Health Management Information System(HMIS)

IT initiatives ofGovernment of Tamilnadu

Department of Health &Family Welfare

Pankaj Kumar Bansal, IAS,Additional Secretary & PD,

TN Health System Project,

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

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

TertiaryCare

3Population 7.21 Crores

No. of Districts-32No. of HUDs-42

32 Districts& 42 Health unit districts

NRHM

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

Population7.21 Crores

(Census 2011)

Area 130,058 sq.kms.

Vital Statistics

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

Project Strategy

1. ICT Initiatives

2. Policy Initiatives

3. Process Initiatives

4. Paradigm Shift

• 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

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 IdentificationUnique 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

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

o Periodic reviews &o Follow up action taken

• Help desk set upo Protocol establishedo Central helpdesk for facilitation and co-ordinationo Equipment break down also monitored by HD

• IT coordinators placed in each districto All infrastructure issues related activitieso Application support and training o Form e-core team in individual hospitals and solve IT issueso Three Server Administrators for Server Management

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

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

Implementation overview

Pilot -5 hospitals

Dec 2008

Phase I – HMS in 36 hospitals

across 5 districts

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

INR2.8

crores

INR5

Crores

INR 87 crores

Phase III- 47 Institutions under Directorate of Medical Education

including 17 Medical Colleges +

Tamil Nadu Dr.MGR Medical University

INR23

Crores

August2010

July

20

11

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

HMIS

Two componentsI. Hospital Management System- HMSII. Management Information System-MIS

HMS MISClinical Information

Automatic Incorporation of

data at the Institutional level

HMSHospital 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 classificationThese module are regarded as patient management information system

MISManagement 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.

MISISMR-(Institutional service monitoring report)

Patient Registration

Consultation with Doctor

Order Investigations

Generate Prescriptions Diagnosis

Lab

PIN

Common Disease listComprehensive List of

tests

OUT PATIENT DEPARTMENT WORKFLOW

Patient History;

Lab results Online

No Data Entry

Operators

Current Status

Hospital Management System (HMS)

o 210 hospitals out of 267 secondary care hospitals on line

Health Management Information System (MIS)

o 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)

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

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)

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.

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.

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 norms5. Implementation follow up by TNHSP Regular stake holders meeting to discuss various issues and resolve the issues6. 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

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 hardwareFrequent break down calls and 24X7 helpdesk role in downtime reduction

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”

Online usage statisticsup to March 2012

Module No. Of Records

Registration 24146259

Lab 7826647

Pharmacy 10816475

Clinical 13505675

HMS Consolidated report for March 2012

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 TNSDCHIPS- Host intrusion prevention system is provided for the application

Current Reporting system

DPH/DM&RHS/NRHM/DME

S.No DirectoratesProject/Mission

Web Based Application

Institution Periodicity Contents

1 NRHM www.nrhm-mis.nic.inwww.tamilnadu.nhsr

c-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 DMEProposed Phase III

www.tnhmis.org Medical College institutions

Daily & monthly

OP, IP,Clinical data ISMR,

www.tnhmis.org

www.tnhmis.org

www.tamilnadu.nhsrc-hmis.org

www.nrhm-mis.nic.in

Mother and Child tracking system(picme)

•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 1st 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)

www.picme.tn.nic.inwww.picme.tn.nic.in

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 1st 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

2nd Installment

– Delivery at any Govt. institutions

3rd Installment

– Should have received 2nd installment– Completion of 3rd dose of immunization within 6½months

1. Duplicate Application given to mothers with the details of residence , Passport size Photo, Bank account details

2. Mothers has to fill up and submit it to PHC, to be entered online with PICME number.

3. Money will be transferred from BMO account to beneficiary through e.transfer

Disabled as these are not the functions of this user

Shows who logged in from where

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

Entry of Application into the system Reviewing

eligible and ineligible list

Verification by SHN Logout

SHN Login

Reviewing applications verified

by SHNTake decision

whether to forward or not

Forwarding the applications Logout

PHC MO

Viewing the applications forwarded Ascertain all PHCs

have forwarded applications

Advise BMO to generate

ProceedingsLogout

CHN Login

Generate proceedings

installment wiseSubmit the bill to

Treasury , receive cheque

Generate ECS list and submit to bank for fund

transfer

Logout

BMO Login

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

Secondary Care Hospital

Out-Patient Registration

Clinical Out-Patient Department

Before After

Before Out Patient Slip

Before After

Pharmacy

Pharmacy Pharmacy Slip

Before After

Laboratory Entries

LAB Slip

Before After