Integration and interoperability

1. Integration and interoperability

2. The Problem: Unify and integrate fragmented structures and information flows - The health sector is “crippled” by uncoordinated vertical structures DNHDP Western Cape City Health Births Deaths Notifiable diseases New /emerging flow of information City Health Clinic 3 City Health Clinic 1 Groote Schuur Hospital Outside hospitals City Health Clinic 2 City Health Clinic 4 School Health Geriatric Services PAWC MOU (Midwife& obstetric unit) PAWC Day Hospital DNHPD City Health Clinic 5 DNHDP Pretoria Private hospital: 31 medical specialists Psyciatric hospital PAWC Environmental office Dental unit 1 PAWC 54 private medical pract. RSC Dental unit 2 PAWC 23 private dental pract. UWC Oral Health Centre Dental unit 3 PAWC 12 private pharmacies 12-15 NGOs Mandalay Mobile clinic RSC Youth Health Services MITCHELL’S PLAIN Apartheid legacy: a fragmented and top down health structure no local governance & control of information

3. / HISP Botswana: Pre-intervention – Fragmentation – No shared IST resources “converging” at district level - Fragmentation at central level IDSR – Notifiable Diseases EPI Home Based Care ARV Health Statistics PMTCT STD Nutrition Nutrition Family Planning MCH HIV/AIDS School Health TB Mental Health And more … District - DHT Facility 1 Facility 2 Facility 3 Facility n

4. / HISP Botswana:integration at District & National levels IDSR – Notifiable Diseases EPI Home Based Care ARV Health Statistics PMTCT STD Nutrition Nutrition Family Planning MCH HIV/AIDS School Health TB National HMIS Stat. unit Mental Health And more … District HMIS Facility 1 Facility 2 Facility 3 Facility n

5. HIS Integration Integration • The process of making multiple subsystems appear as one single system • Includes data, organizational behavior, workforce, and policies • Must be sustained over time through routine processes, and is not a one off technical process (institutionalization) Example • District HIS designed to enable collection, collation, and analysis of HMIS & disease surveillance data across different subsystems

7. Benefitsofintegration Value added to the data • New indicators possible • Enables cross-comparison, correlation checks • Ease of access Cost efficient • Professionalizing information management (e.g. cloud computing) • Pooling of resources (financial, human) • Economies of scale • Centralized technical support

8. Integrated Human Resource & Health service data

9. Chiefdom leaguetable from Moyambadistrict Malaria Deliveries Nutrition Data Quality Antenatal Immunization

11. Data Interoperability Data Interoperability / syntactic/ technical • Essential component to achieve integration • Interoperability uses standardized data definitions for data exchange among sub systems Example • Shared data definitions among data collections tools (paper or software) across different subsystems, and standards for exchanging these data (XML)

12. IntegrationStrategy Top-Down vs Bottom-up Social Redesign Build on local systems Disruptive perspective Evolutionary Perspective “Build from Scratch” Soft Hard User involvement Technology

13. Enterprise architecture & architecting • What is Architecture in our context? • Similar to architecture of buildings, towns, etc. A systematic way to design and plan development and integration of Information Systems • Why Enterprise architecture? • Overall view across health programs and structures in health care. The whole “enterprise” Counteract fragmentation and promote integration • Standardisation? • Prerequisite for integration and interoperability. Without shared “understanding” and meaning, no interoperability or integration, be it within social or technical systems! • Tensions between Standards and Local Flexibility => Essential Data Set

14. Patient records Institutional use of information DHIS Data warehouse Aggregate data iHRIS Open MRS Applications supporting use of information Data & indicator standards SDMX-HD Facility list SDMX-HD Data Standards and infrastructure supporting the applications

15. National District based Integrated data repository DHIS Open Health CRIS Other data sources –programs Statistical data “numbers” DHIS DATA DICTIONARY/ CONCEPT REPOSITORY DHIS Translation & aggregation SDMX-HD Exchange standard HR records “names” iHRIS Open MRS Vertical & Horizontal Integration Low Granularity Vertical: Through levels of aggregation & Translations & use From HR /patient records, to national & global reporting on MDG indicators Horizontal: Across health programs, Services & agencies at each level High Granularity

17. Interoperability and integration require standards Standardisation & interoperability may be seen as going on at 3 levels of increasing complexity Compared to telephone conversations: - Shared interests? -Interested in talking? -Shared language and Shared understanding? -compatible telephones & networks? 3 Levels of (achieving) Interoperability/ Standardisation: --Organisational/ Political /pragmatic --Semantic --Syntactic /technical Increasing differences between views Programs / donors /agencies Agree to standardisation Shared / agreed indicators & meta data Increasing complexity Increasing complexity Unique id. SDMX-HD, etc. Standardisation process: cycling through the levels. For each level, “solutions” based/running on solutions at level below, and rely on agreement at level above

18. Example Sierra Leone • Point of departure • Fragmented information & Poor data quality • 1st step : Integrate data reporting • Use existing data in District /National database repository & Demonstrate integration is possible and useful • Revise data reporting forms & structures • 2nd Step : “Vertical Integration” • Patient record system (OpenMRS) for HIV /AIDS • Export aggregate patient data to DHIS • (In the making) Human resource management (iHRIS) • Export aggregate HR data to DHIS

19. Point of departure Sierra Leone:Fragmentation of information • National: • Fragmented info • Difficult access All programs own systems Directorate of Planning & Information National Statistics Office IDSR EPI HMIS RH/FP TB HIV Census • District: • Fragmented data management • Paper-based transcription and transmission • Not fully dis-aggregated Surveys RH/ FP Outpatient services & morbidity IDSR TB HIV EPI District reports compiled by hand • Facility: • Many reports • Little feedback • Little use at facility • No hospital reports Outpatient services & morbidity RH/ FP Hospital IDSR TB HIV EPI

20. Information use HIS office DHIS:National data repository Integrated data management Feedback Data and tools available to all staff Other districts reporting to national Information use HIS office DHIS: District data repository Integrated data entry Feedback Health facilities and hospitals reporting aggregate paper forms to HIS office at district Information use Harmonised paper forms HF1 HF2 HF3 HFn ….. Sierra Leone: 1st stepintegratedarchitecture- aggregate data from all programs & services (horizontalintegration) National Level District Level Facility Level

21. Sierra Leone: 2nd step Integration & interoperability Others DHIS Interoperability OpenMRS iHRIS <... Integration ...> Patient records Human Resource