Key National HIS Success Technology: Change Management

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 systems
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.

health information systems
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.

7 Responses

  1. Sounds like a fascinating Technology Salon, sorry I missed it.
    One item I would add to the list, in addition to change management: the ability to use the new wealth of data (much of it near real-time) for decision-making purposes.
    Data & reports are great, but if you don’t know what to do with them they’re essentially useless.

  2. Wayan Vota says:

    We did talk about using data for decision making at the Salon and found an interesting result of accurate data: resistance and once accepted, the destruction of long-held assumptions.
    One participant told of their experience with a national government that refused to acknowledge actual numbers from the new ICT-based system as it conflicted with the politically palatable figures from the previous paper system.
    In another experience, once the government accepted the new data as real, it went looking for reasons why the old data was so inaccurate, which lead to a few lost jobs.

  3. Wayan Vota says:

    On a whole other level of data analysis, we did acknowledge that most HIS models recorded data for policy making, not for direct feedback to clinicians for immediately improved patient interventions.

  4. Francis Kiweewa says:

    interesting to eventually have the evidence that HIS reforms do not actually require the system to be technologically advanced. That the most important factors in having a stronger HIS revolve around leadership,human resource culture and behaviour. Technology while important should not limit or restrict reforms.
    I do not know the details of the survey findings but fromwhat I have read from the salon summary it is very possible to integrate HIS once we eliminate the redundancies and improve upon the coordination mechanisms.

  5. Dave Ferguson says:

    One aspect of our discussion I found particularly relevant was the point about what is the purpose of a HIS? There were two thoughts. One revolved around patient care, with information on medical history, daignosis and treatment support for the practioner. The other was focused on public health status.
    The later seems to be the kind of big system that many governments and donors are investing in. Pragmatically, we can appreciate what a dramatic success it would be if we had a system that provided near real time data on the health of a population. My concern is that such a system would be very difficult to achieve. Even when we design and implement something that can get close to this, the bureaucracy and political agendas of those responsible for acting on the data are very likely to “mold” the information to meet political or personal goals.
    Why not focus on the patient first and the system that manages these resources second?

  6. Wayan Vota says:

    Glad you asked about improving patient care with HIS – that’s the focus of the July Technology Salon. I hope you can make it to learn how Baobab Health has improved patient care, using ICT.

  7. Wayan Vota says:

    Over on the Insights on Health Information Forum, we’ve picked up this theme with the conversation How can donors expand national health info system