Health information systems in developing countries: Star Wars or reality?
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In the late 1990s, an international consultant told me that a proposed electronic health information system in the Dominican Republic was “like Star Wars and will not work in this country.”
Our objective was to improve service delivery by virtually connecting health providers to share medical records with one another as patients moved from health centers to hospitals. We learned that this was much more than an overnight task, requiring a sustained medium-term effort by the government to get the system fully up and running.
In recent years, I’ve seen similar efforts realized in the Russian Federation, Georgia, Azerbaijan and Botswana. In two Russian regions, Chuvash Republic and Voronezh Oblast, for example, electronic records are helping coordinate the flow of clinical and financial information across the health systems as facilities, departments within hospitals, and health insurance agencies have been “virtually” connected through broadband networks. The electronic records are supporting clinical decision-making, facilitating performance measurement and pay-for-performance initiatives, and ultimately the continuity of care as patients move across the health system. Inter- and intra-regional medical consultations and distance learning activities are also being supported by telemedicine networks that connect specialized hospitals with general facilities.
In Georgia, the Social Information Management System (SIMS) at the Ministry of Labor, Health and Social Affairs is providing consolidated automated information about all the registered beneficiaries (each with a unique identifier) of government-funded social programs. This has improved management of the Mandatory Health Insurance for the Poor (MIP) and other programs, such as pensions, means-tested targeted assistance, and internally displaced person allowance distribution, bringing transparency in the use of public funds.
In Azerbaijan, electronic case reporting forms, supported by geographic information systems, is helping track and fight, in real time, communicable disease outbreaks.
And in Botswana, the government has rolled out an electronic medical records system to all of the country’s main hospitals, and the country continues to improve the coding and reporting of health conditions and internet connectivity.
These examples from countries clearly show that in reshaping the global health agenda, we need to support the spread and local adaptation of health information technology and overcome the thinking that implementing this information and communications technology is beyond the capacity of countries at different levels of development.
The Star Wars movie saga was entertaining science fiction, but transforming health service delivery in countries is not. Helping deploy the power of electronic health records is not only environmentally friendly (less paper-based medical records), but it has the potential to transform the decision-making capacity and the quality of services in the health system of a country.
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Besides the potential savings in reducing the consumption of paper and improving the quality of the information, it is important to keep in mind that the adoption of EMR has the potential to contribute to implement broader health care organization transformations—e.g., a critical tool to facilitate system integration and optimization. A recent study in Health Affairs that focuses on the Kaiser Permanent experience in the United States provides evidence that shows that introducing HER creates operational efficiencies by offering nontraditional, patient-centered ways of providing care. For example, while over 2004 and 2007, the annual age/sex-adjusted total office visit rate decreased 26.2% , the adjusted primary care office visit rate decreased 25.3%, and the adjusted specialty care office visit rate decreased 21.5%, the scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly six fold by 2007. [Health Affairs 28, no. 2 (2009): 323–333; 10.1377/hlthaff.28.2.323]
I could not agree more about HMIS should be electronic system starting data collection to data analysis. This HMIS in developing countried like Lao PDR should be move quickly away from paper based system, every year more than 100.000 USD spent for printinf HMIS data collection forms. Electronic data collection and reporting is more qucik and relaiable, easy to check for quality of data.
Hi Dr. Chansaly,
It may be time for Lao to move forward by developing a HIS Strategic Plan from the HMN HIS Assessment that was done a few years ago. Was there any follow-up on this.
Thanks for your good comments Saul. Indeed, as you clearly pointed out, a common denominator in a large number of countries is the existence of multitudes of data sets to measure the performance of programs or of international funded projects without any relation or connection, and often this is done at the top of the national information systems. So duplication is the name of the game, and the lack of standards for coding, recording and reporting is a common reality. Another factor that complicates the problem is the weak national structures that are responsible for the coordination of data collection, processing and dissemination, particularly for evidence based policy decisions and monitoring and evaluation of the impact of investments and activities. So the development of unified electronic HMIS systems is needed to bring together over time health program and service delivery data, financial flows data, and human resources and other inputs data. To tho this, a fully funded and sequenced action plan is required as this is not an overnight task.
Given the question on the Lao HIS Strategic Plan, perhaps it would be useful for you to review the article: "Talkin' about a revolution": How electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings," that focuses on an initiative to develop and implement an EHR in a large HIV/AIDS care program in western Kenya. The data were used to manage patients, providers, and the program itself as it grew to encompass 18 sites serving more than 90,000 patients. According to the article, the lessons learned have been applicable beyond HIV/AIDS to include primary care, chronic disease management, and community-based health screening and disease prevention programs.
http://www.ncbi.nlm.nih.gov/pubmed/19858941
Partricio,
I think in many countries a real focus on getting an HMIS system working is key to improving performance, but is often not an immediate priority. Various vertical programmes and funders bolt together various indicator sets that often overlap, or which cannot usefully be cross-referenced. And yet availability and usability of routine (nearer real-time) information are fundamental to actively managing a system, making allocation decisions, monitoring performance and supporting accountability both upwards and downwards.
Whether or not to go straight in with an electronic records management system at facility level will depend on context, but a first step of getting the information architecture in a system right is essential (and will make digitisation far simplier when rolled out). A well thought through architecture can minimise the number of indicators that need to be collected, and support more productive multi-variate analysis.
mHealth solutions are begining to make digitisation closer to point of care a possibility. There are also a number of open source initiatives being developed for mHMIS platforms. Togteher these present fantasitic opporunties (although inter-operability of systems will be essential if we are not to end up with electronic spaghetti).
Crucially, digitisation makes data usable; verification algorithms can reduce manual data cleaning considerably; dashboard approaches can make data accessible; rooms of discarded paper slowly rotting can be dispensed with. And most importantly, if data is used to inform decisions that then impact on service delivery units (feedback) then the motivations to provide data change (why bother providing information that's not going to be used?).
Overhalling an information system is can be daunting, and is often perpetually deferred. As information is often second only in political significance to money, reforms are always contencious. And this is not just within governments. Donors are increasingly trying to aggregate results from across their different country programmes to report back to domestic constituencies. They have their own views on what to record. However, the ongoing inefficiency of current information systems, both in terms of their own running costs and in their lack of fitness for purpose for effective management, is enormous.
Unfortunately, health systems are not like Luke Skywalker (who could fight his enemies by shutting his eyes and feeling the Force), they need to have their eyes open (i.e. have data) to see what's going on.
Your comments are valid. The numerous vertical programmes going on in a developing country makes it very difficult for the country to take control by completing a comprehensive national HMIS initiative. Many countries have problems putting appropriate HIS policies in place. There are many situational analyses and strategic plans etc. that too often really don't go far, and what does get implemented if sidelined by vertical programming needs.
I wonder if a consortia of donors together with the government can collaborate on implementing national and comprehensive HMIS? There may be "turf wars" over indicators etc., but at the end of the day all will utilize the HMIS and government will have more effective say and control.
There certainly is a better climate of donor collaboration and communication than in the past, but still only a lot of lip service to real HMIS developments beyond pilots and strategies.
There are very many local pockets of HMIS success that rarely translate into expansion, this results in no real net benefit to the country as a whole. Why is this so?
The data were used to manage patients, providers, and the program itself as it grew to encompass 18 sites serving more than 90,000 patients. According to the article, the lessons learned have been applicable beyond HIV/AIDS to include primary care, chronic disease management, and community-based health screening and disease prevention programs. We need to implement more focus on information system in developing countries..