HEALTH INFORMATION SYSYTEMS IN INDIA

AMRITA SCHOOL OF DENTISTRY

1. HEALTH INFORMATION SYSTEMS IN INDIA Seminar no:10

2. CONTENTS Introduction Organisation of healthcare administration Role of National Health Mission Role of National Health Authority Digital India Health Management Information Systems (HMIS) Ayushman Bharath Digital Mission (ABDM) Ayushman Bharat Health Account (ABHA) Conclusion References 2

3. INTRODUCTION Electronic Medical Records (EMR) or Electronic Health Records (EHR) is an effective application of Information and Communication Technology (ICT) that can be used to improve delivery and extend the reach of health services in India. Electronic Health Record (EHR) is defined by the International Organization for Standardization (ISO) as “ a repository of information regarding the health status of a subject of care, in computer processable form ”. EMR/EHR systems offer clear advantages over Traditional Paper Based System (TPBS) of medical records and can help provide continuity of care (CoC). 3

4. ELECTRONIC HEALTH RECORD (EHR) STANDARDS FOR INDIA- 2016 4

5. A Health Information System (HIS) is a process whereby health data (input) are recorded, stored, retrieved and processed for decision-making (output). HEALTH INFORMATION SYSTEMS 5 Data Sources Of Health Information Systems

6. ORGANIZATION OF HEALTH CARE ADMINISTRATION IN THE COUNTRY 6

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8. National Health Mission (NHM) is a flagship Programme of the Government of India to address the health needs of under-served rural areas and health concerns of the urban poor population. The mission is on establishing a fully functional, community owned, decentralized, rigorous monitoring & evaluation against standards, improving health delivery system by innovations, flexible financing and interventions with inter-sectoral convergence at all levels. Role of National Health Mission (NHM) 8

9. NHM has two sub missions under it. National Rural Health Mission (NRHM) launched on 5 April 2005 and the National Urban Health Mission (NUHM), launched in 2013. To monitor the performance and quality of the health services being provided under the NHM, the Ministry of Health & Family Welfare has been committed to strengthen the monitoring and evaluation systems, through Performance, Monitoring, Conducting adhoc surveys, supportive supervision, quality assurance, etc. 9

10. The emphasis of NHM is on establishing a fully functional, community owned, decentralized health delivery system. This e-booklet is an effort to consolidate and present an ecosystem of various IT initiatives under the scope of NHM. The e-Booklet is expected to be a useful repository consisting of key information of ICT interventions and act as a ready reference compendium for all the stakeholders. The information/data contained herein is made available and verified by respective programme divisions of Ministry of Health and Family Welfare. ePMU Consultant (Deloitte Touche Tohmatsu India LLP) has assisted MoHFW in compilation of data and preparation of this e-Booklet. Draft Booklet Version 1.0, December 2020 IT INITIATIVES OF NATIONAL HEALTH MISSION 10

11. IT Initiatives under NHM: 1. ANM-Online (ANMOL) 2. Comprehensive Primary Health Care - NCD application 3. Drug & Vaccine Distribution Management System 4. Electronic Vaccine Intelligence Network 5. e- RaktKosh 6. Health and Wellness Centre 7. Health Management Information System 8. Integrated Disease Surveillance Program 9. Kala-azar Management Information System 10. Mera Aspataal 11

12. 11. National Cold Chain Management Information System (NCCMIS) 12. National Identification Number to Health Facility of India 13. National Injury Surveillance Centre 14. National Programme for Control of Blindness & Visual Impairment 15. National Viral Hepatitis Control Program 16. Nikshay 17. Nikshay Aushadhi 18. Rashtriya Bal Swasthya Karyakram 19. Reproductive & Child Health 20. Strategic Information Management System 12

13. 21. Web Based Malaria Management Information System 22. NACO AIDS APP 23. m- D iabetes This e-booklet contains objectives, user details, training and data entry, technology and hosting , roll out status, mobile app and dashboard, mode of application development, key information (major data elements, major KPIs and major reports, major masters, data integration received, and data integration shared) and contact details of program division. 13

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15. 15 NHA is governed by a Governing Board chaired by the Union Minister for Health and Family Welfare. To implement the scheme at the State level, State Health Agencies (SHAs) in the form of a society/trust have been set up by respective States. SHAs have full operational autonomy over the implementation of the scheme in the State. It is the apex body responsible for implementing India’s flagship public health insurance/assurance scheme called “Ayushman Bharat Pradhan Mantri Jan Arogya Yojana” & has been entrusted with the role of designing strategy, building technological infrastructure and implementation of “Ayushman Bharat Digital Mission” to create a National Digital Health Eco-system. NHA has been set-up to implement PM-JAY National Health Authority is the successor of the National Health Agency, which was functioning as a registered society since 23rd May, 2018. National Health Agency was reconstituted as the National Health Authority on 2nd January 2019. ROLE OF NATIONAL HEALTH AUTHORITY (NHA)

16. DI is a flagship Programme of the Government of India with a vision to transform India into a digitally empowered society and knowledge economy. The Digital India Programme is centered on three key vision areas: Digital Infrastructure as a Core Utility to Every Citizen, Governance & Services on Demand and Digital Empowerment of Citizens Agencies enabling DI initiatives in health sector: Department of Empowerment of Persons With Disabilities (DEPWD) National Health Mission (NHM) National Institute of Health and Family Welfare DIGITAL INDIA  16

17. Digital AIIMS The first step in the Digital AIIMS project was taken in January 2015 with the creation of an effective linkage between AIIMS, Unique Identification Authority of India (UIDAI) and the Ministry of Electronics and Information Technology ( MeiTY ). e-Hospital The application is a Hospital Management Information System (HMIS) for internal workflows and processes of hospitals. This one-stop solution helps in connecting patients, hospitals and doctors on a single digital platform. The application is developed based on the global healthcare standards like HL7, SNOMED-CT, ICD10, and Meta Data and Data Standards (MDDS) published by the Ministry of Health & Family Welfare ( MoHFW ). e-Hospital is made available to Central Government/ State Government/ Autonomous/ Cooperative hospitals on cloud through SaaS (Software as a Service) model. 17

18. MCESSATION Ministry of Health & Family Welfare, in partnership with World Health Organisation and the International Telecommunications Union, has started an initiative for utilising mobile technology for tobacco cessation. WHO-ITU’s ‘Be Healthy Be Mobile’ initiative, aims to reach out to tobacco users of all categories who want to quit tobacco use and support them towards successful quitting through constant text messaging on mobile phones. NIKSHAY To monitor Revised National Tuberculosis Programme (RNTCP) effectively, a web enabled and case based monitoring application called NIKSHAY has been developed by National Informatics Centre (NIC). This is used by health functionaries at various levels across the country in association with Central TB Division (CTD), Ministry of Health & Family Welfare. NIKSHAY covers various aspects of controlling TB using technological innovations. Apart from web based technology, SMS services have been used effectively for communication with patients and monitoring the programme on day to day basis. 18

19. SMS-BASED MID-DAY MEAL MONITORING SCHEME Mid-Day Meal mobile app is meant for effective monitoring of daily and monthly mid-day meal data to be sent by the schools. The app provides additional data communicating mechanism for the MDM in-charge/teacher who has to send the daily/monthly data using SMS. The app, once installed on android device, does not need Internet to send MDM figures as user has option to send the figure through SMS from the app which simplifies the job of MDM in-charge. The higher authorities at Block, District and State level have a very simple and effective mechanism in shape of this app on their mobile devices for effective and efficient monitoring of daily as well as monthly data transmission by all the MDM in-charge falling under their jurisdiction. The authorities can send SMS alerts to all defaulters using single button available in the app 19

20. MOTHER & CHILD TRACKING SYSTEM (MCTS) Mother and Child Tracking System (MCTS) is an initiative of Ministry of Health & Family Welfare to leverage information technology for ensuring delivery of full spectrum of healthcare and immunization services to pregnant women and children up to 5 years of age. It facilitates and monitors service delivery and also establishes a two way communication between the service providers and beneficiaries. 20

21. HMIS portal is a gateway to wealth of information regarding the health indicators of India. The information available on this portal is derived data from data uploaded by the States/ UTs. HMIS data specifically designed to support planning, management, and decision making based on Grading of facilities, various indicators at Block, District at State as well as National Level. HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS) 21

22. Health Management Information System (HMIS) is a Government to Government (G2G) web-based Monitoring Information System that has been put in place by Ministry of Health & Family Welfare ( MoHFW ), Government of India to monitor the National Health Mission and other Health programmes and provide key inputs for policy formulation and appropriate programme interventions. HMIS has been utilized in Grading of Health Facilities, identifications of aspirational districts, review of State Programme Implementation Plan (PIPs), etc. The analytical reports generated through HMIS also provides gap analysis and evidence-based course correction. HMIS was launched in October 2008. Currently, around 2 lakh health facilities (across all States/UTs) are uploading facility wise service delivery data on monthly basis, training data on quarterly basis and infrastructure related data on annual basis on HMIS web portal. 22

23. HMIS captures facility-wise information as follows: Service Delivery (Reproductive, Maternal and Child Health related, Immunization, family planning, Vector borne disease, Tuberculosis, Morbidity and Mortality, OPD, IPD Services, Surgeries etc. data) on monthly basis. Training Data (Trainings imparted to Medicals and Paramedics staff at District and State level data) on quarterly basis. Infrastructure (Manpower, Equipment, Cleanliness, Building, Availability of Medical Services such as Surgery etc., Super Specialties services such as Cardiology etc., Diagnostics, Para Medical and Clinical Services etc. data) on annual basis. The HMIS Portal facilitates the flow of physical performance from the Facility level to the Sub-district, District, State and National level using a web-based Health Management Information System (HMIS) interface. The portal provides periodic reports on the status of the health services performances and Human Resources and Infrastructure services facilities available. 23

24. The necessity of sound information system as a support to the various developmental activities of the Health sector in India was identified as early as Bhore committee report soon after the independence. The national health policy of India (1983)in inter states with appropriate decision making and program planning in the health and related fields is not possible with out establishing an effective health information system and that nationwide organizational set up should be established to procure essential health information which may provide support for the local management of the health care and effective decentralization of the activities. The National Health Information Systems provide the inputs in the formulation of regional and global health policies. EVOLUTION OF HMIS 24

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27. ORGANIZATIONAL ARRANGEMENTS FOR THE HMIS IN INDIA The organizational arrangement of HMIS and the agencies responsible for it is discussed in the three levels namely central, state and district. A. Central level At the central level there are three major agencies dealing with the HMIS. Central Bureau of Health Intelligence (CBHI) 2. Statistics division in the department of health and family welfare 3. The Sample Registration System (SRS) 27

28. B. State level organization – an example from Andhra Pradesh C. Organization at the district level Organisation of Health Management Information in Andhra Pradesh 28

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30. CONTENT AND FLOW OF HMIS 30

31. MONITORING OF INFORMATION AND EVALUATION SYSTEM (MIES) The Statistics Division in the Ministry of Health & Family Welfare is responsible for monitoring and evaluation of the Health care services provided by the health facilities in the country. The information flows from the primary levels and is consolidated at Sub-district, district and the State level before the information is sent to the center for the national level consolidation. The system for capturing information on health care programmes has evolved over the years based on the changing needs of the government where daily reporting of facilities is required. 31

32. ACHIEVEMENTS OF HMIS HMIS is an effective tool for monitoring the system monthly by web-based dynamic data to the Ministry and States. Over a period of time, HMIS data is being widely utilized by National and State Governments for monitoring of facilities, policy planning and decision making. Some of the major achievements of HMIS are ; HMIS data has been playing a pivotal role in reviewing the performance of States/UTs during annual Programme Implementation Plans (PIPs), Programme Divisions have been utilizing HMIS data for fixing targets for key programs under National Health Mission (NHM), HMIS has provided a very robust and effective platform for regular monitoring of health facilities and officials as well, HMIS has become a sole source of information related to individual health facilities for all purposes. No other MIS platform in India provides such exhaustive information regarding Government Health facilities. 32

33. CHALLENGES FOR EXISTING HMIS In spite of nearly 94% coverage of government health facilities and huge efforts put in by National and State Governments particularly in terms of manpower, data of HMIS is neither close to the National survey figures nor to the estimated values. Though it is one of the largest MIS across the globe, still quality and usability of data remain its areas of concerns. Since existing data does not have desirable quality, its utilization in designing policies and making decision at district or local level planning is nominal. Major challenges for National HMIS of India are ; At present, paper-based recording system exist across India which contributes to duplication, compilation and data entry errors. India is a vast country with 217780 health workers/ANMs. Lack of time to time training of health workers including data entry operators and MIS officials result in poor data quality. 33

34. 34 Government hospitals in major cities have incorporated IT software in their payment and billing system, however, integration of IT in clinical system is still far away. Poor integration of diverse software systems within hospital impedes inter-hospital information exchanges and creates problem in consolidation of data. HMIS is a centrally funded program and State or local governments have lesser stake for development of IT infrastructure required. Poor coverage and reporting of private sector hospitals is also one of the major impediments for success of HMIS.

35. PROBLEMS OR CONSTRAINTS OF HMIS IN INDIA 35

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37. Systems model on the problems of HMIS 37

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39. The aim is to develop the backbone necessary to support the integrated digital health infrastructure of the country. It aims to bridge the existing gap amongst different stakeholders of healthcare ecosystem through digital highways. Anyone who wishes to participate in ABDM and have their health records available digitally must start by creating ABHA (Ayushman Bharat Health Account). ABHA is a randomly generated 14-digit number used for the purposes of uniquely identifying persons, authenticating them, and threading their health records (only with their informed consent) across multiple systems and stakeholders. NHA is leading the implementation for Ayushman Bharat Digital Mission (ABDM) in coordination with different ministries/departments of India. AYUSHMAN BHARAT DIGITAL MISSION (ABDM) 39

40. Building blocks of ADHM 40

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43. Key to digital healthcare journey Using ABHA (earlier known as Health ID) is the first step towards creating safer and efficient digital health records. ABHA is a hassle-free method of accessing and sharing users health records digitally. Users can opt-in to create a digitally secure ABHA, which allows them to seamlessly access and share their health data with their consent, with participating healthcare providers and payers. AYUSHMAN BHARAT HEALTH ACCOUNT (PREVIOUSLY HEALTH ID) Creating India's digital health ecosystem 43

44. CONCLUSION The HMIS is the only data source in India at the facility level capable of providing micro-level information every month for improving the delivery of health care services. But its potential remains unutilized because of the failure to train the staff and incorporate accountability within the system. Few challenges are: Strengthen the health information workforce to ensure improved availability of trained HMIS resources Ensure dissemination of standardized data definitions and data collection guidelines to ground-level facilities and ensure use of standardized reporting formats by all health facilities  Formalize data management practices and processes for data verification, correction, and feedback and supervisory support Improve data use for planning and management of health services, especially for day-to-day managerial planning and decision making at the facility level Strengthen IT infrastructure, particularly to ensure regular internet connectivity Improve coverage of private facilities in the HMIS, perhaps through regulatory guidelines and customized reporting formats 44

45. Blockchain technology has the potential to revolutionize interactions between governments, businesses and citizens in a manner that was unfathomable just a decade ago. Though very often grouped with technologies such as artificial intelligence (AI) or IoT (Internet of Things). NITI Aayog organized this initiative with a host of partners in the healthcare and technology domain. A unique Indian model of digital foundational infrastructure such as Aadhaar, UPI, e-Sign and Digilocker along with digitally enabled tax governance networks like GSTN or digitally enabled health coverage such as Pradhan Mantri Jan Arogya Yojana(PM-JAY). 45

46. PM-JAY is the world’s largest healthcare initiative with ~500 million beneficiaries covered , ~119 million e-cards issued so far, ~8 million hospital admissions In India, fake medicines are a major concern with approximately 3% of drugs being substandard or counterfeit, as per National Drug survey 2014-2016, conducted by National Institute of Biologics, Ministry of Health & Family Welfare. Blockchains also allow the identification of exact locations of medicines at each point of transaction and allow for ‘batch reminders’ to be sent out efficiently to ensure safety of patient’s health. Challenges (HMIS) : Utilization data recorded by health workers is written onto systems like MCTS (Mother and Child Tracking System) and HMIS (Health Management Information System). These systems are not interoperable. 46

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49. https://www.who.int/india/news/detail/30-06-2019-mohfw-launches-new-real-time-health-management-information-system-online-portal-in-five-states https://cdn1.sph.harvard.edu/wp-content/uploads/sites/114/2012/10/rp176.pdf https://healthid.ndhm.gov.in/ https://hmis.nhp.gov.in/#!/aboutus http://www.himaindia.com/ https://nhsrcindia.org/ Tripathi S, Sharma R, Nagarajan S. Health Information Systems in India: Challenges and way forward. Srivastava D. Health system monitoring using Health Management Information System (HMIS) in India and suggested enhancements to this platform. International Journal of Scientific & Engineering Research. 2015;6(9):1245-8. HFG Project- strengthening-the-health-management-information-system-pilot-assessment-of-data-quality-in-five-districts-of-india REFERENCES 49

50. Thank You 50