Chapter five

Routine Health
Information System
 Outline
Introduction

Information cycle

Data quality

HMIS

HMIS in Ethiopia

3/12/2020 2
 Learning Objectives
At the end of this session students will be able to:
 Define routine health information system
 Identify the sources of routine health information
 Describe the information process/cycle
 Describe the dimensions of data quality
 Identify the stages where data quality may be affected
 Define HMIS
 List the determinants of HMIS

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 Routine Health Information System
Defn: RHIS is an information that is derived at regular intervals
through mechanisms designed to meet predictable information needs.

 It includes information collected from the public, private, and

community-level health facilities and institutions.

 The data give a picture of health status, health services, and health
resources.

 Most of the data are gathered by healthcare providers as they go

about their work, by supervisors, and through routine health
facility surveys.
3/12/2020 4
 Sources for routine health
Information
 Routine data is generally obtained from variety of
sources including:
 Service delivery records/registers maintained by HPs, HCs,
clinics, hospitals and other organizations providing services

 Supportive supervision reports

 Service delivery observations from periodic site visits

 Supplies inventory records

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 RHIS activities at different levels
 HP
– Generate the data
– Submits the reports to HC
– Uses for managing activities of the unit
 Health center
– Aggregate, archive reports
– Analyze and review,
– Decide ,plan ,implement or give feedback
– Gives gap based support to HPs and service units
– Submits reports to WorHO
3/12/2020 6
 Cont’d….
 Woreda Health Office
– Aggregate, archive reports
– Analyze and review
– Decide, plan, implement or give feedback
– Provide HR, equipment funds
 Regional Health Bureau
– Aggregate, archive reports
– Analyze and review,
– Decide, plan, implement or give feedback
– Provide HR, equipment funds
3/12/2020 7
 Cont’d….
 Federal Ministry of Health
– Make policy decisions
– Aggregate, archive reports
– Analyze and review
– Decide, plan, implement or give feedback
– Provide HR. equipment, materials, funds
 Implement Partners/Development Partners
– Build capacity on HMIS tasks
– Provide funds, equipments, HR, materials
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 Information processing cycle
 Are steps undergone to convert raw fact (data) into
information.
 These are:
 Data collection

 Data processing

 Data presentation

 Information utilization

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 Data collection
Two types of routine data collection methods
Health unit data collection – captured at health facilities.
Community data collection
To monitor activities performed in the community by
health unit staff or by community health workers
To obtain more representative data on the health status
and living environment of the communities served,
including data on births and deaths in the community
etc.

3/12/2020 10
 Cont.
Data collection instruments for patient/client
management

Curative Preventive
 Medical records  Growth cards

 Laboratory forms  MCH cards

 Referral forms  Family registration records

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 Cont.
 Service delivery records
– Registers
– Tally sheets
 Resource management records

Data collection instruments for system management

 Health unit report forms
 Supervisory checklists

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 Data processing
o Mainly involves extraction and integration of data.
o extracting data from data sources
o ensuring data consistency and quality
o achieving conformity through data transformation so that data
from separate sources can be used together. Data
transformation may include aggregation, calculation, cleaning,
translating code values, or transposing values
o Data can then be delivered to an integrated data repository in
formats that allow various query methods to generate tangible
outputs that health information system actors can use to inform
their decisions

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 Cont.
 The whole process of data extraction and transformation adds
significant value to the source data by:
Removing mistakes and correcting for missing data
 Providing documented measures of degree of
confidence in data
Adjusting data from multiple sources to allow them to
be used together
 Structuring data to be usable by end-user tools
 Tracking all the above actions to tangibly support
data-quality assessments
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 Data presentation
Useful information is not immediately evident from the
mass of unsorted data
Collected data need to be organized in such a way as to
condense the information they contain in a way that will
show patterns of variation clearly
o Precise methods of analysis can be decided up on only
when the characteristics of the data are understood
o For the primary objective of this different techniques of
data organization and presentation like order array, tables
and diagrams are used
15
 Information utilization
Using information for decision making at all levels of
health information systems for:

o Planning

o Resource allocation

o Identifying priorities

o Availing for stakeholders

o Performance monitoring
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 Data quality
 The degree to which the data or statistics measure what
was intended to be measured when the data collection
system was being designed.
 High-quality data is meaningful, accurate and consistent;
it can be used for its intended purpose.
 Poor-quality clinical data in e-health systems affects
patient safety and quality of care.
 Ensuring data quality is a major challenge—particularly
in complex, multisystem environments in which
subsystems do not share common technical, data,
communication or terminology standards.
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 Dimensions of Data quality
The four Major
dimensions Accuracy

Timelines Data Consiste

s quality ncy

Complet
eness
3/12/2020 18
 Dimensions of Data quality
• Other dimensions
– Legibility
– Accessibility
– Confidentiality
– Precision
– Integrity
– Relevance

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 Cont.
 Accuracy or validity: Is reflecting the event as it actually
happened
 Reliability or Consistency: Is yielding the same results on
repeated collection, processing, storing and display of information.
 Completeness: All necessary data elements on registers or cards
should be filled after provision of the service.
 Timeliness: Information, especially clinical information, should be
documented as an event occurs, treatment is performed or results
noted.
 Delaying documentation could cause information to be omitted
and errors recorded.
 Data delayed is data denied!!!
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 Cont.
 Legibility: All data whether written, transcribed and/or printed
should be readable.
 Accessibility: All necessary data should be available when needed
for patient care and for all other official purposes.
 The value of accurately recorded data is lost if it is not accessible.

 Confidentiality: Avoid inappropriate disclosure of personal data and

that data in hard copy and electronic form are treated with
appropriate levels of security (kept in locked cabinets and in
password-protected files).
 Precision: Data should have sufficient detail. E.g. sex, age…
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 Cont.
 Integrity: Data have integrity when the systems used to generate
them are protected from deliberate bias or manipulation for
political or personal reasons.

 Relevance: The data are logically connected with the matter in

hand. The data should be really significant or useful.

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Stages where quality of data may be affected

23
 How to improve and ensure data quality???

 Keep the design of the information system as simple as

possible

 Involve users in the design of the system

 Standardize procedures and definitions

 Careful and standardized design of data collection

instruments

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 Cont.
 Develop an appropriate incentive structure

 Plan for effective checking procedures such as LQAS,

RDQA……

 Training

 Assess the quality of the data being collected using the

existing forms at different levels.

 Etc…..
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 Chapter six

Health management information system

(HMIS)

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 HMIS
 HMIS: is the routine collection, aggregation, analysis, presentation
and utilization of health and health related data for evidence based
decisions for health workers, managers, policy makers and others.

 Information systems transform raw data into useful information

through input, processing and output.

 An information system specially designed to assist in the

management and planning of health programs.

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 Why information management system
in health?
 To manage a set of activities. In healthcare, there are many
activities that need to be managed and countless decisions to be
made.
 To manage the process to achieve the final outcome.
 Health care delivery need a collection of components working
together to achieve a common purpose.
 To ensure quality of all health data
 Strengthening the ability to analyze and use health care data and
 Making informed and cohesive decisions affects the healthcare
positively.

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 Components of HMIS
I. Information management
• Data collection: Recording of health data using individual and
family folder, registers, tally and reporting formats
• Data processing: is a process of cleaning, entering and
aggregation of data.
• Data analysis and presentation: is a process of interpretation
and comparison of generated information in the form of
sentence, tables and graphs.

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 Cont.
II. Using information for management purposes
 Problem identification: identifying problems using key
indicators
 Prioritizing problems and decision making: Problems
identified should be prioritized and decide what types of
actions need to be taken.
 Action taking: Implementing the agreed action.
 Result monitoring: Assessing whether the desired result
has been achieved or not.
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 HMIS determinants
1. Data Management
– Workflow and process analysis
– Level of staff effort on HMIS
– Number of forms filled
– Amount of time spent
– Data quality
– Information use for decision making
2. HR for HMIS
– Number and mix (interdisciplinary)
– Skill and capacity
3. Physical infrastructure (electricity, ICT)
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 HMIS strategies

 Capacity building

 Standardized & integrated data collection and reporting

 Linkage between information source and Information

use

 Appropriate technology/ICT

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3/12/2020 33
 HMIS in Ethiopia
Ethiopia is currently implementing Health Sector
Transformation Plan (HSTP).
One of the four transformation agendas of the HSTP is
information revolution.
HMIS represents a combination of health services based
data source. The primary aim of HMIS is to support
informed strategic decision-making by providing
quality data that help managers and health workers plan
and manage the health service system.

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 Cont.
HMIS goals
 To support decentralized, action-oriented and evidence-based
decision making, resulting in:
 Use of evidence-based M&E by managers and health workers at
all levels of the health system to plan, monitor, and improve
performance,
 An HMIS that regularly provides timely, reliable, and relevant
information based on routine service delivery and administrative
records.
 To provide health information to international, national, and
decentralized authorities; elected officials; and other public and
private sector organizations.
3/12/2020 35
 Cont.
An on-going reform based on four principles

Integration of data collection and reporting (single

channel)
Standardization of indicators, data collection
instruments and analysis procedures
Simplification to decrease data burden and focus
on use of information
Institutionalization

3/12/2020 36
 Cont.
o Data delivered through the HMIS come from service delivery and
administrative records kept as part of routine transactions at health
facilities and management offices. In a well-performing HMIS, data
should come from every Health Institution (HI) in the country.

o HMIS/M&E weaknesses manifest in several ways:

• Incomplete institutionalization
• Unstandardized data collection
• Un-integrated reporting and data transmission
• Weak information use (analysis and interpretation).
• Limited resources for HMIS/M&E
3/12/2020 37
 Cont.
Problems in HMIS
 Data collection;
– Too much data items;
– Irrelevant
 Reporting;
– Poor quality data
– Incomplete: both in content and representation
– Untimely
– Redundancy, parallel administrative burden
 Data analysis;
– Not done at the point of collection
 Poorly institutionalized

3/12/2020 38
 Cont.
• HMIS has pivotal role for Health Sector’s M&E system
• FMOH adopted ―One plan, One report and One Budget‖
policy
– HMIS providing the core indicators

3/12/2020 39
 Previous reporting lines – Multiple channel

3/12/2020 40
HMIS/M&E Reporting Flow Diagram
Comprehensive
Specialized Hospital
Specialty Center
General Hospital
Primary Hospital
Specialty Clinic
International Bodies
FMOH WHO, UN, etc
Council of Ministers
Other Ministries
RHB
Development Partners
Regional Council
ZHD
Zonal Administrative
Office

Medium clinic
Sub-city/ woreda/ town health Woreda Council
Primary clinic offices
Kebele Council
Health center

Health Post

12-Mar-20 41
 Ultimate goal of HMIS
Better Health

Better decision; Improve Service Delivery

Better information
(HMIS)
Human Resources
Finance

Drugs and Supplies Physical Assets

Service Delivery and

12-Mar-20 Disease 42
 chapter seven
Clinical Information
System

3/12/2020 43
 Outline
 Introduction
 EMR
 Patient monitoring systems

3/12/2020 44
 Learning objectives
At the end of this lesson students will be able to:
 Define what clinical information system is

 Explain the importance of clinical information system

 Define what electronic medical record is?

 Identify the advantage and disadvantage of EMR over

paper based patient record

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 Clinical Information System
 CIS is a computer based system that is designed for
collecting, storing, manipulating and making available
clinical information important to the healthcare delivery.

 Provide a clinical data repository that stores clinical data

such as the patient’s history of illness and the interactions
with care providers.
 Successful clinical consultation systems must be
integrated into daily routines of physicians and other
users.
3/12/2020 46
 Information Flow in Clinical Care

3/12/2020 47
 Health care information system users

Health care professionals

Administrators
Clerical personnel
Patients/clients
Operational personnel
Some of the areas addressed by Clinical Information
Systems are:
 Electronic Medical Record (EMR)
 Patient Monitoring Systems
 Clinical Decision Support Systems (CDSS)
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 Electronic Medical record (EMR)

EMR is a computer based system which contains

information about patients, from their personal details,
such as their name, age, sex and address to details of
every aspect of care given by the health facility (from
routine visits to major operations).

The EMR can be accessed conveniently by appropriate

health professionals to ensure optimal patient care.

3/12/2020 49
 Cont.
o By now most large health care institutions have a computer
database of patients which matches :
 Patient’s Hospital MRN
 Name
 Date of Birth
 Address

o This provides a rapid search to match a patient name with a MRN

when retrieving a record from storage.

3/12/2020 50
 Benefits
o Provides secure, reliable and real-time access to patient
health information where and when it is needed to support
care.
o Capture and manage episodic and longitudinal electronic
health record information.
o Function as clinicians’ primary information resource
during the provision of patient care.
o Assist with planning and delivering evidence-based care
to individuals and groups of patients.

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 Cont.
o Support continuous quality improvement, utilization
review, risk management and performance management.

o Provide longitudinal, appropriately masked information to

support clinical research, public health reporting and
population health initiatives.

o Reduction in time used documenting clinical encounters

(enabling more patient visits)
3/12/2020 52
 Cont.
o Eliminating paper charts and their associated costs

o Reduction in time and effort to locate and assemble paper chart

information.

o Lower malpractice & risk of misuse

o Elimination of duplicate data entry

o Ability to attract caregivers through state-of-the-art systems and

access to patient information

o Increased patient satisfaction through improved patient care

3/12/2020 53
 Cont.
o Ensure all health care data is comprehensive, timely, accurate, and
readily available at all times for patient care.

o Improve communication b/n health care providers both data entry

and retrieval levels.

o Enable individual to access their personal health information

o Provide timely and accurate information for the collection of

morbidity and mortality statistics for clinical research, teaching and
public health reporting

3/12/2020 54
 Barriers to Success of EMR
o Lack of existing HIS or Infrastructure that can be
leveraged

o Staff members with no or limited computer skill

o Resistant to its Adoption by Health professionals

especially doctors.

3/12/2020 55
 Patient Monitoring Systems
What is patient monitoring???

Repeated or continuous observations or measurements of

the patient, his/her physiological function, and the function
of life support equipment, for the purpose of guiding
management decisions, including when to make therapeutic
interventions, and assessment of those interventions
[Hudson, 1985].

3/12/2020 56
 Patient monitoring in ICUs
There are at least four categories of patients who need
physiologic monitoring:
1. Patients with unstable physiologic regulatory systems;
• For example: a patient whose respiratory system is suppressed
by a drug overdose or anesthesia.
2. Patients with a suspected life-threatening condition;
• For example: a patient who has findings indicating an acute
myocardial infarction (heart attack).

3/12/2020 57
 Cont.
3. Patients at high risk of developing a life-threatening
condition;
• For example, patients immediately post open-heart
surgery, or a premature infant whose heart and lungs
are not fully developed.

4. Patients in a critical physiological state;

• For example, patients with multiple trauma or septic
shock.

3/12/2020 58
 Cont.
• Care of the critically ill patient requires prompt and
accurate decisions so that life-protecting and lifesaving
therapy can be appropriately applied. Because of these
requirements, ICUs have become widely established in
hospitals. Such units use computers almost universally for
the following purposes:
o To acquire physiological data frequently or continuously,
such as blood pressure readings
o To communicate information from data-producing
systems to remote locations (for example, laboratory and
radiology departments)
3/12/2020 59
 Cont.
o To store, organize, and report data
o To integrate and correlate data from multiple sources.
o To provide clinical alerts and advisories based on multiple
sources of data.
o To function as a decision-making tool that health
professionals may use in planning then care of critically
ill patients.
o To measure the severity of illness for patient
classification purposes.

3/12/2020 60
 Clinical Decision Support Systems
(CDSS)
o A clinical decision-support system is any computer
program designed to help health professionals make
clinical decisions.

o In a sense, any computer system that deals with clinical

data or medical knowledge is intended to provide decision
support.

3/12/2020 61
 Cont.
• Provides health professionals or other individuals with
knowledge and person-specific information, intelligently
filtered or presented at appropriate times, to enhance health
and health care.
• It encompasses a variety of tools to enhance decision-making
in the clinical workflow.
• These tools include computerized alerts and reminders to care
providers and patients; clinical guidelines; condition-specific
order sets; focused patient data reports and summaries;
documentation templates; diagnostic support, and contextually
relevant reference information, among other tools.
3/12/2020 62
 Tools for Information Management

o Examples:
o Hospital information systems
o Bibliographic retrieval systems (PubMed)
o Specialized knowledge-management workstations
(e.g. electronic textbooks, …)
o These tools provide the data and knowledge needed, but
they do not help to apply that information to a particular
decision task (particular patient)

3/12/2020 63
 Tools for Focusing Attention

o Examples:
o Clinical laboratory systems that flag abnormal values
or that provide lists of possible explanations for those
abnormalities.
o Pharmacy systems that alert providers to possible drug
interactions or incorrect drug dosages.
o Are designed to remind the physician of diagnoses or
problems that might be overlooked.

3/12/2020 64
 Tools for Patient-Specific Consultation

o Provide customized assessments or advice based on sets

of patient-specific data:

o Suggest differential diagnoses

o Advice about additional tests and examinations

o Treatment advice (therapy, surgery, …)

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 Alternative (more specific)
definition of CDSS
o Clinical decision support systems are active knowledge
systems which use two or more items of patient data to
generate case-specific advice.

o Main components:

o Medical knowledge

o Patient data

o Case-specific advice
3/12/2020 66
 Characteristics of CDSS
o System function

o Determining what is true about a patient (e.g. correct diagnosis)

o Determining what to do (what test to order, to treat or not, what

therapy plan…..)

o Mode of giving an advice:

o Passive role (physician uses the system when advice is needed)

o Active role (the system gives advice automatically under certain

conditions)
3/12/2020 67
 Cont.
o Passive Systems
o The user has total control
o Requires advice
o Analyses the advice
o Accepts/Rejects the advice
o Active systems
o The user has partial control
o System gives advice
o User evaluates the advice
o The user accepts/rejects the advice
3/12/2020 68
 Why CDSS ???
o Physicians are overwhelmed
 Insufficient time available for diagnosis and treatment.
 Insufficient time available to stay abreast (side by side) of
latest development
 Limited resources - increased demand
o Error rates are too high
 44,000 to 98,000 deaths in the U.S due to medical error /year.
 2.4 million prescription errors/year in Massachusetts alone.
 $17 Billion spent on preventable errors per year.
o Need for systems that can improve health care
processes and their outcomes.
3/12/2020 69
 Chapter eight
Computer
and
Information
Ethics
3/12/2020 70
 Outline
Health Vs Non-Health Information

Major security concerns

Kinds of health information

Privacy, confidentiality

Security

Cryptography

Computer viruses
3/12/2020 71
 Learning Objectives
At the end of this lesson students will be able to:

Define what health and non health information mean

List the major security concerns

Understand the types of health information

Understand what privacy, confidentiality and security are

Describe the types of malicious codes

3/12/2020 72
 Health Vs Non-Health Information

• Health information:

Is information in any form or medium (paper, electronic,

images) that relates to a living or deceased individual’s
past, present or future physical, mental health or
condition, provision or payment of health care.

3/12/2020 73
 Cont.
 Rarely do people think the information held by the
health facility as being an asset
 The value of information is equivalent to the amount of
money it would cost to recreate the health information
system in the event of the computer file being
completely destroyed/corrupted
 Health facilities have become more highly dependent
upon their information processing and communication
systems

3/12/2020 74
 Non Health Information

 Is information in any form or medium that does not relate

to living or deceased individual's physical, mental or
health condition, or health care provision or payment

3/12/2020 75
 Major Security Concerns
 The extent to which the ability of the health institution to
provide a service is affected by:
Loss/degradation of a given
information/communication system or
Loss of a given dataset
Availability of Data and Services
Accidental/ malicious corruption of a given set of data
Authentication and integrity of data
Disclosure of a given set of data to un authorized
person
Confidentiality of data
76
 Kinds of Health information
1. Individually Identifiable

 They directly identify the individual or reasonably

could be used to identify an individual

2. De- Identified

 Those without individual identifiers

3/12/2020 77
 Cont.
Identifiers
1. Names
2. All geographic information
3.All elements of date including admission, discharge dates
4. Telephone numbers/Fax number
5. Electronic mail address
6. MRN
7. Biometric identifiers
8. Photographs
9. License number
10. Any unique identifying number/Characteristic/code 78
 Privacy and Confidentiality

• Privacy

Is the right of a person not to share information about

himself/herself

• Confidentiality

Is the obligation to keep private information that has

been collected from being shared with others

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 Security
• Is the measures that are taken to ensure privacy,
confidentiality

• The distinction of privacy and security can be expressed

as follows:

 Security is the protection of computers from people

 Privacy is the protection of people from computers

• Maintenance of privacy and security are two of the goals

of health informatics
3/12/2020 80
 Cont.
• One can not reduce the risk of these security concerns
to zero

• Since health information system is so important to the

health process, one must find a balance between the
risk and medical effectiveness

3/12/2020 81
 Security Cont…
Physical Security
 Is part of security concerned with physical measures
designed:
To safeguard personnel
To prevent unauthorized access to equipment, material
and documents and safeguard them against malicious
damage, theft or interference

3/12/2020 82
 Cont.
• The physical Vulnerability to security can be

- Disaster (Both natural and artificial)

- Human vandal

- Interception by an outsider

- Unauthorized access and use

3/12/2020 83
 Cont.
- Back up, UPS can help as a security measures for disasters
and power interruptions

- Unauthorized users can cause:

-Theft of machinery or data

-Destruction of machinery or data

- Viewing sensitive data

3/12/2020 84
 Cont.
• Access control
Guard against the physical presence of people who are
not users
Lock
Various authentication devices to control access
Users can be identified by:
What they know: Password
What objects they posses: Smart card

3/12/2020 85
 Cont.
- What characteristics they have: biometric devices such as
Voice pattern recognition, blood vessels of retina, finger
print)

- The best authentication procedure will combine all the

three.

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 Cryptography
• When information is transmitted along a communication
line, there is a need to protect it

• Cryptology is a science of disguised or secret

communications

• The most common method used to protect information

when it is transmitted, is Encryption

3/12/2020 87
 Cont.
• Encryption is the process of encoding a message so that
the meaning of the message is not obvious.
• Decryption is the reverse process
• The two basic methods used in encryption are:

- Transposition by which the letters of the plain text are

jumbled

- Substitution where the letters of the plain texts are

replaced by other letters, numbers or symbols
3/12/2020 88
 Cont.
• Encryption process

Encryption key Decryption key

Encryption Cipher text Decryption Plain text

Plain text
algorithm algorithm

3/12/2020 89
 Cont.
Computer Viruses
 Are special kind of threats for the health information
system
 Virus is a piece of code present on the system with out
consent of the owner
 Is capable of moving from one computer to another
 Has capability of multiplying
 Has capability of destroying /altering files
 Has capability to deny services to legitimate users.

3/12/2020 90
 Cont.
Why are viruses written???
 Viral code publish in books
 Virus construction software is available
 Fun
 Malicious intent
 Recognition
 Financial benefits

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 Types of Malicious code
A Virus
A Trojan
A Worm
 Virus is a propagating program that attaches to files and
programs and needs a program to propagate
Types of virus: Boot sector virus, program attaching virus,
data virus and source code virus

3/12/2020 92
 Cont.
Trojan Horse is apparently useful program that has
additional hidden functions.

 May have code which is destructive to the user

 Its effect is to copy confidential files, formatting disks,

overwrite files and cause the system to crash.

3/12/2020 93
 Cont.
Worms

 Is a propagating program that propagates through a

network

 It doesn’t require carrier program

 It multiplies it self and occupy space.

3/12/2020 94
 Cont.
Is there a cure for computer virus?
 It is impossible to guarantee that a section of code is not
virus
Steps to be taken to limit the risk
 Regular backups
 Archive all original software
 Always scan new software before using it
 Initiate security procedures to reduce the risk

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