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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.
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
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.
CSIH proposes to develop 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, they will all have a focus on clinical maternal health care, and will provide some administrative and management support. The systems in Armenia and Georgia will also have the potential to report necessary summary data from the districts to the MOH. This concept also means that providers at one or more facilities will be able to access and contribute to a patient's health history at any time 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 Armenian demonstration project is located at two sites; the Center for Perinatal Obstetrics and Gynecology (CPOG) in Yerevan and the maternal and child health facilities in Artashat. At CPOG, CSIH will install a central computer server and five workstations. In Artashat, CSIH will install a computer server at the maternity hospital that will be shared by two workstations within the hospital, one at the Women's Polyclinic and one at the Children's Polyclinic. Each of the sites will have a local area network that spans two buildings to connect all computers.
Because CPOG accepts patient referrals from Artashat, it must be able to share data with and feed back information to Artashat. The servers will exchange data automatically by transferring files using the telephone.
Refer to a Maternity Story.
The Georgian demonstration project is located at two sites. The Center for Medical Statistics and Information (CMSI) in Tbilisi is the principal site. CSIH will install a computer server that will store and report data submitted by the various health care facilities and health offices to CMSI. It will also be used to capture electronic data from a second server to be installed in Gori City. The Gori City site will have workstations housed in four hospitals, the regional health office and the public health office. The computers in Gori City will be connected using wireless communications.
Within the HIS for the demonstration sites CSIH is developing the following major subsystems.
Consider for example, a pregnant teenager who arrives at the women's polyclinic with severe headaches and significant swelling of her face, feet and hands. At the clinic, blood pressure and urinary tests are performed and the teenager is diagnosed with "pre-eclampsia" (also known as "toxemia"). Because she is into only the fifth month of her pregnancy, the physician prescribes a special diet, aspirin, and calcium supplements. The physician advises her to get bed rest.
The physician enters data about the encounter into the HIS. She records the teenager's name, date of birth and contact information. She also enters the date of the encounter, the complaint, signs and symptoms, test results, diagnosis, and a treatment plan. When the patient leaves, the physician advises her to return in a week and then enters that date into the system as a follow-up date.
Depending on the specific needs of the country, certain parts of the application software can be left unimplemented. For example, in Armenia, a child immunization subsystem recording immunization events will be installed but not in Georgia. Similarly, in Georgia a data collection subsystem for manually completed hospital discharge forms will be implemented but not in Armenia. These software modules can be activated at a later date if so desired. Refer to the Immunization Subsystem Handout.
Diagnostic codes are used at the district, regional and national levels to determine the causes and their frequency of morbidity and mortality in the population. Strategic planners use this information to determine the health status of the population. Diagnostic data can be combined with data about procedures, procedure cost, and outcome to determine the effectiveness and efficiency of policies, programs and specific treatments.
International Statistical Classification of Diseases and Related Health Problems is a World Health Organization (WHO) publication that is used by nearly all acute care facilities. Many other health care facilities also accept and use it to code their diagnoses. The current publication, revision 10, was issued in 1992. Although there are three manuals, the first volume is the most important because it contains the full classification with code descriptions and notes. This volume, which has 1243 pages in English, has been translated into many languages including Armenian, Georgian and Russian.
We have included an automated code finder in the CSIH demonstration software. You can use the code finder to find a diagnosis and, moreover, the code finder software will automatically validate any diagnosis you enter manually. The code finder reduces the time and difficulty to code a given diagnosis and it ensures that any diagnosis code that you manually enter is a valid one. Refer to the ICD-10 Diagnostic Subsystem Handout.
The system has been designed with specific attention to the following concerns.
Development of the HIS has been on-going for the past year. As of January 2003, many entry forms have been built that are used to enter basic code tables. These include forms that, for example, are used to enter and report on providers, districts, regions and medications.
A sophisticated report writer has been developed that permits users to create their own reports. This report writer is also capable of generating data files for transfer to other programs such as Microsoft® Excel and Access. This means that the HIS can feed data to existing systems already used for the purposes of planning and analysis.
The basic software structure of the system has been designed and has features to protect patient confidentiality and physical security of the data.
The first subsystems are now ready to be installed. The ICD-10 subsystem will be installed first because it relies on no other subsystem and can be used immediately even with manually completed forms. This installation will be done in the first six months of 2003. It will be followed by other subsystems as they are completed and translated.
Much of the equipment for the demonstration sites has been acquired. In the first half of 2003, we will be installing a local area network at each of those facilities that require one. Refer to the Technical Specifications Handout.
Because we have chosen "open source" software for the operating system and database, you can, with the permission of CSIH, make copies of the HIS. This means that the software can be installed in many other sites over time. As you gain experience with the system, you could make an implementation plan for wider regions.
The HIS could be installed in other than perinatal facilities that include general hospitals, ambulatories and primary care offices. This would provide a more complete view of the health care system and would be a vehicle for policy change with respect to primary care, disease prevention programs and health insurance.
As the number of facilities using the HIS increases, so too does the usefulness of the data collected by the HIS. The data would be more consistent because the entry methods would be the same at each of the empowered institutions. Statistical studies would be more easily performed because there would be case-based data that includes procedures performed, diagnoses, outcomes, and facility utilization. Comparisons among institutions could be done to optimize the allocation of resources.
New means of surveillance and disease incidence could be developed using the data accumulated by the network of health information systems. For example, if an education program designed to reduce the incidence of HIV/AIDS were introduced, the diagnoses of HIV/AIDS could be monitored to evaluate the success of the program.
Patient care would improve because providers would be able to view more of the each patient's history. Exchange of data among providers and facilities would be possible without the use of paper forms. Patient follow-up would be made easier and, consequently, treatment plans could be more closely monitored. The outcome of a patient referral would be available to the referring facility.
Within the South Caucasus Health Information Project, CSIH is committed to setting up a HIS demonstration system in each country that would model good HIS practices. This process includes the development of software, installation of networks, provision of necessary equipment, training of users and HIS specialists, and coordination of initiatives with MOH and donors. But in order to benefit fully from the HIS and ensure its sustainability, there needs to be commitment from all participants.
The HIS is built for you and you will ultimately need to take responsibility for it. This means that you will need to
The South Caucasus Health Information Project is funded by the Canadian International Development Agency and managed by the Canadian Society for International Health.
February 25, 2003