Using HIS to improve essential Health Services in Fiji
2AN ABSTRACTThe Patient Information System (PATIS) was initially set up in Fiji by the Fiji Health ReformProject which was jointly funded by the Government of Australia and Fiji. PATIS is based on aHealth Information System developed in Samoa under a project initiated by the AustralianAgency for International Development (AusAid).PATIS is overseen by the Health Information Unit (HIU), and its principle role is to support theMinistry of Health in the areas of planning, evaluation, research and monitoring to improve thequality, efficiency and effectiveness of health services delivery. The Unit also supports thehospital‟s Medical Records Departments at the national level with policy guidelines for medicalrecords and information system management. At present, PATIS used the IP – VPN, betterknown as the Virtual Private Network.This project paper focus on the role of the Health Information Unit at the Ministry of Health inFiji and will only focus on the Patient Information System (PATIS) to see how it has increasedthe efficiency of the service delivery in the respective areas.The group was not allowed access to many relevant documents for more profound research andfurther explanation of this topic. The group managed to extract most information from theinternet and other relevant bodies like the Pacific Health Network, AusAid, Healthlink, WorldHealth Organization, Online Journals, employees of Ministry of Health, and the backgroundknowledge on the topic from one of the group members. Documents like the Strategic Plan andHealth Information Policy for the Ministry of Health have been accessed from the web.ACKNOWLEDGEMENTThe group acknowledges the assistance provided by the Acting Director IT at Ministry of Health,Mr. Shivnay Naidu who assisted us in providing us the direction for this project.OBJECTIVETo determine how the Health Information Systems at Ministry of Health are adding value to theclient and the organization, as a whole.
3TABLE OF CONTENTSAbstract……………………………………………………………………………2Introduction………………………………………………………………………..4Literature Review………………………………………………………………….6Findings to our Research…………………………………………………………..15A Discussion of the Findings………………………………………………………26Conclusion…………………………………………………………………………34References……………………………………………………………………….....41Annexure 1…………………………………………………………………………45Annexure 2…………………………………………………………………………46Annexure 3…………………………………………………………………………48INTRODUCTION
4This project paper focus on the role of the Health Information Unit at the Ministry of Health inFiji and will only focus on the Patient Information System (PATIS) to see how it has increasedthe efficiency of the service delivery in the respective areas.The group was not allowed access to many relevant documents for more profound research andfurther explanation of this topic. The group managed to extract much information from theinternet and other relevant bodies like the Pacific Health Network, AusAid, Healthlink, WorldHealth Organization, Online Journals, employees of Ministry of Health, and the backgroundknowledge on the topic from one of the group members.The Ministry of Health, in its Strategic Plan for 2011 – 2015 (Page 9), states that there is a “needto strengthen health systems through improving investment in technical infrastructure”.Furthermore it states that “an assessment of Fiji‟s progress towards achieving its health outcomesdepends on a well functioning health information system with access to age, sex andgeographical, time-series disaggregated data, some of which were not available. Efforts are beingmade to address the data gaps to enable planning for prevention and response to emerging healthissues”.The Ministry of Health, in 2011, has also developed and implemented a Health InformationPolicy. The essence of the Policy is “For the Government of Fiji, timely and reliable healthinformation is necessary for improving the healthcare of individuals and is essential in enablingevidence-based decision making and tracking performance towards attainment of its humandevelopment aims ascribed to the Millennium Development Goals (MDGs), as well as theMinistry of Health Strategic Plan (2011-2015) and other related strategic plans. A functionalHealth Information System (HIS) is critical for effective service delivery and overall governanceand stewardship of the health sector. Use of reliable and good quality data from a robust HISleads to improving health systems performance, quality of health care, achieving universalaccess, increasing service delivery, reducing burden, increasing efficiency, and improving cost-effectiveness” (Page 7).PATIS is overseen by the Health Information Unit (HIU), and its principle role is to support theMinistry of Health in the areas of planning, evaluation, research and monitoring to improve thequality, efficiency and effectiveness of health services delivery.The Unit also supports the hospital‟s Medical Records Departments at the national level withpolicy guidelines for medical records and information system management. Figure designed from information provided by Ministry of Health Fiji MINISTRY OF HEALTH HQ (National Level)
5 Divisional LevelInformation for Information forKnowledge Sub divisional Level Action(Feedback) (Reporting) Health Center/ Nursing Station Community Level The Patient Information System (PATIS) was initially set up in Fiji by the Fiji Health Reform Project which was jointly funded by the Government of Australia and Fiji. PATIS is based on a Health Information System developed in Samoa under a project initiated by the Australian Agency for International Development (AusAid). PATIS principally supports the inpatient process, pharmacy, radiology, dental, laboratory, and the outpatient department. Monitoring public health staff utilization and surveillance in remote areas is catered for by a paper-based system with timely entry into the nearest computer system. (Kerrison 2003) The Ministry of Health has the following information systems in use: Patient Information System (PATIS) Logistics Management Information System (LMIS) Asset Management System (AMS) Human Resource Information System (HRIS) Financial Management Information System (FMIS) Public Health Information System (PHIS) LITERATURE REVIEW
6 A Health Information System should be an integrated effort to collect, process, report and use health information and knowledge to influence policy and decision-making, programme action and research. Sound decision-making at all levels of a health system requires reliable health statistics that are disaggregated by sex, age and socioeconomic characteristics. At a policy level, decisions informed by evidence contribute to more efficient resource allocation and, at the delivery level, information about the quality and effectiveness of services can contribute to better outcomes. Information systems, particularly at the lower levels of the health system, need to be simple and sustainable and not overburden health delivery staff or be too costly to run. Peripheral staff needs feedback on how the routine data they collect can be used and to understand the importance of good quality data for improving health. Capacity building is also required to ensure policymakers at all levels have the ability to use and interpret health data, whether it originates from routine systems, health surveys or special operational research. It is also important that staff working at the periphery of the health system understand the significance of local data for local program management, and that their needs for strengthened capacity for critical health statistical analysis are met. Local use of data collected at lower levels of the health system is a key step for improving overall data quality. Essential Modules for an Ideal Health Information Systemhttp://www.uq.edu.au/hishub/definition-of-health-information-systems-104912
7A comprehensive hospital information system to meet the specific needs of a hospital containsmodules for in-patient /out-patient registration, patient care, pharmacy, diet planning,accounting, etc. Sophisticated equipment used in the practice of modern medicine generates hugeamount of data. Evaluation of stored clinical data by using various mining techniques may leadto the discovery of trends and patterns hidden within the data that could significantly enhanceour understanding of disease progression and management(http://www.informaticsreview.com/wiki/index/php).Understanding the Role of Technology in Health Information Systems(Lewis, Hodge, Gamage, Whittaker, 2011) Adapted from Health Information SystemsKnowledge Hub, School of Population Health, University of Queensland.Innovations in, and the use of emerging information and communications technology (ICT) hasrapidly increased in all development contexts, including healthcare. It is believed that the use ofappropriate technologies can increase the quality and reach of both information andcommunication. However, decisions on what ICT to adopt have often been made withoutevidence of their effectiveness; or information on implications; or extensive knowledge on howto maximize benefits from their use. While it has been stated that „healthcare ICT innovation canonly succeed if design is deeply informed by practice‟ (Sanderson 2007: 4), the large number of„failed‟ ICT projects within health indicates the limited application of such an approach.There is a large and growing body of work exploring health ICT issues in the developed world,and some specifically focusing on the developing country context emerging from Africa andIndia; but not for the Pacific Region. Health systems in the Pacific, while diverse in many ways,are also faced with many common problems including competing demands in the face of limitedresources, staff numbers, staff capacity and infrastructure. Senior health managers in the regionare commonly asked to commit money, effort and scarce manpower to supporting newtechnologies on proposals from donor agencies or commercial companies, as well as from seniorstaff within their system. The first decision they must make is if the investment is both plausibleand reasonable; they must also secondly decide how the investment should be made. Theobjective of this paper is four-fold: firstly, to provide a common „language‟ for categorizing anddiscussing health information systems, particularly those in developing countries; secondly, tosummarize the potential benefits and opportunities offered by the use of ICT in health; thirdly, todiscuss the critical factors resulting in ICT success or failure, with an emphasis on thedifferences between developed and developing countries; and fourthly, to introduce evaluationframeworks and models used in developed countries to assess the plausibility of ICT projects inhealth.While infrastructure may be the cornerstone of development (increasing access to knowledge andlinking isolated rural communities); as discussed by Keke (2007), most Pacific Island Countriesand Territories have weak institutional frameworks with limited coordination and managementof staff and infrastructure. Overall, what can be said about the Region is that it is characterizedby remoteness, dispersed and small total populations and vast ocean distances (apart from PapuaNew Guinea) and limited human resource and institutional capacity – especially in relation toICT (PIFS 2002a; PIFS 2002b; Network Strategies 2010). It is these characteristics that have led
8to the growing agreement that „ICTs offer huge potential for social and economic development inthe Pacific‟ (Network Strategies 2010: ii). However it is these very same characteristics thatmake ICT exceptionally difficult to implement and sustain among PICTs.Health Information SystemsThe aim of this section is to provide a common language for talking about Health informationSystems. The first question is what we do mean by a Health Information System (HIS); as theterm is used with two very distinct meanings. The restricted meaning refers to systems thatcapture and report aggregated health statistical information. This is the meaning that, forexample, the Health Metrics Network (HMN) and World Health Organization (WHO)traditionally use. WHO (cited Abouzhar & Commar 2008: 1) define HIS as integrated efforts to,„collect, process, report and use health information and knowledge to influence policy making,program action and research‟ and further states that they are essential to the effective functioningof Health Systems worldwide. For the purposes of this project such systems will be referred to asRoutine Health Information Systems (RHIS). RHIS, such as those operated through healthinformation departments or national statistics offices, provide information on risk factorsassociated with disease, mortality and morbidity, health service coverage, and health systemresources.The broader meaning of HIS refers to any system that captures, stores, manages or transmitsinformation related to the health of individuals or the activities of organizations that work withinthe health sector. It is this broader meaning of Health Information Systems that is used in thispaper. This extended definition incorporates such things as district level routine informationdisease systems, disease surveillance systems but also includes laboratory information systems,hospital Patient Administration Systems (PAS) and human resource management informationsystems (HRMIS) for health workers.The typical components of a “traditional” Health Information System for a “developing countryincludes: • A routine health information system capturing aggregate activity data from paper forms via „district‟ level reporting to be eventually recorded in an electronic system at the „provincial‟ and/or national level • Notifiable disease reporting system (possibly using both routine reporting and sentinel sites) • Disease registries.There is significant academic literature regarding the implementation of such systems,particularly in Africa, but few robust quantitative evaluations of their benefits. Over recent yearsthere has also been significant research published on the impact of new technologies such as theuse of mobile phones to improve the operation of these „traditional‟ systems.Of course many HIS environments will not include all such components and where they do exist,they will have been implemented over an extended period of time building on earlierdevelopments and dependencies. A number of key elements of the differences between the HISenvironments are:
9• Investment in departmental (auxiliary) systems to support acute care, such as radiology and Laboratory Information Systems, initially the prime purpose of these is to manage work flow efficiently• A focus on systems that store, transfer and use information on individual patients for prospective clinical decision making rather than on aggregated information used for policy and monitoring• A focus on sharing information between health care providers to enable continuity of care, reducing duplication and improving patient safety• Richer integration of information available from multiple sources to inform policy and management decisions.It can be expected that countries in the Pacific will be looking to adopt and implement suchsystems over time. The rate of adoption will vary from country to country but will be driven byfactors such as:• Changes in disease patterns, the shift from communicable to non-communicable and chronic diseases, requiring changes in patterns of care and supporting systems• Increased expectation of stakeholders, this includes both increasing expectations from patients and possibly more significantly increasing demands from clinicians.This extended Health Information System is composed of a large number of individual systems.In the past many of these have been isolated, „stand alone‟ systems but intersystemcommunication for data sharing and integration is increasingly the norm. Such communication ofclinical data progresses through a number of distinct stages. Initially data is communicated in aform understandable by humans but not by the machines (a facsimile is a simple example of this)and later moves to full semantic interoperability where transmitted data can be used by thereceiving system for things such as computerized decision support. Individual systems include: • Patient Administration System (PAS): Basic component of a hospital computer system which records patient details, all admission, discharge, ward allocation and transfer, treating clinicians and outpatient attendance. Coding of diagnoses and treatment options allows for the analysis of hospital and national disease burden. Usually one of the first systems to be installed in starting to „computerize‟ a hospital. • Laboratory Information System (LIMS): Primary purpose is to manage the flow of samples through a pathology laboratory. This requires the electronic registration of samples as they flow through the laboratory and the interaction with all laboratory machines to electronically capture the results. The secondary purpose is to provide the results to clinicians in a timely and convenient manner. • Electronic Medical Records (EMR): Facility or organization-based records of all patient interactions. Includes details of patient problems, diagnoses, investigations, test results, treatments and prescribed medicines. Usually requires input from auxiliary systems such laboratory information systems. • Electronic Health Record (EHR): Sometimes termed a Shared Electronic Health Record (SEHR). Includes details from multiple organizations and care settings to provide a complete longitudinal patient medical history. Information is usually a summary from the contributing EMRs. Available to all healthcare providers delivering care to a patient. • Management Information System (MIS): The intention of such a system is to bring together and present in an integrated manner all the information needed to manage and plan
10 the health system. Ideally this includes health system activity data, human resource, financial, supply, disease incidence and demographic information. Few health systems in the world would have such an ideal MIS.The video available at this link from 3M Industries on youtube.com shows in a summary howdata can be linked with outcomes:http://www.youtube.com/watch?feature=player_detailpage&v=m21qZuu24_oOpportunities and BenefitsIn the developed world there have been two key drivers for investment in health ICT. The first isthe ever increasing burden from chronic disease, often with complex co-morbidities, on thehealth care system with costs increasing significantly faster than population or GDP growth. InAustralia, for example 80% of the burden of disease is now from chronic diseases (includingcancers) (AIHW 2003). The treatment and management of such chronic disease continues overan extended period of time and is performed by multiple health care providers in multiplesettings. The second key driver is the recognition of the need for greatly improved quality andsafety in the delivery of health care. This recognition has been driven by such things as theNational Institutes of Medicine report To Err Is Human (Kohn et al 2000) which estimated thatin hospitals alone, between 44,000 and 98,000 Americans died each from medical error.Both of the these factors have led to very significant investments in the development of systemsto enable the sharing of structured data to provide more complete and timely information forclinical decision making. These have included such things as the development of local electronicmedical records, secure messaging to interface systems and shared longitudinal electronic healthrecords. There has been the expectation that these developments would lead to major savings incost and increases in patient safety. In the United States, for example, a RAND CorporationStudy (Hillestad et al 2005) estimated that it would take 10 to 15 years to establish a full e-Health system but such a system would then deliver savings of $81 billion dollars per year aswell as delivering greatly improved quality of care. In Australia, the projected cost ofimplementation of the national broadband network is $42 billion, but in its submission to theNBN Senate Select Committee, iSoft (2009), an Australian medical software company, estimatedthe cost savings for integrated health records to be of the order of $8-$10 billion annually, andemphasized the importance of broadband in realizing the full e-health system.The U.S. based Centre for Information Technology Leadership (CITL) reviewed a sample ofstudies from academic, industry, and provider sources, aiming to answer the question: What arethe demonstrated benefits of a given system or application? They found few concrete answers,noting that:“There is very little hard evidence demonstrating the value of specific HIT investments”;“A good deal of the current literature is conceptual. Rather than discuss demonstrable benefits ofHIT, about one-quarter of sources did not address specific benefits at all. Instead, these largelytheoretical works discussed value assessment frameworks or barriers to value realization.
11Benefits like cost containment or outcomes improvement were mentioned with little if anysupporting primary data”;And“Existing evidence is not sufficient to clearly define “who pays for” and who benefits from HITimplementation in any organization – except those …that are responsible for paying for anddelivering all the care for the defined population” (Walker 2006).While there has been limited rigorous quantitative analysis of the benefits from specific ICTinvestments in the developed world there has been even less for the developing world. There hasbeen a significant level of published literature over recent years around such things as: • Use of mobile phone technology for disease surveillance • Low cost technologies for clinical video case conferencing • Open source technology for the development of routine health information systems and the use of technologies such as hand held PDAs to improve the efficiency and timeliness of systems.It is likely over the next decade that the major ICT investments in health in the developing worldwill be in: • Hospital patient administration systems (PAS) to optimize the use of scarce resources, hospital bed-days and clinicians • Logistics system to help manage the distribution, storage and distribution of drugs and medical supplies, and to reduce loss through retention of out-of-date drugs and pilfering • Simple information transfer systems (referrals and discharge) to support continuity of care as patients move between primary care settings and acute care • Extension of access to routine health information systems to lower geographic levels so data can be entered closer to source and a wider range of users can access information directly • Pathology, radiology and pharmacy information systems to manage the work flow in these areas and subsequently provide information to clinicians and support continuity of care.ICT Project FailureWhile the potential health and financial benefits from the use of technological innovation inhealth are large, the risks are also substantial. A World Bank Study conducted in 2005 found, forexample, that the majority of public sector ICT applications in developed countries were eitherpartial or total failures (cited UNAPCICT 2010). Furthermore, in his report on e-Governmentprojects for development, Heeks (2008) states that 35% of such projects are total failures, 50%partial failures, and only 15% are considered successful.A study by Gheorghiu (2006) found that 70-80% of all information technology and informationsystems fail. Similarly, Kaplan and Harris-Salamone (2009) reported international failure ratesof major health IT projects of between 30% and 70%. Such figures are found repeatedlythroughout the academic and industry literature. There is a far smaller literature base on thedeveloping world, but intuitively one would expect the failure rates to be at least as high as in thedeveloped world. The International Development Research Centre (IRDC) (www.idrc.ca) noted
12a significant failure rate (up to 50%) in the small scale telemedicine projects it had sponsored andin general, an inability to demonstrate improved patient outcomes from the projects.Framework for AnalysisThe Real Access – Real Impact Criteria designed by BRIDGES (2010) offers a framework forthe analysis of all issues around ICT access and use, including anticipating or detecting whycertain e-Health projects have failed, and highlighting how and why other projects can succeed,as outlined below: • Physical access to technology • Appropriateness of technology • Affordability of technology and technology use • Human capacity and training • Locally relevant content, applications and services • Integration into daily routines • Socio-cultural factors • Trust in technology • Local economic environment • Macro-economic environment • Legal and regulatory framework • Political will and public support.Maturity ModelThe concepts of „maturity‟ and „adaption‟ in Information Systems (IS) and InformationTechnology (IT) are well-known in the business literature, with early „maturity models‟ datingback to the 1970s (Wetering & Batenburg 2009). Maturity in this sense refers to the state of anorganization‟s effectiveness in performing tasks and how well organizational behaviors,practices and processes can impact on outcomes (Crawford 2006). Overall, maturity modelsreflect the characteristics of an organization as they move through different stages in a changecycle, providing conceptual guidelines on essential requirements and components at each stage,including key success drivers and indicators (Duffy 2001; Kim & Grant 2010). In defining thedifferent stages of development and growth, maturity models are able to analyze organizations;recognize when and why they should move forward; provide insight into the actions needed; andestablish goals for achieving and measuring progress (Wetering & Batenburg 2009; Duffy 2001;Sharma 2008).Due to their holistic nature maturity models are an important managerial tool, and while theyhave been used extensively in information system development, especially softwaredevelopment, they offer important insight into health information systems (Kim & Grant 2010;Wetering & Batenburg 2009; Crawford 2006). Sharma (2008) describes an „electronicallyimmature healthcare organization‟ as one that is reactive, with personnel focusing on solvingimmediate crises; with no objective basis for judging product quality or solving processproblems; and has unpredictable healthcare product quality. Further, Haux (2006) has proposedseven different stages in the development of HIS:
13• Shift from paper-based systems to computer-based processing and storage and increased data processing• Shift from local to global information system architectures• HIS used by professionals and patients/consumers• Data used for patient care and administration, and also increasingly used for healthcare planning and clinical research• Shift of focus from technical HIS problems to change management and strategic information management• Shift from alpha-numerical data to clinical images and data on a molecular level• Steady increase in new technologies for continuous monitoring of health status.Each stage of a maturity model represents greater expectations and complexity of environments,as well as tracking improvement and transformation over time and the capabilities at each stage(Wetering & Batenburg 2009; Sharma 2008). While critiques of maturity models havehighlighted the limitations of using a strictly linear assumption in regards to system development(Kim & Grant 2010; Moon 2002), a key strength in such models is their ability to highlight themultiple stages in a change cycle, as well as the multiple factors involved (including human,technological, process and organizational) (Duffy 2001).SummaryOverall, information and communication technologies have a potentially major role to play inhealth information systems. Technology in healthcare can improve access for geographicallyisolated communities; provide support for healthcare workers; aid in data sharing; provide visualtools linking population and environmental information with disease outbreaks; and is anelectronic means for data capture, storage, interpretation and management. Such possibilities areespecially important in the Pacific; a region that is characterized by remoteness, dispersed andsmall total populations and limited human resource capacity.However, key issues have emerged in the implementation of ICT in the region:telecommunications infrastructure remains a major limiting factor in the success of many ICTinitiatives in the Pacific (and developing countries in general). It is vital that aspects such aselectricity systems, phone lines and internet connectivity are taken into consideration beforeimplementing any new technology. Furthermore, human capacity and training are fundamentalaspects of any ICT initiative. The affordability of the technology (and use of it) must also beassessed in terms of initial and ongoing costs such as license fees, maintenance and supportcosts. Any ICT initiative that is heavily reliant on external funding is unlikely to be sustainableover the long term. Additionally, the exceptionally high cost of many telecommunicationsservices in the Pacific remains a significant limiting factor to their use. There are also importanthidden costs associated with technology, including maintenance, upgrades and replacing brokenequipment, which need to be assessed.Judgments must be made on the appropriateness of the technology itself. Moreover, the tropicalclimate of the Pacific region is damaging to equipment, such as computer hard-drives that
14require climate-controlled and dust-free environments. Appropriateness also refers to theanticipated benefits of the technology in comparison to its costs.While ICT initiatives have the potential to support health information systems, any project ornew policy must have an appreciation of the context and challenges of the implementationenvironment. These factors are highlighted in the numerous evaluation tools, methodologies andframeworks available on the appropriate and effective use of ICT in health.Overall, maturity models are a potentially effective tool that senior managers in health could useto assist them in making decisions on whether to invest in information and communicationstechnology. Maturity models offer a means to classify different systems in terms of their currentlevel of sophistication (in terms of human and technical capacity) and provide a pathway ofdevelopment for health information systems in the region.The following video shows what a customer focused hospital covers in an ideal HealthInformation System: http://www.youtube.com/watch?v=cvvVFPz6TBI&feature=relatedThe following video from youtube.com explains some of the major benefits of a patientinformation system: http://www.youtube.com/watch?v=6GMCiWl2ArgThe diagram below shows how an ideal Health Information System looks like: www.himss.org
15 FINDINGS TO OUR RESEARCH The population of Fiji is estimated to be 883, 125 as of July 2011 (www.indexmundi.com/fiji/demographics_profile.html). Medically, Fiji is split into three divisions (Central/ Eastern, Western, and Northern). The Health Service Structure is as follows: 3 Divisional Hospitals (200 beds – Labasa, 300 Beds – Lautoka and 450 Beds – Suva) 22 Sub Divisional Hospital‟s (20 – 80 beds) 78 Health Centres 104 National Stations 2 Specialist Hospitals 3 Old People‟s Homes The PATIS Sites Fiji wide is shown in Annexure 1. Manual Data Collection Processes Patient Information Logistics ManagementConsolidated Monthly Report System Information System Hospital Return Asset Management HEALTH INFORMATION UNIT System Cancer Registry Support Informed Decision Making Notifiable Diseases Periodic or Ad Hoc Surveys Financial Management Human Resource Information System Information SystemIndividual Unit Collections Public Health Information System Figure designed from information provided by Ministry of Health Fiji
16The Ministry of Health has the following information systems in use: Patient Information System (PATIS) Logistics Management Information System (LMIS) Asset Management System (AMS) Human Resource Information System (HRIS) Financial Management Information System (FMIS), and Public Health Information System (PHIS)Health Information Unit (HIU)Information has been kindly provided by Ministry of Health.The HIU has undergone various reforms with different names and functions. The Unit wasinitially known as the Medical Registry with the major responsibility of tracer contact for leprosyand tuberculosis apart from the registering of Notifiable diseases, then to Medical Statistics Unitwhere its role as the tracer contact decreased as incidences of leprosy and Tb declined. The focusis now more on the collection and compilation of health statistical data. It further analyzes andinterprets this data into useful information.Its main aim is to develop an integrated health information system to cater for the data andinformation in an efficient and effective way so that information could be analyzed, reported anddisseminated in a timely fashion to facilitate management of programs and the monitoring ofhealth care services. The Unit plays a pivotal role in the areas of planning, evaluation, researchand monitoring in order to improve the quality, efficiency and effectiveness of health servicedelivery. It also supports the hospital‟s Medical Records Department at the National Level withpolicy guidelines for medical records and information management system.The Health Information Unit‟s principle objectives are: To provide a timely, reliable and comprehensive information to the Ministry of Health for decision making, allocation of resources and monitoring of health services. To provide reliable and timely epidemiological information to the Ministry of Health for planning, monitoring and evaluation of the effectiveness of health programs. To provide information for policy guidelines and management support at all levels, including hospital medical records department to establish national standards for provision of effective services to patients while maintaining strict patient confidentiality and assuring the security of medical records. Provision of regular feedback to Managers and Supervisors of services for their regular assessment.
17The core functions of the Health Information Unit are to: Collect and collate data reported from Hospitals and Community Health settings and provide feedback for any discrepancies in reporting. Follow-up of the outstanding returns/ reports Computerization of health information Data analysis Generate reports Presentation of vital and health statistics/ indicators Provide statistical table and graphs for the Ministry of Health Annual Report Provide statistical information at all levels of the Ministry of Health, other Government Departments and NGO‟s for any relevant information needed.In their „Health Metrics Network Report, prepared by the Health Information Unit in 2009, theUnit has acknowledged that there is an absence of both a legislation and also a National HealthInformation Systems strategy which is supported by policies to address the need for informationsharing amongst the Stakeholders. It further added that the current human resources andinfrastructure for the Health Information Systems was not adequate. This finding was furthersupported by the Acting Director IT for the Ministry of Health, Mr. Shivnay Naidu, when thegroup interviewed him on Thursday, 8th December 2011.Feedback for information is necessary for actions to take place within the system, however, thisis lacking in Fiji‟s Health Information System and needs to be strengthened if meaningful andevidence based information is to be utilized for action based planning within the health sector.Fiji‟s current health information reporting system is more information for knowledge basedrather than action based due to the weak analysis and feedback mechanisms in the system. Thereis a need to standardize and streamline data flow at each level to ensure the timely and effectivefeedback and to preserve and promote data integrity, consistency and quality was highlighted bythe “Health Metrics Network Report”.The Ministry of Health Strategic and Corporate Plan for 2012 will use information submittedbased on the data collected from PATIS which is a pioneering achievement for the Ministry ofHealth.Patient Information System (PATIS)The Objectives of PATIS are: Improve patient services and outcomes Assist health service administration Collect information for timely Public Health surveillance and health programme monitoring
18The functionality areas of PATIS are: Software developed on Access database Registers all persons who have been serviced at hospital, health centre and nursing stations Person registered within their locality Local area networks linking into wide area networksAn initial key objective of PATIS was to develop a National Health Number (NHN) for allclients serviced through hospitals and clinics throughout Fiji. The NHM was supposedly to beunique to each client. This was as a client‟s captured medical history is unique to him/ her.PATIS was to eradicate the tedious process of waiting for medical record or other relevantinformation before clients could be treated. The Ministry of Health has successfully implementedthis process.There have been instances where clients have been found with two or more NHN‟s. Now thePATIS support systems are equipped with an option to merger data when a client with two ormore NHN is found.IT ArchitectureA Local Area Network (LAN) is installed at each facility where PATIS is running. Theminimum requirement for each network is a server, personal computers, printers, label printers(National Health Card production and pharmacy) and a modem. The transmission media for thenetworks is principally twisted pair cabling but fibre-optic and wireless communication isinstalled where required. A wide area network is also established between the major centerswhich assists in communications and maintenance (Kerrison 2003)Desktop PC‟s run MS Windows or XP Operating Systems. The number of PC‟s installed variesfrom 8 in the smaller hospitals (25 beds) to 50+ in larger hospitals. Computers are placed in mostwards, radiology, pharmacy, dental, laboratory, clinics, outpatients, dietician, and management.Printers are located at strategic points. Servers are all multi-disc running Redundant Array ofInexpensive Disks (RAID) for faster access and reliability with redundant power supplies andautomated tape backup (Health Information Unit, 2011).MS SQL Server is used as the data base management system. Communication with the databaseis via Open Database Connectivity (ODBC). The SQL Server database structure has been keptrelatively simple principally to alleviate the need for a specialist Database Administrator. Use ismade of database views, functions and triggers. Complex data integrity checks are programmedinto the PATIS application but now need to be upgraded due to the increased workload as fromthe 15 server sites, the number has increased to 32 this year. PATIS has also upgraded to an IP-VPN from 2011 (Naidu, 2011).
19SQL Server Agent is used to automatically backup (dump) the data to a file on a daily basis thatis subsequently backed up to tape. Virtually all data in each database is synchronized (replicated)on a nightly basis.Issues with the National Health Number (NHN) Inadequate supervision of staff Attentiveness of staff Inadequate initial training of staff Lack of adequate and appropriate training of new staff members Programmatic inefficiencies (e.g. Too many people returned when search criteria entered), and Misunderstanding by patients of the meaning and use of the NHN and/ or embarrassment to admit they have lost their card or left their card at home.TrainingA series of “PATIS Train the Trainer” courses are run to build a group of experienced PATIStrainers. Participants are selected from around the country and from all disciplines, includingnursing. Component trainers within the Fiji Ministry of Health now facilitate the courses.User training has been structured to emphasize not only the “how” but also the importance of thedata, data accuracy, the effect it has at all levels and how the data is to be used. For users whoattend to public/ clients, the training also includes a session on public relations and “interview”techniques specific to patient registration and/ or their particular task. Use of the registrationequipment (label printers and laminators) is an integral part of the training. Refresher trainingcourses are run in facilities as and when the need is identified.For users who have little or no previous experience with computers, an “Introduction toComputers” course is run immediately prior to the PATIS training. The course is one or two daysdepending on the level of experience of the users and covers the basics of computers (hardware,turning on and off, keyboards, windows, excel, etc). The courses have been very successful inmaking users comfortable with computers and have increased the productivity of the PATIStraining.Search ParametersBefore registering a patient on PATIS a search must be carried out on the database to ascertain ifthe individual has been previously registered. It is not possible to usually bypass the searchroutine if the NHN of the person is unknown. During training courses, it is stresses vigorouslythat staffs must perform the search rigorously every time because of various reasons (lack ofunderstanding, embarrassment); many patients do not inform staffs that they already possess aNHN.
20Replication OverviewIn PATIS, replication is the process whereby data in each installation of PATIS is synchronizedwith data from all other installations of PATIS. Additions, modifications and deletions of data atany given installation are applied to the other PATIS installations using an automated nightlyreplication process.The process is controlled from the Ministry of Health Central Office server. All additions,changes and deletions to all data in the Patient Master Index, with the exception of some systemand installation specific tables, at each hospital, health center and divisional office, are replicatedto the Central Office. This process is known as “One-Way” replication All the data from theseplaces are the consolidated on the Central Office database, extracted and subsequentlydispatched to all installations that are online. This process is known as “Two Way” replication.At the completion of the nightly replication process, all installations are synchronized.IssuesThe most common problem encountered has been the telecommunication infrastructure andrelated equipment. The reliability and the quality of the telephone lines has been an issue overtime. The modems originally installed also appeared to be problematic with sporadic failuresand/ or degradation in performance.Another problem has been with intermittent power supply to some of the more remote locations.On occasions, the timing of the replication processes are adjusted for a particular hospital toensure data is extracted and loaded when the power supply is most likely to be available or theprocess is initiated manually.National PATIS AdministratorA National PATIS Administrator has been appointed who is championing the effective andefficiency of PATIS, dealing with administrative & operational issues and setting up trainingcourses for the relevant personnel. He is based at the Ministry of Health Head Quarters andreports to the Director IT.
21Example of a Service Delivery Process before PATIS was Introduced Patient comes to Outpaitents Department Patient details Gets filled manually number, Waits by Outpatients to see doctor Staff. Attendant goes to Medical Record Patient seen Department to by doctor collect patients Medical Folder When the Medical Record Outpatient attendant goes Attendant is free to Storage then he/ she Room collects this folder Looks physically Retrieves folder for and comes to folder, sometim Medical Records es missing
22Example of the Same Service Delivery Process after PATIS was Introduced Patient comes to Outpaitents Department Patient details filled Gets number, Waits to see manually by Outpatients doctor Staff. Patient Seen by doctor
23Health Information Systems Assessment - FijiAn assessment workshop was conducted by the Ministry of Health to: Raise awareness on the importance of Health Information System at inter-governmental level between the Ministry of Health, Ministry of Finance & National Planning, Registrar General of Births, Deaths & Marriages, Bureau of Statistics Unit and the Donor Community, Introduce the Health Metrics Network framework and tool to improve Health Information sharing, analysis and use, Explore the views of the stakeholders, of the status of Health Information Systems in Fiji and capture recommendations, and Facilitate a systematic reflection and sharing of views between the different Stakeholders on Fiji‟s Health Information Systems strengths and limitations.The following is a summarized version of the SWOT analysis carried out by this team on theHealth Information Systems (HIS) in Fiji, operated by the Ministry of Health.SWOT Analysis – Fiji’s Health Information System (HIS)HIS Strengths Established administrative and organizational framework already exists; both electronic and manual systems exist and are being strengthened, Availability of data, indicators and data collection methods, Staff capacity has improved over the years, Availability of support and assistance from other sources, name Fiji Health Sector Improvement Project, Presence of the Health Metrics Network Steering Committee at the national level.HIS Weaknesses Weak linkages and coordination with other stakeholders, Absence of specific HIS legislation at a national level, strategic plan and policies to facilitate information sharing, Lack of skilled and trained human resources especially in data analysis, validation, reporting and use, Inadequate HIS Infrastructure and limited technology to facilitate data compatibility between the existing databases which limits data integration, Lack of systematic training, development & provision of other resources at national level to support existing structures, Limitation in the national infrastructure development to allow continuous roll-out of HIS and absence of an upgrade plan of IT Infrastructure,
24 Delay in technology innovation in Fiji to explore better ways of improving HIS for sustainability, Low capacity on the sustainability of the existing systems/ databases. Inactive National HIS Committee Lack of operational budget to facilitate HIS needs Lack of data use culture Under-utilization of available data Irregular and incomplete reports leading to inconsistency in reporting system, Weak supervisory capability and absence of efficient feedback mechanism, Overlapping of project and donor supports, Information occasionally used for planning, rather than management and decision – making, Weak integration and use of census data.HIS Opportunities Integration of HIS data amongst the major stakeholders to facilitate information sharing, Integration of the existing Ministry of Health standalone databases to ensure a more efficient, effective internal health information system, Strengthening of system will lead to improved performance and higher productivity, Stronger and attractive system in the eyes of donors, Widespread dissemination of information, Developing a culture of evidence based decision making.HIS Threats Unstable political environment which could affect donor interests and initiatives, High staff turnover, Frequent interdepartmental re-shuffles, Conflicting information from other Health Information Users, producers with regards to population distribution and administrative divisions at a national level.In summary, the assessment results revealed that most items under the six Health InformationSystems components assessed (resources, indicators, data sources, data management,information products, dissemination and use) are weak requiring further development andstrengthening for overall improvement of the National Health Information System in Fiji.The group recommended the following for further improvement of the current systems in place: Strengthen linkages and coordination among the stakeholders so that mandatory reporting is facilitated through an automated system feeding from the main HIS system,
25Develop a National HIS Strategic Plan in line with the Health Metrics Networkframework,Develop a national HIS Policy that will form the basis of a legal framework to developrelevant legislation (Developed in 2011),Upgrade and integrate the current databases existing with the different stakeholders,especially Ministry of Health, into a data warehousing at a national level,Improve HIS reporting system,Have a separate server to be kept for the Health Information Unit at the Ministry ofHealth so that the downtime of the main server does not interfere with data entry andvalidation at the National Level of the Ministry,Develop a web – based application and web – based reporting system to accommodateinformation sharing amongst all stakeholders,Assess and strengthen computerization of all HIS functions at peripheral levels throughthe identification of the most appropriate technology to facilitate data consolidation,Strengthen capacity of the HIS staff, health managers and decision makers at all levels toimprove routine data accessibility, analysis, reporting and information sharing,Strengthen data management at all levels,Strengthen and improve data collection methods and reporting systems,Strengthen data coverage, processing and reporting of vital statistics, for national healthplanning and reporting of mandatory data,Improve the disease surveillance system records, health services records reportingsystems and documentation of patient records.Develop a GIS or GPS mapping system at the national level that incorporates all publichealth facilities, populations, infrastructure, health risks and population that is at risk, forhealth planning and decision making purposes.
26A DISCUSSION OF YOUR FINDINGSReview of Health Information Systems in the Pacific IslandsHealth information is essential for proper management and deployment of limited resources inthe health services of the Pacific Islands. There have been numerous efforts to establish andstrengthen sustainable information systems but the common feature of these attempts has beenthe very limited achievement. Subsequently, the use of information as a management tool hasbeen abandoned in favour of gut feeling, hearsay and adhocry. In the last decade health planningand primary health care activities have necessitated the re-emphasis of monitoring andsurveillance of health and health service indicators. Therefore a revival of interest in healthinformation systems is taking place.A review of national health information systems in the Pacific showed that routinely collecteddata remained largely untouched by human thought. The contributing factors to the currentinertia are examined with suggestions on how to elevate health information from its currentlowly status to its rightful place as an essential tool for management. The special problems ofsmall island states, like limited resources, geographical isolation, natural barriers to technology,and diverse cultural milieu, will be examined in relation to an appropriate health informationsystem for Pacific Island countries in the twenty-first century.(http://heapol.oxfordjournals.org/content/9/2/161.abstract)Management of Information SystemsGood work has been done in the area of management information systems, including the currentroll out of the Public Health Information System (PHIS) in Fiji. The roll–out is completed but ispaper based. A database at HQ level is being finalized, as is additional work with PATIS. WhilePATIS is used at the hospital level for patient care and internal management purposes, there isonly limited evidence of the widespread use of these systems as a research tool and dynamicmanagement tools. There are exceptions and in those locations where there are PATIS“champions”, there is evidence of its potential. The review team was told that the system is beingtransferred to one that is web based and this will help encourage wider use of the very valuabledata being generated by the system. In this regard there would likely be benefit from closeliaison with the FSM. Unfortunately PATIS still does not include a module to capture data inhealth centers and nursing stations. (Freeman, Sutton, 2010)E-Health (Adopted from General Practitioner Volume 8, Number 3)Although the cost of setting up an e-Health platform that relies on internet, may be initially highdue to the need to provide internet services in especially rural areas, progressing towards a tele-health strategy for countries like Fiji using tele-health technologies, may be more realistic in theshort term. A key step though is to have a formalized strategy for developing telemedicine and towork towards having the capability to have IT systems in place that will enable the transitionfrom tele-health to e-health when such systems are in place and fully integrated. A government-
27sponsored workshop on e-Governance highlighted the need to formalize a tele-health program tonot only provide for improved doctor-patient consultations in rural areas, but also to provide amore accessible database on patients‟ records. The Fiji School of Medicine is taking a leadingrole in developing a regional tele-health facility, whilst the Fiji Ministry of Health‟s developmentof its PATIS database system is well advanced.The internet based provision of health services and products has further been subdivided into twomajor areas by health care professionals (HCP): that of information management and in the areaof clinical research and health education. The former has mainly concentrated on providing on-line records and inventory systems to store information such as patient records; video-conferencing and presentation of audio-visual information; and the dissemination of relateddigital information. The latter though has been focused more in the areas of health and marketingcampaigns; evaluation of the effectiveness of drugs research and the like; health education inespecially cancer and AIDS; mental health research and the specialized areas of robotic surgery.The establishment of a patient information system (PATIS) in Fiji‟s Ministry of Health is anexample of the development of a part of an information management system; signifying a keystep in the development of a tele-health and e-health platform. This system of informationmanagement comprises a series of independent Local Area Networks (LAN) in the variousdivisions and/or subdivisions that are linked to a central database system in the various regionalhospitals. The central database system is then automatically updated using a phone link/downlinkinterface. The PATIS database though works on a patient identification system where eachperson registered on the PATIS database is given a unique National Health Number (NHN).Using a paper input, the NHN then provides key patient details comprising medical history andother personal details required for assisting the delivery of health care services. Benefits such asa holistic patient record, accuracy of information, and efficient retrieval of patient records areenvisaged when the system is fully implemented, besides the long-term benefits of cost-effectivepublic health care service.A key force in moving the PATIS system to the higher levels of health information managementwill have to come from the Fiji College of General Practitioners and its list of consultativespecialists. Web based and innovative network server technologies can provide a powerfulinterface with the PATIS database to make it more accessible and useable in an environment thatis quickly becoming digital and online.Development of PHIS (Public Health Information System)Despite recent improvements in health status, Fiji, like other Pacific Island countries isundergoing an epidemiological transition, and is now faced with a triple burden of disease:communicable and non-communicable diseases and injuries and accidents (WHO WPRO 2008).Non-communicable diseases such as diabetes, heart disease, high blood pressure, respiratorydiseases and cancers, have now replaced infectious and parasitic diseases as the principal causes
28of mortality and morbidity in Fiji. Around 82% of deaths in Fiji in 2007 were due to non-communicable diseases and 10% due to communicable diseases (WHO WPRO 2009).As such the Ministry of Health has now started implementing the Public Health InformationSystem, better known as PHIS. Public Health Information System (PHIS) provides timely,complete and accurate information that is being used to measure public health outcomes and planfuture activitiesAustralia - Fiji Health Sector Support Program 2011-2015Australia - Fiji Health Sector Support Program 2011-2015 has found a decline in the capacity ofsome components of the health system to support decentralized service delivery as follows: Ineffective and inefficient use of data for policy, planning and service delivery: Data are routinely processed at the MoH Health Information Unit, but information is rarely disseminated back to health service delivery points, where it is most needed for situational assessments and planning. The weakness in analysis and feedback of public health data was repeatedly raised as an issue by MoH headquarters and during site visits by the design team. Weak monitoring and evaluation: The design team noted that the MoH does not have a strong culture of monitoring and evaluation (M&E). Nor does its current Annual Plan include a detailed performance measurement framework. There is an identified need to strengthen monitoring and evaluation skills both within the central MoH headquarters in Suva and also at divisional and sub-divisional levels, and to foster a culture where M&E becomes a routine component of service delivery. Critical knowledge gaps: The design team noted that there were some critical knowledge gaps where information is not available from routine information sources. The issue of urban and peri-urban migration and the effect this is having on health parameters was identified as an area that needs further research; other potential research areas include investigation of new disease trends and a review of the effectiveness of health interventions. Weak supervision: Senior officers at each level in the health system are expected to provide an important role in supporting; supervising, monitoring, and providing in- service training for their junior colleagues at lower levels in the system. There was concern, however, that this system was not institutionalized and that it was highly dependent on the initiative and motivation of the doctor or nurse practitioner. There was also a concern about whether supervising staff have the appropriate skills for this supervisory role. JICA has identified this as a key area of constraint and has developed and piloted a nursing supervision program in the Central Division prior to rolling it out to other areas. It is believed that strengthening this vital link could significantly improve health outcomes.
29 Clinical Quality Improvement and Risk Management: A component of the current FHSIP program is the introduction of risk management and Clinical Quality Improvement (CQI) at the divisional level. The value of this was highlighted several times by MoH staff during the design mission, but it was also noted that it needed to be consolidated and expanded to the sub-divisional level. Transport constraints: Transport was identified as a major constraint with respect to timely access to health services for patients and for Ministry staff conducting outreach. The Design Team noted the need for vehicles, boats and even horses to improve access to services. However, there was some indication that existing transport facilities could be better managed and coordinated. Attrition of human resources in the health sector: As outlined earlier, the combination of political uncertainty and recent government policies on public sector staffing cuts and lowering of the civil service compulsory retirement age to 55 years has resulted in the loss to the MoH of up to 1000 health staff, many of them consultants and nurses with specialist skills in areas such as pediatrics, obstetrics, intensive care and oncology.Expected outcomes of this program include: Public Health Information System (PHIS) provides timely, complete and accurate information that is being used to measure public health outcomes and plan future activities at central and decentralized levels; Maternal & Child Health and diabetic health services are regularly monitored, audited and evaluated, and gaps/weaknesses addressed; Improved M&E at central level and across service delivery areas; Clinical Service Guidelines and protocols related to MCH and diabetes standardized, disseminated and used systematically throughout all service delivery areas; Improved supervisory system institutionalized across MoH; Operational research provides information to support evidence-based policy and planning of health services in urban/peri-urban areas. Other potential areas for operational research may be identified by the ongoing Fiji Health Systems in Transition (HiT) profile; Improved corporate and strategic planning leading towards a sectoral approach to planning; and Improved transport systems to: a) facilitate patient referrals and access to health services from remote villages/islands, and b) facilitate outreach and supervisory visits by health staff to remote locations.Shift to Web Based SystemsThe shifting of the PATIS infrastructure to a web based system from late 2011 (beginning fromthe Central Division and the 3 major hospitals) and the increased bandwidth will now lead toincreased efficiency of the system. With more leased lines, the information flow is expecting tobe improved significantly.
30Bulk SMS SystemThe Ministry of Health has teamed up with Vodafone Fiji Ltd and a NGO, namely ACATA, todisseminate productive information collected from the Patient Information System and the PublicHealth Information System to Vodafone‟s customers. The data will initially focus on the trendsof non-communicable diseases and what steps can be taken to avoid them.LicensesThe Ministry of Health is currently negotiating with the Government of Fiji to renew theLicenses for the Windows software as most of the PATIS infrastructure as now Windows based.There is some debate that the Government ITC Center should take over this role. At present theMinistry of Health has 1,300 PC‟s and now has 32 server sites.Electronic DashboardThe Ministry of Health has approved the development of an Electronic Dashboard for the PatientInformation System and the Public Health Information System from early 2012. This will becompared against pre-defined key performance and will be critical to the collection of BusinessIntelligence for the improvement of organizational wide health care.Partnership with Healthlink (http://www.healthlink.net/)Healthlink is a health-system integrator. Its key purpose is to enable medical practices tocommunicate electronically with the rest of the health system. Since 1993, it has been doing thisby integrating or connecting the computer systems of health care practitioners so they can talkwith each other and share information, securely.Its mission is to eradicate paper from the health care system, saving practitioners vast amounts oftime and money and opening up a world of information to them so they can make betterdecisions for their patients. We are already well on the way to making this happen, with over15,000 practitioners from more than 9,000 healthcare organizations across Australia, NewZealand and the Pacific using Healthlink daily.In 2010, Healthlink processed over 65 million clinical messages. Imagine if all these messageshad been processed the old fashioned way, on paper. Stacking them one by one would reach wellover 29,000 feet - thats the height of Mt Everest!Healthlink doesn‟t see why practitioners should have to put up with slow and unreliable paper-based practices when there is a better way electronically. One that is faster, more reliable andtotally secure. Its customers agree and they utilize Healthlink to get the following information attheir fingertips: Pathology and radiology reports Radiology image viewing Hospital discharge summaries
31 Patient referrals Specialist letters Lab test ordering Messages between general practice and community based care providers Emergency Room access to a patients general practice or pharmacy-held recordsBusiness Intelligence (Adopted from TeleTracking Technologies “Business IntelligenceReport”)Patient Flow: Data vs. InformationSeveral patient flow automation systems exist on the market today. While many of these providea means to streamline core patient flow processes such as patient placement, bed management,transport and EVS, few provide the robust data needed to evaluate and monitor performance.Many of these solutions simply provide basic data – raw figures on where patients are and wherethey have been. Most systems do not provide a robust way to organize this data into actionableinformation. The standard, built-in reports available in these products are indeed useful; vitalpieces of data can be located and tracked, which are well suited to the needs of operationalmanagers for analysis. However, advanced analytics allow managers to drill down through thesame data to quickly analyze trends and comparisons with a much smaller overhead of requiredwork, turning the data into fuel for an engine of change.A few examples can serve to illustrate how patient flow data can be employed to drive truechange in the enterprise:Admission and discharge analysis. Efficient patient placement is paramount to good patientflow. BI allows for users not only to track general patient flow statistics, but to slice thosestatistics into user efficiency and system compliance numbers. By breaking down discharges bytime of day as well as overall volume, hospitals can identify bottlenecks in the discharge processand use the information to drive for earlier discharges.Patient Safety: Infection and isolation control. At the current infection rate, a 500-bed hospitalwill experience 194 unnecessary deaths and $28 million in unnecessary costs per year. Asreadmissions due to hospital-acquired infections (HAIs) continue to increase, BI can contributeto the fight by tracking patients‟ movements and how their infection and isolation attributeschange, then presenting it in a way that allows for targeted improvements in areas that are notmanaging HAIs well.Capacity Management: “Dead bed” time. While patient flow software is excellent at tellingusers where patients are, it is often hard to find where patients aren‟t. By turning patient flowdata on its head, BI can satisfy a core requirement of improving patient flow through identifyingunderused assets: capturing beds that are not being used and the spans of time in which they lieempty, therefore enabling hospitals to target patients more efficiently to those areas. Proactively
32acting on the information provided by a robust BI solution translates directly into better patientcare and increased revenue.Transport and housekeeping performance: These vital departments have a profound effect onpatient flow; patients can‟t occupy clean beds without efficient transportation and housekeeping,and flow can grind to a halt with inefficient departments. BI can track job times, but moreimportantly, can present long-term information on jobs by date, employee and geographical area,in an easily digestible format suitable for executives. BI can also power the live display oftransport and housekeeping information, allowing for immediate action on staffing or job timeissues.Overall scorecard-based reporting: BI can pull information from multiple sourcessimultaneously, allowing for easy, executive-level summaries of the most important patient flowstatistics. Popular examples include length of stay analysis; early discharge metrics; dischargeand transfer process compliance; totals for admissions and discharges; and transport andhousekeeping turn times.BI with TeleTracking Business AnalyticsTeleTracking Business Analytics offers best-of-breed BI systems that can turn data from yourTeleTracking XT system and other operational and clinical systems into valuable,transformational information, and put it directly into the hands of hospital decision-makers.TeleTracking Business Analytics and Avanti Patient Flow Consulting professionals have deepexperience with technology and patient flow improvement, allowing them to work with bothtechnical and operational staff at hospitals. This ability allows Business Analytics to synthesizeprocess and technology to create personalized packages of information while keeping the costsof hospital staff involvement and IT upkeep to an absolute minimum.The Patient Flow Dashboard™ application lets the user see a “live” enterprise-wide snapshot,including a multi-campus roll-up, of your healthcare organization‟s operational performance,moment by moment. This can help hospital systems avoid bottlenecks and delays as theydevelop, without the details of reports, which are often geared toward historical trend analysis.
33Research Based UnitThe Ministry of Health to develop a Research based Unit with the Health Information Unit witha genuine view of creating more “resource based value” out of the Health Information Systems.As the Ministry of Health‟s National Health Information Policy states on page 19, Section 7 that“ideally Fiji‟s HIS should provide evidence for informed and effective health system decisions.Policy and decision – makers in Fiji do occasionally use the information in the planning processbut do not often analyze their respective health statistics comparative to the national benchmarks.It is acknowledged that, if not disseminated and/or shared, health research outputs will notincrease the existing stock of knowledge or contribute towards improved service delivery.However, a good proportion of the health research work done in Fiji remains unpublished andinadequately disseminated. Consequently, key stakeholders are not adequately informed aboutresearch processes and outcomes. Poor dissemination and packaging of research outcomes alsoresults in poor linkages between research, policy and programme development.
34CONCLUSION1. The Health Information Systems at the Ministry of Health, in particular the Patient Information System, has added a lot value and provided return on investment to the Ministry and its customers such as: Data being used for development of Corporate and Strategic Plan for 2012 onwards (Naidu 2011), Reduced waiting time for patients at the relevant departments (as opposed to previously where a lot of time was spent on search manually for medical record folders), Based on the data collated, most of the outpatients department functions has been shifted to relevant health centers (as opposed to the previous arrangement where the capacity of the General Outpatients Department at the major hospitals was exceeded as people living far away from the hospital, chose to visit them instead of their nearest health facilities), Close to real time historical information available for Clinicians and nurses when assessing patients, Information used from the data collected from the system enabled the Ministry of Health to identify the rise of the non communicable diseases (as people are getting less physically active) and then proposed to the Government to remove duty on health related sporting equipments. The Government of Fiji, in the 2012 National Budget announcement, removed all duty on health related sporting equipment, for e.g. treadmills, Patient‟s information (medical records) are now in virtual space and will not be lost (as opposed to the manual system before where patient information was lost sporadically), The program has met its key initial objectives of a) Improve patient services and outcomes and assist health service administration and, b) collect information for timely public health surveillance and health programme monitoring, The data collated from PATIS has been used to determine the capital expenditure budget of hospital infrastructure in the Ministry of Health 2012 budget (Naidu 2011), and Development of a tele-health and subsequently an e-health platform (Fiji School of Medicine developed an e-newsletter for clinicians and now is working on developing a virtual platform for the training of doctors). 2. The Ministry of Health needs to now shift its focus from collecting data (as is very evident in their Strategic Plan) and move towards using these data to evaluate and make more informed decisions. This should be part of the Strategic Plan with clearly set Key Performance Indicators, a IS and IT Strategy, Measurement Plans with definitive
35 deadlines. These should be done as part of a “Lateral Change Framework for better IT Governance”, as when PATIS was implemented, it was enforced on the health staff in 2001. Staffs have now got onboard after nearly a decade, after seeing the benefits and results of the system and its potential to improve even further. This will lead to more action-based planning. As discussed in our findings, the Ministry of Health‟s Health Information Unit should have a Research Based Unit, within it, to carry out this task effectively and efficient health website.3. The shifting of the PATIS infrastructure to a web based system, from late 2011 (beginning from the Central Division and the 3 major hospitals) and the increased bandwidth will now lead to increased efficiency of the system. With more leased lines, the information flow is expecting to be improved significantly4. The Bulk SMS System with Vodafone is a very good example of how the information generated from the Patient Information System and the Public Health Information System can be used to provide additional value for the customers of Ministry of Health. The mobile health platform can be further developed as is evident in the article presented as Annexure 2.5. The Ministry of Health could use the social networking tools to gather feedback about its service delivery and administration process from the deep end users – its customers. An example would be the Ministry of Health‟s blog on its website. This would be a radical approach, which goes without saying that there would be a lot of comments in the initial years. Ministry of Health then should work seriously in solving these issues if it genuinely has the best interests of its customers at its heart.6. The development of the Electronic Dashboard is a positive step from the Ministry of Health. This will be compared against pre-defined key performance and will be critical to the collection of Business Intelligence for the improvement of organizational wide health care. As per the “2011 TeleTracking Technologies report”, published in July 2011, “Robust BI solutions from professionals steeped in the patient flow continuum allow hospitals of all sizes to gain new perspectives on their patient flow data: the ability to see emerging trends and take action immediately; the ability to present complex, long-term historical information in easily digestible formats; the ability to project future needs. In short, proper BI allows hospitals to turn data into information – useful, actionable intelligence, which is what‟s needed for transformational change”. A sample performance dashboard from 3M Information Systems looks as follows:
36 www.nationalimagingnetwork.com The Performance Dashboard is in line with the Ministry of Health‟s National Health Information Policy Section 3.3, which states “Ensure all HIS sub-systems (including, but not limited to, PATIS, PHIS, HRIS, FMIS, LIS, Drug Inventory and NIMS) are standards – based to promote inter-operability and can support a national health observatory or dashboard.7. Healthlink is the trusted provider of healthcare information systems and technology in New Zealand and Australia. The Group feels that Ministry of Health should partner with Healthlink and allow Healthlink to access the data on PATIS and PHIS. This way the Ministry will be able to upgrade its systems to the best practices in health care information systems in Australia and New Zealand. This will also allow the Ministry of Health to get electronically connected, in a secure way, to the various General
37 Practitioners in Fiji. The potential of this partnership is gigantic! This will also complement what has been discussed in the Literature Review that “Shift from local to global information system architectures” is one of the key outcomes of a functional Health Information System. The following figure shows how such a system can be integrated together for such an objective: www.karoshealth.com8. The Group believes that Ministry of Health, in partnership with AusAid, is on the right path in terms of developing its Health Information Systems for more improved patient care and medical facilities in and around Fiji. This can only be achieved if all staff at the Ministry works collectively towards this goal. It is stated in the “Australia - Fiji Health Sector Support Program 2011-2015 Report” that “Ministry of Health staff at operational level are not supportive of some of the key objectives and approaches used in this program” (pg. 53). These positive changes need to be embraced as a “culture” and as it is already part of the best practices in Australia and New Zealand.9. It‟s now an opportune time for the Ministry of Health to generate feedback from Key Stakeholders to see where the gaps are in the system and how it could be improved with the contribution of these stakeholders, who are, but not limited to, customers, doctors/ nurses/ other staff, government members, Board of Visitors, Community Leaders,
38 Donors, potential donors, etc. This will engage “end user involvement” to ensure that the sustainability of the PATIS beyond the time when AusAid is not around.10. The group believes that the use and upgrading of the Health Information System should be part of government legislation so that there is more action and accountability at the relevant level and specific points. The HIS Policy, IS & IT strategies shall be aligned to this legislation, and partnerships with Health Care solution providers like Healthlink. The use and upgrading of the Health Information Systems should also be embedded in the national curriculum of the relevant courses at places like the Fiji School of Medicine, Fiji School of Nursing, Sangam School of Nursing, University of the South Pacific, University of Fiji, etc. Ongoing training for administrative staff at all levels in Ministry of Health, in this area, should also be an on-going process. HIS embedded in teaching curriculum of MoH staff providers PRM - Link with Health Care IT Strategy - Business Level HIS Strategy HIS Steering Committee National Legislation HIS This will also ensure the future sustainability of the HIS at the Ministry.
3911. The Government of Fiji, through the Ministry of Health, in its National Budget should allocate adequate funds to continue with the various Health Information Systems and upgrade them to realize its full potential by becoming a front end application where a patient can get easy access to his/ her medical records online in a secure environment.. The dependency on donor funds must stop as this will further ensure the sustainability of these information systems.12. This will present a new set of problems as in the rural and remote areas of Fiji; the customers are not techno savvy. The Group believes that whilst there will be initial problems in this area; the Government‟s National Broadband Policy is a long term solution to this issue. This policy focuses on the 2 key areas of education and health, especially in the rural and remote areas, and aims to make the future generation techno savvy at a young age.13. The National HIS Steering Committee is currently inactive and such legislation will ensure that it does what is required of the committee promptly in terms of Direction Setting, structuring, staffing, communicating, evaluating and governing. This will negate the threat of government change (thus direction change) as identified in the SWOT analysis in our findings.14. The use of historical and current data from the Health Information Systems should continuously be used in a strategic and operational manner to improve the service delivery process to the clients of Ministry of Health at the relevant service delivery points. This is use of the “Predictive Analysis” concept, discussed in our course book, in the real world to improve the service delivery of essential public services.15. The group believes that more “Product Champions” should be introduced at the various levels of the whole organization and at the respective service delivery points to ensure the efficiency and future sustainability of the Health Information Systems.16. As outlined in the figure below the Ministry of Health could work harder to ensure that there is a more effective alignment of the 3 key segments which ensure that the IT tools and software realize their full potential in terms of adding value and providing a return on investment in providing a more efficient and improved service delivery process. These are its people, its processes and its IT and IS systems!
40 People Processes IT and IS A MORE EFFICIENT AND IMPROVED SERVICE DELIVERY PROCESS17. The Health Information Systems at Ministry of Health have progressed and are making a difference. There is enormous opportunities for these systems to make further more value added difference on a more macro and micro level. The Ministry of Health now needs to make that decision to make more significant use of these systems by further upgrading the system and infrastructure. “What we are living with is the result of human choices and it can be changed by making better, wiser choices”. Robert Redford
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