WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE:LA SANT£
REGIONAL OFFICE FOR
THE WESTERN PACIFIC
BUREAU R'GIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Thirty-eighth session Beijing 8-14 September 1987
WPR/RC38/Technical Discussions/2 2 September 1987 ORIGINAL: ENGLISH
INFORMATICS TECHNOLOGY AND HEALTH MANAGEMENT Technical Discussions
Health informatics is a relatively new technology which is rapidly being applied to health systems all over the world. The advent of microcomputers (personal computers) has further increased the benefits of informatics use for national health administrators, especially in support of the monitoring and evaluation of their health services. Global and regional interest in the use of informatics in health has been officially articulated by the Executive Board and by resolutions of the World Health Assembly, and by the Regional Committee for the Western Pacific in 1986, which decided that the subject of the Technical Discussions in conjunction with the thirty-eighth session would be "Informatics technology and health management". This background document aims to direct the attention of Member States to the potential of health informatics in the management of health systems and to encourage them to take advantage of such technology. The benefits and problems of the application of informatics in diversified areas of health and medicine are discussed. The document also draws attention to the needs and concerns of informatics management within an organization or country.
WPR/RC38/Technical Discussions/2 page 2
1.
INTRODUCTION
1.1
Relevance to WHO programmes
Since their adoption of the Global Strategy for Health for All by the Year 2000, the Member States of WHO have reoriented their health systems on the basis of the primary health care approach in order to provide essential health care to their populations. To this end, countries have re-examined their health services in the light of national and international social, economic and political considerations, reshaped and refined their plans to achieve their national targets, and made significant changes in their health and health-related services to ensure effective and efficient delivery and management, guided al~ays by the paramount overriding concern for social equity. The inadequacy of relevant management information has long since been recognized as one of the most significant impediments to progress. This deficiency has hindered the administration of health services at the national, intermediate and local levels aimed at developing and maintaining health systems based on primary health care. At the same time, it has been observed that, although a plethora of health data exists, its usefulness is diminished by lack of timeliness, lo~ reliability and validity, inadequate interpretation and high processing costs. The recent global evaluation of the health-for-all strategies has underscored the persistence of these deficiencies in the area of information support. At the World Health Assembly in 1986, Member States resolved to improve their health management information support by introducing and making increasing use of informatics in health. Informatics in this context may be defined as 11 the combination of technology and methodology which enables the collection, storage, processing, retrieval distribution and management of information by electronic means". 1 1 .2 Background in of the its
There have been rapid and significant advances development of informatics and the potential benefits application to the health services have considerably grown.
The utilization of digital computers within existing manual health information systems began in the 1950s when the first registers and laboratories were computerized. Already at that time
1Present and potential uses of informatics and telematics in health (WHO document ISS/86/36), 1986, page 4•
WPR/RC38/Technical Discussions/2 page 3
diagnostic decision support was accepted as a potential outcome ~f the new technologies. During the 1960s and 1970s, the bas1c framework for the use of computers in patient care and health management was established. A major lesson to be learnt was that, without systematic preparation, including medium-term plannin~, and without qualified personnel, the introduction of computer systems can very easily result in failure. Since 1980, microcomputer (personal computer) technolo'P' arid telecommunications technology ( telema tics) has made computers affordable and usable, even in remote areas, by every institution and individual. Telematics in this context is used as a comprehensive term to refer to the use of computer-based information processing through telecommunication tools like telephone · iines or radio transmission. Technological development will continue to make rapid strides; technologies will be constantly improved and more efficient methods of data management, processing, analysis and dissemination will be developed. However, there is a strong need now to develop a set of planning guidelines for the use of available technologies of information transfer in support of health care deli very in the context of health for all based on primary health care. These Technical Discussions are intended to be a first step in this direction. 1.3 ObJectives and framework of present document
To · facilitate discussion, this paper has been divided into several arbitrary albeit logical sections. The introduction briefly defines informatics and reviews informatics development within WHO. This is followed by a consideration of several important background documents. Then follows a definitive discussion of the benefits and problems of informatics applications in diverse areas of health and medicine, ranging from individual patient management, facility management, biomedical information and document services to broad health services administration and management. A fourth and final section deals with the needs and concerns of informatics management within a given organization or country.
2.
REVIEW OF DOCUMENTS
2.1
Informatics and telematics in health
In 1986 WHO Headquarters issued a technical report, 1 which was based on contributions from international consultations vith senior
1Present and potential uses of informatics and telematics in health (WHO document ISS/86/36), 1986.
WPR/RC38/Technical Discussions/.2 page 4
health administrators and in.formatics specialists. The report gives a broad overview o.f the potential bene.fits o.f in.formatics as applied to health. Speci.fically, the report covers the need .for Member States to develop a national health in.formatics policy and strategy, examines the bene.fits o.f applying in.formatics technology to the management o.f health programmes and to the provision o.f health care, reviews the manpower development issues associated with in.formatics training .for health workers and .for in.forma tics specialists, and reviews some o.f the considerations for selecting the hardware and so.ftware to be used in health in.formatics applications • .2 • .2 Working Group report
The WHO Regional O.f.fice .for the Western Paci.fic organized the Working Group on Application o.f In.formatics in Health in Manila in April 1987 comprising senior health managers and in.formatics specialists .from the Region. The purpose o.f the Working Group was to make speci.fic recommenda tiona to guide the Regional Director and Member States in their activities in the next six years. The Working Group report sets out the first operational guidelines tO- be .formulated in WHO concerning the utilization o.f informatics and telematics in support o.f the heal th-.for-.all strategy.1 .2.3 Other sources o.f in.formation
International journals and the proceedings of national and international pro.fessional and scienti.fic associations, con.ferences and seminars are now available on all specialized aspects o.f health informatics. A .few examples are listed in the bibliography at the end of this paper. Apart .from countries in Europe and North America, several developing countries include short courses on health informatics in their curricula for health administrators, nurses and medical doctors.
3.
APPLICATION OF HEALTH INFORMATICS IN THE REGION
3.1
Support .for health administration and management
There is increasing recognition of the importance of management in health programmes, which comprises various steps such as policy formulation, broad programming, detailed programming, budgeting, monitoring and control of implementation, evaluation, and reprogramming.
1Report of the Working Group on Application of In.formatics in Health, Manila , 20-24 April 1987.
WPR/RC38/Teehnical Discussions/2 page 5
There are three types of data necessary for health systems management, namely: (1) demographic and epidemiological ·. data; (2) health resources and services data; (3) operational interaction data related to intervention, i.e. health services coverage of population by district. Most of the health data are collected at the local level such as health centres, health clinics and hospitals. These data are accumulated monthly and reported to a second level to be consolidated, usually at the district or regional level. Finally, data are sent to the central government office where they are analysed and utilized in making policy decisions. Some data may not be fully utilized because of delays in submission and processing. To overcome these problems and to meet the needs for analysis, dissemination and timely response, the demand for computer processing has emerged. At the same time, computer technologies have greatly improved and the cost of computers, particularly microcomputers, has dramatically decreased. Application software is also easier to learn and use. Once health data are computerized, they can be utilized over and over again. Moreover, they can be easily transmitted and combined with other data. Combined data can also be utilized for policy making. Provision of computer support at all levels, from the local level up to the senior health management level, is usually hampered by limitations such as budgetary constraints, lack of manpower, unwillingness to adapt to a new workstyle, and the like. To overcome these constraints, it is most important to educate all levels on how to produce reliable data and to install systems which, to be effective, must address the limitations outlined earlier. Some developing countries have now introduced microcomputers into their central government offices and have developed applications using software packages. Some of this software may be available through WHO support. Since the early days of health informatics, computers have been used in patient treatment, for example, in prevention (dietary control); diagnosis (image processing, automated laboratories); survival care (intensive care systems); illness management (computer-controlled prostheses); clinics (radiation optimization). During the last three years, increasing use has been made of reliable and relatively cheap systems for use in primary health care, e.g. computer-supported quantitative laboratory systems and automatic ECG interpretation systems. With more and more powerful microcomputers available, many researchers believe that decision-support systems for primary health care will become more widely available over the next few years. Decision-support systems can be expected to appreciably improve the quality of care, provided the use of these systems is closely monitored.
WPR/RCJ8/Technical Discussions/2 page 6
One of the most successful and widespread uses of informatics is in its application to administrative processes, whether for the automation of payroll systems in all institutions dealing with health care or for the optimization of stock control. Many standardized software systems exist worldwide and, provided they can be easily modified to meet special organizational requirements, can easily be transported to new institutions. These administrative systems may improve the efficiency of administrative work considerably. However, as informatics is only a tool, the education of administrative officers and clerical staff is necessary. Word processing and other office automation systems provide efficient and easily applied support to administration, particularly where clerical services are overwhelmed by paperwork. Experiences in most countries have shown that the use of health informatics in most medical applications does not lead to a reduction of staff. Health informatics commonly results in changes in the personnel structure of health institutions and modifications in the tasks and nature of work of those directly affected by the application of health informatics. In general, it can be said that the use of informatics in administrative services (besides its application to research) is usually the first step to be taken in an overall national strategy to improve health care. 3.2 Health and biomedical information and documentation services
Rapid access to health and biomedical information and documentation services is a modern requirement, particularly when it is essential to receive timely and relevant information on the results of medical investigations. On-line access to nationally and internationally available data bases and knowledge, using microcomputers connected as terminals to national and international networks, is possible today. Even in remote locations, access is possible through the use of telecommunications. Health literature, as distinguished from biomedical literature, contains mainly information about the nature and extent of the people 1 s health problems and health management-related questions. A health information service should assist health policy makers, administrative staff and other health workers in making correct decisions. In order to achieve WHO's goal of health for all by the year 2000, and to improve health planning in the context of primary health care, it is necessary for each country or region to have its own health and biomedical information policy. Based upon a. sound policy, each country should build up i:ts own health and biomedical information system. In the development of these systems, such policy will have . to take into consideration factors as varied as funding, availability of appropriate staff skills, and someti.mes even language differences.
WPR/RCJ8/Technical Discussions/2 page 7
The ultimate aim of each country should be the formation of an efficient working integrated information network. This network may eventually take care of both health and biomedical literature and information. Subject to the availability of funds, the latest costeffective technology should be utilized, bearing in mind possible future developments. The technology being applied should be readily usable by end users. For it to work efficiently, a unified terminology, a common bibliographical format, and a common data base management software package are necessary. A key factor in ensuring the successful establishment of an integrated information network is the formation of a stable and dedicated team representative of both technical and administrative interests. Furthermore, at each network node of the information network, appropriately trained and qualified personnel are required. It is also essential to provide continuous user-oriented, costefficient and appropriate training at all levels.
3.3
Informatics in education and training
Many countries suffer from a shortage of teaching manpower, particularly at all levels of health care. In the past few years, informatics has been increasingly used to fill this gap. Special microcomputer programs have been designed to support educational activities for all levels of health manpower, from physicians to community health workers. These programmes have increased efficiency and reduced the costs of learning. Experts believe that informatics support of education and training could play a major role in the future as more and more software become · available for various disciplines and in different languages. At present, the pace of informatics development is beyond the capacity of institutions dedicated to preparing health professionals to absorb this technology. The challenge facing health institutions is to adopt and adapt computer-assisted training methods to their current curricula.
3.4 Implications of the use of health informatics An automated information system that can rapidly collate, process and analyse thousands of items of data clearly offers a powerful tool to health managers. The urgent need for an increasing amount of reliable, relevant and timely information in health management can be met by this technology, which is now less costly and more widely available. Informatics and telematics open up the possibility of worldwide access to medical and scientific information, supply word processing support, and provide the capability for complex record linkage and retrieval networks with telecommunications linkages. The potential and advantages of these advances are self-evident.
WPR/RCJ8/Technical Discussions/2 page 8
3.5 Constraints on the use of health informatics Surprisingly, cost is not a major limiting factor. It is rather the response of personnel to the new technology at different levels in the organization and the way in which the new technology is utilized which are the more significant factors hampering the spread of informatics. The ability to process large quantities of data depends on the efficiency and accuracy of methods by which data are collected. Furthermore, the data collected must be relevant and of use. Overzealous collection of irrelevant information that is not effectively utilized can quickly give rise to resentment and an uncooperative attitude on the part of field staff, who find themselves burdened with the collection of apparently useless information. The end result is the generation of unreliable and incomplete information and all its attendant problems. To overcome those difficulties, not only should the data to be collected be carefully selected to ensure it is utilized, but there should be some regular feedback to the periphery to demonstrate to the collecting personnel that the data are being utilized. Field staff should also be involved early in the planning process and included in special training sessions before computerization is undertaken. To facilitate data en try, it is also important to review the method of data collection and recording in order to make the process of data entry as easy and as rapid as possible. Complex recording and lengthy transmission times rapidly lead to a breakdown of the recording system. Problems can also be encountered at the higher levels of health administration. Health managers, particularly middle-level managers, may prove resistant to proposals to introduce new systems which, in the transition period, are likely to be disruptive and demand extra staff time and resources, unless they are convinced, through their own involvement in the planning process, of the advantages the new systems offer. Communication difficulties between health managers and informatics experts can lead to the organizational isolation of the latter. This in turn may result in inadequate use of the available computer systems due to poor understanding of the nature and benefits of these systems. Resistance to change at lower levels can also result in the old systems of data collection being maintained in spite of the introduction of computer-based technologies. In order to minimize these misunderstandings, it is essential that management at all levels, including top management, should be actively involved, from the very outset, together with their informatics counterparts, in the planning and development of new systems. This partnership approach should extend throughout the
WPR/RC38/Technical Discussions/2 page 9
organization. Only in this way will management and staff acquire adequate skills and an understanding of the capabilities of the new processes, thus ensuring that the data collected are effectively assessed and acted upon at every level.
4.
MANAGEMENT OF HEALTH INFORMATICS
Setting aside the technologically more advanced countries in the Region, the other Member States find themselves on the threshold of a new- technological age in which the rapidly expanding know-ledge and applications of health informatics could soon revolutionize the day-to-day practice of medicine and management of the health enterprise as well as health and medical education. 4.1 National health informatics strategies and standards
Because of the pervasive nature of health informatics, affecting as it does every facet of health care, decision makers at the highest administrative level need to concert their efforts to ensure that health informatics is integrated in an orderly fashion within existing health information systems and management structures operational in their countries. This should be done to avoid waste of scarce financial and human resources, duplication of · efforts, incompatibility of systems, not to speak of downright confusion and chaos. For these reasons, it is essential that each Member State take the necessary steps to formulate a national health information systems policy which includes strategies for automation and computerization. To ensure that such a policy plays a key role in the development of health information systems including informatics and saf'eguards its effective integration ·in existing health care management, the policy should be in harmony with existing national health policy or plans. The need to set standards should be one of the main purposes of formulating such a policy. Among others, the standards to be considered should be applied to: ( 1) Technological aspects. The rationale is that this would allow for the easy interchange of data and programmes between various areas of health activities, regardless of organizational level. Straightforward issues such as choice of hardware/ software are obvious, but the policy should also set guidelines indicating how state-of-the-art applications are to be reviewed and define mechanisms for deciding how and when technologies or applications should be introduced.
WPR/RCJ8/Technical Discussions/2 page 10 (2) Data management aspects. As data are collected from a wide variety of sources and are aggregated at several levels, it is essential that clear guidelines on the quality and quantity of data be spelt out. This consideration cannot be overstressed as the output data, of necessity, are affected by the quality of raw data entered into the computer. Prior to or with the introduction of health informatics, existing mechanisms of information collection as well as the types of information that are collected should be critically reviewed. The full potential of health informatics, which does not become apparent until some time after its introduction, can only be realized if the underlying information systems are well designed and appropriate to local conditions. Well-designed systems allow for data collection practices to be rationalized. For example, data can be separated into a common data base, of use to all health care users, and specialized data bases, specifically for use by particular health programmes. (J) Manpower aspects. The policy should define standards for recruitment of specialist personnel, whether local or from overseas. If a decision is made to restrict recruitment to local staff only, the extra training that might be required could affect the timing of implementation of health informatics. As the work force trained in health informatics represents an important investment in human resources which could be critical for the country's development, it is very important that the policy should set employment standards, especially to ensure staff retention. Issues such as professional behaviour, codes of practice and technical competence and confidentiality should be defined. 4.2 Informatics personnel development
Looking at personnel in relation to informatics, one has to distinguish between various user types. First, there are the end-users whose knowledge of computers is nil or very superficial (these may be community health workers or senior health policy makers); second, there are various levels of informatics specialists; third, there are the data entry clerks for capturing health data for further analysis. The latter just need a basic technical training of a few hours provided they can read and write and have learnt to use a typewriter keyboard. Personnel development for specialists is a long-term obligation. Even the training of basic computer programmers or systems analysts requires several months of training after graduation from a secondary school. A few highly educated specialists will also be needed to serve, guide and plan systems development in close cooperation with health care management. As this training process takes years, some countries may have to import this specialist manpower for the next decade through international organizations or through bilateral contacts.
WPR/RC38/Technical Discussions/2 page 11/12
Education and training of end-users at all levels are essential for the success of any system. No computer system should be installed in the health care system without close cooperation with end-users and after providing adequate trai ning to them. 4.3 Administrative and financial requirements
Informatics should be introduced into the national health care system in a developing country as an integral part of a national health information policy. This policy should provide a framework for the introduction of health informatics and its expansion within agreed budgetary and administrative support constraints. Although the costs of microcomputer equipment are low in relation to mainframe computers, the number of microcomputer systems required as well as . maintenance costs demand continuous financial monitoring. Registers of the types of hardware and software systems used, reflecting the numbers of microcomputers and the diversity of the programs involved, should be established and maintained to ensure management control over these systems. As mentioned earlier, personnel development is a long-term obligation. As a consequence, there are continuing and sometimes substantial costs for informatics training at all levels of the health system. Besides implementation costs, there are other expenses which have to be considered. As modern microcomputers are often amortized over a period of three and eight years, financial provision for their replacement is necessary upon purchase of the equipment. The successful use of health informatics in the long run depends - as with any other health technology on continuous and careful administrative and financial control.
WPR/RC38/Technical Discussions/2 page 13
BIBLIOGRAPHY Kalman, R. E. , ed. :;.R~e.~:~.g::io:::,:n~a~l=::.._....,!c:;!o~m~p~u~t::::e~r-.!::.co~o~p~e:::.:r~a~t::;i~o::;n~..::i~n~~d~e..:..v~el: o: :.Jpr::.:i!:.!n:!f>.g countries. Amsterdam/New York/Oxford, North Holland Publishing Corp., 1984. Microcomputers and their applications Boulder, Colorado, Westview Press, 1986. for developing countries. ISBN 0-8133...:7252-6.
Perez de Talens, F. et al, ed • .::H~e=a:.l.::::th==---==.:..==::..r:.:=--.::.:.;..,.....::=..:,.;=;.:..r::::= countries: Experiences and viewpoints. North Holland Publishing Corp., 1983. Peterson, H.E. and Isaksson, A. I., ed. The computers in the doctor's office, Amsterdam/New· York/Oxford, North Holland Publishing Corp., 1980. Present and potential uses of informatics and telematics in health, (WHO document ISS/86/36), 1986. Report of the Working Group on Application of Informatics in Health, Manila, 20-24 April 1987.