CSIH Health Information System

Without reliable, relevant health information, health care managers and providers cannot make informed decisions to allocate resources effectively, improve the quality of health services, or address epidemics. As health systems around the world decentralize, the demand for sound information and the skills to use information effectively is increasing dramatically. The Canadian Society for International Health (CSIH) is supporting the three countries of the South Caucasus - Armenia, Azerbaijan, Georgia - in their health reform efforts by building capacity for health information systems.

In addition to significant training activities, such as a 150-hour certificate course to train Health Information specialists, development of curricula for universities and post-graduate academies, or thematic workshops, CSIH is establishing demonstration sites to model good health information practices. A key component of developing health information systems is moving from a paper-based system of documentation to an electronic one and, to the extent feasible, connecting elements of the system electronically to enhance efficiency and the timely availability of information. In establishing a health information system (HIS) demonstration project short-term training for personnel of the participating institutions would be provided, the institutions would be equipped with the necessary technology, and networks would be created, both within and among institutions. This demonstration project is expected to provide guidance and experience on how the various parts of the health information system may be linked. Such a model could then be replicated, as required, in other facilities or applied to other areas of health care.

The Purpose of a Health Information System (HIS)

A Health Information System (HIS) is used to gather information about events or observations that are related to health status and health service delivery. An HIS can help

support the information requirements of government to make and follow strategic plans for the administration of health services,
monitor the health status of a population such as collecting data about reportable diseases,
account for the use of resources and their financial implications to government and to the population served, and
track patients who receive or should receive services.

A clinical HIS is used to store and report the history of patients who receive health care services. Ideally, it provides a health record for each individual that shows every health-related event. The health record should show all significant events for the patient regardless of when they happened or which professional took the observation, made the diagnosis, performed the procedure, or determined the outcome of a treatment.

A surveillance HIS collects observations about the health status of a population. One of the most common types of surveillance is that for reportable diseases like tuberculosis or HIV/AIDS. Surveillance systems are also used to track epidemics, such as malaria, and health status issues such as malnutrition. These systems are often used with socio-economic and demographic statistics to make projections and comparisons.

An administrative, managerial or financial HIS or Management Information System (MIS) is used to manage resources for a facility, district, region or nation. It collects demographic statistics, service delivery statistics, and financial records and produces reports showing information such as utilization, revenue, expenditure, efficiency, and accessibility.

Although the health information systems can be characterized in different ways, their essential purpose is to contribute to the formulation of a national strategic plan and its implementation. Without accurate and current information, the Ministry of Health is unable to establish priorities, initiate appropriate programs, allocate resources, or determine the outcome of its initiatives. The Ministry needs to be able to assess various indicators such as morbidity, mortality, fertility, and cost. Much of the needed data can be collected and analyzed using the same health information systems that support clinical, surveillance and administrative functions.

The CSIH Demonstration Projects

CSIH is developing a small scale HIS for Armenia, Azerbaijan and Georgia, encompassing a national-level institution and district level facility(ies); the site for each of the demonstration project has been determined through consultation with the respective Ministry of Health. Although each of the systems will be tailored to its respective country, each system will provide some administrative and management support and will permit providers at one or more facilities to contribute to a patient's health history concurrently without the exchange of paper forms.

The demonstration projects are integrated into a HIS certificate course being delivered by CSIH 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 is used as a case study for network and database design, project planning, computer system operation and system maintenance.

The Georgian Project

The Georgian demonstration project is located at two sites (Figure 1). The Center for Medical Statistics and Information (CMSI) in Tbilisi is the principal site. CSIH has installed a computer server that will store and report data submitted by the various health care facilities and health offices to CMSI. It will also capture electronic data from a second server that is to be installed in Gori City. The Gori City site has workstations housed in four hospitals, the regional health office and the public health office. The computers in Gori City are connected by a wireless network.

Figure 1. Schematic of the Georgian Demonstration Project

The Gori City Installation

Figure 2. Network Topology for Gori City

The database server, is housed in the Children's Hospital and connected by a wireless network to three other facilities: the City Hospital, the Public Health Department and the Rayon Hospital. There is a wired connection between the City Hospital and the Maternity House and another wired connection between the Rayon Hospital and the co-located Regional Health Department. The network (Figure 2) is now fully installed and operational.

Each of the facilities will have one or more "client" workstations that will be used for entering and analyzing healthcare data that is stored on the database server. Many of these computers will have spreadsheet and word processor applications as well. Although the network will not be connected to the Internet, it will provide electronic mail service among the different facilities. Additional client computers can be added to the network as they are needed.

Software Applications

CSIH is developing the following major application subsystems.

Encounters - Each visit or stay at a health care facility is recorded. The data collected includes the patient identification and demographics, the patient's health status and family relationships. As well, the date, duration, reason, and discharge status is captured with information about the provider who was responsible for admitting, attending and/or referring the patient. The Admissions, Discharge and Transfer subsystem is complete and is now being installed. An electronic ICD-10 code book has been incorporated into the system to facilitate the recording of diagnoses for each patient.
Events - Each diagnosis and treatment event is recorded with its test results, observations, procedures, medications, clinical notes and outcome. When the event is a delivery, birth data is also collected. This subsystem is currently under development and will be released in the next quarter (Spring 2004).
Reporting - The demonstration software provides report builder and report writer tools that allow users to define their own reports and to analyze the data stored in the database. The report builder tool allows users to customize the format of a report. Several complex reports have already been designed for the Admissions, Discharge and Transfer subsystem. The report writer tool, which generates the reports, allows users to specify the parameters of data for analysis (e.g., data for a specified period). These tools are now being installed. The reports can also be downloaded to Microsoft® Word, Access or Excel for further processing
Application program customization - The software has a tool to enable user customization of prompts, labels, and help text. This setup tool is used extensively during initial installation to enter translations. Users can change the meaning of certain descriptive data fields in entry and reporting programs to suit their needs. This tool is now being used by CMSI to translate the application programs into the Georgian language.

HIS Operation and Administration

The system also has a number of programs that can be used by the system operator and the system administrator. In most cases these programs can be run remotely from a client workstation. They include but are not limited to database backup and restore; database server shutdown; exporting and importing data from the CMSI server; audit log reporting; and checking the integrity of the database.

Data Confidentiality

Because medical data must be kept confidential, all programs in the system have certain standard security features.

Each user is given a user login name and a password that the user must keep confidential.
When the user logins into the HIS, an entry is made in an audit log. Additional entries are made in the audit log when the user accesses a specific subsystem and when the user enters data into the database.
If the user leaves their workstation logged in but unattended, their login expires and they must log in again to resume their work.
Normal users are assigned to a single facility. They may not enter data for another facility other than their own even though the database contains data for four different hospitals in Gori City.
Normal users may not change critical data, including that of their own user status.
If restrictions are in place, normal users are permitted to view only clinical data to which they have permission.
Application menus can be tailored to fit individual users or groups of users. This simplifies menus while, at the same time, restricting user capabilities.

Data Security

Primary data is stored at the central database server. This means that only the server computer must be protected against failure rather than each workstation. The following methods are used to protect the data:

The database can be backed up manually from a remote workstation by any designated operator.
The database can be backed up automatically provided the database server is running when users are not logged in.
The backups are kept on a second disk drive, not the disk drive where the database itself is stored.
The backups can be archived to CD-ROM periodically.
The database server is protected from sudden power failures and poorly conditioned power by an Uninterruptable Power Supply (UPS) that automatically shuts down the server in an orderly way.
Encryption is applied automatically to all data that is communicated over wireless links.
The network is not connected to the Internet, which is a major source of risk.
The database server is of a standard type and is easily repaired or replaced should there be an equipment failure. The backup can be restored to rebuild the database.
The audit log helps to determine security breaches by recording invalid HIS logins. As well, it records any operator activities that might affect the database.
The database server is to be used principally for one thing - the HIS. This way, other unrelated programs will not be permitted to interact with the HIS applications.

Business Processes (Health Record Management)

Gori City will be taking its first step into implementing an Electronic Medical Record (EMR). Consequently, business processes should change. In the current paper-based system, a paper trail follows the patient as he or she is admitted, treated and discharged. Upon discharge, the facility collects the essential case data as well as the "established principal diagnosis" for submission to the national, public and regional health administrations. Some of the discharge data can then be entered by computer to fulfil legal/(Ministry of Health) reporting requirements. This limited method of data collection works well but can be improved in several areas.

Data sharing - Data can not be shared among different facilities, or even among providers within a facility, unless forms or copies of forms are physically transferred.
Data access - Data is not readily accessible from encounter to encounter. For a physician to review the diagnoses and treatments of a previous encounter at the same facility, the paper records must be found and pulled.
Continuity of care - In order to ensure continuity of care within a paper based system, the patient must be able to tell the physician where, when and from whom he has been receiving treatment, otherwise there will be gaps in the patient history. Unless all this information is accurate, complete and shared among all of the providers involved, there is a risk of disruption of care, duplication of treatments and tests, or worse, conflicting or contraindicated medications/treatments.
Timeliness - Patient paper records are not fully compiled until the patient is discharged. At that time, timeliness is no longer considered critical as the remainder of the information processing is solely for purpose of legal reporting. A delay of a month can be tolerated. In the meantime, though, it is difficult for anyone to analyze trends. Consider, for example, an increasing incidence of an infectious disease such as shigellosis. Under the current system, it would be difficult to determine the incidence of such a disease until it is well underway because of reporting latency.
Level of detail - Legal reporting requirements currently place an emphasis on just the "established principal diagnosis." There is no reporting of secondary diagnoses, drugs or medical procedures. Moreover, even if these were reported on paper, the analysis would be difficult. This information is extremely useful in allocating and monitoring the resources of the facility, the region, and the country. It is essential for planning, managing and evaluating public health programs.
Special studies - With paper records, it becomes nearly impossible to perform special studies to examine trends and interactions among sets of factors influencing patient or public health. The legal reporting requirements capture only the most essential data required to manage the healthcare system. There is usually no way to examine specific aspects of healthcare without examining all of the relevant paper records.
Inventory - With patient records, additional record keeping must be used to track the number and location of patients within the facility, and the inventory of drugs and daily drug dispensing needs.

The HIS has the potential to improve health planning, monitoring and administration as well as patient care but only if the business processes change to take advantage of the new system. The following process flow shows the types of events occurring in an acute care setting and how these events can be captured in an HIS.

Figure 3. Typical Process Flow for an HIS Hybrid Record System

The diagram in Figure 3 shows a hybrid system consisting of both paper and electronic records. Some large hospital systems are capable of operating using paperless records but hybrid systems like the one shown are more common. With a manual system, the patient registration is where the paper trail begins. It ends upon patient discharge.

The demonstration HIS supplements the paper trail with an electronic record. As more data is entered in the database, it becomes available in the form of patient history on subsequent visits by the patient to the same and other facilities. Once the HIS is being used on a regular basis, certain parts of the manual paper system would be discontinued; eventually, after there is full confidence in the HIS, the HIS would become the primary system. The paper trail would continue to support incidental episodic observations and notes that lose their importance once the patient is discharged.

Once the demonstration HIS is fully installed and training is complete, it should require little additional effort to use than what is currently being done. New business processes merely replace existing manual processes. Yet, the HIS can provide more useful information; particularly if the data is entered into the database when it is collected. Any workstation would give access to the patient history and to the current health status of a patient. Workstations could be installed in the registration office and at other sites in the hospital to make access more convenient.

System Support

CMSI and CSIH are delivering user training and system support to the Gori HIS during this final project year. The network and computers are being supplied and existing equipment is being upgraded and maintained, as required. CSIH will be providing updates to the operating system and application software as needed. Whenever errors in the software are detected and described, they will be repaired by CSIH. CMSI is translating the prompts and help text from English into the Georgian language. CMSI is assuming responsibility for maintaining essential database tables such as those for medications and services. Both CMSI and CSIH will be designing new reports as their need is revealed. CSIH has already begun to train several selected individuals in Gori in system operation and administration.

User Training

Two training rooms, one in Gori City and one at CMSI, have been established for individualized hands-on user training. Personnel from CSIH and CMSI have already started to "train the trainers." Workshops such as this one are being held to keep users informed and to prepare them to use the new HIS.

HANDOUTS OR ANNEXES

Acknowledgement:

The South Caucasus Health Information Project is funded by the Canadian International Development Agency and managed by the Canadian Society for International Health.

February, 2004