Hospital Information Systems 10 Oct

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Hospital Information Systems

Producing Accurate Hospital Data

HST Conference

11 October 2007

Sonja Venter: HISP

A Myth or Possibility?


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Poor quality hospital data

can be fixed with very expensive

sophisticated software solutions


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An information system is as

good as the human resource

efforts put into and attitudestowards the system


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WhenHas a System Failed? The total failure:

Major goals have never been implementedNew system is implemented but immediately

abandoned The partial failure:

Major goals are unattained Significant undesirable outcomes.More difficult to identify due to subjectivityissues.

Whose goals are unattained? and For who are theoutcomes undesirable?.

The success:Most stakeholder groups attain their major goals.No significant undesirable outcomes.Might be an element ofsubjectivityin identifying such

outcomes. Richard Heeks


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System designers need to be in touch with user realities.

Success and failure of a new HIS

depend on the size of the gap that exists

between current realities and design

conceptions of the new HIS or

design existing reality gap

Heeks Model


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Terminology Working Definitions

Health Information System:An organised procedure or method to collect andstore data. It can be an electronic (software) systemand/or a paper based.

Design:

The process of developing a plan or an outline for ahealth information system (software or paper based).This involves both the design of the informationsystem itself as well as the design of the process ofimplementation of the new system.


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Design Reality Gap Closure Design-to-reality gap closure takes place with

improvisation:Changing the design to make it closer to current user

reality.

Changing current reality to make it closer to the design. One important technique for closure of the design

reality gap is prototyping: Put users in touch with the design before implementation.

Provides a better sense for all stakeholders of what thedesign - reality gaps are.

Mechanism that legitimates the process of improvisation

for design - reality gap closure.


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The Heeks model will be used as an

evaluation tool showing how large design -

reality gaps underpin HIS

failureand small gaps underpin success.


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Reasons Why Hospital

Information Systems Fail

Taking heed of lessons learned from failed hospital information systems mightavoid the waste of valuable health resources when implementing hospital

information systems in future.


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Reasons Why Hospital Information Systems Fail

Change management: Plays a very important role when introducing new

systems. End user must understand the benefit of the new

system it must demonstrate alleviation of workpressure or the ineffectiveness of old systems (thatthey are familiar with) at a very early stage of theproject.

If not it is very difficult to get buy-in from users (closethe design reality gap).


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Hospital Information System Project Limpopo (1997)


Underestimating the complexity of healthcare processes: Most healthcare interactions occur in the context ofapprehension,

anxiety and time pressure with staff shortages being very common in

the public sector.

Health care providers are mostly concerned with managing the clinicalneeds of the patient. Even the most basic administrative tasks have

more complex dimensions than equivalent tasks in the non-health

sector.

Both the above are very important design reality gaps.

Failure to take account of healthcare cultures: Increased the workload of staff, but they received insufficient education

before the system was introduced.

Evaluation highlighted that training efforts concentrated too much on

howto work the system rather than whyit should be used.


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Hospital Information System Project LimpopoContinue

Staff turn-over: Healthcare management is changing rapidly and admin staff often switches

responsibility in hospitals. Very common design - reality gap in the public health scenario.

Stop putting good money after bad:

Difficult to decide when funding should have been withdrawn. At the time, it is often easier to continue to inject resources in an attempt toachieve a result.

If fundamental underlying factors are not corrected, the project will still fail but at

additional cost.

Failure to learn lessons from past projects:

Evaluation of expensive healthcare interventions often fails to take an overallview. Managers usually monitor costs and meeting of contractual milestones,

whereas academics or health economists assess effectiveness and overallworth (cost effectiveness).

This fragmentation of responsibility (often with an absence of external andunbiased observers) can result in quite large deficits being missed until it is too

late.


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Reasons Why Hospital Information Systems FailElectronic Patient Record Systems

Responsibility of Professional Staff? Developers of EPR systems are keen to afford the utilisation of

data gathered in the patient process forsecondary purposes:administrative and financial management, research etc.

Does the care giver or the patient benefit from the system anddo generators of data understand the importance of their role? If the goal of EPR systems are to support the secondary

utilisation of data outside the context of the health careprocess itself, this additional burdening of the actual care giver

is highly problematic. It might even be unacceptable given the time and staffing

constraints in public health and the fact that this additionaltask will take time away from their core responsibility, i.e.caring for the patient.


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Staff Shortages Implementation of such EPR systems in hospitals with critical staff

shortages yields a highly ironic paradox. Systems implemented in thename ofefficiency and improving quality of care and these systemslead to an additional burdening of the primary data collectors, it mayactually diminish quality of care by diluting time available for actualpatient care.

Ifallthe patient information is not captured by month end (or anyreporting period), these systems can not generate reliable, up to datesecondary data for management of the hospital.

These issues have emerged in the implementation of many EPR

hospital information systems - a huge design reality gap with very littleevidence of improvisation to close the gap

The only way to improvise for this very common design reality gap isto ensure adequate staffing levels and the correct mix of staff (admin,support and clinical staff) as the first and most important considerationwhen the implementation of EPR systems is considered.

Reasons Why Hospital Information Systems FailElectronic Patient Record Systems Continue


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Problems with data quality always

arise whenever doctors and nurses who

are expected to invest time and effort to

collect and produce data are not the

primary beneficiaries of these efforts


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Possible Solutions for the Successful

Implementation of Hospital Information Systems

Analysis and use of data at the level where thedata is generated is of utmost importance if wewant to improve the quality of the data.

Data collection should be a natural part ofnormal patient care and administrativeprocesses and data collection tools should beplaced at points where routine recordkeeping of

patient care takes place. As far as possible the burden of data collection,

processing and capturing should be shared bynon-clinical personnel.


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The Pocket Book for District Hospital ManagersGuiding Principles

Act on information. Managers must know how to useinformation to improve the hospitals functioning.

People on the ground level who record the information

need to know the importance and relevance of the data sothat care will be taken to record it correctly. Data need tobe fed back to these staff members.

Analysis at ward leveland graphs displaying the latestdata keep staff informed.

Start by collecting a small amount of crucial data and useit well, rather than collecting a large amount of informationand not doing anything with it. Start small, but make surethat the quality of the data is good.


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Sharing of Experiences with

Implementation of Hospital

Information Systems


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Eastern Cape Hospital Project

One year project in selected Eastern CapeHospitals using the DHIS at ward level.

The main objective of the project was toimprove the use of information in:3 Regional Hospital Complexes (8 hospitals)

2 Regional Hospitals2 District Hospitals1 Specialised Hospital


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Strengthening of Hospital Information

Systems Mpumalanga

Analysis of current hospital information systems

and data collection tools.

Identify problem areas and challenges in existing

information systems. Development of an Excel based electronic

collection and collation tool customised for every

hospital in the province.

Training in the DHIS software and user support.

Training in the use of hospital information for

planning and budgeting of services in hospitals.


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Change management why is there a need to

change the old system to the new system.

Staff shortage and high staff turn-over. A standard design does not address the

needs of all users there are different needs

and challenges at every hospital and every

ward.

Design Reality Gaps:

Eastern Cape and Mpumalanga Projects


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How did we close the design

to reality gaps in the Eastern

Cape Project?


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Change Management Eastern Cape

Introduction of the DHIS system as well as new registers tocollect the data was done through a consultative processinvolving province and representatives from all the hospitalsinvolved in the project.

Strong managerial involvement setting targets to the

information team, providing feedback to reporting units topromote a culture of information use and buy in to what

Providing and receiving feedback to reporting units with sitevisits and workshops was crucial to identify challenges.

The ward supervisors are an important group to target asthey link the wards to the information unit.


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Staff Turn-Over: Eastern Cape

Trained 3 different Hospital InformationOfficers in at least 2 of the hospitals.

Capacity building - establishing

information teams in each hospital withbalanced skills in clinical information,information technology and data entry andprocessing clerks (wards and information

unit).


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A Standard Design does not Address the

Needs of all Users: Eastern CapeAllowing piloting in some hospitals allowed

experiences from this to be rolled out in others.

Development of new registers to support collection ofnew hospital data set

The design of the new tools and registers providedflexibility for the diverse needs of different clinics andwards through provision of some blank columns wherestaff may include their own column headings.

Based on comments from staff the registers were revisedand a number of potential formats presented torepresentatives of the various facilities at a workshop inDecember 2004.

Based on inputs from this workshop, the second draft wasproduced and introduced to facilities during February andMarch 2005.


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Needs of all Users continue

Using the DHIS at Ward Level The DHIS Software was customised to accommodate

reporting needs from 564 different in- and outpatientreporting units in the 8 hospitals and the data elementsof the new hospital data set was added.

In general the designers of the DHIS system pridethemselves in their efforts to stay in touch with userrealities and constant change in the public healthenvironment.

The flexibility of the DHIS system allows forconstantimprovisation from both designer and user. This isproven by the successful implementation of the DHISsystem in this project and in many countries and healthscenarios.


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How did we close the

design to reality gaps in theMpumalanga Projects?


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Change Management Mpumalanga

Poor design/use of the existing hospital collection andcollation tool. Poor data quality and undercounting of patients, but

incorrect formulas inflated indicator values that gavemanagers a false picture that the hospital was performing

well. The same raw data from the tool was entered in the DHIS

where the data was processed correctly (according to theNIDS) resulting in lower values that in turn made managershostile/sceptical towards using the DHIS data.

The new tool demonstrated the problems with the old tooland proved decrease in workload and improvement of dataquality.

Analysis of data at ward levelproved to be the biggest

advantage of the tool.


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High Staff Turn-Over

Capacity building ToT (DIOs and Sub-

District Information Officers)

Trained at least 2 persons from each hospital Capacity for maintenance/changes to the tool

not successful


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Needs of all Users: Mpumalanga

The project work plan was changed according to theneeds identified during the analysis of the hospitalsystems

A lot problems were identified and addressed during thepiloting and the tool was re-designed a number of timesaccording to feedback and needs identified from users .

Close collaboration with the users during thedevelopment of the tool. Users had a lot of input in thedesign the new tool before implementation

Customisation for every hospitals unique reportingneeds improved ownership of the tool. Adjustments to the system to be as close as possible to

the user realities in every hospital proved to have beenvery successful in this project.


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Conclusion

Flexibility of hospital information systems tobe re-designed to constantly changing

realities in the Public Health environment

and understanding of the human resource

dynamics in the organisation/s that the

system is intended for, is among others,

very important factors to take in

consideration when hospital informationsystems are implemented.


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Thank You

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Hospital Information Systems 10 Oct

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