Journal of Medical Systems, Vol. 15, No. 3, 1991
A Multicenter Study of Data Collection and Communication at Primary Health Care Centers K. Moidu,*'t O. Wigertz,* and E. Treli~f
Health care delivery is information intensive. As computer applications make information available to the decision maker with speed and accuracy, informatics applications will strengthen the infrastructure. This paper is the second part of a multicenter systems analysis study to design a common application software to support primary health care focused on information flow. We present the questionnaire analysis and observations from a field study of a district health site. Analyses using contingency tables revealed differences, some statistically significant. The field study confirmed that minor differences exist even within a district health site. Development of a common application software on the basis of information flow studies is feasible. However, to make optimum use of computer implementation, revision of the health information systems was recommended. It was suggested that application software be developed with the core data set required by the care providers to deliver and administrators to manage a vertical health program.
INTRODUCTION The demands made on an information system by program management are not commensurate with the attention paid to the development of the information system, and the system therefore found to be inadequate) Computers are used with the objective of making information available to the decision makers with speed and accuracy. Computers strengthen the information infrastructure and enhance information value, and this can contribute to improvement in the delivery of care and management, even at a Primary Health Care (PHC) center. 2 A PHC center is the foundation of a health care system and the routine source of information about the community) Computer based PHC information system implementations have been reported from a number of developed countries. 4 In a prophylactic community care program, computer assistance was used in history taking by means of an interactive computer program, and as a sentinel system to follow-up the high risks. This computer-assisted screening program provided medicosocial benefits to the community.5 Decision support for the general practitioner in the form of a dynamic From the *Department of Medical Informatics and tDepartment of General Practice, Faculty of Health Sciences, Link@ing University, S-581 83 Link@ing, Sweden. 205 0148-5598/91/0600-0205506.50/0
© 1991 Plenum Publishing Corporation
206
Moidu et al.
textbook is implemented in Hypermedia. 6 And as the microcomputer becomes an ubiquitous tool, the rate of diffusion of computers in primary care increases. 4 Efforts to strengthen the information infrastructure in developing countries are ongoing. In India this is seen in the improvement of data collection and reporting formats. 7 Microcomputers are used to collate reports in Egypt. 8 In Bangladesh they are used for health services research, 9 in Gambia for field-based epidemiological research, 1° and in many other areas within PHC. 11 Computer hardware prices have fallen and their power has increased. However, software systems for mass implementation at low cost are not available, and is identified as a priority issue of research interest. 8 In a delphic approach, professionals with health care and computing experience in developing countries have met to evolve strategies and seek solutions. 11 A multicenter field study was undertaken to formulate an objective, factual base for designing a common application software for implementation at a PHC center. It has been described previously with results from analyses of socio-organizational and human factors.3 After reviewing earlier microcomputer implementations in developing countries, one expert strongly recommends such studies.12 In this paper we present the second part of the multicenter systems analysis study. The response to questions about information flow are presented, along with observations from an on-site study of a district health site. Differences between sites are present, but development of software on the basis of information flow is possible. First, we present a theoretical examination of information and its roles in decision making at the hierarchic levels of health care management, and the consequential demands on a health information system, based on a model of the health care organization in India. Health Information System
In an organization with many different groups of information users (decision makers), the perceptions of information role and the health information system are equally many. Information is described in computer processing terms, with the simplest level text and measurements called data. It is organized to give a sense of order and then information is derived from this organization of data, with the implicit relationships demonstrated. Finally knowledge is obtained when the data is processed to provide explicit relationships. 13,14 In a recent publication another description of the terms is considered. Information is taken as a generic term, and may be either simple data or organized with greater detail as knowledge. 15 Information in health care terms is explained by the meaning imparted to health care delivery, such as health status, care provider actions, and information about resources. 16 In India, the actual delivery of health care is the duty of the State governments within the framework laid down by the Central Ministry of Health. For serious health problems, public health programs are instituted to specifically control or eradicate the disease. Because of the high morbidity and mortality due to Malaria, the National Malaria Eradication Program was initiated in 1954. Since then similar programs have been started from time to time. They are often described as vertical health programs since, for administrative purposes, the administrators are organized within the ministries in a vertical hierarchy for each program. This administrative structure extends down to the district level and
207
Multicenter S t u d y o f Data Collection at P r i m a r y Health Care Centers
integration occurs at the point of delivery, i.e., the PHC center and below. The exact hierarchy and number of program officers differs between states. 17 At Level I is " X , " the beneficiary o f the services and the first decision maker. The decision made is whether to make use of the services being provided. However, " X " may also be the head of the family or community, as is often the case in India. This level is not a user o f the health information system but is the subject matter. The information needs for decision making are met by health education through mass media, such as Television, which is often very effective. The health information system links the central policy making body to the most
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208
Moidu et al.
peripheral care provider. Levels 2-7 contribute and use the system. The primary health care providers, the Auxiliary Nurse Midwife (ANM) and Health Workers (HW) at the subcenter (Level 2), and the physician and staff at a PHC center (Level 3), are the actual deliverers of the service and are the routine sources of information. In order to follow-up each individual at higher risk or susceptibility, the data required by them about the community must be more detailed. A large amount of information flows in at the level of a PHC center, which must function as a collimator and pass-up restricted amounts of appropriate data in parallel to the different vertical program administrators at the levels above (see Fig. 1). The District (Level 4) and State level administrators (Level 5) require head-counts to support monitoring of the respective programs. They send reports as collated head-counts to the Central ministry level administrators (Level 6), who define the technical methodologies to follow for the policy formulated by the policy makers (Level 7). Health information systems have been designed to convey reports of actions, and the lower levels receive feedback related to their accomplishment of the targets, i.e., goals which have been set by a higher level of authority. Emphasis is primarily on information about the delivery process and very little on the outcomes. The bottle neck in the flow of information is at the PHC center (see Fig. 1), since it reports to the various program administrators at the district health level, and data is collected from many villages serviced by the PHC center. This tiered structure of a health organization, with different vertical programs, is similar to the organizational model of health care organizations in other countries. The vertical programs management structure is also seen in WHO.
AIMS OF THE STUDY As research in Medical Informatics, a descriptive study, using a questionnaire, was made of District Health Sites in developing countries to analyse whether a common specialized application software design for implementation at a primary health care center was feasible. It was a non-experimental, one-time cross-sectional study, primarily descriptive, to compare the district health sites. The study with results from socioorganizational and human factors has been reported earlier. 3 In this paper we study the factors that influence information flow, i.e. data collection, compilation and communication.
MATERIALS
AND METHODS
Part of the data (quantitative) was from the multicenter systems analysis study and was obtained from questionnaires about the data collection registers and reporting patterns. A descriptive analysis using contingency tables and the X2 t e s t was made to compare the district health sites. The statistical package STATVIEW© (© Program copyright ©Abacus Concepts, Inc. 1986.) was used on a Macintosh microcomputer. In some cases correlations were analyzed. Observations from a field visit to the Pravara Health District form a second data
Multicenter Study of Data Collection at Primary Health Care Centers
209
source and is largely qualitative. Pravara Health District is a part of the administrative district of Ahmednagar, in Maharashtra, India (see Fig. 2). The 6 PHC centers, with the hospital of the Pravara Rural Medical College as a secondary care center, formed the district health site. At each PHC center all the registers maintained were examined, and a physician, plus 1 or 2 of the peripheral care providers (such as the ANM or HW), were interviewed using a questionnaire designed to investigate the information flow. This was followed up with a district level meeting held at the collaborating institution, the Pravara Rural Medical College, Loni. The meeting was attended by the District Health Officer of Ahmednagar and the staff of the Pravara Rural Medical College, who provide specialist cover at the PHC centers. The discussions related to district health level problems due to inadequate information.
RESULTS First the responses from the multicenter study are compared. Next, observations from the visit to the Pravara Health District are presented. The Multicenter Study
Analyses of the data were done to study common patterns that will contribute to the factual base of a common software design for PHC center level implementation. Data Collection. The data collected from the various clinical and other health care delivery visits are maintained in separate registers for each of the programs. The number of registers maintained or available to the responding physicians vary, not only between PHC centers, but also within district health sites (see Table 1). Registers for activities such as immunization, patient visits, and prenatal care were most frequently available. Registers for recording referrals to the hospital or family folders were available to fewer respondents. Data Compilation and Communication. Data compilation and communication are major tasks, and the reports from the PHC centers form the base for the district level health information system. Table 2 shows that reports are rarely compiled by the physicians alone. Differences in frequency of reporting existed even within sites. The most popular mode for communication appears to be a designated messenger, the next most common mode is by post. In respect to a clinically expedient task, the identification and diagnoses of patients with communicable diseases, and the communication of this information to the authorities was analyzed. As seen in Table 3, the physicians themselves most often made the reports and reported within 72 hr. Based on observations from clinical examinations the physicians could infer that there was an epidemic raging. There were significant differences between sites in the time taken to recognize this (p =
A Multicenter Study of Data Collection and Communication at Primary Health Care Centers K. Moidu,*'t O. Wigertz,* and E. Treli~f
Health care delivery is information intensive. As computer applications make information available to the decision maker with speed and accuracy, informatics applications will strengthen the infrastructure. This paper is the second part of a multicenter systems analysis study to design a common application software to support primary health care focused on information flow. We present the questionnaire analysis and observations from a field study of a district health site. Analyses using contingency tables revealed differences, some statistically significant. The field study confirmed that minor differences exist even within a district health site. Development of a common application software on the basis of information flow studies is feasible. However, to make optimum use of computer implementation, revision of the health information systems was recommended. It was suggested that application software be developed with the core data set required by the care providers to deliver and administrators to manage a vertical health program.
INTRODUCTION The demands made on an information system by program management are not commensurate with the attention paid to the development of the information system, and the system therefore found to be inadequate) Computers are used with the objective of making information available to the decision makers with speed and accuracy. Computers strengthen the information infrastructure and enhance information value, and this can contribute to improvement in the delivery of care and management, even at a Primary Health Care (PHC) center. 2 A PHC center is the foundation of a health care system and the routine source of information about the community) Computer based PHC information system implementations have been reported from a number of developed countries. 4 In a prophylactic community care program, computer assistance was used in history taking by means of an interactive computer program, and as a sentinel system to follow-up the high risks. This computer-assisted screening program provided medicosocial benefits to the community.5 Decision support for the general practitioner in the form of a dynamic From the *Department of Medical Informatics and tDepartment of General Practice, Faculty of Health Sciences, Link@ing University, S-581 83 Link@ing, Sweden. 205 0148-5598/91/0600-0205506.50/0
© 1991 Plenum Publishing Corporation
206
Moidu et al.
textbook is implemented in Hypermedia. 6 And as the microcomputer becomes an ubiquitous tool, the rate of diffusion of computers in primary care increases. 4 Efforts to strengthen the information infrastructure in developing countries are ongoing. In India this is seen in the improvement of data collection and reporting formats. 7 Microcomputers are used to collate reports in Egypt. 8 In Bangladesh they are used for health services research, 9 in Gambia for field-based epidemiological research, 1° and in many other areas within PHC. 11 Computer hardware prices have fallen and their power has increased. However, software systems for mass implementation at low cost are not available, and is identified as a priority issue of research interest. 8 In a delphic approach, professionals with health care and computing experience in developing countries have met to evolve strategies and seek solutions. 11 A multicenter field study was undertaken to formulate an objective, factual base for designing a common application software for implementation at a PHC center. It has been described previously with results from analyses of socio-organizational and human factors.3 After reviewing earlier microcomputer implementations in developing countries, one expert strongly recommends such studies.12 In this paper we present the second part of the multicenter systems analysis study. The response to questions about information flow are presented, along with observations from an on-site study of a district health site. Differences between sites are present, but development of software on the basis of information flow is possible. First, we present a theoretical examination of information and its roles in decision making at the hierarchic levels of health care management, and the consequential demands on a health information system, based on a model of the health care organization in India. Health Information System
In an organization with many different groups of information users (decision makers), the perceptions of information role and the health information system are equally many. Information is described in computer processing terms, with the simplest level text and measurements called data. It is organized to give a sense of order and then information is derived from this organization of data, with the implicit relationships demonstrated. Finally knowledge is obtained when the data is processed to provide explicit relationships. 13,14 In a recent publication another description of the terms is considered. Information is taken as a generic term, and may be either simple data or organized with greater detail as knowledge. 15 Information in health care terms is explained by the meaning imparted to health care delivery, such as health status, care provider actions, and information about resources. 16 In India, the actual delivery of health care is the duty of the State governments within the framework laid down by the Central Ministry of Health. For serious health problems, public health programs are instituted to specifically control or eradicate the disease. Because of the high morbidity and mortality due to Malaria, the National Malaria Eradication Program was initiated in 1954. Since then similar programs have been started from time to time. They are often described as vertical health programs since, for administrative purposes, the administrators are organized within the ministries in a vertical hierarchy for each program. This administrative structure extends down to the district level and
207
Multicenter S t u d y o f Data Collection at P r i m a r y Health Care Centers
integration occurs at the point of delivery, i.e., the PHC center and below. The exact hierarchy and number of program officers differs between states. 17 At Level I is " X , " the beneficiary o f the services and the first decision maker. The decision made is whether to make use of the services being provided. However, " X " may also be the head of the family or community, as is often the case in India. This level is not a user o f the health information system but is the subject matter. The information needs for decision making are met by health education through mass media, such as Television, which is often very effective. The health information system links the central policy making body to the most
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Level 2 Peripheral Care Providers such as Auxiliary Nurse Midwives
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"X" or the Head of Family / Community
Sub-Camtre
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~ ~
~
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~
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~
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Figure 1. Hierarchic levels in the organization of end-users of a health information system
208
Moidu et al.
peripheral care provider. Levels 2-7 contribute and use the system. The primary health care providers, the Auxiliary Nurse Midwife (ANM) and Health Workers (HW) at the subcenter (Level 2), and the physician and staff at a PHC center (Level 3), are the actual deliverers of the service and are the routine sources of information. In order to follow-up each individual at higher risk or susceptibility, the data required by them about the community must be more detailed. A large amount of information flows in at the level of a PHC center, which must function as a collimator and pass-up restricted amounts of appropriate data in parallel to the different vertical program administrators at the levels above (see Fig. 1). The District (Level 4) and State level administrators (Level 5) require head-counts to support monitoring of the respective programs. They send reports as collated head-counts to the Central ministry level administrators (Level 6), who define the technical methodologies to follow for the policy formulated by the policy makers (Level 7). Health information systems have been designed to convey reports of actions, and the lower levels receive feedback related to their accomplishment of the targets, i.e., goals which have been set by a higher level of authority. Emphasis is primarily on information about the delivery process and very little on the outcomes. The bottle neck in the flow of information is at the PHC center (see Fig. 1), since it reports to the various program administrators at the district health level, and data is collected from many villages serviced by the PHC center. This tiered structure of a health organization, with different vertical programs, is similar to the organizational model of health care organizations in other countries. The vertical programs management structure is also seen in WHO.
AIMS OF THE STUDY As research in Medical Informatics, a descriptive study, using a questionnaire, was made of District Health Sites in developing countries to analyse whether a common specialized application software design for implementation at a primary health care center was feasible. It was a non-experimental, one-time cross-sectional study, primarily descriptive, to compare the district health sites. The study with results from socioorganizational and human factors has been reported earlier. 3 In this paper we study the factors that influence information flow, i.e. data collection, compilation and communication.
MATERIALS
AND METHODS
Part of the data (quantitative) was from the multicenter systems analysis study and was obtained from questionnaires about the data collection registers and reporting patterns. A descriptive analysis using contingency tables and the X2 t e s t was made to compare the district health sites. The statistical package STATVIEW© (© Program copyright ©Abacus Concepts, Inc. 1986.) was used on a Macintosh microcomputer. In some cases correlations were analyzed. Observations from a field visit to the Pravara Health District form a second data
Multicenter Study of Data Collection at Primary Health Care Centers
209
source and is largely qualitative. Pravara Health District is a part of the administrative district of Ahmednagar, in Maharashtra, India (see Fig. 2). The 6 PHC centers, with the hospital of the Pravara Rural Medical College as a secondary care center, formed the district health site. At each PHC center all the registers maintained were examined, and a physician, plus 1 or 2 of the peripheral care providers (such as the ANM or HW), were interviewed using a questionnaire designed to investigate the information flow. This was followed up with a district level meeting held at the collaborating institution, the Pravara Rural Medical College, Loni. The meeting was attended by the District Health Officer of Ahmednagar and the staff of the Pravara Rural Medical College, who provide specialist cover at the PHC centers. The discussions related to district health level problems due to inadequate information.
RESULTS First the responses from the multicenter study are compared. Next, observations from the visit to the Pravara Health District are presented. The Multicenter Study
Analyses of the data were done to study common patterns that will contribute to the factual base of a common software design for PHC center level implementation. Data Collection. The data collected from the various clinical and other health care delivery visits are maintained in separate registers for each of the programs. The number of registers maintained or available to the responding physicians vary, not only between PHC centers, but also within district health sites (see Table 1). Registers for activities such as immunization, patient visits, and prenatal care were most frequently available. Registers for recording referrals to the hospital or family folders were available to fewer respondents. Data Compilation and Communication. Data compilation and communication are major tasks, and the reports from the PHC centers form the base for the district level health information system. Table 2 shows that reports are rarely compiled by the physicians alone. Differences in frequency of reporting existed even within sites. The most popular mode for communication appears to be a designated messenger, the next most common mode is by post. In respect to a clinically expedient task, the identification and diagnoses of patients with communicable diseases, and the communication of this information to the authorities was analyzed. As seen in Table 3, the physicians themselves most often made the reports and reported within 72 hr. Based on observations from clinical examinations the physicians could infer that there was an epidemic raging. There were significant differences between sites in the time taken to recognize this (p =
