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:
- District Routine Health System Data Reporting
Manual tallies from activity registers using redundant paper forms reviewed only at higher Ministerial levels
- Optimized District Health Data
Still paper-based, but indicators rationalized and simplified to reduce collection burden and increase data quality
- 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
- Incorporation of Operational IT Systems
Automatic data capture in routine transactions where indicators are automatically generated with access to information from all levels
- 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.