How HIE improves health-care services for a country?
A Journey towards Digital Health.
Before I Start
Well, Before I jump into what/how/why, Let’s go through a small story about a person in my village.
Few days back my neighbour who is 42 years old, started feeling pain in his chest. In villages people don’t run to hospital as soon as they find some problem. First, They try to figure out how serious the problem is? He did the same, got some painkillers and waited for two days. After two days, he went to the district hospital. Here is the part of conversation between doctor and patient:-
Doctor:- For how many days have you been facing this ?
Patient:- 2 days.
D:- Is this the first time you faced this problem?
P:- Around 2 weeks before I faced the same problem. I was at a different place for some work. I went to the district hospital there. Few tests and x-ray or ultrasound was done and few medicines were given.
D:- Do you have the reports for those with you?
P:- No. I don’t have it right now, but I remember the results were normal.
D:- You will need to get these tests done again. I can’t be sure without looking at the reports myself.
Above is not the only problem which we face when we visit the hospital.
- The medical terms we can’t explain verbally to the doctors. It’s better if it’s written by a doctor on paper, which the other doctors can refer.
- Even if it is written on a paper, it is hard to keep it safe. You never know which of these you are going to need when. It’s better to store in a computer at hospital, so next time when patient visits the hospital it can be retrieved from the computer.
- Even if it is stored in a computer at the hospital, in above case patients will have to keep the papers in case of going to different hospitals.
What if the records entered in one hospital, same can be accessed on other hospitals as well.
That is one of the primary objectives of HIE(Health Information Exchange) and that’s what we have built here in ThoughtWorks.
What is HIE(Health Information Exchange):-
HIE is a system which is responsible to electronically move clinical information among various health-care systems.
Primary objectives of a Health Information Exchange (HIE) is the consistent integration, aggregation and communication of diverse health-care information. HIE facilitates access to and retrieval of clinical data to provide safer and more timely, efficient, effective, and equitable patient-centered care.
All the data collected in different health-care systems will be stored in a central repository of HIE. This clinical data can be retrieved by any health-care system according to their need. The HIE system built by ThoughtWorks, is a platform to integrate various hospital systems and stores country-wide clinical information for every patient.
We have been working with Bahmni (An EMR system built by ThoughtWorks) as hospital systems. However HIE can be connected to any EMR system.
How the HIE is useful in a country ?
HIE is useful for different kind of people in different ways:-
- Patient: Portable and easily accessible health records
- Doctor/Practitioners: View patient’s clinical history to make a clinical decision.
- Health Authorities:- For Public health surveillance which is needed for administrative decisions. The reporting systems are useful for decision making.
- Insurance Payers:- Health Coverage.
Why a country should have the HIE ?
Below are the things the HIE provides
- Digital Health Record:- Along with introduction of HIE, hospitals will be moving towards the use of EMR Systems. This reduces the manual work for people in hospital and keeping paper records of patients.
- Lifetime Clinical History:- All the hospitals will be connected to HIE. On first visit of patient, the patient will be created in HIE. On subsequent visits all the records will be added to the same patient in HIE, which helps to keep lifetime clinical history at single place.
- Improved public health reporting:- HIE will store all the clinical information across the country. It can be used for reporting on national, state and district level. This will be helpful in making decision for officials.
- Secured Health Information:- To access information stored in HIE one need to be authenticated and authorised. HIE has got Infrastructure security of different level and type. There are policies for “by whom and how the data can be accessed”.
- Designed for low resource settings:- While designing the architecture we considered that hospitals might not have very good resources. This included availability of electricity, internet connectivity, hardware and human resource limitations.
- Flexible Design:- The HIE has been designed in such a way that it can be integrated by any EMR. The HIE components are not very tightly coupled with each other and can be replaced by other components.
HIE Components:-
Here is an image with components of HIE:-
Below is brief information about components:-
- SHR(Shared Health Record):- SHR is one of the systems in HIE storing patient’s clinical information.
- MCI (Master Client Index):- SHR identifies patients through another system called MCI (Master Client Index). MCI is responsible for storing general information about patient. E.g. :- Name, Address, Phone Number. It provides a Unique HealthId to each patient. MCI can identify a patient by other identifiers like NID, BRN, UID, location etc.
- Terminologies Registry — Manages all terms against coding systems to maintain data consistent across the hospitals. E.g. Diagnosis, complaints, symptoms, tests, drugs etc.
- Provider Registry — Manages all health care providers(e.g. Doctors, Nurses and others) in the system.
- Facility Registry — Manages all facilities(e.g. Hospitals, Clinics) in the system.
- Location Registry — Assigns a geo-location code in a hierarchical manner for all regions.
- Identity Provider — Manages all the users and access for all HIE Systems.
- Datasense — This is a service which is responsible for aggregating all data for reporting and analysis.
- Patient Journal — This is a patient record viewer, where a patient can view his/her own clinical history.
There are few questions which comes to mind after reading all above things:-
How the HIE actually works ?
All the hospitals across the country will be connected to HIE. When a patient visits the hospital, the records will be entered in hospital system. The hospital system will be connected to HIE and will send these records to HIE. When you visit another hospital you can get the same records from HIE. You add new records and these as well will be sent to HIE in addition to existing records for the same patient.
Does this mean the hospitals will need to have an internet connection all the time ?
Not really. They need not to be connected to internet all the time. The design of system is in a way that whenever there is an internet connection all the new records will be sent to HIE.
That’s good! But how the system identifies the patient?
As soon as a patient is registered in HIE a unique identifier Health-ID will be assigned for that patient. This is unique across the country. When revisiting the hospital the patient will be identified by this ID in local hospital computer.
I have been referred to another hospital. How the other hospital will get my records ?
When the patient visits a new hospital for first time, he/she can be searched in HIE with Health-ID and download the records in local hospital system. Now the new records can be added for same patient. This process will require internet connection at that time.
But I can’t remember my Health-ID? Now what to do?
Well! While registering if the patient has given National-Id/Birth Registration Number/Phone Number, the same can be used to search for the patient in HIE.
Am I supposed to remember the Health-Id forever?
Not Really. With the help of Bahmni we provide a way to print the Health-Id card for every patient. The patient can carry this card to the hospital. These cards have Bar-Code representation of Health-ID which can be easily scanned.
I’ve lost my Health-ID card, now what I am supposed to do?
You lost your Health-ID card, no worries. No one is going to sue you because you lost a piece of paper. You need to visit the nearest hospital and they will be able to print a new Health-ID card for you.
We have health-workers who go on the field in villages and visit patients, how they are supposed to work with HIE?
HIE is designed in a way so that hospital systems can continue working without internet. This gives us freedom to capture records in mobile devices even if they are out of internet. The records will be sent to HIE whenever they have internet.
I am visiting a new hospital, where internet is not available right now. How my data is supposed to entered in system ?
If the system doesn’t have the same patient locally and there is no internet, a new patient can be created in current hospital. Whenever internet available these details will be again pushed to HIE and HIE will create a new patient. However if HIE detects the same records for patient i.e. same national-id or same birth-registration-number or same name and address, it marks them as possible duplicate patients. An Admin can merge these duplicate patients which will merge all the records of these patients in HIE.
Patients mostly registered by health-workers often visit the hospital nearby. In case of not able to download on that time we will end up creating a lot of duplicate patients. Isn’t that a big problem?
Given the fact a patient will mostly visit a hospital which is close to them, The HIE is designed such a way, that hospital will automatically download all the patient records which belongs to it’s area(catchment). A sub-district hospital will download all the patients in that sub-district and a district hospital all the patients in that district and so on.
If HIE stores my lifetime clinical records, can I check what was the last time I got Tetanus Injection?
Yeah! Otherwise there is no point in just storing the records if you can not view them. HIE provides a web portal where a patient can login and view all his clinical history.
Fabulous! Since there is a lot of information stored in the HIE. Can we use that for some other purpose as well?
Why Not! We can use this for reporting and visualisation. Right now HIE sends data to DHIS forms. It can be configured to send data per hospital/clinic on District/State/National level.
The above will give an idea about how is the workflow of HIE as a system. If you have more questions there is always the option to explore.
In the End…
Well! That’s more or less about what is HIE and why a country should have it. As of today the HIE is deployed in Bangladesh and a district and a sub district hospitals along with few clinics are connected to HIE.
With this I will end my blog. I will be writing another blog explaining The Journey of HIE in Bangladesh. 😊
Disclaimer: The perspectives and sentiments communicated above are close to home to the author and not necessarily mirror the places of ThoughtWorks.
