Natarajan.S,Panchanathan.V,Pankaj Kumar Bansal*
Abstract -The HMIS or the Health Management Information System is an online portal through which medical professionals and the support staff in medical establishments can maintain crucial information about the patients. Ever since the creation of government health centres and public health services, there has been a great gap created between the decision makers and the implementers. This gap has been due to the lack of processes when it comes to processing the information and the lack of feedback upon sub-functional but existing systems. One of the many initiatives to bridge this gap has been the implementation of the HMIS system in every major public hospital, rural health centre and primary health centres across the state.
Index Terms - HMIS, HMS, Inpatient, Outpatient, Pharmacy, Staff, Tamil Nadu Health Systems Project
*Natarajan.S-Additional Director of Medical Services (Administration),Dr.N.Panchanathan – Professor & Head of Department, Annamalai University
,PankajKumarBansal IAS-Special Secretary to Government, Health & Family Welfare & Project Director ,Tamilnadu Health System Project
—————————— ——————————
system (3) CMS....College Management System (4)
UAS......University Automation System
“A next generation MIS, that is powerful, flexible
and easy to use has been designed and developed to deliver
real conceivable benefits to hospitals.” “Hospitals need to
decide how services could be delivered more effectively to
reduce costs, improve quality and extend reach.”
Tamilnadu Health Systems Project (TNHSP) is
being implemented since 2005 by the Government of
Tamilnadu with World Bank soft loan for several programs
to improve the health delivery systems. One of the key
areas was the introduction of Hospital Management Information System (HMIS) a flagship programme of TNHSP, to be implemented in three phases after a successful Pilot phase. “Access to the right information and automation of complex tasks and work flow is the key focus of the HMIS, enabling freeing the staff to spend more time on caring for patients and extending the reach of services. HMIS has four components (1) HMS....Hospital Management System (2)MIS.....Management Information
In the pilot phase, Government Hospitals in Tambaram, Sriperumbudur in Kancheepuram district, Sholingur in Vellore district, and Padmanabhapuram, Colachel in Kanyakumari district were identified.
Under Phase I, Hospital Management System (HMS) was implemented in five districts viz. Theni, Kanyakumari, Dharmapuri, Krishnagiri and Pudukottai districts comprising of thirty six hospitals. Phase II is an extension of this work across the state for 222 hospitals. Currently HMS & MIS is functional in 267 Secondary Care hospitals, MIS in all the 1613 PHCs.
Phase III is a comprehensive project involving Govt Tertiary care hospitals and implementation of a University Automation System for Tamilnadu Dr.MGR Medical University with a College Management System. 47 institutions under Directorate of Medical Education including 17 Medical Colleges will also be in the stream (shown in Fig.1).
August 2010
INR
87 crores
INR 2.8
crores
Dec 2008
Pilot -5 hospitals
INR 8
Crores
Nov 2009
Phase I – HMS in 36 hospitals
Phase II – HMS in 222 secondary care hospitals
+
HMIS in 1613 PHC’s fully
online
INR 21
Crores
Software
across 5 districts
July 2011
Phase III- 47 Institutions under Directorate of Medical Education including 17 Medical Colleges
+
Tamil Nadu Dr.MGR Medical
development cost
9.69 cores
University
Fig. 1 Implementation Overview
Even though there have been multiple attempts at quantifying the effectiveness of management systems, there have not been much research on the bench marks that have been achieved in the medical system today. This paper attempts to look at the benchmarks that have been achieved and provide a clear understanding of the pain points of the system that existed earlier. With the growth and prevalence of information technology, a detailed look into how the issues have been managed and resolved is presented in this paper. The HMIS Solution architecture has been designed for scalability and long term sustainability. 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.
All the hospital records were being maintained manually, which meant more time consuming and even more time utilised for retrieving records. Spending more funds towards procurement of manual registers, Duplication of records of the patients, unreliability of the collected data, lack of monitoring the performance of the ANALYSIS BASED ON DATA
The state of Tamil Nadu has been segregated into
32 districts for effective administration and in these 32
districts the Government of Tamil Nadu under the auspices
hospitals, 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 had to overcome.
By identifying key features which can be taken as a
benchmark for the performance of the HMIS system, we
attempt to measure the impact of this system on the
existing issues. The project has been conceptualized as a
centralized web based software solution to minimize
technology support and maintenance dependencies. 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 centralized 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.
of the Health and Family Welfare departments, 268 institutions have been identified to be connected through the centralised HMIS system (shown in Fig.2).
Hospitals covered under HMS | |
HQRS | 30 |
Taluk Hospitals | 156 |
Non Taluk Hospitals | 75 |
Women and Children Hospital | 7 |
Fig.2
For the purposes of this paper, the data collected from these 268 institutions are analysed and the effectiveness of the HMIS system in terms of transparency and efficiency is presented. One of the main sources of information that is generated by the system is the reports that are available to the various senior officials. These officials in turn can use the data for making decisions and recommendations to the government aimed at making the overall health system more effective.
To improve the performance and functionality of the HMIS system, the supposed users are trained by experts on everyday basis. Every mode of input and the various nuances of using the system will be shown screen by screen and case by case.
These systems require regular maintenance and servicing for proper functioning of the system. These IT Co- ordinators would be available at every institution and would be the caretaker of hardware like Computer, Monitor, UPS etc. Also they monitor the Primary and Secondary Connectivity provided by TNSWAN & BSNL. They regularly interact with hospital staff; resolve the hardware and software issues by interaction with helpdesk at headquarters .The IT Coordinators with the help of Three Server Administrators at State Data Center ensure uninterrupted system functionality & data backup. The HMIS team at Head quarters supervise the effective functionality of HMIS along with the Technical expertise of ELCOT and other Stake holders of TNHSP HMIS. Thus maintenance of the system would determine its efficiency and reliability.
The concept of help desk is to guide and provide every single end user with all the relevant information that they are looking for. This toll free number can be reached by end user 24X7 and they can get their help and guidelines from the helpdesk IT coordinators and Medical Officers.CUG number for the helpdesk is obtained and all end users can get connected to helpdesk for their IT infra issues. An exclusive software helpdesk with SW professionals are also available at headquarters for answering all queries related to application. This is executed by application stakeholder M/s Tata Consultancy Services.
The AMC (Application Maintenance Cost) reports are the feedback and suggestions on the software that is being implemented by the TNHSP. It gives a detailed report about the usage of the software and modifications required for field usage. These reports helps us estimate the costing and longevity of each set up, which in turn helps us decide the monetary allocation for each district.
The HMS comparative performances for the years 2012 (July – June) and 2013 (July – June) on various parameters are displayed below as a comparative statement. On analysing these data we can find out that there is a remarkable improvement in the usage of HMS in respect of Outpatients, In-patient registration, Lab tests, Stores, Discharge, Diet, Bio Medical Waste Management, Blood bank, and Radiology. 68 % of Out patients registered at HMS are treated by doctors at HMS and for 85% of their pharmacy issues are made through HMS. 66% of the inpatients are discharged, 83% of the laboratory results are entered and 73% of the store issues are done through HMS.
HMS usage for two year 2012 and 2013 in the state
Parameters | July 2011 to June 2012 | July 2012 to June 2013 |
O.OP----Old OP | 55,80,452 | 97,99,517 |
N.OP----New OP | 1,05,73,215 | 1,85,53,860 |
Cas----Casualty OP | 9,47,830 | 17,15,861 |
Spec----Speciality OP | 8,82,923 | 11,67,172 |
MLC----Medico Legal Cases | 3,261 | 3,279 |
Tot----Total OP | 1,79,87,792 | 3,12,39,689 |
IP----IP Registration | 4,11,376 | 7,94,541 |
L.Req----Lab Tests | 53,24,646 | 98,79,984 |
L.Res----Lab Results | 45,21,677 | 79,74,117 |
Cl.OP----Clinical OP | 1,19,77,001 | 2,12,41,802 |
Ph----Pharmacy | 1,01,76,443 | 1,80,92,083 |
S.Ind----Stores Indents | 89,545 | 2,18,066 |
S.Iss----Stores Issues | 68,195 | 1,77,511 |
Wd.Dis----Ward Discharge | 2,97,145 | 5,67,007 |
Diet----Diet | 3,78,913 | 5,43,296 |
BMW----Bio Medical Waste Management | 92,270 | 2,61,106 |
BB----Blood Bank Donor Registration | 5,746 | 14,965 |
X.Ray----Radiology | 64,370 | 1,41,096 |
Fig. 3
COMPARISON OF HMS USAGE FOR TWO YEARS | ||||||||
S.No | District Name | Institution Name | Total OP registration | Clinical OP | Pharmacy | |||
July | July | July | July | July | July | |||
2011 to | 2012 to | 2011 to | 2012 to | 2011 to | 2012 to | |||
June | June | June | June | June | June | |||
2012 | 2013 | 2012 | 2013 | 2012 | 2013 | |||
1 | ERODE | ERODE | 72781 | 322816 | 24564 | 121022 | 19569 | 95809 |
2 | KANCHEEPURAM | TAMBARAM | 246183 | 261316 | 143505 | 171175 | 125199 | 170950 |
3 | KRISHNAGIRI | KRISHNAGIRI | 239039 | 260408 | 117247 | 142750 | 76877 | 102410 |
4 | MADURAI | USILAMPATTI | 238882 | 295289 | 168721 | 178214 | 134942 | 140263 |
5 | NAGAPATTINAM | MAYILADUTHURAI | 33514 | 236729 | 15242 | 119701 | 10856 | 92611 |
6 | NAGAPATTINAM | NAGAPATTINAM | 162409 | 316622 | 56714 | 158843 | 38546 | 111613 |
7 | NAGAPATTINAM | SIRKAZHI | 179409 | 257930 | 120565 | 130954 | 101020 | 153845 |
8 | NAMAKKAL | NAMAKKAL | 347737 | 351202 | 185862 | 249251 | 144225 | 203164 |
9 | RAMANATHAPURAM | RAMANATHAPURAM | 86593 | 344650 | 41941 | 209762 | 32820 | 144254 |
10 | THANJAVUR | KUMBAKONAM | 51281 | 241308 | 34273 | 161389 | 29406 | 135279 |
11 | THENI | PERIAKULAM | 197269 | 278135 | 91819 | 179609 | 74206 | 152399 |
12 | THOOTHUKUDI | KOVILPATTI | 90219 | 263894 | 59368 | 190375 | 46149 | 157294 |
13 | TIRUNELVELI | TENKASI | 104680 | 288957 | 29362 | 153062 | 23726 | 126290 |
14 | TIRUPUR | TIRUPPUR | 39396 | 284702 | 20773 | 103674 | 14849 | 61003 |
15 | TIRUPUR | UDUMALPET | 36094 | 249221 | 28874 | 206987 | 23438 | 174205 |
16 | TIRUVALLUR | THIRUVALLUR | 204687 | 270253 | 111749 | 187136 | 75141 | 142412 |
17 | TIRUVANNAMALAI | ARANI | 74762 | 236756 | 57754 | 191049 | 55210 | 177935 |
18 | TIRUVANNAMALAI | POLUR | 83571 | 243781 | 77144 | 225555 | 68413 | 200410 |
19 | TIRUVANNAMALAI | WANDAVASH | 82439 | 249130 | 71050 | 204628 | 60846 | 177682 |
20 | TIRUVARUR | MANNARGUDI | 208160 | 391460 | 147558 | 319791 | 131361 | 290358 |
21 | VELLORE | GUDIYATHAM | 245623 | 310842 | 177651 | 211514 | 134935 | 187634 |
22 | VELLORE | TIRUPATHUR | 200829 | 324414 | 165118 | 257899 | 144164 | 222272 |
23 | VELLORE | WALAJAPET | 138453 | 291896 | 94380 | 164656 | 73801 | 147364 |
24 | VILLUPURAM | GINGEE | 61116 | 266292 | 52898 | 227891 | 47781 | 200955 |
25 | VILLUPURAM | TIRUKOILUR | 90740 | 376777 | 72404 | 316696 | 58796 | 270615 |
Fig. 4
On analyzing the HMS usage of outpatients, OP registration, Clinical OP and pharmacy for 25 hospitals during the past two years 2012 and 2013 (July to June) we
found that there is remarkable increase in Op registration, Clinical Op and Pharmacy.
Fig.5
Fig.6
In order to set up this entire system the costing would be divided into 2, the system and people working on the system.
The cost incurred by the system would depend on the cost of the software and hardware that is being used. Apart from the cost of hardware the cost of implementing the hardware for this system should be taken in account. The other cost of implementation of this system would be the cost of training people for this specialised task and to hire them to work as a part of this system. Additional cost that would add up for this system would be that of maintaining and monitoring the whole system for efficiency and accuracy.
Health Management Information System provides information based support for the implementation of cutting-edge reforms by the Tamilnadu 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.
Under the Tamil Nadu Health Systems project (TNHSP) this World bank Funded initiative has now turned into one of the largest Healthcare Information Systems platform in the world supporting over 1613 Primary Care Centres (Server + MIS Support), 268 Secondary Care Hospitals (HMS+MIS) and is currently
being up scaled to cover Govt Medical Colleges & hospitals
.
One of the important measurable outcomes of the HMIS implementation is that approximately 80% of the registered patients bring back the PIN (Patient Identification Number) during their subsequent visits, which shows the high patient compliance with this system. The results are clearly indicative of the success of this project and TNHSP HMIS received 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 and the Prestigious National e- Governance Gold Medal award for the year 2012 under the category of “Exemplary reuse of ICT based solutions”.
CONCLUSION:
While there has been commendable progress there are also new challenges which are systemic. One of such systemic issues is the management of the available information for action and coordination between all health verticals to design comprehensive and integrated health planning. A robust HMIS is available in the state addressing few concerns at present.
By introducing the judicious combination of Information Technology (IT) and Management Systems a remarkable change has been attained as follows (1) Automation of work flow process at the Government hospitals (2) Gradual removal of manual registers and records (3) Real Time monitoring of Secondary care
hospitals performances from the head quarters (4) Electronic Medical records are now available for the poor patients (5) Since the system does not encourage data entry operators, involvement of regular staff ultimately lead to computer skill development among the hospital staff. Online drug and equipment inventory also being maintained by hospital staff effectively.
This study explains the ICT initiatives, the Policy initiatives, Process initiatives with Challenges faced during implementation of HMIS, levels of success, capacity building and finally about the paradigm shift which leads to a revolutionary change in the Health Department.
HMIS reports from www.tnhmis.org
Health Management & Information System
(HMIS), Nov 2006, Quintegra
Solutions
Report on Tamil Nadu Health Management
Information Systems submitted to Department of
Administrative reforms & Personnel Grievances(DARPG),Govt of India for National e- Governance awards for the year 2012
http://egovreach.in/uploads/presentation/chenn
Presentation for National Institute of Smart
Government(NISG eGCP) by Project Director
TNHSP on “ICT initiatives” of Govt of Tamil
Nadu,Health &Family Welfare Department.2013