Tamil Nadu Health Systems Project
December 2009

Tamil Nadu Health Systems Project – Successful Implementation of HMIS across Government Hospitals

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The article illustrates implementation of a centralised web-based health management information system for all government-run secondary care hospitals and medical colleges under Tamil Nadu Health Systems Project. The broad objective of the project is to use ICT in improving the ability to collect, store and analyze accurate health data across the state. The project was conceptualized to provide critical health data across the health chain for quick and timely intervention by health directorates.


 

Scope of the Project:

The HMIS project comprehensively covers the key functionalities and processes within the hospitals as well as provides for an online reporting system for all health information.

  1. The services covered for  hospitals as part of the HMS comprise 10 modules including –

    1. Registration, Lab services, Pharmacy, Stores, Wards, Blood Bank, Linen management, Diet, Biomedical waste management, Equipment Inventory and Clinical module covering patient Outpatient (OP) record, In patient (IP) record, Nurses notes, Operation notes, discharge summary, Ante Natal Records (ANC) record, Natal & Post Natal record , Family welfare services and Referral services.

    2. Online access is provided to all end users/primary data entry owners to input data directly into the online system with no data entry support.  Patients receive printouts of the OP slip, lab results, and prescriptions.

    3. The services computerised include

      • Online registration of outpatients and inpatients

      • Doctors services for OP patients including diagnosis, prescriptions, and lab requests entered online (real time)

      • Reporting of the lab test results online

      • Online indents and issues (for drugs)

      • Online ward transfers, linen, diet and biomedical waste  management related transactions

      • Online day end/ periodic reports generation saving significant time for end users in collation and consolidation of data.

      • Discharge Summary and the final disease diagnosis is mapped to International  Classification of Diseases- 10

  2. The HMIS comprises four modules, namely, Clinical, Ancillary, Programme Information and Administrative Information system.

    • The clinical module comprises OP, IP census and details of maternal, child health, immunization details, family welfare services and disease wise data of treatment and cases, etc.

    • The Programme information module covers the national and state level programmes like Blindness control, Malaria, TB, Infectious diseases, School Health, etc.

    • The Ancillary module includes reporting forms for blood bank services, laboratory services, Stores/Inventory details for drugs and other consumables, diet details and biomedical waste management.

    • The Administrative information system module contains Finance related forms for budget, etc.; and infrastructure related forms including buildings, equipment, vehicles, etc.  This module also comprises establishment related forms for capture and reporting details of all the health department personnel including transfers, training, leave, etc.

  3. The security module handles all the access and privileges to be given to end users for each application and reporting.

  4. The Pilot was implemented in 5 secondary care hospitals during January 2009. After the successful implementation of the pilot the next Phase of implementation was carried out in 5 districts, which begun during May 2009.

  5. The Project will be extended to cover the remaining 222 secondary care hospitals across 25 districts in the state, during Phase II implementation.

Scenario before implementing the project:

All the hospital records were being maintained manually, which meant more time consuming and even more time utilised for retrieving records

  • Government was spending more funds towards procurement of manual registers which were difficult to maintain.

  • Duplication of records in the sense, same patient was registered each time he/she visits the hospital and difficulty in maintenance of the old vital records of the patients.

  • For analysis of health care data, reliability of the collected data was questionable.

  • There were no snap shot/dashboard view available to monitor the  performance of the hospitals, prior to introduction of this system.

  • Real time data transactions happening at the hospitals, were previously unavailable at the Institutional level, District level or the state level.

  • Proper maintenance of Equipment Inventory, monitoring of Equipment downtime, Drug stocks auto indent, drug stock accountability and monitoring for the drug expiry dates were some of the challenges, that we have now overcome to a large extent.

  • At the Institutional level, it was very difficult to map the In Patient Disease classification to the International Classification of Diseases (ICD)-10 that is recommended and followed worldwide.
  • Strategy Adopted to overcome the challenges:

    The project has been conceptualized as a centralised web based software solution to minimize technology support and maintenance dependencies.

  • The end users across various Institutions and Offices were called upon for finalizing the Software requirement specifications, so that the entire application was customized to suit the needs of each and every department.

  • TNHSP wisely chose an Open Source software stack in order to prevent a vendor lock in state, in case the project needs to be up scaled.

  • Extremely simple, user friendly screens designed by application provider to ensure end user ease of use and optimized for performance.

  • Adequate training for the end users on HMS, at the Institutional level, to ensure the full participation and to increase the comfort level of the end users. The HMIS training were carried out at the ELCOT district training centers.

  • Hassle free connectivity through Tamil Nadu State Wide Area Network (TNSWAN) , which is a 2 Mbps dedicated leased line terminating at each hospital level.

  • Broadband Connectivity of 2 Mbps connectivity has also been setup at all hospitals as a redundant connection. We have also established Automatic switch over from TNSWAN to broadband and vise-a-versa during times when either one of them fails.

  • A centralised web server which houses the entire database placed at a fully equipped Data center.

  • TNHSP in coordination with Tamil Nadu Electricity Board has ensured that there are no power cuts during the Outpatient hours of the hospitals. We have also supplied UPS with 2 hours back up to all the hospitals in case of a power failure.

  • TNHSP has requested the State Government to issue necessary orders to do away with the manual registers, so that all the hospital staff would eventually use HMS for all transactions.

  • Continuous motivation of all the end users from the top level of the management and a daily review of the performance of the hospitals on HMS at the Directorate level ensured that the implementation was a success.

  • Creation of a “Centralised Help Desk” to register calls/ clarify queries from end users regarding hardware/application related issues, which will also ensure coordination among various stake holders.

  • TNHSP has posted an IT Technical coordinator at each district for the 5 districts to supervise, troubleshoot and handhold for the various issues occurring at the institutional level.
  • Innovations of this project:

    The project brought in institution level changes and provides for the following

    1. Unique Patient Identification Number (PIN)

    2. Unique Institution codes across all government hospitals and office

    3. Unique employee numbers/ user names and passwords � for access to system

    4. Re-use of drug codes (from other Central procurement agency)

    5. Re- use of the treasury codes for Finance related information

    6. Uniform and standardized reporting formats across all institutions.

    7. TNHSP has proposed to link the PIN to the UID that is to be developed by the Government of India.

    8. The Lab tests results are being given to the patient with test report reference values

    9. The final disease diagnosis is linked to International Disease Code- 10

    10.  Tamil Nadu Health Systems Project has requested the Government to issue orders for doing away with the manual registers and using the HMS for all transactions.

    After several iterations of requirements, uniformity and standardization of input formats were finalized and resulted in significant level of changes. Common uniform system of reporting will provide for ease of data comparison and performance monitoring across institutions.

    The rationalisation of some of the processes and report formats has also been done.  The HMS application provides for removal of many manual processes including manual tokens for drugs, lab request slips, indent forms, etc.  The day end consolidation of reports for drug issues, indents, daily census, etc. has been automated resulting in substantial saving of time for the end users.

    Scalability of this Project:

    A centralised web based solution on open source technologies designed based on factors like maintenance issues at hospital end (being situated in remote locations, lack of trained manpower at hospitals, cost of support, ease of deployment, training, etc.

  • The servers and data storage architecture configured for ensuring scaling up with optimal additional investments only.

  •  This solution architecture has been designed for scaling up the application deployment/ access to large number of Institutions and to other Directorates like Medical Education and Primary Health.

  • HMIS data entry formats fully standardized and provides for uniformity in reporting and data consolidation.

  • Data input and collection in forms includes the data requirements for NRHM and other reporting needs at State and Central level.

  • The Solution is highly replicable across other States in India and even other developing countries. HMIS forms easily customizable for reporting requirements.

  • Hardware infrastructure (Desktops, LAN, UPS) fully with standardized specifications at all institutions help in quicker maintenance and troubleshooting.

  • Existing State level infrastructure harnessed for the project with the use of the connectivity backbone set up in the State (TNSWAN) for the last mile connectivity to hospitals.

  • Existing State Data Center facilities used to co-locate the Application and Data servers thereby creating a central repository of all health information.
  • Sustainability of the Project:

    The HMIS Solution architecture has been designed for scalability and long term sustainability.

  • The centralised web based solution offers several advantages in terms of ease of maintenance, ease of changes

  • incorporations, enhancements to formats, and ensuring data integrity and safety.

  • As all data is managed centrally which ensures the availability of trained and skilled manpower at fully equipped Data Center

  • All end users fully trained to directly use the online system for data entry. No data entry support and thereby no additional hiring of manpower envisaged.

  • Identification of nodal teams at each hospital and at district level for training on   troubleshooting and quick response mechanism for support at local level

  • Built up the Connectivity redundancy and UPS power back up facilities at all locations as part of basic infrastructure set up.

  • The use of State wide area network brings in additional security features of running on a secure communication link within the state.

  • Centralised help desk set up to support end users � coordination and close follow up to ensure quick resolution of issues

  • Applications fully scalable to meet the requirements of Tertiary care and Primary care Hospitals in the State.
  • Achievements of this Project:

    36 hospitals across 5 districts are currently LIVE with the online system in a short period of 7 months. All respective end users are expected to use the system with no data entry support. All Registration, Stores, Pharmacy, Wards, Lab, Doctors’ Out Patient (OP) processes are fully online and no manual records are maintained.

    Real time data is available, 24/7 at these 36 hospitals. The doctors are making direct online entries for diagnosis, ordering lab tests and drug prescriptions. The HMIS reporting system covering Clinical, Program, Administrative including Finance, Personnel, Infrastructure modules provides, immediate online access to the Health Administrators at the Institutional level, District level and at the State Level on various critical data sets.

    After our successful implementation of HMIS in 5 districts, approvals have been sanctioned immediately to extend this project to 222 secondary care hospitals across the remaining 25 districts in the state. The 18 medical college hospitals across the state are also likely to be included during the Phase II implementation, which is expected to be rolled out in the beginning of 2010. It was awarded the “e -India 2009 award for category e- Health � Best Government initiative/policy for the year 2009” at the e- India event, held at Hyderabad during August 25-27, 2009. 

 

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