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Project Description

The South Caucasus Health Information Project (SCHIP) is managed by the Canadian Society for International Health (CSIH) and funded by the Canadian International Development Agency (CIDA). The Project, in its second phase, commenced in September 2001 and will continue working with its three partner countries, Armenia, Azerbaijan and Georgia, until June 2005.

The South Caucasus Health Information Project strives to achieve its goal 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 Project’s main activities include:

1. HIS Certificate Course – This 150-hour (five weeks over two years) participatory course is designed to train specialists in the development and management of an integrated HIS.

2. Demonstration Projects – A model HIS will be 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 will be tailored to its respective nation.

3. Curriculum Development – This activity will focus on the development of HIS curricula, which will be incorporated into existing undergraduate and post-graduate programs for physicians, other health professionals.

4. Regional HIS Initiatives – CSIH will support opportunities for the discussion of HIS issues among the three countries by way of regional meetings and an annual HIS conference where experiences and information can be shared.

5. HIS and Population Health Issues – This activity will address the development of HIS within a determinants of health framework. The main focus will be on the role of health information systems in monitoring poverty reduction.

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

The implementation of the project 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. Focal points have been designated by each Ministry of Health to coordinate the implementation of project activities in their respective countries:

Dr. Vladimir Davidiants, Deputy Minister of Health, Armenia

Dr. Alexander Umnyashkin, Advisor to Minister of Health, Azerbaijan

Manana Tsintsadze, Deputy Director, Centre for Disease Control and Medical Statistics, Georgia

Project liaison is further assisted by CSIH field offices, staffed with a part-time logistical coordinator in each country:

Dr. Ruben Hovhannisyan, Armenia

Zarema Ahmadova, Azerbaijan

Marina Pochkhua, Georgia.

Project Activities

1. HIS Certificate Course

The HIS Certificate Course has been completed, with five modules having been delivered and a final exam administered in April 2004; the individuals achieving the highest results on their 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. Study tour participants then developed proposals for training activities to be delivered in their own countries in order to pass on their knowledge and experience to their peers.

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 with an 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:
• Module 1 - “Computing Fundamentals” (delivered by local trainers)
• Module 2 - “Introduction to Health Statistics”
• Module 3 - “System Analysis and Database Development”
• Module 4 - “Health Information System Project Management”
• Module 5 - “Information Systems, Population Health and Health Policy”

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 final exam was followed by a train-the-trainer session for the top ten graduates of the course in each country (please see appendix A for a list of certificate course graduates). Graduation ceremonies were held with certificates presented by their respective Ministries of Health, after which the participants who would attend the HIS Study Tour to Canada were chosen. The HIS Study Tour took place from June 26 – July 11, 2004, with eleven participants from the Caucasus taking part in the two week visit to various health facilities and health information agencies in Toronto and Ottawa.

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. As a final assignment for the selected top graduates who came to Canada, each national group prepared a workshop outline to train their colleagues on the uses of HIS and the demonstration project. This workshop was conducted successfully by local trainers in Armenia in October 2004; similar ones will take place in Georgia and Azerbaijan in 2005.

The lead trainer for the HIS Certificate Course, Dr. Paul Fisher, will compile a monograph to share with MOH partners and course graduates, in order for them to continue teaching the course according to national needs.

2. Demonstration Project

A key component of developing health information systems is moving from paper-based medical records to an Electronic Health Record (EHR) system (EHR). An EHR makes it possible to share health information among clinicians, planners, administrators and managers by providing greater access, availability and timeliness of health information. In order to establish a health information system (HIS), the demonstration project is providing short-term training for personnel of the participating institutions, equipping the institutions with the necessary technology, and building telecommunication networks both within and among institutions. The demonstration projects are expected to provide guidance and experience on how the various health-related activities and observed conditions in the catchment population may be linked and used for health planning and governance. This experience and the model demonstration system can be expanded to other modes of health care delivery and replicated, as required, in other institutions.

HIS application software, designed by CSIH consultant Dr. James McDaniel, is incorporating data from the current health forms as well as basic patient demographic and social data. The software, which uses current Ministry of Health coding and procedures, also incorporates the International Classification of Diseases (ICD-10) coding into the “Signs, Systems and Diagnoses Entry”, which is supported by the World Health Organization. Additional software modules are also available, allowing staff to enter medication, procedure and consultation orders and record the results. This adds history to the patient health record about medications, consultations and procedures.

2004 saw rapid improvements in the HIS demonstration software, with four software releases delivered to CSIH’s partner organizations. Other highlights include:

The development of an Inpatient Care module
Further development of the ICD-9 procedure modules and the ICD-10 diagnosis modules
Addition of drugs and drug classes to the HIS database
Completion of the software’s data dictionary
Addition of immunization to both the Inpatient Care and Outpatient Encounter modules
Development of a number of reports aimed at making the software more useful to clinicians and health care providers

In addition to the further development of the HIS software, 2004 also presented a number of training opportunities for system users in each country. In August, a specialized two-week Linux course was offered in Tbilisi for ten users. In December, Dr. McDaniel led a four-day report writer workshop to continue training users and system administrators of the HIS demonstration software project on how to build reports to meet the individual needs of each partner facility.

In Armenia, the demonstration project is located at two sites: the Center for Perinatology, Obstetrics and Gynecology (CPOG) in the Armenian capital, Yerevan, and the maternity hospital and women’s polyclinic in Artashat, about 30 minutes outside Yerevan. At CPOG, CSIH has purchased a computer server and five client workstations. In Artashat, CSIH has installed a computer server at the maternity hospital that is accessed by four workstations within the hospital, a Women's Polyclinic and a Children's Polyclinic. Each of the sites now has a Local Area Network (LAN) that spans two buildings. Because CPOG is the major obstetrics and gynecology hospital in Armenia, it accepts patient referrals from other hospitals including the Artashat maternity hospital. The two servers are able to share data by exchanging files over a dial-up telephone line.

The HIS in Armenia will support an electronic patient record for women's polyclinics, maternity hospitals and children’s polyclinics. Each of the participating facilities will be able to access the others' records stored in a common database to facilitate continuity of care. The database will contain basic patient demographic and social data; events that include diagnoses, orders, tests, medications and services; and risk assessments for both the mother and infant. The system will also produce consolidated summary data for use by CPOG.

In 2005, as UNFPA is planning on purchasing computer equipment to run their own Logistical Management Information System (LMIS), CSIH hopes to roll-out the HIS software to UNFPA-supported facilities in every region of Armenia.

In Georgia the HIS demonstration project is located at two sites. The Center for Disease Control and Medical Statistics (CDCMS) in Tbilisi is the principle site. CSIH has installed a computer server that will store and report data submitted by the various health care facilities and health offices to the Center. It will also be used to capture electronic data from a second server to be installed in Gori City Health Department, which is approximately two hours distant from Tbilisi. The Gori City site has workstations housed in four hospitals, the Regional Health Office and the Public Health Office.

The prime objective of the regional information system is to collect, communicate and process data to generate statistics for management and planning purposes. While it is not intentionally designed to include data required for clinical decision support, the system collects a wide range of clinical observations and can be extended further as needed. The HIS application software incorporates the data from the forms currently used by CDCMS and the MOH, as well as several core international datasets that itemize basic patient demographic and social data.

CSIH conducted a follow-up demonstration project software workshop in Tbilisi in March 2004 with approximately forty participants from various health facilities and institutions in Georgia, including the Ministry of Labour, Social Affairs and Health, CDCMS, and Gori health facilities. The workshop provided an overview of health information systems and described the software being developed for the demonstration project in Georgia. The goal of the workshop was to raise awareness among users of the practical applications of an HIS, the impact that health information has on health care planning and management, and to familiarize them with the capabilities of the software.

In 2005, activities will include software workshops, fine-tuning and final installation of software, continued user training for system administrators and operators, and a possible expansion of the system to other hospitals in Gori.

The demonstration project in Azerbaijan has been conducted in partnership with the Public Health Department in Ganja City and has resulted in a limited demonstration project in five medical facilities with a server in the Health Department. Five stand-alone workstations were purchased for use in the selected medical facilities and a server and laptop have been set up in the Public Health Department of Ganja City. A HIS training workshop was held for doctors, nurses, clerks and system users in Ganja in December, to be followed up with more training in March 2005. Similar to the workshops already held in Tbilisi in 2003 and 2004, training consists of the practical applications of an HIS, the impact that health information has on health care planning and management, and the capabilities of the software.

3. Health Informatics Curriculum Development

CSIH is 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 (please see Appendix B for a more detailed outline of the curriculum):

• 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

Local partners in delivering this curriculum include the Azerbaijan State Medical University and the Azerbaijan State Advanced Training Institute for Doctors. CSIH provided equipment for a computer lab at the Institute in November 2003 and an equivalent lab was installed at the Azerbaijan State Medical University in January 2004. These instructional labs, consisting of at least ten computers and an instructor workstation, have already been set-up in the National Institute of Health and the Yerevan State Medical University in Armenia as well as the Tbilisi State Medical University and the Tbilisi State Medical Academy to support the delivery of HIS content to students.

The curriculum material in English and Russian was distributed to the partners in the South Caucasus in CD-Rom format in 2004. Azerbaijani language translations will be completed in 2005 (preliminary Armenian and Georgian translations had been completed in 2003).

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. 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 12^th Annual Colloquium being held in Ottawa October 6-9^th. 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.

EBM and Cochrane Library training will continue in January 2005 with CSIH support, and further training sessions are being planned according to individual partner needs over the next few months. The Tbilisi State Medical University is also hosting a conference on “New Perspectives on Georgian Health” January 20-24^th 2005 and CSIH is supporting the attendance of invited colleagues from Azerbaijan and Armenia.

A final curriculum mission is planned for the spring of 2005 with the intent to provide further support for helping CSIH’s partner institutions effectively integrate the health informatics into their own curriculum.

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 donor organizations. The first HIS Policy Conference, with a focus on standardization of data, was held in Tbilisi, Georgia, May 27 – 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 of 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 the conference, 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, various 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 consultation 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. CSIH continues to coordinate with the WHO to effectively integrate HIS policy in Azerbaijan’s national health strategy.

Similar policy-level workshops will be held in Azerbaijan and Armenia in 2005. A final regional meeting will be held in Tbilisi in the spring of 2005 to discuss HIS sustainability and future policy implications.

5. HIS and Population Health

Health information systems play a key role in the monitoring and evaluation of health status of populations. Through consultation with our partners this activity focuses on highlighting the role of health information systems in health policy decision-making and monitoring poverty reduction.

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 11^th Annual Canadian Conference on International Health and met with various organizations involved in health information including: Health Canada, Canadian Institute for Health Information, and visited the Sandy Hill Community Health Centre. 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.

6. Summary

In the final months of the project, CSIH will focus on developing a resource manual for the consolidation and dissemination of project results. Results will also be shared through various promotional opportunities, including the following conferences:

The Institute of Electrical and Electronics Engineers’ (IEEE) “Wireless Communications and Networking Conference” in April 2005.
Emory University’s Institute of Human Rights’ “Lessons Learned from Rights-Based Approach to Health” conference in April 2005.
The Global Health Council’s “Health Systems: Putting Pieces Together” conference in June 2005.

CSIH will also focus its energies on consolidating its achievements, identifying and sharing lessons learned and addressing outstanding sustainability issues with other stakeholders through a stakeholder consultation process.

Local partners

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
National Health Management Centre
Public Health Department, Shida Kartli Region
Tbilisi State Medical Academy
Tbilisi State Medical University

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

Appendix A - HIS Certificate Course List of Participants

Appendix B - HIS Curriculum Table of Contents

1 Nicholas Street, Suite 1105
Ottawa, Ontario,
Canada K1N 7B7
Phone: (613) 241-5785 Fax: (613) 241-3845 Email: csih@csih.org