Chapter 11 Health information systems

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Contents

• Unit 23: Health information systems
• Objectives
• Unit 24: eHealth and mHealth
• Objectives
• Case studies

Unit 23: Health information systems

Objectives

When you have completed this unit you should be able to:

• Describe the characteristics of a good health information system.
• Explain how a good health information system can be used to improve patient care.
• Give the advantages of an electronic health information system.

23-1 What is a health information system?

A health information system captures and processes information about the health of individuals and the activities of a healthcare system.

There are several components of a health information system:

• Collecting and recording data
• Analysing data
• Communicating the results of the analysis and using it to improve care

The use of health and healthcare information to improve care is a very important aspect of health information systems.

The components of a health information system are collecting and recording data, analysing data and communicating the results of the analysis.

23-2 How is information used in a health information system?

Different types of information are used at different levels. The following are important examples:

• At patient level: Recording individual patient information to help clinical decision making (for example, blood tests and radiology results), and to help other providers who care for the same patient (for example, discharge summaries and management plans)
• At facility level: Recording use of drugs and consumables to assist in ordering and supply chain management
• At population and community level: Assessing the use of healthcare as well as unmet needs and disease surveillance. This information is used for service planning.

23-3 What does a good health information system look like?

There are 2 important characteristics of a good health information system:

• How the data is collected: In a good health information system, data collection is accurate and complete. This means the information is reliable.
• How the data is used: In a good health information system the information collected is used to improve services. Anybody working in the system should have access to information related to their area of work.

In a good health information system data is reliably collected, and used to improving care.

23-4 Should a good health information system be paper-based or computer-based?

In some health systems, information is collected on paper and then transferred to a computer by a data entry clerk. In other systems, clinical or technical staff are expected to collect and transfer the data using electronic methods (a computer or cellphone).

A good health information system could be either paper-based or computer-based (electronic), but using electronic methods means that larger amounts of data can be collected and processed faster. It also means that there are less likely to be mistakes as paper information can be lost or unreadable. A well-designed electronic system is therefore preferable to a paper-based system, but a badly designed electronic information system is a nuisance and often fails.

There are advantages of an electronic over a paper-based health information system.

23-5 How can data collection be made as accurate and complete as possible?

To achieve thorough collection of data it is important that staff are able to enter data easily and accurately. This means that:

• Data collection demands on clinical and technical staff are minimised. In some health systems there is an unnecessary burden of data collection because there are poorly coordinated, overlapping demands for data from different information “sub-systems”.
• The people collecting the data can see how it is used to improve the service.
• The means to enter data are easily accessible (staff do not have to search for forms or wait for a computer terminal to be free).
• When using a computer or cellphone display (this is called the user interface), it should be easy for the user to see what to do and the choices must be clear and obvious.
• The data collection system must be able to deal with power cuts and interruptions in telephone and internet access.

23-6 What is a good “user interface” and how does it help data collection?

The “user interface” refers to the way in which staff interact with a computer-based system. If the programme is confusing or unnecessarily complicated, people find it difficult to use, annoying or pointless, so data collection is often inaccurate or incomplete. In a good user interface:

• Staff can easily choose appropriate options to collect important data
• Unnecessary steps are removed.

A good user interface is therefore quick and easy to use. Sometimes information from clinical staff is collected on paper forms and entered onto a computer by a data entry clerk. The same principles for a good user interface apply to a paper form. It needs to be “user friendly”.

The better the user interface, the more likely it is that information will be entered completed and accurately.

23-7 How can the “user interface” be improved?

The people who design programmes are not usually the ones who work with them, so it is important that new computer systems are tested with the people who are actually going to be using them. Some problems become apparent only after people start to use a new computer programme. Therefore the user-experience needs to be monitored after implementation as the programme may need to be improved. With a good user interface more staff will be willing to use the system and become computer literate.

A good electronic system requires an ongoing interaction between the experts who design the system and the people who use it.

23-8 How can learning come from a good health information system?

A good health information system is a learning system. The learning can come from:

• Quality improvement programmes based on the information collected
• Guidance on clinical management that is made available to clinicians as the data is entered. For example alerts for vital signs, such as high blood pressure, or clinical features that are dangerous, such as neck burns with swelling that might result in respiratory obstruction and need special care.

Health information is often collected for the benefit of the managers responsible for a programme. However in a good health information system data can also be accessed and used by those providing or using services to improve care. This enables them to learn from the data and improve the way data is collected and analysed. This positive feedback between data collected and the way the information is used helps to increase the standard of both the data collecting system and patient care.

A good health information system collects data that can also be used by those providing or using services to improve care.

Unit 24: eHealth and mHealth

Objectives

When you have completed of this unit you should be able to:

• Define eHealth and mHealth.
• List ways in which health professionals can use eHealth to provide continuity of care.
• Describe how both eHealth and mHealth can be used by patients to improve self-care.
• Protect a patient’s privacy when using informal eHealth methods.
• Explain why “interoperability” is limiting the spread of eHealth solutions.

24-1 What is eHealth?

There are many different definitions of eHealth (electronic health), but the World Health Organisation (WHO) defines it as: “The transfer of health resources and healthcare by electronic means”.

In general, “electronic means” is understood as the use of the internet and the cellphone network to transfer information. This can be done using:

• Desktop and laptop computers.
• Basic cellphones (mobile phones) and “smartphones”. A smartphone is a mobile telephone that can connect to the internet, and can also download and operate “apps”. An “app” is short for an “application”. This is a computer programme that allows the user to perform specific tasks.

Therefore eHealth is the use of the internet and cellphone network by both healthcare providers and the public to transfer health information.

eHealth uses the internet and cellphones to transfer health information.

24-2 How is eHealth used by healthcare providers?

eHealth can be used by healthcare providers to:

• Store and share information about patients, using electronic health records, radiology results and laboratory systems.
• Support decision making by allowing communication with specialists, by allowing easy access to information on sites such as a poison information centre, and by having warnings and alerts built into patient records.
• Contact patients, if needed.
• Provide education and training.
• Collect and store information about caseload and the performance of health facilities.

eHealth can be used in many different ways by healthcare providers to improve the service they provide.

Note

The free online Bettercare course books are an excellent example of using eHealth for healthcare education. (https://bettercare.co.za/learn)

Afritox is a South African poison information centre.

24-3 How is eHealth used by patients?

eHealth can be used by patients to:

• Find out information about their condition.
• Find support groups on social media.
• To monitor their own conditions. For example, some apps record how much somebody exercises.
• In some health systems, patients can book appointments and renew prescriptions over the internet the same way as they use the internet for banking or booking travel tickets.

eHealth includes use by the public to “crowd source” and report information about environmental hazards. For example, some apps allow mobile devices to sense air pollution, and this information is sent back to a central map for use by activists.

eHealth can be used by both healthcare providers and patients in many areas of supplying and accessing services.

Note

Crowd sourcing allows a wide group of people to send in data to a central site. For example, a woman with diabetes can use the internet to ask if anyone else is also having problems obtaining insulin from a particular manufacturer.

24-4 What is mHealth and how is it used?

mHealth (mobile health) is the use of mobile phones and wireless devices, such as tablets, to deliver healthcare information. mHealth is a category of eHealth which includes the use of mobile telephone networks to transfer information, for example using SMS or WhatsApp messaging. Although the use of computers and smartphones is rapidly increasing in South Africa, many people still do not have internet access and rely on simpler cellphones and mobile telephone networks. mHealth approaches can include a much broader group of users.

mHealth is the use of mobile devices, such as cellphones, to deliver healthcare information.

24-5 Is eHealth or mHealth mostly a solution for richer countries?

No. eHealth has the potential to address some of the biggest healthcare frustrations in all low- and middle-income countries, especially in Africa. These frustrations are:

• Poor communication between different levels of providers. Patients with complicated chronic diseases often arrive in the emergency departments of hospitals where they are not known, and they often have very little information about their conditions. It can be very difficult to know how best to manage these patients without knowing their medical background. On the other hand, primary care practitioners often refer patients to hospitals for further management but receive little or no feedback on what happened, or the patient’s ongoing management. eHealth can provide a central patient record that all providers can access. Discharge summaries are particularly helpful.
• Poor access to specialist care in more remote communities. Specialist opinions can be more easily accessed using electronic means for a “virtual” consultation. This might mean a video consultation using either a formal (expensive and not widely available) telecommunications system, or an informal (low cost and widely used) system like Skype. A very simple, informal use of eHealth is the taking of photographs, for example, of an X- ray, rash or a wound, and sending it over a mobile phone link. There are also some free and easy-to-use apps for remote consultations such as the “Vula” app for eye consultations.
• Poor adherence. mHealth can be used to send reminders to patients, and to share health information. It has the potential to make patients more engaged in their own healthcare and, if self-care is improved, it may reduce demand on clinical services.
• Failure to attend appointments on the correct date. Patients can be reminded of the medical appointments.
• Reminders to patients to take medication on time.
• Collecting vital data such as mortality statistics.

Two of the largest mHealth projects in South Africa are MomConnect and NurseConnect.

24-6 What is MomConnect?

MomConnect is a project using SMSes or WhatsApp to link pregnant women and mothers of infants with the health service. Women register when they book for antenatal care and then get 3 messages a week in their home language. These will provide both support and knowledge about pregnancy, infant and child care. Mothers can also ask questions as well as send compliments or complaints about the service at their local health facility. Over 2 million women are using MomConnect.

MomConnect is a project to support, educate and link mothers to the health service via SMSes and WhatsApp.

24-7 What is NurseConnect?

NurseConnect is similar to MomConnect but provides support and continuing education to midwives and nurses caring for pregnant women and their infants using SMS messages as well as Facebook messenger or WhatsApp. From a website they are able to access additional information. You first need to registration on their website.

Both these projects of the National Department of Health form a model which could be applied to support and educate the public and healthcare providers in many other areas of healthcare in South Africa.

NurseConnect is a mHealth project to support and provide continuing education to nurses and midwives.

24-8 Are there any concerns about eHealth and mHealth?

Yes. The main concern about eHealth and mHealth is that patients’ confidential information will not be secure, and may be inappropriately shared. In an ideal world, all practitioners would be using the same system and all information would be sent over a secure link. However informal systems, such as the sending of photographs, have become widespread because the implementation of formal eHealth systems has been slow. It is always important to keep confidentiality in mind and remember that any piece of electronic information can be copied and shared with the rest of the world. For example, do not include the patient’s name if you are sending a photograph for an opinion, and never share clinical information on social media.

Confidentiality is important when using eHealth or mHealth.

24-9 Why has the implementation of eHealth been slow?

There are several reasons why the implementation of eHealth has been slow:

• Broadband and fibre infrastructure is not widely spread in more remote areas and when it is present, systems can be subject to power outages.
• Different systems do not “talk to each other” because they send and understand digital information in different ways. In a good electronic patient record, a healthcare provider (or even the patient) should be able to access information such as X-rays and laboratory results, as well as clinical notes. At present, even in some quite advanced eHealth systems, administrative information, clinical notes, radiology and laboratory results are all captured on different programmes, to which all users do not have access. The ability of different health systems to link with each other is called interoperability.
• New electronic systems are sometimes introduced without consulting the users and without offering the necessary training. This often means that they are not used.

Access to broadband or fibre and good interoperability are essential as is consulting and training of healthcare providers for eHealth to function well.

Case study 1

Dr Prudence is a new community service doctor at St Jude’s Hospital. She is finding her feet and starting to relax. She recently managed an interesting respiratory case and feels it is important to share her learning with her friends and colleagues who are also doing community service in rural and remote hospitals. She knows that confidentiality is important and that she cannot use names. She writes the following on her Facebook page:

“Hi Guys. Just want to share this case – nearly missed a killer here. Had a 32-year-old HIV positive teacher in c/o short of breath. Here is the X ray – normal hey? Luckily I remembered to check the sats - 74% on room air! PCP pneumonia. Nearly missed it but all’s well that ends well”.

1. Is there a problem with confidentiality here?

Yes. Her Facebook friends are likely to know where she is working and there will be few 32-year-old teachers in the community. Without meaning to, she has broken this patient’s right to confidentiality. Information about patients should never be shared on social media.

Case study 2

St Jude’s hospital would like to introduce an internet-based electronic system for drug prescribing. They feel it will reduce medication errors by flagging warnings for drug interactions and inappropriate doses. They also wish to use it for inventory control so that they can order appropriately and reduce stock outs.

1. Which of the following are important reasons why their eHealth system may fail?

• The internet connection is unreliable.\
• There is no technician to maintain the computers and troubleshoot technical problems.\
• The new system is not user friendly.\
• The new system is not discussed with staff beforehand and training is not provided.\
• Clinical staff are expected to prescribe on paper, because this is what the pharmacy wants, and then enter the same prescription electronically because this is what management wants.

These are all true. There are electronic systems to manage most of the “paperwork” that providers do, but implementation may be difficult. This can be related to technical problems with the internet and with the computers, but is more often related to the ways in which humans use computers. A successful system will have been extensively tested on the users, will be introduced to adequately trained people and will replace rather than add to existing “paperwork”. Users should also be able to see the value of it, in this example by reducing stock outs, and not see it as an extra job that management has given them.

Case study 3

Cellphones are widely used throughout South Africa. There have been many new pilot projects using mHealth over the past few years. One of the important ones is MomConnect. It was piloted in 2 districts in KwaZulu-Natal in 2012 and then rolled out throughout the country.

1. What particular problems might mothers-to-be in a South African rural health district face?

Several answers are possible, but the following factors are important:

• There may be limited access to clinics for antenatal visits
• If people are moving around without a secure place to live, they may attend a number of clinics and also give birth in a different facility. This means that continuity of care is difficult
• In districts where there is a high HIV prevalence, adherence to anti-retrovirals is important
• Many women face pregnancy alone, and may feel fearful and unsupported without a partner

Case study 3 continued

New expectant mothers were enrolled at the antenatal clinic. They then received free customised SMS messages in their home language, reminding them about clinic appointments and giving them important information during the pregnancy and after their baby was born. There was also an SMS helpline where they could ask anonymous questions, together with a survey where they could rate their experience at the clinic.

1. Which important health system function did the survey address?

Accountability. It allows the health department to learn from mothers where there are gaps and problems in the service.

Note

Over 2014 and 2015, MomConnect was made national and now has well over 2 million mothers enrolled. Strong leadership and a clear vision from the national minister, together with partnerships with over 20 partners from the private and public sectors was necessary to make this work. MomConnect is recognised as one of the very first successful national “roll outs” of mHealth in low- and middle-income countries.

Case study 4

To deal with the problem around continuity of care for pregnant and young mothers, the National Department of Health wanted the information to go to the District Health Information System (DHIS) so that any midwife or primary care nurse could register. This would mean that any midwife or primary care nurse at a healthcare facility registered with NurseConnect would be able to access continuing education and information to guide care.

1. Which other health workers may benefit from a similar use of mHealth?

This method of using SMS, WhatsApp, Facebook messenger and websites to support health workers could be used with all grades of doctors, nurses and professions allied to medicine. It could also be used with community health workers.