The countries of the South Caucasus inherited a data collection system from the old Soviet Union that was characterized by a centralized paper based collection system that generated a great number of statistics but provided little useful information and scant feedback to the republics within the union. Currently, the countries do not have a modern health information system (HIS) to meet their informational needs and on which rational resource and other allocative decisions are normally based. Management decisions have relied in the past on centralized directions and personal judgment with politics also contributing to decision making.

An efficient health information system is essential for the management of a modern and cost effective health care delivery system. Countries in the South Caucasushave entered a period of transition from the previous centralized system to a newer model of health care delivery. This transition requires the replacement of an archaic system of paper based data collection with multiple forms that served no management function to a modern program of limited but useful data collection using electronic means and a management culture that uses information to make decisions. The transition will take time to be fully effective, since health information systems are complex and have to evolve to meet and reflect local needs and conditions.

Implications for Health Information Systems

A health information system is able to support systematic behaviour in a health care system, that is, behaviour that is predictable according to a predetermined set of rules. The more predictable the behaviour, the easier it is to develop, implement and use an information system to support that behaviour. Health care in general is less systematic than other types of activity such as manufacturing because of individual biological variation and the unpredictable nature that many of the determinants of health exhibit.

Engineers of health information systems have learned to cope with the inherently unsystematic aspects of health care activities. However, many unsystematic behaviours, especially in low-income countries, are not biologically inherent nor can they be attributed to the unpredictability of environmental determinants. They are controllable but are not being controlled. They include but are not limited to:

The behaviour of a health care system can be so unsystematic that it is difficult, if not impossible, to develop a health information system to support its behaviour. Consequently, the health information system, which is merely a tool, is often cited as the cause of health care system ineffectiveness and inefficiency.

Although resource levels in these countries are unlikely to change dramatically, two other factors that impede the responsiveness of the health care systems can be addressed. The mitigation of both relies on appropriate and effective health information practices.

The first step in the process of reforming the health care system must be the implementation of a national health information system that provides clinicians, managers and planners with accurate information about the health status of individuals and populations and about the status of the health care system. The health information system would support the collection, storage and communication of health data; and the processing of that data into health information. There would be a complementary introduction, through training, of new information management practices that would allow health care professionals to use such information to respond appropriately to the changing health needs of their client population.

An Approach to Effective Health Information Systems

Training and Education

The greatest challenge in designing, developing and operating an effective health information system is developing the human skill and motivation to do so. People in low-income countries require training and education in:

Establishment of National Health Information Committees

These committees are comprised of representatives from each group of health information stake holders. Under the leadership of the Ministry of Health, the committee would be charged with identifying the information required to address current and emerging health issues, identifying the data required to produce the information and its source, and making recommendations regarding the infrastructure required to facilitate the collection, communication and processing of that data.

HEALTH INFORMATION COMMISSION - DRAFT TERMS OF REFERENCE Design and development of a health information system that will best serve the planning needs of the Ministry of Health, management needs of institutions and programs as well as clinical needs of care givers, is a complex process as the health care system continues to reform and marches away from the inherited Soviet model toward a system that better reflects the country's needs and resources. Part of this restructuring exercise must be to assess information needs, based on current and future decision making, determine what data is required and how it is processed to produce the necessary information, and how data and information flow through the health care system to achieve the desired results. This analysis is a complex and time consuming process but it must be done prior to the specification, purchase and installation of information technology. This is the only way that the country can be assured that the composition and structure of the computers and telecommunications technology will actually address the decision making needs of health care professionals responsible for the effective and efficient operation of its health care system. The process of analyzing information and data needs and the information technology required to support its storage processing and communication can only be conducted successfully by the cooperative consideration of the issues by representatives of all of the health care sectors involved and those that will ultimately be responsible for the development and operation of the supporting infrastructure of information technology. In this light, it is proposed that a committee or a commission be struck under the authority and chairmanship of the Minister of Health. This body will include representatives from all health care stakeholder groups that will be impacted by the information system, those that will be responsible for the design, development and operation of the health information system, and such external consultants that may be required from time to time. Its mandate will be to guide the continued development of an efficient, effected and integrated health information system that truly supports the health care priorities of the people.

Data Processing and Communication Infrastructure

Low-income countries require an infusion of infrastructure and technology to be used in the collection and communication of health care data. This technology, though, should be accompanied by training and education or it would be wasted.

Decentralization of Capacity

In low-income countries much of the available capacity, both human and technical is concentrated in national centres. While it may be inappropriate to decentralize this capacity to the point of care in rural areas, significant gains in operational efficiency and effectiveness could be gained by decentralizing the information systems to where regional or district authorities are.

A Health Information System for Low-Income Countries

The health information system proposed herein would conform to the hierarchical topology shown in Figure VIII-1. In the ideal system the point-of-care component would be responsible for collecting and maintaining case-based event records in its own computerized database. For low-income countries, this is prevented by environmental and capacity limitations. As a compromise, most of the points of care would use paper forms to capture data and to transfer it to electronic databases at the regional levels.

The flow of data and information within the system is shown in Figure VIII-2. Case data, which includes data describing events, would be collected on paper or electronic forms. The data would be transferred regularly to the database at the regional level and remain available for point-of-care decision support via point-of-care workstations located physically at the regional information centres. The patient-centred records would be combined relationally with management records entered at the regional level. The resulting database would be used to generate the information required for institutional and program management. Portions of the case and management records would be replicated on a daily basis in the national database and combined relationally with planning records entered at the national level. The resulting database structure would be used to generate the information required for national health care system administration and planning. While the national database would be a separate database physically, it would not be logically separate. The records in the national database would be replicates of selected portions of records stored at the regional level. Although there are separate physical databases shown in Figure VIII-2 the system is logically a single database.

Although regional health departments do exist, they do not currently have a capacity for processing data in this way. Staff would have to be hired and trained and the required processing and communication capacity would have to be put in place.

The scope of the regional information system would initially be limited to the collection, communication and processing of the data required to produce morbidity and mortality statistics for management and planning purposes. While it would not include data required for clinical decision support, the system functionality could be extended.

Infrastructure Development

Figure VIII-3 shows a possible topology for an infrastructure that supports the information system described in Figure VIII-2. The national database would reside in a dedicated server located at the national health information centre. Some of the point-of-care sites are equipped with the appropriate equipment and will communicate electronically with the national health information centre. The other point-of-care sites will send their data to the regional health information centre on paper forms designed for that purpose.

The DBMS used to support the Health Database will have to be robust, capable of dealing with large volumes of data, many users, and a high frequency of transactions. It will have to provide reliable security for patient records and provide backup and rollback features. It should have an SQL interface. There are a variety of GPL (General Public License) and commercial DBMS's that have these features.

Regional information centres would connect through modem links via the telephone system as shown. Alternatively, and where feasible and justified by the volume of data being transferred, leased lines could be used that provide permanent and higher speed connections to the national centre. Modem connections could be dispensed with as telecommunication services become more available and less expensive.