Health Management Information Systems

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Health Management Information System (HMIS) IT initiatives of Government of Tamilnadu Department of Health &Family Welfare Pankaj Kumar Bansal, IAS, Additional Secretary & PD, TN Health System Project,

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HMIS Envisaged by the Health & Family welfare department of Govt of Tamil Nadu through Tamilnadu Health Systems Project as part of the on going initiatives for IT enablement of health sector. Conceptualized to provide critical health data across the health chain for quick and timely intervention by the health directorates. The World Bank’s involvement in the project has been extremely advantageous. It has helped in introducing new approaches in the health sector .

Three Tier Health Care delivery in Tamil Nadu:

Three Tier Health Care delivery in Tamil Nadu Directorate of Public Health & Preventive Medicine Directorate of Medical & Rural Health Services Directorate of Medical Education Medical Colleges – 18 MC Hospitals – 41 Taluk – 161 Non-Taluk – 78 b HQ Hosp – 28 HSCs – 8706 PHCs – 1589 Primary Care Secondary Care Tertiary Care 3 Population 7.21 Crores

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No. of Districts-32 No. of HUDs-42 32 Districts& 42 Health unit districts

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NRHM

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Birth rate 15.9 (2011) Death rate 7.6 (2011) Infant mortality rate 24 (2011) Maternal mortality ratio 79 (2011) Total fertility rate 1.7 Population 7.21 Crores (Census 2011) Area 130,058 sq.kms.   Vital Statistics

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Project Rationale No real time data available to monitor the performance of the hospital Evidence based program management was a challenge Undue delays in receipt of data Retrieval of old manual records was ineffective & time consuming. Duplication of records was again a setback within the hospital Monthly reports sent as hard copy- a real challenge for data analysis/comparison Drug & equipment inventory - maintenance and tracking of warranty/AMC-more cumbersome Lack of standard names and codes

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Project Strategy 1 . ICT Initiatives 2. Policy Initiatives 3. Process Initiatives 4. Paradigm Shift

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Centralised Web based Application Infrastructure investments-Hard Ware /Connectivity/UPS etc Utilizing the existing Infrastructure investments by State Government- State data centre /TNSWAN 1. ICT Initiatives

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Application Software Developed and implemented by Tata Consultancy Services GoTN owner of the application Centralized web based application on open source platform J2EE (Java 2 enterprise edition) Postgre SQL data base Glass fish Application Server Solaris Operating System Follows industry standard-three tier architecture viz (Presentation, Business logic and Data layer) SUSE Linux OS at the end user level-user friendly screens

Patient Identification Unique ID-PIN -:

Patient Identification Unique ID-PIN - 15 Digits First digit indicates Directorate Next five digits denotes institutional code Last nine digits refers to patient number This number is different from OP number OP number has 17 digits Two more digits next to institutional code makes 17 digits for op number

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2. Process Initiatives For Software requirement specifications (SRS) thorough study of the entire health system and its process were studied Extensive training sessions were conducted for various categories Stakeholders meetings Periodic reviews & Follow up action taken Help desk set up Protocol established Central helpdesk for facilitation and co-ordination Equipment break down also monitored by HD IT coordinators placed in each district All infrastructure issues related activities Application support and training Form e-core team in individual hospitals and solve IT issues Three Server Administrators for Server Management

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3.Policy Initiatives Issue of government orders for:- Implementation, Sustainability & Usage Fixing of responsibility on the end users Budgetary provisions for maintenance & support Removal of Manual records Creation of new posts at district level and state level to support ICT interventions Instructions to the Heads of Departments and Directorates to use data from HMIS for purpose of monitoring, review and analysis Instructions to dispense away with the system of manual reporting and instructions to audit teams Formation of a dedicated team at the Directorate Establishing a centralized help desk at the directorate

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4.Paradigm Shift Automation of work flow process at the hospitals Manual Registers/Records removed from hospitals Real Time monitoring of hospitals performances Electronic Medical records Standardization of health systems and processes Computer skill development among the hospital staff Online maintenance of drug inventory/equipment inventory No data entry operators-involvement of regular staff

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Implementation overview Pilot -5 hospitals Dec 2008 Phase I – HMS in 36 hospitals across 5 districts Nov 2009 Phase II – HMS in 222 secondary care hospitals + HMIS in 1613 PHC’s fully online INR 2.8 crores INR 5 Crores INR 87 crores Phase III- 47 Institutions under Directorate of Medical Education including 17 Medical Colleges + Tamil Nadu Dr.MGR Medical University INR 23 Crores August 2010 July 2011

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Users Primary Health Centers…….1589 centers Secondary Care Hospitals….267 hospitals Tertiary Care Medical College Hospitals..17 Medical colleges and a Medical University ………………………………………………………………………………….. Doctors, Pharmacists, Nurses, Lab technicians, Hospital Workers and other staff of hospitals & Administrators

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HMIS Two components Hospital Management System- HMS Management Information System-MIS HMS MIS Clinical Information Automatic Incorporation of data at the Institutional level

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HMS Hospital Management System Registration Out patient Inpatient Medical Records Lab ,X-ray & other investigations Pharmacy Stores Blood Bank Diet Linen Module for online daily report generation-MRD Final diagnosis is mapped to ICD-10 classification These module are regarded as patient management information system

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MIS Management Information System Unified Health Reporting system Clinical Information (auto populate+) Patient census, Morbidity, Mortality, Patient services, Immunization, etc Ancillary Services ISMR Blood Bank, Lab services, etc Administrative Information Buildings, Finance, Personnel, Vehicle, etc Program Information Malaria, Blindness control, etc.

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MIS ISMR-(Institutional service monitoring report)

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Patient Registration Consultation with Doctor Order Investigations Generate Prescriptions Diagnosis Lab PIN Common Disease list Comprehensive List of tests OUT PATIENT DEPARTMENT WORKFLOW Patient History; Lab results Online No Data Entry Operators

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Current Status Hospital Management System (HMS) 210 hospitals out of 267 secondary care hospitals on line Health Management Information System (MIS) PHC’s under Directorate of Public Health & Govt Hospitals under Directorate of Medical and Rural Health Services- send monthly reports online (1589 PHCs and 267 Secondary care hospitals)

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Advantages For the Patient Patient identification number (PIN) On next visit, patient can approach the consultant directly, need not wait in long queue for registering again Print out of the prescription is given to the patient Old records not required on review-it is available on line The clinical records of the patient are safe for a longer period of time Patient can visit any secondary care hospital across TN with PIN The Patient identification Number (PIN) can be interfaced with UID

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Advantages of HMS For Doctors- Saves a lot of time Drugs/lab investigations can be grouped into packages and more often a package may be prescribed. Can view the previous clinical history ports on line Specialty OP- Doctors with a single click, can repeat the previous prescription. In certain cases the doctor can follow the Standard treatment guidelines (master data)

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Advantages of HMS For Staff Nurses Saves a lot of time- need not maintain too many registers Diet, drugs &linen -indenting can be done from wards Ward inventory easy maintenance Lab investigations results can be viewed from the ward Discharge summary given to the patient as print outs Handing over and taking over of charges, patients census- made accountable and transparent Ward transfer in & out managed effectively Monitor and manage the blood bag availability Drug expiry dates –monitored on a real time basis .

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Advantages of HMS For Pharmacists Transparency and accountability in managing drugs, equipment stocks. Drug stocks are updated upon each drug issue. The pharmacist can monitor the expiry dates and the batch number of each drug. Need not count the tokens & consolidate them for stock position. The Warranty/AMC of equipments can be easily tracked .

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1. Strong ownership and support from Top Health Administration Communication to hospitals – by State authorities 2. Supporting Government orders Mandating usage of Online system 3. End users trained to use system No data entry support 4. Procurement Policy TNMSC &ELCOT-as per norms 5. Implementation follow up by TNHSP Regular stake holders meeting to discuss various issues and resolve the issues 6. Utilizing State Investments in establishing the Infrastructure 7. World Bank’s periodical monitoring and review helps to attain the benchmark during implementation Levers of success

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Challenges in Implementation Mindset and Involvement of the hospital staff Change Management and Total system transformation Lack of co ordination among various vendors (no single vendor for IT infra) No senior IT consultant to co ordinate all IT activities. Only Medical Officers handle Connectivity and server stabilization still continues to be major challenges Man power shortage at the user-end.(HR of Directorate) Lack of basic computer knowledge - training on BCK, HMS & MIS Mapping existing process and rationalization of input forms for standardization Safe custody of hardware Frequent break down calls and 24X7 helpdesk role in downtime reduction

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Recognition Winner of the e- India jury award for “e- Health- best Government Initiative/policy for the year 2009” Selected paper for Oral presentation at e-Asia 2009 International conference at Colombo during Dec 2-4, 2009 Selected paper for Oral presentation at Med-e-Tel 2010 International conference at Luxembourg during April 14-16, 2010 International Publishing houses -VDM International Publishers, Mauritius and Lambert Academic of Publishing(LAP), Germany -have offered to publish HMIS implementation in the form of a book Finalist CSI –Nihilent e-governance awards 2011-12 National e-governance award-Gold 2011-12 under category ”exemplary reuse of ICT based solutions”

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Online usage statistics up to March 2012 Module No. Of Records Registration 24146259 Lab 7826647 Pharmacy 10816475 Clinical 13505675

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HMS Consolidated report for March 2012

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Back-up at State Data Centre In case of disaster we have:- 1.Tape back-up 2.NAS-Network array storage (cluster hard disc) (Two NAS available –on site & off site) 3.Disaster Recovery site for TNSDC -proposed ------------------------------------------------------------------------------------------------- STQC -Standardization Testing and Quality Certification ensures all mandatory requirements for TNSDC HIPS - Host intrusion prevention system is provided for the application

Current Reporting system DPH/DM&RHS/NRHM/DME:

Current Reporting system DPH/DM&RHS/NRHM/DME

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S.No Directorates Project/Mission Web Based Application Institution Periodicity Contents 1 NRHM www.nrhm-mis.nic.in www.tamilnadu.nhsrc-hmis.org (bridging between state to central-encrypted data transmission) District Monitoring unit Monthly, quarterly and Annually Monthly NRHM report (GOI) XML file from tnhmis.org 2 NRHM-TN DPH www.tnhmis.org PHC Monthly ISMR, Form 9 and other reports 3 DPH www.picme.tn.nic.in, www.mrmbs.tn.nic.in PHC Daily, Weekly MCH - MCR & CCR DETAILS, Maternal Benefit details 4 DM&RHS,DPH, www.tnhmis.org Secondary care hospitals & PHCs Daily & Monthly OP, IP,Clinical data ISMR, 5 NRHM www.nrhm-mcts.nic.in State NIC Weekly (transferring data from picme state portal to central portal) Service delivery of pregnant women and children 6 DME Proposed Phase III www.tnhmis.org Medical College institutions Daily & monthly OP, IP,Clinical data ISMR,

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www.tnhmis.org

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www.tnhmis.org

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www.tamilnadu.nhsrc-hmis.org

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www.nrhm-mis.nic.in

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Mother and Child tracking system (picme)

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Started on 1st April 2008,sw developed by NIC To find the missing pregnancy outcome being reported by the VHN To reduce MMR and IMR Pregnant mother details from the date of AN Registration is captured in PICME till the 1 st birthday of the Infant by the VHN Till date, the system has captured details of more than 35 lakhs mothersc The pregnant mothers and infants are given a unique ID called “PICME Number” Using this number, the details of the pregnant mother and infant can be viewed anywhere. Generate work plan for pregnant women and infants EMRI -108 Ambulance service has list of EDD mothers from the system Pregnancy and Infant Cohort Monitoring and Evaluation (PICME)

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www.picme.tn.nic.in

Dr.Muthulakshmi Reddy Maternity Benefit Scheme:

Dr.Muthulakshmi Reddy Maternity Benefit Scheme Rs. 12,000/- is given in 3 installment as Maternity Benefit to Pregnant mothers delivering in Government Institutions on conditional basis This scheme is monitored online with certain conditions such as first two live births with BPL For 1 st Installment Minimum 3 AN visits in Govt. institution, Early AN registration, Compulsory recording of BP ,Weight, Blood grouping & typing ,Blood sugar, HIV testing and TT immunisation Minimum one ultrasound scan 2 nd Installment Delivery at any Govt. institutions 3 rd Installment Should have received 2 nd installment Completion of 3 rd dose of immunization within 6½months Duplicate Application given to mothers with the details of residence , Passport size Photo, Bank account details Mothers has to fill up and submit it to PHC, to be entered online with PICME number. Money will be transferred from BMO account to beneficiary through e.transfer

Dr. Muthulakshmi Reddy Maternity Benefit Scheme Online Software:

Dr. Muthulakshmi Reddy Maternity Benefit Scheme Online Software Disabled as these are not the functions of this user Shows who logged in from where

Fund Flow:

Fund Flow State Level Budget Allocation – Directorate District Level Budget Allocation - DDHS At Block Level - Block Medical officer claims from treasury & deposited in BMOs account. Municipalities/Corporation - Commissioner account To all Beneficiaries thro’ Bank –Transfer of Funds More than Rs 320 Crores disbursed online

Flow of Operation:

Flow of Operation Entry of Application into the system Reviewing eligible and ineligible list Verification by SHN Logout SHN Login Reviewing applications verified by SHN Take decision whether to forward or not Forwarding the applications Logout PHC MO

Flow of Operation:

Flow of Operation Viewing the applications forwarded Ascertain all PHCs have forwarded applications Advise BMO to generate Proceedings Logout CHN Login Generate proceedings installment wise Submit the bill to Treasury , receive cheque Generate ECS list and submit to bank for fund transfer Logout BMO Login

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State Health Data Resource Center (SHDRC) Central repository of data for all tertiary, secondary and primary health care facilities in the state (currently 17 verticals reporting health data) To utilise the data and convert them into information and knowledge to improve the health outcomes in the state through performance, policy evaluation and enhancement

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Secondary Care Hospital

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Out-Patient Registration

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Clinical Out-Patient Department

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Before After Before Out Patient Slip Before After

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Pharmacy

Pharmacy Slip:

Pharmacy Pharmacy Slip Before After

Laboratory Entries:

Laboratory Entries

LAB Slip:

LAB Slip Before After

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