CSIH to prepare a background document on the link between poverty and health in the South Caucasus. With input from the Ministries of Health, CSIH presented the paper, “Poverty and Health in the South Caucasus” during the regional planning meeting in September 2002. The paper highlighted the growing importance of PRSPs in the health reform process and the significance of health information systems in monitoring the results of these reforms. In October 2002, CSIH presented the paper at the 9th Annual Canadian Conference on International Health in Ottawa.


6. Dissemination of Information

Results of the project were shared through various promotional opportunities, including the following conferences:
In October 2004, six senior Ministry of Health officials from Armenia, Azerbaijan and Georgia participated in an official visit to Ottawa. The officials presented at a symposium for Health Reform in Countries in Transition during the 11th Annual Canadian Conference on International Health and met with various organizations involved in health information, including Health Canada and the Canadian Institute for Health Information. During meetings with CIDA, the visitors had an opportunity to discuss health reform issues in their respective countries and were able to share how the South Caucasus Health Information Project can continue to the assist with ongoing reform efforts.


Project Outcomes & Results

Inheriting the Soviet system and then needing to significantly reform has meant an increased need for accurate information that the existing fragmented system was incapable of producing. There have been many priorities that the respective governments have had to deal with but development of a useful health information system has been increasingly seen as an essential tool for the management and monitoring and evaluating the reforms in the delivery of health care in the three countries.

The CIDA funded, South Caucasus Health Information Project (SCHIP) has been playing a crucial role in assisting the respective governments assess and reform their health information systems to meet new demands and needs. As in Canada, this is an evolving process and activity that will need sustained inputs over a substantial period of time. The project has already made significant contributions to reforms in the information systems and will continue its strategy of assisting Government reform efforts in this subject area.

Significant advances in the understanding and functions of a health information system have been made over the course of SCHIP. These include the training of a considerable number of health personnel in the application of computer science to health information, the establishment of a demonstration electronic health information system in each country, the development of a health information training curriculum including printed materials, the establishment of computer lab facilities and some gains in the appreciation of the advantages of having a functional health information system. Efforts should be made to build on these contributions. A small amount of progress has been made in developing either overall health system policies or health information system policies, which have been limited by the realities of governments being overwhelmed by more urgent policy and political realities with a lack of resources to practically implement health or health information policies.

In reference to the project's original objectives, it can be said that the three Ministries of Health are in varying stages of health reform and all have shown interest in incorporating HIS into their national health reform plans. CSIH has been actively coordinating efforts with other donors and local stakeholders to support the development of HIS strategies by decision-makers. Efforts to build capacity for health information management through the training of professionals have been focused on health informatics curriculum development activities, which have begun to successfully enhance health informatics programs within the undergraduate and post-graduate medical institutions and have been formally accepted into curricula in all three countries.

The capacity of stakeholders to use health information for better decision-making in health and other sectors has been enhanced by Ministerial support for increased quality of information from certain sectors of their health care system in order to improve their decision-making capacity. Political support for improved health information which includes broader population health indicators has also increased. In addition, with the intention to move from isolated to integrated health information systems focused on better health outcomes, the Ministries of Health and partner health care facilities have been actively promoting their demonstration HIS projects to various shareholders and have requested support to expand the system to throughout the rest of the country.


For more information, please contact:

Eva Slawecki
Project Manager
South Caucasus Health Information Project
Canadian Society for International Health
One Nicholas Street, Suite 1105
Ottawa, ON K1N 7B7 Canada
Tel: (613) 241-5785 ext. 325
Fax: (613) 241-3845
eslawecki@csih.org
www.csih.org