Submitted by: Dr. Isha Jain PG/11/032

1. THE EVALUATION OF THE HOSPITAL INFORMATION SYSTEM (HIS) AT district HOSPITAL, SHIMLA, HIMACHAL PRADESH Submitted by: Dr. Isha Jain PG/11/032

2. CONTENTS • Organization profile • Introduction to HIS • Rationale of the Study • Objectives of the Study • Methodology • Results and Outcomes • Discussion and Conclusions • Limitations of the study • Recommendations • Case study- Challenges faced during Mobile Training at Shimla district • References

3. ORGANIZATION PROFILE-HISP India • HiSP India is a not for profit NGO specializing since more than a decade in designing and implementing solutions in health informatics for the public health sector in India, and also recently in Bangladesh and Sri Lanka. • In India, it has worked in at least 90% of the states, and currently has a presence in about 20 states.

4. MISSION To enable networks of collaborative action with like-minded actors who aspire to the ideology of open source software, open standards and decentralized decision-making to create complementary strengths in providing integrated and public health friendly health information systems. VISION It works with a Vision “to enable and coordinate a network of excellence in public health informatics, specializing in integrated health information architectures, with a geographical focus on South-East Asia.” HiSPIndia has a registered and head office in New Delhi, and project offices in Kerala, Himachal Pradesh, and Punjab

5. ABOUTDistrict hospital It is an old heritage hospital and was opened in 1885. There is an average of about 1200 out- patient (OPD) visits per day. It is the first district hospital of Himachal Pradesh where HIS is implemented by HiSPIndia. It is the most established and functional government hospital. It is a 150 bedded hospital with all functionalities.

6. INTRODUCTION

7. HIS (Hospital information system) • Health Information System (HIS) is a system that integrates data collection, processing, reporting, and use of information necessary for improving health service effectiveness and efficiency through better management at all levels of health services [Lippeveld et al., 2000]. • HIS is a collection of tools, systems, users, routines, that together seek to improve health services

8. Tertiary hospitals Hospital information system (HIS) Health management information system (HMIS) Secondary hospitals Primary hospitals

9. RATIONALE OF THE STUDY • Evaluate the system efficiency under various parameters. • The chief criterions under consideration are system acceptance and satisfaction amongst end users and patients. • This will help in assessing effectiveness of HIS along with the current shortcomings in the deployed system. As NRHM funded HiSPproject is in the process of implementing the HIS in 21 government hospitals of Himachal Pradesh, the results of this study will be useful for improving the existing system.

10. GENERAL OBJECTIVES • “Evaluation of Hospital Information System (HIS) in Hospital, Shimla” is to analyze the impact of the implemented system at the hospital by knowing the user satisfaction of the stakeholders. • Also, to attain feedback onto the implemented system and to improvise on the drawbacks of the same. SPECIFIC OBJECTIVES • User satisfaction towards HIS by the Study Population or Stakeholders • Technological glitches (if any) in DDU Hospital after implementation of HIS • Impact of eliminating paper based records on the Study Population or Stakeholders

11. METHODOLOGY

12. Implementation of the HIS application: September 2010 • Tenure of implementation till date: 1.5 Years • Evaluation of the HIS: April 2012 • No. and Names of the Modules implemented: 09 (Registration, Billing, Radiology, Laboratory, Blood Bank, Inventory, Pharmacy, OPD and IPD) • No. and Names of Modules in use : 07 • (Registration, Billing, Laboratory, Inventory, Pharmacy, IPD • and OPD) • Study site: DeenDayalUpadhyay (DDU) Hospital, Shimla (HP) • Tools for the Study: • Questionnaires for Administrators, Doctors, Nursing Staff, Laboratory Technicians, Radiology Technician.

13. FGDs for Nursing Staff, Laboratory and Radiology Technicians and Patients. • Interviews for Data Operators of Registration and Billing, JAS, Inventory and Patients • Type of study: Descriptive/cross sectional study • Study population (Stakeholders Identified):

14. RESULTS & OUTCOMES

15. Types Of Users Note : All the values are in Percentages Total No. of Clinicians = 23 Total No. of Nursing Staff = 40

16. No. of Clinicians = 8 No. of Data Entry Operators = 6 No. of Nursing Staff = 16

17. No. of Clinicians = 8 No. of Data Entry Operators = 6 No. of Nursing Staff = 16

18. Most of the users have technical issues like Computer hangs and Server problems but only the data entry operators also have printer related issues. No. of Clinicians = 8 No. of Data Entry Operators = 6 No. of Nursing Staff = 16

19. Only 3 out of 8 Clinicians said that the procedures and diagnosis comply with their requirements

20. All of the Nursing staff said that HIS has in turn increased their time and effort because they have to maintain both the registers as well as the electronic records at the same time.

21. Most of the i.e., 12 out of 16 Nursing Staff make the patient entries by the end of the day and only 4 out 16 Nursing Staff makes them as and when patient comes

22. REASONS FOR NOT USING HIS APPLICATION BY PASSIVE AND NON-USERS NUMBER OF PASSIVE USERS: CLINICANS: 9 NURSING STAFF: 9 NUMBER OF NON- USERS: CLINICANS: 6 NURSING STAFF: 15 TECHNICIANS: 7

23. All the technicians said they got training 3 out of 15 doctors said they did not get the training 9 out of 24 nurses also did not get the training

24. WORK LOAD here means, FOR NURSES(24) : They have to attend to patients as well as clerical work. FOR CLINICIANS(15): patient consultation at OPD 7 Nurses and 6 clinicians stated workload as a reason for non-usage of application

25. Most of doctors i.e. 8 (non-usersand passive users) also pointed out that diagnosis and procedures were incomplete and inadequate as a reason for non-usage of application.

26. When asked from nurses i.e., 24 (non-users and passive users) while doctors said they did not require any training.

27. SatisfactionLevel of the Users/Stakeholders with the Trainingprovided by the HIS Team 8% 2% 21% 25% 24% 39% 47.8% 75% 26% 34% Nursing Staff Clinicians Others 75% of the others Stakeholders, 35% of the Nursing Staff and 25% of the Clinicians were satisfied with the training and support provided by the HIS Team.

28. Administrator’sFeedback • Inefficient and Ineffective • Not being used properly by clinicians, nursing staff and inventory • Staff is not confident about the utility and efficiency of HIS application. • Further training is also required for all the departments. • Require data-entry operator

29. Benefits of HIS • Records are easy to maintain for BPL and RSBY patients • Patient receives a compiled report for all the laboratory tests. • Feedback was received on interviewing JAS, registration and billing as they were satisfied with the time taken and efficiency of system even at rush hours

30. FEED BACK OF PATIENTS REGARDING HIS • BPL and RSBY patients were not satisfied because of long waiting time for registration. • Delay in receiving the laboratory reports due printer issues. • Patient favoritism in Government hospitals. • Patients, only from Medicine, Dental and Surgery OPDs were aware of some kind of application being used by the clinicians.

31. Reasons observed for under utilization of HIS • lack of motivation of clinicians • Limited staff at DDU • Heavy patient load • HIS is not properly implemented, as they are using same old slip system during admission and discharge process of IPD patients.

32. Limitations of the study • The sample population for study was taken on conveniences basis. • The Patients were not aware of the HIS application, therefore had lesser interest in participating for the interviews and FGDs.. • The HIS application is not fully functional in most of the IPD/OPD departments of the hospital. • The sample was taken from single hospital; therefore a generalized inference could not be obtained for the study.

33. RECOMMENDATIONS

34. Cont… • Firm policies are required for proper usage of the system by the government • Monitoring team should be constituted • Behavior change management of staff is required. • Data entry operators are required to reduce the burden of staff • Training and follow up is required

35. Cont… • Onsite support will be good for staff having different computer skills • Regular updating of system in terms of procedures and diagnosis is required. • Proper hardware support for all the departments. • Help desk should be constituted • Also, in spite of provision of referral system in the application it was seen that clinicians were not using this application leading to unnecessary inconvenience for patients as a result management should promote proper and complete usage of this application.

36. CASE-STUDY CHALLENGES FACED DURING MOBILE TRAINING AT SHIMLA DISTRICT.

37. INTRODUCTION Mobile services are emerging, making it accessible and citizen-centric by extending the benefits of remote delivery of government services to those who are unable or unwilling to access public services through the Internet Governments are expressing interest in m Health as a complementary strategy for strengthening health systems and achieving the health-related Millennium Development Goals (MDGs) in low and middle income countries. M Health is being applied in maternal and child health, and programmes reducing the burden of the diseases linked with poverty, including HIV/AIDS, malaria, and tuberculosis (TB). Primary Health Care Services using Mobile ensures improved access to healthcare

38. Methodology: Study design: Observational study The team interacted with various health workers during mobile training at various training centers and issues that came from health workers were noted and addressed. Study site: Study population: There were about 201 health workers (ANMs).

39. Various implementation challenges faced are discussed under following headings: • User end challenges • Challenges with user phones • Administrative challenges

40. USER END CHALLENGES • Most of Health workers had compatibility issues which resulted in • Reluctance in reporting. • Lack of interest to undergo training. • Also many of health workers demanded money for sending SMS’s for reporting. • Lack of knowledge, awareness • Not all health workers present for training.

41. CHALLENGES WITH USER PHONES: • DHIS2 mobile compatibility issue: Applicationcould be installed on only 42 % user phones. Remaining 58 % phones were in-compatible. These phones were either: • 1.1 - not java based • 1.2 - were black and white phones • 1.3 - were not Bluetooth enabled • 1.4- some mobile phones got hanged while using the application (local and Chinese brands) • 1.5- some phones had memory issues and hence ‘jar’ files could not be installed • Accountability issue: Using the health workers personnel phones for training and reporting makes them less accountable for sending reports on timely basis.

42. ADMINISTRATIVE ISSUES • Timely information not given to health workers and other officials: In many blocks the health workers are not given timely information about the training schedule or the training dates are kept in such a way that it clashes with their other day to day work. • State not sure about which technology to go for and whether to provide phones to health workers or not:Before the start of state wide implementation the state should be sure of which technology (sms or gprs) to go for. This not only helps in better training plan but also prevents wastage of time, money and human resources.

43. Conclusions and recommendations: • State should provide mobile phones to health workers: This has following advantages : • No need to depend on mobile phone of health worker. • No issue of application in-compatibility. • Training becomes easy and fruitful. • Any technical or user issue can be solved quickly • A sense of encouragement and motivation to learn new technology is there. • Health workers can learn and share their user experiences with each other since all would be having same kind of phones. • Any up gradation or change in the application can be made quickly. • No issue of phone being used by family members of health worker.

44. Training should be started only when the use of technology is decided: Once the implementation is started there should be least changes in things. Browser based training has already been given to Syri block of Solan district and Shahpur block of Kangra district. And now SMS based training has to be given. We cannot ensure sustainability in mobile health implementation if we keep on changing our technology use.

45. References • http://www.marketsandmarkets.com/Market-Reports/healthcare-information-technology-market-136.html • 2007 HIMSS US Leadership Survey -http://www.asianhhm.com/knowledge_bank/articles/healthcareit.htm • http://www.vantagemedifest.com/catalogue-2008/indian-healthcare.pdf • http://www.asianhhm.com/information_technology/ajaysharma_interview.htm • http://www.expresshealthcare.in/201204/itathealthcare03.shtml • Author, I. N. (Year). Title of the article.Title of the Journal or Periodical, volume number, page numbers. • Smith, L. V. (2000). Referencing articles in APA format. APA Format Weekly, 34, 4-10. • James, S. A. (2001, June 7). Magazine articles in APA format. Newsweek, 20, 48-52. • Jones, H., Smith, P., Kingly, R., Plathford, R. H., Florin, S., Breckherst, P., . . . Lightlen, P. S. (2012). How to reference an article with more than seven authors. APA Format Today, 17, 35-36. • Scientists seek source of creativity. (2012, March, 6). Dayton County News.Retrieved from http://www.daytoncountynews.com/news/39756_39275.html • Author, A. A. (2000). Title of work. Retrieved from source. For example: Cherry, K. (2006). Guide to APA format. About Psychology. Retrieved from http://psychology.about.com/od/apastyle/guide • Author, A. B., Author, C. D., & Author, E. F. (2000). Title of article. Title of Periodical, Volume number, page numbers. • http://hillpost.in/2010/01/27/hmis-to-revamp-health-sector-himachal-health-minister/18268/latest-news/ravinder

46. Cont… • 1st Annual HIMSS EMEA Leadership Survey, October 2007, HIMSS EMEA, www.emea.himss.org • Health Affairs, 26, no. 6 (2007): w717-2734 doi: 10.1377/hlthaff.26.6.w717 • National Institute on Aging, National Institutes of Health, “Why Population Aging Matters – A Global Perspective,” Publication No. 07-6134, March 2007 • Walker, Pan, Johnston, Adler-Milstein, Bates, and Middleton: Health Affairs Online: January, 2005 • World Health Organization, World Health Statistics: “Part 1, Ten statistical highlights in global public health.” http://www.who.int/whosis/whostat2007_10highlights.pdf. • Cusack CM: Electronic health records and electronic prescribing: promise and pitfalls.ObstetGynecolClin North Am. 2008 Mar; 35(1):63-79, ix. Review. PMID:

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