Unit 9: Health Information Systems

Outline

• Typology of Health Information Systems

• Agents, Units, and Institutions in health information

• What goes wrong? What goes right?

Part 1: Health Information Typology

Information for Decisions

• Types of information follow types of decisions– Primary health delivery– Health workforce– Quality and governance– Financing– Supply chain

Decisions for primary health delivery

• Primary health worker decisions– Strategies for diagnosing

and treating• What is the local

epidemiology?• What are local treatment

options?• What are my patients’

priorities?

– Quality feedback• How am I performing?• Are my patients

responding to treatment?

• Health district supervisor decisions– Reach

• Local epidemiology• Facility location• Facility staffing• Facility utilization

– Impact• Provider quality• Supply adequacy

Information Sources in Primary Care

• Passive Data from Facilities– Patient registers– Stock registers– Staff attendance logs

• Active Data Collection from Facilities– Exit interviews– Site inspections– Mystery Shoppers– Quality testing of drugs

• Household surveys– Vital events registration– Demographic and Health

Surveys– Morbidity surveys with or

without biomarkers

Decisions for Workforce

• Decisions at Schools– Are we teaching

workers what they need to know?

– What new programs will we need?

– What old programs need to close

– How to finance training

• Decisions at Ministry– What types of workers

will we need?– What types of workers

do we have– How many?

Information Sources for Workforce

• Census of licensed professionals

• Census of schools and class size

• Household surveys: “Who did you see?”

• Active market surveys– Prices of services– Prices of medical resources– Numbers of private sellers

National Data :Ecology of Medical Care

Decisions on Quality

• How? Who? Where? to intervene on quality levels

• Assess performance of norms and institutions– What information could improve ability of

principals and agents to execute contracts?– What governance procedures are working

best—what would help them work better?– What laws and regulations are needed?

Information on Quality

• Grievances– Complaints by peers,

patients, inspectors

• Statistical outliers– Poorest performers in

a facility survey

• Epidemiology– Epidemics of

preventable diseases– Vaccine coverage

Palace of the ruler of Venice:Box for citizens to denounce corrupt officials. (Photo by D Bishai 2008)

Information on Institutions

• Practice surveys– Adherence to guidelines– Provider knowledge quizzes– Incentives to adhere

• Population surveys– How much do they know about their provider?– What information can they use?

Decisions in Financing

• Who is paying out of pocket and do they need financial protection?– Frequency and depth of catastrophic medical

spending?

• What are costs of care? Where are costs falling?– To design actuarially fair premium– How fairly are costs of care being borne?

• Where is new revenue for health going to come from?– Chart of sources of health system finance over time

Information in Health Financing

• National Health Accounts– Public “Health Spending”

• Look at ministry of health accounts• Look at NGO spending

– Private “Health Spending”• Household surveys of out of pocket medical spending

• “Public Health” Spending– Public Health is financed by several agencies at many

different levels of government• Education, Transport, Defense, Environment

Decisions on Supply

• Where is my stuff?

• When will it get here?

• Where are the bottlenecks?

• Where is the wastage?

• How much should I order?

Supply Informatics

• Shipment tracking systems

• Accessible inventory data

• Forecasts– Based on last year’s performance– Based on last year plus trend– Based on population information

Part 2: Agents, Units, Institutions

Information and Development

• Less developed countries– Information is power– Exploited, never shared

• More developed countries– Information sharing institutions get support– Information is a public good

• Public funding devoted to health information units• Health information collected and made public

National Health Information Unit

• Nationally representative databases– Household surveys (DHS)– Facility surveys– Price surveys

• Epidemiological reports all public– Reportable infectious diseases– Chronic diseases– Injuries– Deaths, Births

Health Services Data

• Facility quality report cards public– Facility staffing public– Supply availability public

• Utilization data for Hospitals, Clinics, Offices public

• Provider performance public– National provider complaint databases

• Price data on medical prices public

Privatizing Information?

• Some health information starts out private– Drug sales at retail pharmacy chains– Insurance claims by private insurers

• Can be resold and remain private– Valued by pharmaceutical companies– Valued by other insurers

Part 3: Pitfalls

Humans: The Weakest Link

• Health information systems built on 3 legs– Hardware– Software– People

• Upgrades to hardware and software are objective and easy to finance

• Upgrading producers and users of health information is difficult

Leading and Trailing Edge

• Health information systems are a blend of software and hardware and people from the last 10-20 years

• Coexistence– Leading edge institutions have the latest of

everything– Trailing edge has components from the past

• Rapidly developing countries have to work harder to make these compatible

Diagnosis 1: Information hoarding

• Human holdovers from trailing edge see information as power and do not share– Political incentives remain– Information threatens some groups and they will push

to keep information hidden• Institutions that should be working to fix this:

– Media– Universities– Public health champions

• Simple rule: if information is paid for by public and does not violate privacy it must be made public

Diagnosis 2:Information wastage

• Ready sources of health utilization information are never collated

• Public finance for information units is usually the culprit– Diagnosis of information hoarding should be

suspected

• Institutions that reward managers who make evidence based decisions would lead them to not waste data

Diagnosis 3: Misreports

• Often an unintended consequence of hefty incentives in a contract

• Data process checks only partly helpful

• Gold standard checks are also necessary

In 2004 after Gavi began to pay $30 per Covered child, Niger’s reported coverageDeviated markedly from mother’s reports(Lim et al. Lancet December 2008)

Diagnosis 4: Information neglect

• Most common syndrome

• Information that could have informed a decision is not accessed or disregarded– Information in inaccessible format– Human decision makers don’t know how to

use data– Information threatens political balance

• Solutions are both technical and human

Best Practices in Information

• Have wise leaders who understand the value of investing in freely flowing health information

• Invest in people as well as machines

• Integrate the data generating and data using systems

Summary

• Health information needs exist wherever there are decisions in health systems

• Health information collection and distribution is a public good and subject to undersupply and underutilization

• Developed societies led by wise leaders open the doors and let information flow