In this month's Technology Salon, National Health Information Systems: Who Uses What, Where?, we discussed a recently-completed study by Vital Wave Consulting that surveyed the global landscape of national HIS ecosystems in the developing world. The overall outcome may surprise some development practitioners, but its well known to IT experts: basic change management matters more than fancy technology.

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Brendan Smith started the Salon with a great overview of the challenges faced by contemporary paper-based national Health Information Systems (HIS), from delayed initial reporting, to transcription errors, to the massive time commitment required to analyze the data. In fact, Jamaica clinicians have over 500 forms to record their activities, and Indian clinicians typically spend every Saturday recording the events of their week.

Health information system in practice

With the obvious drawbacks to paper systems and the allure of massive efficiencies expected with automated ICT-based systems, many countries are looking at or actively moving to electronic national Health Information Systems. Vital Wave Consulting identified 5 levels of sophistication that countries go through in their HIS automation progress:

1. District Routine Health System Data Reporting
   Manual tallies from activity registers using redundant paper forms reviewed only at higher Ministerial levels
2. Optimized District Health Data
   Still paper-based, but indicators rationalized and simplified to reduce collection burden and increase data quality
3. Electronic Storage & Reporting of District Health Data
   Manual data entry from log books to electronic forms for stronger analytics, requires basic computer literacy and continuous tech support
4. Incorporation of Operational IT Systems
   Automatic data capture in routine transactions where indicators are automatically generated with access to information from all levels
5. Fully Integrated National Health Information Systems
   Data from all key sources (public & private), governed by explicit national policies, creating a strong data-driven culture with sense of ownership at all levels

They also categorized the studied countries into each level, with one notable exception. Not a single country made it to Category 5 - Fully Integrated HIS. In discussions with Technology Salon attendees, it was our opinion that no country - developing or developed - is in that category either. And skipping ahead to Vital Wave's report conclusions, shows us why.

In their analysis of national HIS efforts, Vital Wave found five key metrics to success, which should look familiar to anyone involved in change management for large organizations:

• Integrate an HIS in conjunction with broader health system reforms
• Streamline data collection and reporting as a first step
• Plan for hidden costs and staff resistance
• Cultivate a data-driven management culture
• Create change management and incentive structures

To bring home the point about change management vs. technology, let's walk through the India HIS example Vital Wave gave from their own field research.

India's National Rural Health Mission is rolling out a health information system to gather data from the block level - an administration point, usually a hospital-type community health center, that has local and rural clinics beneath it. These clinics will still use a paper system, but 3,000 data points have been reduced to 200. These paper forms will be entered by dedicated data entry staff at the block level, and eventually block level clinicians and higher will enter their own data directly.

Category 3 advance

While this system will greatly increase accuracy, timelines, and efficiency overall, Ministry staff were the most proud of the data point reduction. It was seen as the greatest challenge and accomplishment of the HIS - more than even the computerization of the process. In fact, that single act alone took the personal intervention by India's Health Secretary as there was huge resistance to giving up indicators.

Each indicator was seen by the person tracking it as integral to their work, maybe even to their continued employment, so reducing the number of indicators, while creating benefit for the whole, also created intense fear and uncertainty in the Ministry rank and file. In addition, the reduction of errors also posed its own problems. With more accurate information, long-held assumptions, some of which careers were tied to, were revealed to be false. Salon participants reported instances of Ministry staff, even Ministers themselves being fired when the new HIS data reflected a different reality than previous systems.

So deploying a national health information system successfully does not require the high-end technology resources available to richer countries. The major hurtles to successful national health information systems are human, not high-tech. Having a clear goal of improving data quality, and a solid change management approach to achieve is the critical success factor. And this can be accomplished in countries as varied in resources as Belize, India, and Sierra Leone.

It often seems that there are as many health information systems (HIS) as there are governments - from custom legacy systems to new web-based applications. But which governments are using a HIS, what system do they employ, how has it helped them, and and what can we all learn from their experiences?

Health information system in practice

For the next Technology Salon, we'll focus on a recently-completed study by Vital Wave Consulting that surveyed the global landscape of national HIS ecosystems in the developing world. This study was sponsored by the Bill & Melinda Gates Foundation to:

1. analyze the landscape of national HIS ecosystems
2. review prominent examples of HIS implementations
3. identify critical success factors to strengthen health outcomes

We'll have Brendan Smith of Vital Wave Consulting lead us through the report highlights, India case study, and an accompanying online HIS forum with an engaged discussion around the various health information systems, fueled by a hot coffee and Krispe Kreme donuts sugar rush.

National Health Information Systems: Who Uses What, Where?
June Technology Salon
Friday, June 26, 8:30-10am
UN Foundation Conference Room
1800 Mass Avenue, NW, Suite 400
Washington, D.C. 20036 (map)

Do note that this Salon is on Friday morning, instead of Thursday, seating is limited and the UN Foundation is in a secure building. So the first fifteen (15) to RSVP will be confirmed attendance and then there will be a waitlist.

Last week I had the privilege to participate in the Humanitarian Technology Challenge - a call to action for the IEEE membership to get engaged with the multiple issues facing development that could be overcome with technology. The HTC is a partnership between IEEE and the United Nations Foundation Technology Partnership with the Vodafone Foundation. (more on the HTC partnership)

Mark Summer of Inveneo

Over two days, IEEE members were encouraged to develop and implement technological responses to three humanitarian challenges in developing countries:

1. Reliable Electricity: Availability of power for electronic devices
2. Data Connectivity of Rural District Health Offices: Capability of exchanging data among remote field offices and central health facilities
3. Patient ID Tied to Health Records: Maintain consistent patient records, including when patients visit different clinics and when they relocate

Working with them were representatives of 10 humanitarian organizations, and the brainstorming sessions where technology and development experts came together to devise solutions made the conference feel like a large-scale Technology Salon.

We did not achieve any immediate solutions, but we did practice a number of key skills in deploying development solutions. My favorite was using elevator pitches to increase excitement and buy-in by local leaders around solutions to the three challenges. We started with the challenge to sell a power system to generate electricity for a school, for a day, where I came up with the following pitch:

You want power. You want cheap power. You want cheap power through people power! And people power from those with the most energy: kids. Better yet, naughty kids. Put the youth on bicycles that recharge batteries. And while this idea is not new, my plan has a bonus: electroshock therapy. That's right, electrodes to shock the kids if they don't pedal fast enough. Which gives you a reward that every parent will find even more impressive that electrical power, exhausted, calmed children.

While my pitch was greeted with laughter, it was also meant as a lesson. Think outside the box for your solution, use cheap, available materials that are easy to maintain and expand on locally, and be flexible to respond to unforeseen needs.

From here, the IEEE membership will do deep dives into these three areas and we should see interesting outcomes in a few months around possible technology solutions to these vexing development challenges.