Health Cards (36)
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I would like to continue the discussion of the use of the comprehensive
health card (CHC),but first I would like to discuss some a couple of
related issues. I will respond to previous comments and questions later
in the week.
I am pleased that several African-based professionals have joined in the
conference regarding the use of CHC or patient-retained records. Jaap,
your input has been extremely beneficial and deeply appreciated. This
is the kind of information that I have been seeking in order to make a
more objective appraisal regarding the practical applications of a CHC.
I would be very interested in the details of your HIS. Is there any
documentation available?
It should not surprise us that what began as an issue regarding the use
a specific instrument(CHC) has evolved into the discussion and
evaluation of HIS in general. It is indeed impossible to separate
specific functions of a system that requires multiple sources and uses
for the same data.
I would like to respond to a several very important issues that keep
surfacing in our discussions regarding HIS i.e. the issue of maintaining
parallel systems and the idea of collecting "too much" information. I
would like to address these issues by discussing two issues that are
directly related to the IMPACT methodology. They are EQUITY and
ACCOUNTABILITY. Until an HIS deals with these two issues as they relate
to the care and prevention of illness the prodigious health problems
that permeate so much of the developing world may never be properly
addressed. Equity is related to health care beneficiaries and
accountability is related to service providers.
I will attempt to address these two issues via this wonderful Afro-Nets
network, but it is going to be rather difficult to present the full
concept considering the need for brevity. If you would like a full hard
copy presentation of the IMPACT methodology (110 pages)it is available
free of charge. The presentation contains information that may benefit
many other HIS methodologies. It also has many different reports, flow
charts, and graphs that better illustrate the methodology.
Equity
Equity regarding the beneficiaries means that no individual will be
prevented from receiving health related services. We all know that the
"poorest of the poor" sometimes do not receive even the most basic of
health care services. Reasons for such a lack of services are numerous
and it is not our intention to address these issues at this time.
However, I would like to ask one question. Do we know which individuals
are NOT benefiting from our services? Facility-based data provides
information on who is utilizing services, but it cannot tell us who is
not utilizing those services, which to me is more important. Family
planning, immunization and general consultation registers are important,
but they cannot tell us who has not accepted family planning, who is not
fully immunized, and who is not utilizing available health services.
A properly designed HIS will always know who makes up this TARGET
group. If a district has an immunization coverage rate of 95% the HIS
should be able to generate a roster showing the names and address of all
the remaining 5% in order that action can be taken to see that the
remaining children are immunized. When coverage rates are summarized
through aggregation you cannot possibly individualize your target.
Now how do you address the issue of equity within the scope of an HIS?
Well, the very basic idea is to know who all the potential beneficiaries
are within your target area. This necessitates first and foremost
identification. They must be uniquely identified and all services
provided within the health care system must be linked to that individual
in a unique way. This is where the introduction of a CHC, or health
passport, plays a key role in supporting both equity and accountability.
Ideally identification of all potential beneficiaries should occur
through the process of a "family registration" (Please refer to the
IMPACT abstract at the end of this discussion). This registration
identifies every individual and provides them with a health
identification number(HIN). If a family registration is not possible,
then the assignment of a HIN through the use of a CHC, or health
passport, becomes necessary. Either way, every service provided is
documented by the use of the HIN. The central database contains all
potential beneficiaries. Those utilizing services(beneficiaries) are
matched against the central database and non-beneficiaries, or
non-utilizers, are identified.
Accountability
Now addressing the issue of accountability. In reviewing the Afro-Nets
dialogue concerning the use of CHCs the issue of non-benevolent
providers is mentioned on several occasions. As mentioned above
accountability is directly related to those of us who provide health
care services. This includes everyone from the volunteer community
health worker giving instructions on the use of ORS to an illiterate
mother, to the MOH officer providing district wide reports to his
superior. Issues regarding quality of care, inventory control, health
worker competence, and malfeasance in general can only be addressed
through the use of information, and its relationship to other
information. The implementation of a properly designed HIS which links
inventory, or treatment, with clinical diagnoses and outcomes will
significantly impact quality of care through health worker evaluation,
as well as loss of medications through inventory control.
"Investments in computerization are investments in integrity,
accountability, equity, efficiency, and ultimately human resources.
Properly installed computerized systems reflect standards of
accountability towards which performance can be evaluated and deceptive
practices are exposed. Present manual information and supplies systems
in developing countries encourage employees and patients to practice
dishonesty through theft and fraud and oftentimes with impunity. In a
very real way we have become accomplices to our own demise. Present day
institutions have the knowledge and resources to prevent this
travesty. Organizations need to invest in the necessary resources that
will enable its employees and patients to coexist in an environment that
allows them the freedom from the temptations that currently abound
within the present system." (Statement by WRB to Board of Directors,
1995)
By implementing a system that requires HCWs to document services in a
specified manner we can begin to address some of these core issues
revolving around quality of care and inventory control. The IMPACT
methodology links treatments and outcomes to diagnoses, which are linked
to a consultation, including vital signs, amount paid, referral source,
and other unique encounter specific issues. These are then directly
linked to a patient who has a unique HIN. To commit fraud within such a
system is almost impossible due to the multi-level controls. It's not a
simple matter of making a mark in a box showing that a specific
medication was dispensed. Also, treatment patterns and outcomes can be
analyzed by HCW, clinic or any other group. At the original IMPACT
development site there is a significant amount of documentation showing
the impact this system had on these issues. Some are noted below in the
IMPACT abstract.
I have just completed a draft abstract of the IMPACT system and would
appreciate any additional comments. The original development site for
IMPACT had a population of 220,000 served by 6 outlying dispensaries
(120,000 annual consults) and a referral hospital(50,000 annual out-patient
visits). The entire population was registered according to the method
described in the abstract.
IMPACT
A Demographic Health Surveillance Information System
Abstract
The IMPACT (Integrating Medicine's Preventive And Curative Therapies)
System is an information system for primary health care which links
census-based data from community, primary care, and secondary care to
impact monitoring and assessment. The IMPACT methodology utilizes both
computerized software and manual instruments to achieve intervention
and assessment goals, as well as providing the core health indicators
recommended by the World Health Organization(WHO) and the United States
Agency for International Development(USAID). IMPACT has the capability
to provide these indicators through the integration of facility-based
curative services and the community-based programs which are primarily
preventive/promotive in nature. This synergistic approach creates a
comprehensive methodology that maximizes the provision of key indicators
and practical applications at all levels of care and management.
The IMPACT System provides an information infrastructure capable of
supporting the health care delivery system structure at all levels. This
necessitates both demographic surveillance as well as disease
surveillance on the entire population. Data regarding specific morbidity
and mortality, gender and age subgroups etc. can be extracted from this
core data to meet specific project and/or governmental reporting
requirements. Routine service delivery data at the peripheral level is
the source to meet these requirements. Summaries and other statistics
are generated from the raw data sent up from lower levels at each
reporting level and ensures that health care workers are not
overburdened with ever-changing reporting requirements. This data
warehousing approach also provides a multilevel data backup system
should loss occur, and the service delivery data collection methodology
contributes to sustainability due to staff functions support at the
level of collection.
The IMPACT System begins by locating communities, numbering houses,
mapping each community, and registering nuclear families. This
demographic data is entered into the computerized database where high
risk or target groups are identified and vital events recorded.
Individual records are maintained in birth order within each family by
household. Community rosters are printed for use by community health
workers(CHW) grouped in the same fashion and is one of the most
pragmatic examples of IMPACT's practical usefulness. The rosters enable
a house-to-house "roll call" to be conducted by the CHW for routine
health monitoring and updating vital events. This also ensures that no
potential beneficiary will be omitted and thus supports the concept of
equity within the health care system. Once the family registration is
complete, a patient registry is generated from the demographic data
which enables all services and consultations to be linked to each
patient. This would include immunizations, Vitamin A supplements, growth
monitoring (including anthropometry), women's reproductive health, and
other consultation-related issues such as any diagnoses, treatments
(including medications), procedures, and vital signs. Directly Observed
Tuberculosis Therapy (DOTT), school attendance, nutritional hearths, and
other project-specific interventions can be "plugged in" and integrated
with the current system.
A major link to the patient registry is the consultation registry. Here
each encounter is documented either by a paper consultation form, or if
resources permit, the computerized consultation form. Consultation data
from multiple decentralized sources is combined at upper levels to meet
managerial reporting requirements. Reference tables utilizing the
International Classification of Disease Codes(ICD9), and a customizable
medications inventory assist in standardization and quality control.
Practical outcomes include, but are not limited to, daily financial
reconciliation, inventory control (treatment is directly linked to the
diagnosis), referral and counter-referral assessment and confirmation,
outcomes linked to treatments and diagnoses, health worker evaluations
(appropriate treatment for diagnosis), immediate patient profiles, and
the provision of rates, trends, and indicators at the service delivery,
project, district, and provincial levels.
Through the use of the inventory control and HCW evaluation functions,
the executive director at the original development site concluded that
the implementation and maintenance of the system had paid for itself by
the end its second year of use, including all equipment and personnel.
Some immediate and documented benefits included;
1) Immunization coverage increased from approximately 33% to almost 90%
by the end of the third year.
2) Waiting time for access to hospital services for non-confirmed district
patients decreased from upwards to several hours, to in most cases just
a few minutes.
3) Recognition of barriers to access hospital services by clinic referrals
and re-writing of management protocols.
4) Due to the automated patient profile which links treatments to
diagnoses, there was a significant decrease in prescription fraud and an
increase in protocol compliance.
5) Recognition of inappropriate treatments by rural clinic-based
auxiliaries.
The IMPACT System is so designed that either the demographic or clinical
modules can be utilized separately, if desired. The software is not a
"canned" package and on-site customization is necessary in order to
meet project-specific requirements.
Looking forward to your comments.
Bill
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William Billingsley
Impact Demographic Health Surveillance Information Systems
Application Software Technologies, Inc.
1841 South Ridge Road
Green Bay, WI 54304
+1 (800) 992-0533 : Voice
+1 (414) 499-0533 : Voice
+1 (414) 655-3962 : Cell
+1 (414) 490-3218 : Fax
+1 (715) 823-6375 : Home
mailto:wbillingsley@aztechcon.com
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