UNIT CODE; HEALTH INFORMATION SYSTEMS - I

INTRODUCTION HEALTH INFORMATION SYSTEMS

What is a health information system?
1. Health Information has been defined as information about people’s health and how the
community, government and non-governmental organisations use the information to plan and
provide health care and services.
2. Health information describes the incidence, prevalence and causes of major diseases. It also
tells us about the availability and the effectiveness of curative services.
3. It has also been defined as a system that collects and presents health information and is
responsible for creation and maintenance of a data base.
4. Another definition of health information is that it refers to organised and interpreted data about
health status, resources, activities and events as related to health.

• System
Definition: A set of interrelated elements each contributing to the accomplishment of an aggregate.
The elements and relationships consist of resources, technologies, activities and actors
A health information system does not exist by itself. Health information has been variously
described as the “foundation” for better health, as the “glue” holding the health system together,
and as the “oil” keeping the health system running (Lippeveld T, 2001). There is however a broad
consensus that a strong health information system (HIS) is an integral part of the health system,
the operational boundaries of which include: … all resources, organizations and actors that are
involved in the regulation, financing, and provision of actions whose primary intent is to protect,
promote or improve health (Murray C, Frenk J and WHO, 2000).
It is universally accepted that health information is essential for health decision-making at all levels
of the health pyramid. From the level of individual patient care, to the management of specific
health programs through to the policy level where strategic decisions are made information is an
integral part of the health pyramid. The health information system has been aptly described as “an
integrated effort to collect, process, report and use health information and knowledge to influence
policy-making, programme action and research” (WHO, 2000).

Historical development of Health Information System

• In 1970, the MOH became conscious of the need for more useful data to assist in
formulation of health policies, the setting of priorities and the evaluation of health care
programs
• 1972 - A committee comprising of representatives from CBS, MOH, AG and WHO was
set up. Their task was to establish an HIS for Kenya
• A pilot project designed and tested in Mombasa which represented urban districts, Kwale
represented peri-urban districts and Kitui represented rural districts
• 1974 – the idea of an HMIS was conceived with the creation of vital statistics unit
• 1975- the creation of an evaluation and research unit
• The project was completed in 1976 with the following two major recommendations
 – Merge the section of Vital and Health Statistics of the Division of Communicable
Diseases Control and Research and Evaluation section of the Division of Family
Health into one entity-The HIS
– Remove the prefix MED in our data collection and reporting tools and replace it
with MOH along the number.
• Med 800 - Outpatient Register
• Med 801 - Outpatient card
• Med 802 - Outpatient tally sheet.
• Med 803 - Immunization tally sheet.
• Med 804 - Monthly Laboratory report
• Med 901 - Discharge sheet.
• Med 902 - Outpatient Monthly Activity Report.
• Med 903 - Immunization summary
• In 1978, KMTC Nairobi started a two-year professional course on Medical Records
Technology which boosted the HIS to a greater extent.
• HIS Department -1980
The functions of this department were:
o Collection, processing, and analyzing of health and management
(administrative)data
o Improvement of quality of health data, review and modify where necessary the
reporting system to enhance the utilization of data by end users
o Assist in the training of health personnel in medical records keeping and
programme evaluation techniques
o Dissemination of health information to end users within the Ministry and other
relevant organization
o HIS was also charged with the task of providing other departments within MOH
with the information necessary for planning purposes
o Function as a data bank for various types of data in the Ministry of Health

• In 1982, another committee of professionals was appointed to review and evaluate the
system to establish the accuracy and relevance of the data collected by the system
• In 1984 – in response to the National Policy on District Focus for Rural Development, HIS
decentralised is services by establishing offices in all districts
• In the subsequent years, disease specific programs emerged, each with its own HIS, a
process that weakened the system and went against the goal. Efforts to integrated the
system were initiated to again strengthen the central HIS and hence the integration and
revision of data collection and reporting tools. The process has reduced the tools due to
identification of core indicators.
• All along the district health reports were manually compiled and posted to the MOH
headquarter (HIS) before 15th of the preceding month. Computers by then were dreams to
many organizations.
• In 1990, KMTC Nairobi initiated a diploma class in Health Records and information
officers basically for in- service officers. The 1st batch of pre- service 3-year course HRIO
class commenced the following year.
 • In 2008, the department of HIS came up with a reporting system which embraced sending
of health care reports electronically. It had series of data sets which were summarized and
sent through file transfer protocol (FTP). Every district had its own rights to access the
data in FTP though this was purely DHRIO business.
• In August 2009, the first bachelor degree course was initiated in Kenyatta University.
• In 2010, a new system of reporting came up and has to date been adopted by all districts
in Kenya. It actually replaced FTP and has managed to integrate all reporting systems. It
borrows from different systems to enhance a strong and comprehensive database for
decision making. Constant improvements are still going on to make it even better.

Goal of health information systems

The goal is to develop and maintain an accessible and comprehensive health information system
which is flexible to the needs of patients, health care providers, health managers, evaluators and
other allied health personnel.
However, what is clear is that health information is much more than the collecting of data. Data
have no value in themselves – value and relevance come only when they are analyzed, transformed
into meaningful information, and used

The objectives of Health Information systems:

➢ Provide quantitative and qualitative data which is essential for identifying major health
problems
➢ Generate information which can be used to evaluate health policies for planning health
programmes and the efficient management of health services
➢ Open up a continuous dialogue between those who collect and the users of information
with the aim of improving health services
➢ Disseminate timely information to users, including those who work in research and health
administration
➢ Provide regular feedback to all personnel in the information system which helps to
emphasize the important role each of them plays
➢ Create and maintain a health information data base at district
➢ Health information as part of PHC is required for health planning, monitoring and
Evaluation of health programs

The ultimate objective of a health information system is to produce information for taking action
in the health sector. Performance of such a system should therefore be measured not only on the
basis of the quality of data produced, but on evidence of the continued use of these data for
improving health systems operations and health status (RHINO, 2003).

This principle applies at all levels – at the level of patient care, at the health facility, and at the
community, district, national and global levels. A health information system is not a static entity
but a process through which health related data are gathered, shared, analyzed, and used for
decision-making – information is transformed into knowledge for action. These principles also
apply to all countries, whatever the level of income and degree of sophistication of the health
system. Nor are the boundaries of a health information system confined to health – there is a strong
interdependence between health information systems and information systems in other sectors.
For example, higher levels of female literacy are associated with higher compliance with home
treatment for diarrhea/dehydration in infants; improved sanitation is associated with increased
child survival; food and nutrition policies affect the health of children and adults alike. Making
links such as these and identifying broad areas of data common to health and other sectors is
properly within the responsibility of a health information system.

Domains of health information

The domains or areas of interest that a health information system should address can be grouped
into four main types
• Health determinants – socioeconomic, environmental, behavioral, and genetic factors and
the contextual environments within which the health system operates.
• Health system inputs – the structures and processes of the health system (policy and
organization, health infrastructure including facilities, human and financial resources, and
health information systems.
• Health system outputs – the quality, use and availability of health information and services.
• Health outcomes – mortality, morbidity, disease outbreaks, and health status.
Health information subsystems
A health information system can be considered to consist of several separate subsystems:
• Disease surveillance and outbreak notification.
• Data generated through household surveys.
• Registration of vital events and censuses (births, deaths and causes of death).
• Data collection based on patient and service records and reporting from community health
workers, health workers and health facilities.
• Programme-specific monitoring and evaluation (for example for TB, HIV/AIDS, and EPI).
• Administration and resource management (including finance/budget, personnel, and
supplies).

The function of a health information system is to bring together data from all these different
subsystems, to share and disseminate them to the many different audiences for health information,
and to ensure that health information is used rationally, effectively and efficiently to improve
health action.

A strong health information system is an essential component of sound programme development

and implementation, and is a prerequisite for strategic decision-making – ultimately, it provides
the basis upon which improved health outcomes depend. In theory, a health information system
consists of a process of gathering, sharing, analyzing, and using health-related data for decision-
making – information transformed into knowledge for action.
1.2.3 Who are the main actors in the health information system?
A health information system should generate information for different uses by different health
system actors.
Some of these actors operate at macro-decision level (for example, strategic planning, allocation
of resources, and evaluation) while others operate at micro-management level (for example, case
management, programme management, administration, and deployment of human resources) as
shown in figure 4.

Figure 4 - Levels of production of health information

and use of health information

Strategic
Global
Information
Regions
Policy-making

Countries
Programme
monitoring Provinces
and evaluation
Districts

Patient care
Facility Communities Facilities
Management

The kinds of information required by each type of health system actor differ in ways such as degree
of reliability, levels of aggregation, levels of detail, and diversity of topics. Given the range of
actors involved and the diversity of potential data items, it is imperative that the health information
system has the following interlinked characteristics:
• The ability to identify detailed and disaggregated information items useful for decision-
making at various levels within the health care system that are also immediately relevant at
the level of data collection.
• The ability to screen and channel to central level only what is most essential and detailed
enough for strategic decision-making and policy analysis
Users of health information
At each level of the health care system, users of health information have differing needs and use
information in different ways. At the most basic level of client–health worker interactions,
patient records are a vital source of information, whose utility is not confined to the individual
level. Record reviews can be used to ascertain the extent of conformity with agreed norms and
standards of care. Confidential enquiries and facility-based audits review provider practices in
order to determine to what extent care could be improved and the degree to which deaths were
avoidable and the potential policy implications of such avoidable factors.
At the facility level, managers need information on patient profiles, patterns of admissions and
discharges, length of hospital stay, use of medicines and equipment, deployment of different
categories of health care workers and ancillary staff, costs and income. At district level, planners
and managers use this information and data on locally relevant population profiles and risk
factors in decision-making regarding allocation of resources to different facilities. Within the
public health sector, such information is transmitted upwards through district and provincial
levels to the national level where basic resource allocation decisions are made. More problematic
is the extent of such reporting by the private sector – unless there is a strong regulatory
framework within which the private sector operates, it is unlikely that such information will be
transmitted to the planning authorities. Districts should try as much as possible to encourage all
health providers to submit their service data.
Although the health information generated through the reporting of routine activities by health
care facilities and health care workers provides important and useful information on the activities
of the health system, this is insufficient for strategic decision-making regarding the allocation of
health resources. Decision-makers need information not only about service activities and users of
services, but also about those who for whatever reason do not use the services. This information
is generally harder to come by than routine service statistics. Health care facilities may undertake
special studies of their catchment populations in order to ascertain demand or need for
information and services. More often, such information is derived from household surveys in
which people are asked direct questions about their perceived need for and use of health care
services. The major advantage of using household surveys for such information is that it is
possible to obtain socio-economically stratified information on use of all types of service,
including the private sector (modern, private-for-profit, private, non-profit, traditional providers,
social marketing outlets, pharmacies, etc.). An important disadvantage, however, is that
household surveys are generally undertaken at national level and for reasons of costs, sample
sizes are generally insufficient to permit detailed analysis at the district level.
When making strategic health sector decisions, national level authorities use health-related
information from sources such as routine service statistics, household surveys, vital registration,
census, national accounts, and education and employment data (particularly with regard to the
production and availability of human resources for health). One visible manifestation of this
process is the reporting at national level of progress towards national health-related goals such as
reductions in child mortality or reduced disease transmission.
National authorities also report health-related information to international bodies such as the
United Nations. Increasing interest in the performance of national health systems has been
stimulated by the goals-oriented international conferences of the 1990s, summarized in the
Millennium Development Goals, endorsed by 189 heads of state and government in 2000. The
progress made by countries towards these and similar goals is of interest to donor agencies and
governments desirous of tracking the extent to which external assistance produces tangible
results in terms of improved health.
This rapid overview of the different users of health information at different levels demonstrates
three important principles:
 • Different types of health-related data are needed at different levels of the health care
pyramid – not all items of information need to be reported at every level.
• Those working at the periphery, closest to patient management, need more detailed
information on clients seen and services provided than those working at the central level.
• In order to avoid overburdening health care workers at the peripheral level, managers and
planners should consider carefully what type of data should be generated at each level,
bearing in mind that to the extent possible, those collecting and transmitting data upwards
through the system need to understand and appreciate why the data are required.

Investing in the development of effective health information systems would have multiple
benefits and would enable decision- makers at all levels to; -

• Detect and control emerging and endemic health problems, monitoring progress towards
health goal.
• Empower individuals, communities and women in particular with timely and
understandable health related information.
• Strengthen the evidence-based decisions for effective health policies.
• Improve governance, mobilize new resources and ensure accountability in their use.
• Frequently monitor short-term programme outputs and support performance-based
resource allocations;
• Enhance reporting of health outcomes to monitor MDGs
• Provide a foundation for sound informed decision-making.

Importance of HIS
• Helping decision makers to plan, monitor & evaluate, detect and control emerging and
endemic health problems, monitor progress towards health goals, and promote equity;
• Empowering individuals and communities with timely and understandable health-related
information, and drive improvements in quality & coverage of services;
• Effective and efficient use of the limited resources;
• Strengthening the evidence-based decision for effective health policies, permitting
evaluation of scale-up efforts, and enabling innovation through research.
• Improving governance, mobilizing new resources, and ensuring accountability in the way
they are used.
• To know benefits/profits or losses of a project.
Advantages of a functional HIS
• Information is readily available when requested or required, avoiding the last-minute
rush to look for data.
• Policy makers and managers of programs use the information for health and
development planning and implementation and are sensitized on importance and effective
utilization of information
• Resource mobilization and allocation. once data is readily available it is easy to project
the required resources by extrapolating from the past trends with a fairly good accuracy.
Rule of the thumb should not be norm or the practice.
• Monitoring trends: - Disease surveillance is functional and it is thus easy to predict the
occurrence of epidemics of diseases.
• Problems and gap identification: - Various departments and institutions becomes part
of the system; there is collaboration and coordination among various actors.
• The work and duties of the staff that are involved in the system is appreciated and
recognized.
• Ad-hoc surveys and consultancies are avoided.
• Decision making and priority service setting.
• Operational research and training become easy and enables quick retrieval of the
evidences in practice and use evidence-based practices for demonstration.
• Monitoring and evaluation of projects and programs will be made easier and alongside
working corrective measures or change of strategies will be realized in the initial stages.
• Donor influence in HMIS is also avoided as in case of reviews.
Characteristics of well-designed HIS
• Collecting less data – collects prioritized/essential data based on indicators on a routine
basis
• Uses the data collected
• Non duplication of data collection
• Interdependence / Integration -various depts., units have to contribute or various player to
cooperate
• Interoperability – ability of the system to communicate with other systems
• Availability of forms/reporting tools (Manual or modern e.g., computers, smartphones,
PDA)
 • Encourages decentralized planning and management
• Support Primary Health Care (PHC)
• Includes all service providers at all levels

1.2.2 The needs and expectations of health information system

Mandate of health information system
• To collect, process, analyze and disseminate health information to users

Vision of the Health Information System

• Be a center of excellent for quality health and health related data and information

Mission of the Health Information System

• To provide timely, reliable and accessible quality health information for evidence-based
decision making to promote the health of the nation

Policy goal
• This policy seeks to enhance availability of comprehensive quality health and health related
data and information for evidence-based decision making. It seeks to address such issues
as partnership in data collection and information sharing, guidelines and data processing,
and data warehousing as well as instituting standardized mandatory reporting by all care
providers and quality in data management in the health sector

Policy Objectives
a) Promote one health information system in Kenya upon which all shall be committed to.
b) Promote use of health information for evidence-based decision making, promote
accountability and empower citizens to make healthy choices
c) Promote collection of sufficient, relevant, reliable and quality health statistical data
pertaining to the health status of the nation, health services coverage and utilization.
d) Promote and encourage production and dissemination of timely, easily understood health
and health related information for evidence-based decision making by managers at various
managerial levels within the health sector
e) Enhance closer co-operation between producers and users of health-related data and
information through regular meetings, seminars, training and publications.
f) Promote reporting by all health-related statistical constituencies through the use of
standardized data collection and reporting tools

Advantages of a functioning health information system:

➢ Information is readily available when requested or required, avoiding the last-minute
rushes to look for data.
➢ Policy makers and managers of programs use the information for the health and
development planning and implementation and are sensitized on importance and effective
utilization of information.
 ➢ Resource mobilization and allocation. Once data is readily available, it is easy to project
the required resources by extrapolating from the past trends with a fairly good accuracy.
Rule of the thumb should not be the norm or the practice.
➢ Monitoring trends – Disease surveillance is functional and it is thus easy to predict the
occurrence of epidemics of diseases.
➢ Problem and gap identification – Various departments and institutions becomes part of the
system; there is collaboration and co-ordination among various actors.
➢ The work and duties of the staff that are involved in the system is appreciated and
recognized.
➢ Ad-hoc surveys and consultancies are avoided.
➢ Decision making and priority service setting.
➢ Operational research and training become easy and enables quick retrieval of the evidences
in practice and use evidence-based practices for demonstration.
➢ Monitoring and evaluation of projects and programs will be made easier and alongside
working corrective measures or change of strategies will be realized in the initial stages.
➢ Donor influence in Health information system is also avoided as in case of reviews.

The link between health information services and the user:

Accurate health information is needed at all levels of the health system including national/ global
/ provincial / regional/ district levels and health facility and community levels. Health planners
and programme officers require information to identify the health problems to define strategies
and to set targets. Development partners, programme implementers and communities need
information to measure the progress of the Programmes and to monitor a selected number of
health indicators. For example, lower mortality rates or fewer episodes of illnesses, malnutrition
rates, immunization coverage, disease prevalence etc.
Stakeholders
Who is a stakeholder?
There are various individuals and field staff who are involved or vested interest in a typical HIS
• Internal
• External
• Influencers
Internal
• HR&IT/Os
• Clinical staffs (nurses and doctors)
• Other paramedics
• Hospital management Team (HMT)
• Supportive staffs
• Patients/beneficiaries
• HMB
External
• CHMT/ and sub-county managers
• Field workers e.g., PHT, field educators, CHWs, CBDDs
• Central ministry / National health managers/ officials
• Community
• Insurance companies
• NGOs, CBOs, DMS, PS (C/Secretary) Policy makers
• Donor, program managers, journalists
• Politicians e.g., governors, ward rep.
• Researchers / investigators
• Other line ministries e.g., civil registration etc.
Uses of Health Information System
H.I is one of the most essential components of health delivery system. It has numerous uses
including: -

1. Parents use height and weight information to monitor nutritional status of their children.
2. Community groups use health information to identify and control environmental hazards
3. Health workers use such information to identify and screen persons who need treatment
4. Clinical staff use patients’ history to diagnose and treat individual health problems
5. Managers use information to maximize program effectiveness and efficiency
6. Administrators use information to identify health problems and audit the use of program
funds and other resources to justify expenditure and future funding.
7. Epidemic control units use information for disease surveillance
8. Donor agencies use information to compare alternative methods of health care delivery
and assess program effectiveness
9. International agencies use health information to monitor progress
10. Health workers use health information system to identify persons needing treatment and
follow up those who miss appointments and seek out those who may be candidates to
special services
11. Health information system help to evaluate the impact or input of programs of health
12. Health information helps the MoH to justify man power training and assess if there is
need to train more workers or employ more
13. Research purposes – research is very vital function in health institutions. Analysis and
conclusions of proper research can come up with recommendations which can be a guide
to any changes concerning the ministry, health facilities or even the community involved

Two principals need to be emphasized about health information collection and use

These are:

- Data flows in systems and is made up of individuals and departments. If one unit is weak,
the entire system suffers.
- Data collection is closely related to data use. Any improvement in the collection of data is
not enough without corresponding improvement in its use. Managers who use data are
more likely to encourage its collection. Health information is a vital resource for health
planning, implementation and evaluation.
- Data users include everyone in health delivery system ranging from individual parents
and patients to national planners and international donor agencies. Uses of data likewise
range from monitoring of individual health and nutritional programs, evaluation and
long-term policy development. It is absolutely essential to be selective and identify
priority areas for data collection, since data collection have limited capacity and data
users have limited interest.
 How data is collected in H.I.S

HIS collects data from all possible sources that have a bearing on health in a systematic way.
The data is processed and turned into information that is used to plan and manage health
services efficiently. HIS therefore aims at providing adequate and timely information for the
determination of health policies and evaluation of health services and programs

The H.I.S should give:

 Good quality and quantity data

 Essential data for identifying agent health program
 Generate good health information for evaluation of health policies for effective
management to health services
 Open up a continuous dialogue between the users and producers
 Disseminate timely information
 Give regular feedback to the producers
 Create and maintain database

Types of data

There are two types of data;

• Primary data
• Secondary data

Primary data is data that has been collected by an investigator himself for a certain objective and
is therefore original in character e.g., POPULATION CENSUS collected by central bureau of
statistics.

Secondary data is one that had been used in an investigation but originally collected by someone
else. Therefore, if someone else uses the data becomes a secondary user. Primary data in the
hands of one person becomes a secondary in another users.
Organization of Health Information Systems in Kenya
• In Kenya, health services are now organized based on:
– Type
– Target group (Cohorts)
– Level
• By Type: The KHSSP III 2012–2017 defines the Kenya Essential Package for Health
(KEPH):
– Promotive
– Preventive
– curative and
– Rehabilitative

• BY Cohorts (target)
KEPH revised Cohorts represent the life-cycle approach to health service management. Each age
group has special needs that relate to the development phase they are passing through. Services
based on 5 life cohorts and cross-cutting category, encompassing the expectations of persons in
Kenya.

– Pregnancy and the new born (up to 28 days)

– Early childhood (29 days – 59 months)
– Late childhood and youth (5 – 19 years)
– Adulthood (20 – 59 years)
– Elderly (60 years and over)
– Cross cutting interventions (All cohorts)

• By Tiers (Levels).

KEPH services defined for each of the 6 cohorts for the newly defined 4 tiers of the Health
System (KHSSP III 2012- 2017) which are interlinked

o Tier 1: Community level

o Tier 2: Primary Care level (Health Centers/Dispensary)
o Tier 3: County level (District /Sub district hospitals)
o Tier 4: National level (Teaching/referral/specialist HF

Tier 1: Community level

This form of health care service delivery, we have community health worker, community
volunteers, CORPS & CHEWs

They facilitate individuals’ households and community carries out appropriate health behaviors.
They also agreed health services, recognize sign and symptoms of a disease, also refer to a health
facility, facilitate community diagnosis

Tier 2: Primary Care level (Health Centers/Dispensary)

Dispensaries, Clinics, Maternity Home, Health Care Centers

Functions

• Disease prevention and health promotion services i.e., immunization

• Health promotion services – health education, awareness.
• Basics of patient diagnostics.
• Medical/ Minor surgery.
• Rehabilitative services i.e., Counselling, physiotherapy Services.
• Inpatient Services for emergency clients awaiting referral and client observation.
• Normal delivery services.
• Facilitate referral of clients from communities and to other higher tiers.

Tier 3: County level (District /Sub district hospitals)

Former district and sub district hospital which include NGO and private hospital i.e., Thika
Level (V) Hospital and Ruiru Hospital.

Functions

• Comprehensive patient diagnostic

• Surgical and rehabilitative care
• Reproductive health care services:
o Safe motherhood
o Breast feeding
o Family planning
o Parental mother to child transmission
• Specialized outpatient services
• Facilitate and manage referrals from lower levels

Tier 4: National level (Teaching/referral/specialist HF)

Is the highest level of health care which provides highly specialized health care services. It links
up with other national and international health care providers.

Made up of:

• Provincial General Hospital (PGH)

• National Referral Facilities i.e., KNH
• Specialized Health Care i.e., Mathari Hospital
• National Spinal & Injury Centre i.e., Texas Cancer Centre.

Functions

• Provision of highly specialized services

• In consultation with other levels of health and social care, setting national norms and
standards for quality patient care
• Provides specialist outreach and reference support services to lower-level health
facilities.
• Provides clinical and practical training for attached students
• Conducts scientific and operational research.
• Monitors and evaluates and reviews the functioning of the referral system
• Conducts consultative meetings with private health care providers and establish referral
procedures including air transportation of clients
Health Sector Indicators
Define indicators

• Indicators are statistical values which give insight into the quality of health services or
health status.
• A Measurable marker of a change over time
• A Unit of Information Measured overtime that documents change in a specific
condition.

Obviously, indicators are intimately related to activities. Each issue or problem is measured in
terms of indicators which define the magnitude of the problem.

Developing indicators is the 1st step in performing a meaningful analysis of Health Information.

The most useful method in developing indicators for health information is a review of the objective
of the various programs of health services. If program objectives are clearly stated, developing
indicators become a relatively simple task.

Indicators are signs or measures that show the extend of change in a project or organization.
Indicators help measure what actually happened in terms of quality, quantity, and timeliness
against what was planned.

Fundamentally, an indicator provides a sign or a signal that something exists or is true. It is used
to show the presence or state of a situation or condition. In the context of monitoring and
evaluation, an indicator is a quantitative metric that provides information to monitor
performance, measure achievement and determine accountability. It is important to note that a
quantitative metric can be used to provide data on the quality of an activity, project or
programme.

Why are indicators useful?

Very simply, indicators are standardized measures that allow for comparisons over time, over
different geographic areas and/or across Programmes. The ability to compare temporally and
spatially differentiates indicators from raw data, as does the ability to aggregate data for higher-
level interpretation and application.

Definition;

Outputs:

The products or services, which are delivered on completion of the project activities. In other
words: What was done?
Examples of outputs that PEN might use:

• Reading Circles: monthly meetings for PEN members and the general public, with book
presentations, readings and discussion.
• Writers’ workshops where published authors will support participants with ideas and
guidance
• Story competitions in schools

Impact

This concerns longer-term changes that have come about as a result of a project or programme.
Impact can be either positive or negative – both are equally important. What changed?

Impact is an indicator which describes the changes in conditions of the community after a
programme., changes in behavior or practices upon a population as result of the programme e.g.,
increased literacy.

An impact is a long-term result. It can be measured both quantitatively and qualitatively. In

health care Programmes, an impact assessment can be carried out at every stage/phase of the
health care programme in terms of impact evaluation. Impact evaluation is a tool for policy
makers, programme/project planners and programme management. Therefore, impact evaluation
requires information before therefore health care programme begins, during the programmer's
life and after the programme has ended.

Examples;

• Higher attendance at school

• More girls going into work after completing school
• Girls having their first babies later than previously

Outcome

Immediate and observable changes in relation to the project objectives, which were brought
about as a direct result of project activities and outputs. In other words: What happened?

This is an indicator which measures the product of an activity or programme e.g., number of
pupils attending a school. It indicates what changes have occurred and shows if outputs lead to
the expected positive changes.

An out-come is a medium-term consequence occurring after an event. It can be measured

qualitatively in terms of data and reports. For example, the uptake of ITNs by expectant mothers
and children under 5 years that die of malaria disease as a result of not being protected by
sleeping under the insecticide treated bed nets (ITNs) and use of anti-malarial drugs for both the
treatment of malaria and prophylaxis
 • Examples of outcomes that PEN Centre might use:
• Greater interest and enthusiasm for literature
• More and better quality of materials produced
• Changes in amount and quality of press coverage
• Improved levels of literacy in schools
• Improved exam results

Health system elements

Inputs (drugs, funds, infrastructure, and equipment)

Inputs are the data items necessary to generate outputs and reports for management use.
Managers have to weigh the costs and benefits in determining how complete, accurate and
reliable data should be.
Selection of indicators
• No single “best” measure to use in developing data for decision makers.
• The most useful indicators are often those which provide information but limit the
quantity of data collected.
Data collection instruments
• Easy to use
• Avoid duplication of data.
Processes (clinical services, management services, technological process)

Means by which inputs are transported (Data flows) and analyzed to provide useful outputs for
decision making.
Raw data is generally unusable; it has to be transformed through collating, aggregating,
analyzing and presenting on time in legible, understandable formats.
Not all processing require computer.
Manual procedures can be adequate, less complex and less costly.
The flow of data. Data should flow back to the collectors (Vertical transmission) as well as to
line stakeholders/ managers (horizontal transmission) as regularly as they flow up to the top level
of the organization.
Problems in processing of data;
• Computer breakdown
• Delay in producing reports
• Volume of data too high for staff use.
Outputs

The products or services, which are delivered on completion of the project activities. In other
words: What was done?

(Health: persons treated, recovered or died: responsiveness or fairness).

Define and differentiate between impact and out-come?

An out-come is a medium-term consequence occurring after an event. It can be measured

qualitatively in terms of data and reports. For example, the uptake of ITNs by expectant mothers
and children under 5 years that die of malaria disease as a result of not being protected by
sleeping under the insecticide treated bed nets (ITNs) and use of anti-malarial drugs for both the
treatment of malaria and prophylaxis.

An impact is a long-term result. It can be measured both quantitatively and qualitatively. In

health care programme, an impact assessment can be carried out at every stage/phase of the
health care programme in terms of impact evaluation. Impact evaluation is a tool for policy
makers, programme/project planners and programme management. Therefore, impact evaluation
requires information before therefore health care programme begins, during the programmer's
life and after the programme has ended.

What Is a Good Indicator?

1.SIGNIFICANCE- the indicator should represent information that is

• Important
• Useful for action
• Interesting.

2. VALIDITY –It should measure what is intended. Does the indicator represent information that
can be correctly identified?

Measure what is intended.

3. RELIABILITY-Does the indicator represents the information that can be correctly quantified
repeatedly.

Measurement of the indicator should be the same no matter how many times it is carried out.

4. FEASIBILITY (Possible) does the indicator represent information that can be collected with
available resources?

5. PRECISE DEFINATION-Indicators should be defined using clear, specific terms

6. TIMELINESS-Indicators should be measured at appropriate time interval according to

availability of data

7. COMPAREABLE -Indicators should be comparable across different population groups

8. RELEVANT FOR NATIONAL AND PROGRAM MONITORING-The indicator can
serve to measure progress toward stated National and Program Goals, objectives targets, norms
and standards. Such indicators focus on priority Health problems in the country and the service
and resources’ intended to manage those problems.

9. EASE OF GENERATION AND MEASUREMENT-The indicator data should as much as

possible result from normal service and surveillance usually existing within routine records and
reports

10. ETHICAL –Data collection including the choice of the data source, computerization of the
indicator and its use should not conflict with accepted ethical values.

Summary on qualities

• Valid: Measures the effect it is supposed to measure

• Reliable: Gives same result if measured in the same way
• Precise: Is operationally defined so people are clear about what they are measuring
• Timely: Can be measured at an interval that is appropriate to the level of change expected
• Comparable: Can be compared across different target groups or project approaches

The selection and definition of a manageable data set or set of “Essential health indicators” is
recommended as a sound activity for initiating the review and strengthening of health
information systems and for devising a practical National Health Service monitoring capability.
Core health indicators should be chosen for national, provincial and district use with the
following criteria in mind: -

a) Useful for action. – the data needed for the indicator are useful for the person doing the
recording with recorded data contributing to necessary action being taken with regard to
the case, family, community or district being served.
b) Relevant for national and programme monitoring. - the indicator can serve to measure
progress toward stated national and programme goals, objectives, targets, norms and
standards. Such indicators focus on priority health problems in the country and the
services and resources intended to manage those problems. Promotion and use of the
indicator should strengthen routine programme management and the health information
system in the country
c) Valid, consistent, reliable, representative and sensitive. - the indicators should possess the
normal desirable characteristics of health data, example capable of being recorded across
the services with the necessary degree of validity, consistency, reliability, representative
of all population groups and be sensitive to short term changes in the variable of interest.
 d) Ease of generation and measurement. - The indicator data should as much as possible
result from normal service and surveillance, usually existing within routine records and
reports.
e) Understandable: - the indicator should deal with a single clear idea which everyone will
see as an important measure. Composite indexes should be avoided.
f) Ethical: - Data collection, including the choice of the data source, computation of the
indicator and its use should not conflict with accepted ethical values. Sometimes it is
necessary to define proxy indicators to reflect conditions which are difficult or impossible
to measure directly. For example, the rate of school absenteeism could be used as a proxy
for the morbidity rate of school aged children, where there is high rate of school
enrolment.

One of the principal objectives of the compendium is to emphasize the importance of choosing
standard indicators and measuring them repeatedly over time. The indicators suggested in this
manual are based on a review of country and programme experiences in Performance Monitoring
& Evaluation (PME). The list of the indicator below is as a result of efforts by various
stakeholders in health through a process of harmonization of Health sector indicators that was
started several years ago. The arrangement of the indictors is by KEPH levels in accordance with
NHSSP II and Performance Monitoring and Evaluation Framework (PMEF).

USES OF INDICATORS

• Setting performance targets and assessing progress towards achieving them

• Identify problem via early warning system to allow corrective action to be taken
• Indicating whether an in-depth evaluation or review is needed
• Benchmarking comparisons between different organizational units, sub
counties/counties/facilities over time
• Indicators are tools used to convert raw data into useful information and to enable
comparison between different programs or facilities.
• They are observable Markers of progress towards defined targets
• Are used to describe the situation and to measure changes overtime
• Provide information about a broad range of conditions through a single measure (e.g.,
ALOS)
• Provide a yardstick whereby institutions or teams can compare themselves to others doing
similar work
• Indicators allow managers to compare actual program implementation and results to work
plans and predictions
To understand the operationalization of the indicator, the following questions are essential:

❖ At what frequency should the numerator and denominator be collected?

❖ At what frequency should the indicator be processed and analyzed?
❖ Who will actually make use of indicators?
❖ What is the target (objective) of the indicator that needs to be achieved?
❖ What is the threshold. the minimum or the maximum
❖ What will be the nature of the action (decision) once the indicator reaches the threshold?

TYPES OF INDICATORS (Domains inputs, output, impact)

Input indicator

Input measures resources invested in the program in the program at the beginning of a phase or
those that need to be available for implementation of program e.g., Drugs, vaccines, staffs, training,
finances.

Process indicators

It measures the activities that must be performed or action normally done under several
rules/standards e.g., procedure for treatment or making a diagnosis.

Output indicator

Measures the number of activities completed or services/ goods delivered to target population e.g.,
number of children vaccinated, number of women bringing children for vaccination etc.

Outcome/ impact indicators

These measure long-term eventual outcome /output of a program or changes in behavior or practice
upon a population as a result of the program e.g., impact of program on morbidity and mortality
levels compared to baseline.
Other Classifications of Indicators: -

• Morbidity and Mortality

• Morbidly Indicators include

Units of measurements; Rate, Ratio, Numbers,

Type of measurement Description Example

(Calculating Matrix)

Count indicator No. of events without a No. of new ARV clients

denominator

Proportion indicator Numerator is contained in the 35% of facilities do not have

denominator electricity

Rate indicator Frequency of events in a Incidence of STI cases in a

specified time in a given given population in a given
population year

Ration indicator Numerator is not contained in Ratio of patience to a doctor

the denominator

Indicator

1. Count Indicators e.g., Number of Malaria cases

2. Proportion Indicators e.g., Percentage of WRA receiving FP commodities
3. Rate Indicators e.g., Facility Infant Mortality Rate
4. Ratio Indicator e.g., Doctor Patient Ratio
Difference between coverage and performance

The analysis of data collected in the health information system is simple and straightforward. Not
having a calculator is an invalid excuse for lack of analysis as analysis can be done without one.
The most important data analysis is to estimate coverage for the services offered e.g., what
proportion of children less than 1-year complete immunization schedule before their first birth
day? Or what percentage of women delivers without attending antenatal clinics?
Percentage coverage = number of cases in clinic X 100
Total number of cases in catchment population
It is vital in data analysis to identify appropriate denominators and numerators. Population data
are available from the past census and population projections.
Having estimated the catchment population, the next step is to estimate the target population for
various services which is the denominator of the coverage fraction. E.g., catchment population =
25,000.
a) Antenatal care
Target population 4.5 Percentage of 25,000 = 4.5/100 * 25,000 = 1, 125
If number of new visits are 976 therefore coverage = 976/1125 * 100 = 86.76Percentage
If number of re-visits are 2, 090 the mean number of visits per new attendant for antenatal care is
new visits +
revisits divide by new visits.
= (976+2090)/ 976 = 3.1 visits Per new antenatal attendant.
b) Morbidity data
Morbidity data are collected in both outpatient and in-patient by age, and diagnosis. Considering
new cases
gives a picture of the morbidity pattern at the health facility for example;

Data source; numerators and denominators

Application-level sector, program, national, county, facility, community, MDGs

HEALTH SECTOR INDICATORS BY COHORTS:

One of the principal objectives of the compendium is to emphasize the importance of choosing
standard indicators and measuring them repeatedly over time. The list of core indicators
suggested in this compendium is based on a review of country and programme experiences in
monitoring and evaluation. Protocols for the measurement of all indicators are provided and most
have been field-tested. Indicators contained here can be used as they are; every effort has been
made during their development to ensure that they are relevant to most situations and countries
comparisons and that they provide a comprehensive view of Kenya’s health sector.

A description of each indicator is given to provide fundamental information that will help the
reader to select, calculate, collect and interpret the indicator. Each indicator is described with a
brief statement that includes the following:

• Definition: This is the standard description of the indicator.

• Calculation: This is the computation of the indicator using numerator and denominator
where applicable.
• Data source: These are the primary data collection tools where data is obtained.
• Level: This is the point where data is used or transmitted from. This can be at health
facility level, District level, provincial level or national level.
• Periodicity/ frequency: This indicates how often data is transmitted from one point to the
next on a specified timeline.
• Use(s): The main purpose for which the data is collected.
• Status: This is the responsible institution/programme where data is primarily used or
reported to.
• *Functions i.e., 1 = Routine Reporting, 2 = Process Evaluation/ Monitoring, 3 =
Programme Review/Impact evaluation, 4= special survey
• Levels of care:
• N = Numerator
• D = Denominator
HEALTH INFORMATION SYSTEMS - II
INTRODUCTION TO DATA SETS

Current national forms or data sets used in collecting data required by the
health information services
Type of data collection tools
• Individual patient/client cards
• Registers
• Collation forms
• Aggregation and Reporting

Patient/client-held
 Held by client [mostly] for continuity of care
 Used for short periods of time
 Usually shifts most of its contents to the register
 Examples: Maternal health card or Child health card

Pros:
 Opportunity for seeking service outside the issuing facility
 Decisions can quickly be made by the receiving service provider on the basis of details
already on card
Cons:
 Highly prone to loss and damage
 Propensity for duplicating data elements onto registers
 Recipe for gaps when conducting a detailed clinical review for quality of care
 Comprise in data integrity - may be falsely updated

Facility-retained [cards]
 Privacy and confidentiality
 Longevity of use – demand for a detailed history
 When used in conjunction with registers – registers only retain data needed for health
unit management and higher demands.
Examples; HIV Care/ART Card, HIV-Exposed Infant Card, OPD/IPD cards

Pros
 Preserves confidentiality
 Preserves content integrity - facility retains responsibility of all the
contents on the document
 Can be used to verify/update related records on registers
Cons
  Locks client/patient to one facility
 Missing cards in high-volume facilities
 Consumes storage space with time

Registers or Patient Listings

 Patients/clients are listed according to the timing of the visit – as a primary

grouping criterion
 Usually more than one entry is made for each patient/client [as many as
the visits]
 Useful for short-duration services
 May contain detailed client/patient information

Collation Tools
 Tally Sheets
◦ Like activity sheet, contains reportable data only
◦ Tallying is done on contact or from registers
Aggregation Forms
Designated form for each level
 E.g., PHC, Hospital, District, etc.
Example = Cohort Summary Form

Comprehensive forms
o Same form flows through the hierarchy
o Usually in paper form from facility to district level and may be electronic from district
upwards.
National tools used in the collection of information in Kenya;

Common terminologies

Baseline:

1. Information gathered at the beginning of a study against which variations found in the study
are measured.

2. A known value or quantity with which an unknown is compared when measured or assessed

3. The initial time point in a clinical trial, just before a participant starts to receive the experimental
treatment which is being tested. At this reference point, measurable values such as CD4 count are
recorded. Safety and efficacy of a drug are often determined by monitoring changes from the
baseline values.

4. A value representing a normal background level or an initial level of a measurable quantity and
used for comparison with values representing response to an environmental stimulus or
intervention.

5. A known value or quantity used to measure or assess an unknown, for example a baseline urine
sample.

Baseline data

1. A set of data collected at the beginning of a study or before intervention has occurred.

2. Baseline: a reference point used to indicate the initial condition against which future
measurements are compared.

Population: denoted (n)

1. The total number of people inhabiting a specific area.

2. The set of individuals, items, or data from which a statistical sample is taken.

3. All the organisms that constitute a specific group or occur in a specified habitat

4. All of the animals in a specifically defined area considered as a whole. The population may also
be defined in modes other than geography, for example the human population.
Parent population: the original population about which it is hoped to make some inferences by
examination of a sample of its constituent members.

Population proportion: the percentage of the population that has the subject characteristics.

Population pyramid: a graphic presentation of the composition of a population with the largest
group forming the baseline, the smallest at the apex.

Population at risk: the individuals belonging to a certain group or community who have the
potential to contract a medical condition or

The population which is composed of animals that are exposed to the pathogenic agent under
discussion and is inherently susceptible to it. High or special risk groups are those which have had
more than average exposure to the pathogenic agent.

Population size: actual counting of a total population, the census method, is not often possible in
large human populations. Alternatives are by various sampling techniques including area trapping,
the trapping of all animals in an area, the capture-release-recapture method, the nearest neighbor
and line transect methods,

The population size is expressed as the population present at a particular instant. Alternatively, it
can be expressed as a number of person-duration expression when the population is a shifting one
and it is desired to express the population size over a period (e.g., persons per day).

Stable population: a population which has constant mortality and fertility rates, and no migration,
therefore a fixed age distribution and constant growth rate.

Target population: in epidemiological terms the population from which an experimenter wishes
to draw an unbiased sample and make inferences about it.

Catchment area: The surrounding area served by an institution, such as a hospital or school.

Catchment population; The population being served by an institution such as a hospital or school.

Eligible population; the number of persons targeted for a particular indicator.

Monitoring

Evaluation

Input; the resources need to achieve the results.eg. Finances, supplies, commodities, facilities etc.
Process; the activities you do to achieve results e.g., providing new contraceptive methods,
improving services, developing systems, conducting trainings etc.

Output; immediate results of activities e.g., number of new family planning users, total number
of users, number of people trained.

Outcome short term change e.g., change in service use comparing one period to another, change
in knowledge, attitude or practice of a population or client group.

Impact the long-term change among a population e.g., changes in the contraceptive prevalence
rate, total fertility rate, child morbidity and mortality rate.

NATIONAL ELIGIBLE POPULATION AND PROPORTIONS

POPULATION PROPORTION

Under 1 year 4.5% of total population/catchment population

Under 5 years 18 % of total population/catchment population

(0-11) months 20 % of under 5 years/catchment population

(6-11) months 80 % of (0-11) months/catchment population

(9-11) months 25 % of (0-11) months/catchment population

(12-59) months 80% of (0-59) months/catchment population

(9-59) months 85 % of under 5 years or (9-11) months+(12-59) months

(5-14) years 29 % of total population/catchment population

Under 15 years 48 % of total population/catchment population

WRA (15-49) years 24 % of total population/catchment population

Elderly 60 years and above 5.2 % of total population/catchment population

Live births Expected /estimated no. of deliveries

Expected pregnant women 4.5% of total population/catchment population

 Surviving infants Total live births- total infant deaths

Estimated no. of Emergency 0.75% of the expectant/pregnant women

obstetric complications

Estimated no. of abortions 0.75% of the expectant/pregnant women

NOTE: The above proportions are derived from national population of 2002 projected from the
Kenya 1999 population census but the proportions vary from district to district.
Source: Analytical report on population projections Volume VII August 2002.

Data collection

It is the processes of gathering raw facts or figures. It provides the basic raw data from which
further analysis is made and conclusions drawn. For any project or program to be acted upon it
must be backed by variable data. Before collecting data, obvious questions must be decided or
answered.

1. Purpose of collection.
2. Scope of inquiry. (Extent of the area/subject matter that is to be dealt with)
3. Source of data; primary or secondary
4. Method of collection.
5. Degree of accuracy desired.

Primary data: it is data that has been collected by the investigator for a certain objective and it’s
therefore original in character. E.g., population census collected by the Kenya National Bureau of
statistics.

Secondary data; it is data which has been used in an investigation but originally collected by
someone else. Therefore, if someone else uses the KNBS data, it may constitute secondary data to
him.

Therefore, primary data in the hands of one person becomes secondary in the hands of another
user. Data is usually in any of the two forms.

DATA COLLECTION TOOLS (SERVICE REGISTERS)

1. MOH 204 An Outpatient Register (under five years);

 The register is used for both Male and Female below 5 years (0 – 59 months) who are sick and
visit the Health Facility for treatment. The patient/client is registered as an outpatient upon
issuance of OPD card. The register also covers the IMCI component and should not have any
other register for districts implementing IMCI. The register has various data elements which
need to be captured in it. These include the patient’s name, age, sex, first visit or revisit,
diagnosis, treatment given, danger signs and others. This register is supposed to feed the MOH
701 An Under-five (<5) years Daily outpatient morbidity tally sheet before posting the daily
summaries to MOH 705 An Under-five (< 5) years Daily outpatient morbidity summary sheet.

2. MOH 204 B Outpatient Register (over 5 years)

Just like the MOH 204 An Outpatient Register (under five years), this the register is used for
both Male and Female above 5 years (60+ months) who are sick and therefore seek treatment
in the health facility. The patient/client is registered as an outpatient upon issuance of OPD
card. The register has various data elements which need to be captured in it. These include the
patient’s name, age, sex, first visit or revisit, diagnosis, treatment given and others. This
register is supposed to feed the MOH 701 B Over five (>5) years Daily outpatient morbidity
tally sheet before posting the daily summaries to MOH 705 B Over five (>5) years Daily
outpatient morbidity summary sheet.

3. MOH 511 Child Welfare Clinic (CWC) Register

The register is used at the MCH for clients/children less than 5 years (0 - 59 Months) who
attend Child Welfare Clinic (CWC). This register is kept SEPARATE from Permanent EPI
register. This register is kept in MCH clinic basically for growth monitoring of the children
until they attain five years. It is a cross sectional type of client listings. The child details are
captured in the register upon visiting the health facility. The information includes the CWC
number which should be used until the age of five years. The child Welfare Clinic number that
will be given to new clients only visiting any Health Facility for the FIRST TIME. It is usually
given once for the child and it should be used throughout the life time when visiting any clinic.
Other details include child’s name, age, village, cellphone number, weight, height, any
abnormality, ITNs issued and others. It feeds it information to the MOH 711A as well as MOH
717 (Monthly Workload for hospitals)

4. MOH 405 Ante natal Clinic (ANC) Register

ANC register is completed the 1st time a pregnant mother attends the MCH clinic and this is
usually referred to as 1st ANC visit. Any other subsequent visit is considered as revisit. It is
recommended that pregnant mothers should make at least 4 attendances during a specific
pregnancy. In other words, ANC number is issued to new or 1st visit clients visiting your health
facility for that particular pregnancy. Upon re-attendance, the ANC number is derived from
the Maternal and Child Health Booklet/ Card. It gives an account of the voluntary visit that the
client makes to the clinic for checkup or follow ups.
It also captures the EDD, the HIV status, any abnormality detected, the number of ANC visits
done etc. It feeds it information to MOH 711A Integrated tool for RH, HIV/AIDS, Malaria,
TB, and CHANIS summary as well as MOH 717 Monthly workload for hospitals.

5. MOH 510 Immunization Register for Children (Permanent EPI Register)

 The register is longitudinal type and is only held in facilities which offer immunization services
to children less than one year. The serial number is issued to the child upon registration in that
facility which acts as an identification number on the first attendance and is facility specific.
Usually written serially. 1, 2, 3…. Some of the information which is captured include the serial
number, child’s number, name of the child, parent’s name, cellphone number of the child’s
guardian, physical address, dates when the child was vaccinated as per KEPI schedule. Dates
when vaccination was done must be indicated and ticks or checks should not be used in those
date cells. This register is complementing the MOH 702 Immunization and Vitamin “A” Tally
sheet before posting the daily summaries to MOH 710 Immunization and Vitamin “A”
summary sheet. Children served in this clinic use the mother child booklet issued to their
mothers during ANC period.

6. MOH 333 Maternity (Delivery) Register

The register should be used in all maternity units for the purpose of recording the processes
and procedures during the child delivery. It is a cross sectional register. A separate row should
be used for each baby in case of a multiple birth. It is completed when a mother gets admitted
in the maternity unit. An in-patient admission number is given to all clients/patients admitted
to the maternity unit. Some of the information recorded in those registers include date of
admission, name of the mother, maternity inpatient number, Date of birth, mode of delivery,
child sex, liter of blood lost, tested for HIV and results, birth notification number, who
conducted the delivery, date of discharge and others. It feeds it information to MOH 711A as
well as MOH 717 Monthly workload for hospitals.

7. MOH 406 Postnatal Register

This register is 1st completed upon the 1st contact with mother following giving birth or
delivery. It records the date the mother reports to your health facility either as a first visit or
re-visits (recorded as DD: MM: YY). It is a cross sectional register. It records the date of
delivery, place of birth, mode of delivery, any observation done, family planning options
chosen etc.

8. MOH 512 Daily Activity (Family Planning) Register

The register is used to record all contraceptives dispensed to the mother clients whenever they
call in for family planning service. It accommodates change of methods among of mothers
from one contraceptive to another. A mother who has previously on female condoms may opt
to change to Oral pills. It captures the opening balances in all the FP commodities, how much
was issued and the remaining balance in each page.

9. MOH 209 Radiology Register

Radiology register is confined to the X-ray department in health facility where radiological
examinations are conducted. The X-ray number is issued to all patients receiving service from
Mathai radiology department. Type of X-ray, radiographer’s name, residence is among the
information captured in the register. It is a cross sectional register and an important tool which
can be used to solve legal issues pertaining to health facility involved and patient or client. It
feeds the MOH 717 (Monthly workload report for hospitals).
10. MOH 240 Laboratory Register
The laboratory register is basically confined in all Laboratory Centers/Health facilities with
laboratory services. Upon the clinician requesting a laboratory test for a patient, the laboratory
technologist initiates a process by registering the patient, type of specimen requested, specimen
results, condition of the specimen and who conducted the test. Just like radiology register, it is
a cross sectional register and an important tool which can be used to solve legal issues
pertaining to health facility involved and patient or client. It feeds the MOH 717 (Monthly
workload report for hospitals).

11. MOH 301 Inpatient Register

The inpatient register is placed in inpatient desk for registering the patients recommended for
hospital admission. Unlike the OPD number which changes every calendar year, once the
patient is admitted he or she retains the same number throughout his or her life of medical care
in your facility. The number is important in retrieving the patient notes in future when patient
comes for further treatment or management. The final diagnosis of the patient is posted to the
inpatient register as well as in the patient notes.

12. MOH 268 Diagnostic Index Card

This card acts as a collation tool as well as data collection tool. It derives information from the
patient notes once the patient is discharged. The same information is relayed to MOH 718 In-
patient morbidity and mortality summary sheet.

DATA REPORTING TOOLS (SUMMARIES)

If the health information system forms are so complicated that those who are to complete them
cannot understand them or the forms are not available all the time, data will not be collected
properly. Therefore, every effort must be made to simplify forms and to ensure that there is a
constant supply of them. Such forms can have a space for some simple on the spot analysis e.g.,
total numbers or percentage to be calculated. The summaries which draw information from the
above registers are listed below:

1. MOH 105 Service delivery

2. MOH 701 An Under-five (<5) years Daily outpatient morbidity tally sheet.
3. MOH 701 B Over five (>5) years Daily outpatient morbidity tally sheet.
4. MOH 705 An Under-five (<5) years Daily outpatient morbidity summary sheet.
5. MOH 705 B Over five (>5) years Daily outpatient morbidity summary sheet.
6. MOH 702 Immunization and Vitamin “A” Tally sheet
7. MOH 710 Immunization and Vitamin “A” summary sheet.
8. MOH 704 Child Health and Nutrition Information System tally sheet.
9. MOH 711 An Integrated tool for RH, HIV/AIDS, Malaria, TB, and CHANIS summary.
10. MOH 711 B Integrated tool - RH, HIV/AIDS, Malaria, TB, and CHANIS District summary.
11. MOH 717 Monthly Workload report for hospitals (Service workload for all areas)
12. MOH 268 Diagnostic Disease Index
 13. MOH 718 In-patient morbidity and mortality summary sheet.
14. MOH 708 Environmental Health services

Summary:
Source of data Collation tool Aggregation tools Remarks
• Out Patient card • MOH 701 A <5 years tally • MOH 705 A <5 yrs. Summaries gives the total
• MOH 204 An Outpatient sheet. summary sheet. number of cases seen in OPD
register • MOH 701 B >5 years tally • MOH 705 B >5 yrs. on daily basis
• MOH 204 B outpatient sheet. summary sheet.
register

• Mother child booklet MOH 702 Immunization and MOH 710 Immunization and The easiest way of deriving
• MOH 510 Immunization Vitamin “A” Tally sheet Vitamin “A” summary sheet. data is basically from tally
Register sheet once vaccination is done
to a child
• Mother child booklet No collation tools but MOH 711 An Integrated tool for MOH 711A has different
• MOH 405 Antenatal provision of page summaries RH, HIV/AIDS, Malaria, TB, components to be reported on
register available in all those registers and CHANIS summary. besides maternal safe delivery
• MOH 333 Maternity and ANC services
register
• MOH 406 Postnatal
Register
MOH 512 Daily Activity No collation tools but • MOH 711 An Integrated tool Reproductive health activities
(Family Planning) Register provision of page summaries for RH, HIV/AIDS, Malaria, report
available in all those registers
TB, and CHANIS summary.
• Service delivery point FP
commodity consumption
report
• MOH 209 Radiology No specific data collation MOH 717 Monthly Workload Service workload for all areas
Register tools report for hospitals
• MOH 240 Laboratory
Register
• Most of registers outlined
above
• Inpatient file, MOH 301 No specific data collation MOH 718 In-patient morbidity Coding and indexing of the
• MOH 268 Diagnostic tools and mortality summary sheet. inpatient’s conditions
Disease Index involved
Services summaries used as No specific data collation MOH 105 Service delivery report Derives the data for indicators
source tools from all other facility
summaries
INSTRUCTIONS ON DATA REPORTING TOOLS (Summary forms)

MATERNAL AND CHILD HEALTH BOOKLET MOH 216

The Maternal and Child Health Booklet is a revised version and combination of the Antenatal
card and Child Welfare Card. The first part contains the mother’s full antenatal and post-natal
profile.

• ANC
• Postnatal
• Second part contains the child’s details on immunizations and other services delivered to
a child before age 5 years that will be detached from the booklet.

In case of multiple deliveries, the health worker should initiate a booklet for each child.

The health worker is advised to be extra careful while filling the information in the booklet by
ensuring that correct information is recorded in the appropriate spaces provided. The growth
monitoring charts should be marked progressively as the child grows. Health workers are advised
to share the information pertaining to the child with the mother or care taker.

GENERAL GUIDELINES FOR FILLING THE SUMMARY FORMS:

1. The first step in completing data reporting forms is to ensure that all the identification
particulars are filled in before completing the particular form. These are the names of the
province, district, constituency, facility and the period for which the report is covering.
2. Specific ages should be reported within the appropriate age classification.
3. In forms where data is disaggregated by sex, the appropriate data should be filled in the
correct column or spaces provided.
4. Care must be taken to separate new or first visits and re-visits or re-attendances.
Note: New or first visit –these are patients/clients who come to your facility for the First
time. While Revisit or Re-attendance- these are patients/clients who make subsequent
return visits after the first visit.
5. Where there is a provision to show totals, they MUST be aggregated.
6. While making entries in the forms, accuracy MUST be maintained to avoid errors or
transposition of figures.
7. While reporting, completeness MUST be observed. No spaces should be left blank and no
dashes. You are instead encouraged to practice zero reporting.
8. The name of person preparing the report, the date the report is being completed and the
commitment signature MUST be filled in.
9. Once the reports are completed, they are supposed to leave your facility before the 5th of
the following month to the District Health Information System (DHIS).
10. At the district, once all the reports from the health facilities have been received, summaries
should be promptly made.
 11. The district MUST maintain a checklist of all reports and all facilities and check the reports
against the facilities to ensure completeness and timeliness.
12. Using a copy of the summaries made, districts MUST analyze and share the information at
their level.
13. Districts should submit the summaries to the province or national level on or before 15th
of the following month and give feedback to the health facilities.
14. The province collects all the district reports, make copies (manual or electronic) do the
analysis and use the information as they make arrangement to transmit the summaries to
the national level before 21st of the following month if data flows through the province
inform of hard copies
15. Likewise, provinces should make and maintain a checklist of the reports and districts to
ensure timeliness and completeness. They must give feedback to the districts and share the
report at that level.
16. To maintain accuracy in recording data collected through tally sheets, health workers
should tally from the registers on daily basis.
17. The national level data repository (HIS) should acknowledge receipt, process and analyze
the data and give feedback to the lower levels and share the information horizontally and
vertically.
18. All levels are encouraged to prepare annual reports that will encompass all activities,
outputs and in-puts.
19. For communicable diseases that are for immediate reporting, such should be reported
without further delay using the appropriate tools and channels for example using case-
based investigation forms.
20. Using the DHIS2 the district should upload their data to the DHIS2 site on or before 15th
of the following month.

How to handle the tally sheets

Tally sheets are working sheets on which data is recorded to facilitate ease of count at the time of
making summaries. Proper understanding of the content of each tally sheet is essential. The proper
way of making a tally is to slash a zero with forward slash (Killing one zero at ago)
Tallies are normally made immediately a clinician is through with a patient/ client before attending
to the next and at the end of the day or early next morning from the register. This depends on
circumstances at the facility.

How to handle the Summary sheets

Summary sheets will be completed at the end of the specified period, either from tally sheet or
registers or any other source documents. As the health facility submits the summaries to the next
level, a copy Must remain in the health facility.
SOURCES OF DATA FOR HIS
Sources of data may be categorized into two:
Population based data;
• Vital registration
• National population census
• Survey

Health and disease-based data

• Absenteeism records
• Sentinel surveillance
• Routine data collection
• Disease registers

i) Vital registration: e.g., Birth, death, marriage Certificates etc.

This is the data that is derived from vital statistics registries that track all births and deaths
as well as certain changes in legal status such as marriage, divorce and migration
(registration of place or residence).
In developed countries, who have invested in good registration systems (such as the United
States and much of Europe), registry statistics are the best method for estimating the number
of births and deaths.

Advantages
• Ensures continuous data collection and thus qualifying possible at any given time
• It is less expensive to manage
• Standardized manner of data collection
• Near complete coverage of vital events
• Many natality and mortality indicators may be derived from those statistics. Useful in compilation
of the denominator e.g., IMR

Disadvantage
◦ Some of the data variables may be incomplete

ii) Census: Latin word which means “Assess”

A census is referred to as a complete enumeration or count of people in a given country
conducted periodically usually every 10 years. A census is usually conducted by a national
government and attempts to enumerate every person in a country. However, in contrast to
vital statistics data, which are typically collected continuously and summarized on an annual
basis, censuses typically, occur after every 10 years or so and thus are not usually the best
source of data on births and deaths.
Census does more than just counting people. They typically collect information about
families or households, as well as individual characteristics such as age, sex, marital status,
literacy/education, employment status and occupation, and geographical location. They also
collect data on migration (or place of birth or of previous residence), language, religion,
nationality (or ethnicity or race), and citizenship. In countries in which the vital registration
 system may be incomplete, the censuses are also used as a direct source of information about
fertility and mortality;

One of the major limitations regarding census is that 10 years is quite a long duration where
a lot of developments will have taken place and some events disregarded during the exercise.

Others include;
• Lack of data for those unavailable during the exercise
• Takes a long time to analyses and disseminate results
• Most notably data for nomadic population unreliable
iii) Demographic data service (Survey):

Data is collected from a sample drawn from a given population. The sample picked should
have all characteristics of the population studied and thus representative of such population.
In demographic data service there is a single round and multiple round surveys. This
method requires a lot of planning and administrative and logistical support. It is used to
obtain current information on fertility and mortality and other factors surrounding these
events. It is used to gauge performance of certain population. They include nutritional
surveys, KDHS etc.

iv) Routine data collection:

This entails sources of data for disease burden specifically for mortality and morbidity. f
care and organization of the health services.
These records are not fully utilized as required. They contain data which could be used to
calculate rates which may be required for planning purposes.
Weaknesses in routine reporting:
• Constant staff operation required.
• Excessive inappropriate data types requested
• Incomplete late reporting
• Inadequate use of data locally
• Central analysis of data often delayed
• Central action is irrelevant to the local needs.

Disease registers:
• Prevalence of some disease such as cancer, TB, HIV/AIDS are monitored through the
disease registers
• These are limited as they are kept only in specialized facilities capable of diagnosing
diseases covered by the register.
They are useful in monitoring performance of health services and resource allocation.
Other Sources of health information

1. Outpatient records
2. Inpatient records
3. Notification of infectious diseases
4. Registration of persons- (Births and deaths)
5. Surveys
6. Community based health care projects

Outpatient records

In the outpatient we have information on preventive, curative, health promotion and rehabilitative
services. We have information on vertical programs such as

• Patient support center

• KEPI currently DVI
• Maternal and Child Health
• Family planning.

Each of these vertical programs has its own health information system. Each information system
gives different health statistics for example from DVI we can get immunization coverage and the
number of mothers who have received tetanus toxoid.

The information can be used for planning and management of the health facility.

Several reports are prepared at the outpatient department such as;

In patient records

In the inpatient department we collect information on curative services from all patients stay in the
health facilities. Upon discharge the health records personnel collects patients records and
calculates the following hospital statistics, Bed occupancy, ALOS, TOI, VBD etc.

The statistics are used to monitor the operational efficiency of the health facility.
Notification of infectious diseases

These are limited to infectious diseases. They are important indicators that show the presence of
communicable diseases in the community. It helps to identify the need for control and prevention
action.

Registration of births and deaths

The information on births and deaths is a vital element of vital statistics. Health begins at birth and
end in death.

This information is important in projecting population growth rate and mortality rates.

Surveys

They are periodic methods of collecting health care data using sample population. There are two
types;

• Formal surveys; they are sample based surveys. They are scientific in design.
• Informal surveys; they are like home visits conducted by health workers.

Community based health care projects

They are run by NGO’s. Its main aim is to stimulate individuals and local communities to
determine their own health care needs. They also initiate interventions.

In the CBHCP, people determine their own needs and decide on PHC activities to solve their health
problems on a self-help basis. Individuals, families and community members should be
encouraged to participate in health promotion activities.

Data collected from CBHCP may include information about;

1. Local people and their distribution

2. Diseases they suffer from
3. Organization of the local health services.
Uses of health information from CBHCP

Health information is one of the most essential components of an effective health delivery system.
The uses include;

1. Parents use height and weight information to monitor the nutritional status of their children
(BMI= weight in kgs/height in m2)
2. Community groups use H.I to identify and correct environmental hazards.
3. Health workers use H.I to identify and screen persons who need treatment.
4. Clinical staffs use patients’ history to diagnose and treat individual health problems.
5. Managers use H.I to maximize program effectiveness and efficiency and compare
alternative methods of health care services.
6. Administrators use H.I to identify problems and audit the use of program funds and other
resources.
7. Epidemic control units which use information for surveillance (predict outbreaks).
8. To help donor organizations identify priority areas to justify new program funding.
9. International agencies use H.I to monitor progress towards health goals (MDG’s).
10. H.I is used for purposes of research.
11. To justify manpower training.
12. To help evaluate the impact of all health programs initiated
Health sector
The health sector is the primary supplier of health information. It is responsible for information
generated through disease surveillance and response efforts designed to provide early warning of
disease outbreaks (such as polio, Ebola, and SARS); to illustrate patterns of chronic disease spread
(such as HIV/AIDS or cancer); and to produce information relating individual risk behaviors to
health outcomes (for example smoking and cardiovascular diseases).

Data related to the performance of health services, to the management of resources for health, and
to the policy and legal framework relevant to health are also largely generated through the health
sector. Information about the quantity, distribution, reach and quality of health information and
service provision, on the resources needed to provide those services, and on the use of information
and services by the population can be generated through routine health management information
systems (HMIS).

Within the health sector, there are multiple producers of health information and while the public
health authorities may be primary (particularly with regard to information for public health policy-
making) information from the private for-profit and non-profit sectors is also key to an effective
health information system. In many settings, health insurance systems are primary producers of
data on patterns of disease and health care use. Employers too are also important potential
producers of health information. Other branches of industry, such as the pharmaceutical sector, are
both producers and consumers of health information. It is rarely evident that the information that
can be derived in these ways is linked to the national health information system.

Other sectors
The health sector is also a consumer of information generated by actors external to health. In many
settings, the primary data producer for the ultimate health outcome (mortality) is not the health
sector. Instead, data on vital events such as births, deaths and sex and age patterns of mortality,
are produced through the census and the civil registration system, often under the overall
responsibility of ministries of the interior or planning and national statistics offices. On the other
hand, the health sector has to work closely with the civil registration authorities to generate
information on patterns of causes of death because attribution of cause of death is generally the
responsibility of health care professionals. Health-related information may also be produced by
local and municipal authorities.

Information on resources allocated and consumed for health generally derive from departments of
finance and planning, and resource flows to the health sector can be extracted from national
accounts where these are available.

Surveys, research, and communities

In some settings departments of national statistics are primary producers of health information
derived from household surveys – often the sole source of population-based information on the
use of health services or health-related behaviors. Although the increasing frequency of poverty
monitoring, household budget surveys and household living standards surveys can provide useful
health-related data down to provincial level, they are rarely used by health information systems.
Household surveys are of particular importance in settings where vital registration is incomplete
(which is the case in most developing countries) and may be the sole source of population-based
information on important health outcomes such as infant mortality.

Other important producers of health information are academic and research institutions, often
supported by external funding. Researchers may develop new tools and methods for assessing
different aspects of health and can play a major role in the evaluation of health interventions.

Frequently neglected sources of health information are communities and advocacy groups.
Communities can play a major role in gathering information on disease surveillance, births and
deaths, environmental issues, follow-up of patients, patterns of health-seeking behavior and
perceptions of health services. Although the information they produce may be considered non-
representative or incomplete, and may be limited to qualitative information rather than quantitative
statistics, it should be considered a potentially important component of the health information
system. The importance of qualitative information, such as stakeholder opinions and perceptions,
should not be neglected in health information systems
STATUTORY REPORTING TOOLS
LEGAL FORMS USED IN HEALTH SYSTEMS
1. P3

A form acquired from Kenya Police as a conclusion for medical report. P3 acts as evidence that a
violent act occurred and is therefore referred to as an exhibit in court. It must be handed as
evidence at all time

Parts of P3 form

I. Part 1: It is filled out by the police officer assigned to the case, indicating the details of the
compliant/suspect in question in a particular case as well as the brief summary of the allegation.
II. Part 2; It is stated clearly that a registered medical officer filled the form, also done by a nurse /
dental officer, clinical officer

In criminal offences, government doctor must fill the form.

Assaults

Victim injured in the case of the following cases;

• Sexual assaults
• Domestic violence
• Child abuse and negligence
• Road traffic accidents
• Cases of occupational hazards
• Animal attacks

2. Death Notification form (D1)

Medical form issued when medical practitioner certifies cause of death of the person in a
compulsory registration area.

Form is filled in triplicates and shall issue the original and duplicate to the next of kin which is
then to the registrar to obtain permit to dispose of the body.

Medical practitioners maintain the other duplicate copy. When intricate of the original and
duplicate of death notification form, the registrar shall sign the top copy which shall constitute
the original entry.

3. Birth Notification form (B1)

It is filled with parents by hospital staff in case you have given birth at the hospital or by the
doctor/mid wife to guarantee accurate info is recorded.
This form outline to be recorded in registrar of birth then the form is forwarded to registrar office
to inform registrar about occurrence of birth.

Requirements of B1

• Name of newly born baby

• Date
• Place of birth
• Sex of child
• Type of birth – single/twin
• Nature of birth (alive or dead)
• Name of the mother
• Name of the father
• Signature of the applicant
• Age
• Marital status
• Previous birth
• Presidential area.

The form is forwarded to the registrar office, to notify that the birth occurred. This service and
form are available to all registered health institution.
 DHR 2107 HEALTH INFORMATION SYSTEMS - III

1. Data Processing
The goal of data processing is to present information in a way that aids/helps in decision making
in all levels. It is a process of transforming raw data to a state which analysis can be done
smoothly with minimal distortion of results.

Data processing ranges from simple manual compilation to sophisticated computerized

processing but basically entails data cleaning and re-arrangement or classification.

Editing is basically checking of obvious mistakes, omissions and any other logical entries on the
data collection or reporting tool

Data cleaning is the proofreading of the data to catch and correct errors and inconsistent

Data sets are rarely error free. Even if careful and thorough cleaning procedure are one, it is
likely that undetectable errors will exist. The goals are to try and ensure errors are small enough
such that they do not bias decision making.

Data Classification is the process of keeping data with common characteristics together e.g.,
you may need to put data concerning males, females, children separate from each other. This
enables to analyze data concerning specific character or items more easily.

• It helps in tabulation

• Computerized data processing at any level will depend on

– Availability of resource (equipment and maintenance, cost, skilled personnel

– Volume of data, complexity of analysis required etc.

Benefits associated with computerized data processing

• Efficient and timely processing of large amount of data

• Quality of data tends to improve since fewer staffs are responsible for data input

• Staffs are not required to make mathematical computations

• Allows production of a wide range of outputs including targeted feedback reports

• Allows integration - data collected for different purposes can be combined

• Eliminated duplicate processing of work that is typically seen in many areas of data
collection
Review Questions

1. Identify some of the common errors/mistakes in routine data collection and reporting
tools
2. What are the causes of errors and mistakes?
3. Explain how you can ensure data quality (Minimize errors/mistakes)
4. Discuss how incomplete and incorrect health data/information can bring about poor
decision making and waste of resources.

DATA QUALITY
• Quality

– Value of the data- source, accuracy, reliability, quantity, relevance& timeliness

• Assessment

– Continuous & systematic evaluation through observation and recommendation of

an ongoing activity to enable you make an informed decision

DATA QUALITY

Data Quality - the degree of excellence exhibited by the data in relation to the portrayal of the
actual scenario.

-The state of completeness, validity, consistency, timeliness, and accuracy that makes data
appropriate for a specific use.

Data Quality Assessment (DQA) - a process of verifying the quality of data, assessing the system
that produces that data, and developing actions to improve both the process and the system

Routine Data Quality Assessment (RDQA) - A continuous/regular process of verifying the

quality of data, assessing the system that produces that data and developing action plans for
improvement

Quality Assurance (QA) - A process that focuses mainly on measuring compliance with
established standards

Quality Improvement (QI) - A systematic process to improve the quality of health care by
monitoring quality, finding out what is not working, and fixing the problems of health care delivery
Quality control- the process of monitoring and maintaining the reliability, accuracy and
completeness of data

Dimensions/attributes of Data Quality

 Accuracy - data that measure what they are intended to measure . its also known as validity

 Reliability - data that are generated based on protocols and procedures that do not change
according to who is using them and when or how they are used

 Timeliness - data that are produced on time, adhering to standard schedules

 Completeness – the capture of all of the data and not just a fraction of what should be
included

 Confidentiality - clients are assured that their data will be maintained according to national
and/or international ethical standards; personal data are not disclosed

 Precision - all variables required for data analysis and use are captured, and the data have
sufficient detail

 Integrity - the system used to generate data is protected from deliberate bias or
manipulation

The AHIMA model (1998) includes following characteristics of quality data

• Accessibility - Data items should be easily obtainable. should be available on time and at
all levels (old data is of historical value only)- decisions must be made based on current
information,

• Comprehensiveness- It is complete. All required data items are included. Ensure the
entire scope of data is collected

• Accuracy - Data are free from errors (typographical or misspelling)

• Consistency – Data need to be consistent in terms of collection, transmission and use of

abbreviations

• Representative - It represents all recorders of similar data

• Comparable - using the same definitions of items – if we don’t measure by the same
tool, we can’t compare each other’s results.
Characteristics of good quality data

• Timeliness- available on time

• Currency – up to date. Many types of healthcare data become obsolete after a period of
time

• Precision – It denotes how close to an actual size, weight, or other standard a particular
measurement. E.g., drug dosage must be very precise

• Relevancy – Collect data will be used

• Granularity/Atomicity - Means individual data elements cannot be further subdivided;

they are “atonic”

• Definitions – Clear definitions should be provided so that current and future users will
know what the data mean. Each data element should have clear meaning and acceptable
values

• Note – Data quality need to maintained from the data collection, application/purpose,
analysis and warehousing

Essential principles of health care documentation

• Unique identification of patient

• Accuracy
• Completeness
• Timeliness
• Interoperability – enable authorized practitioners to share and report health care
information from any system whether paper or electronic based
• Retrievability- capacity of allowing information to be found efficiently
• Authentication and accountability – uniquely identify users/persons or system that
create the information and takes responsibility for the accuracy
• Auditability
• Confidentiality and security – adhere to related legislation, regulations or guidelines
Threats to data quality

Impediments to good data quality

Three sources that threaten data quality

I. Inappropriate data collection instruments

II. Poor recording and reporting
III. Errors in processing data

Inappropriate data collection instruments and procedures.

One important requirement of a well planned and executed information system is the development
of a set of concepts to be covered and adherence of all stages of data collection and processing
operations.

These concepts provide the basis for development of questions, wordings, instruments for data
collectors and specifications, for editing, coding and tabulating data.

Imprecise definition of terms, lack of standardization, inaccurate translations of materials adopted

from other context, leaving inadequate space for writing responses on data collection forms are
some of the ways that can bring about errors.

Sometimes a well-designed instrument might be used in an inappropriate setting for example, a

sentinel surveillance system designed to classify the mechanism of HIV transmission in Sub
Saharan Africa cannot be replicated in Western Asia without significant modifications of the data
instrument.

The poor layout and quality of printed forms often contribute to low quality data in developing
countries where resources are scarce. Forms are sometimes illegible due to quality of the original
form and repeated photocopying.
Threats to data quality from Poor recording and reporting

(a) Failure to report data

Despite procedures for timely transmission of data between different levels of a health care system,
sometimes data transmission does not occur.

Given the high cost of stationery (forms, operational cards, registers etc.) and the inefficient supply
system in many developing countries, the reporting health facility may lack access to necessary
supplies or data transmission may be hampered by the frequent absence of personnel in charge of
the information system or even if the personnel are available the high opportunity cost of time
spent recording data on multiple forms coupled with lack of incentives for reporting may hamper
regular reporting.

Another problem may be lack of transportation and other means of communication (Electronic
Data transfer).

(b) Unintentional recording and reporting of inaccurate data

Errors are sometimes introduced into the data for innocent reasons. Staffs may not have appropriate
skills or supporting equipment to effectively carry out their data reporting responsibilities for
example it is not uncommon in developing countries for the same reporting forms to be used at
different levels of the health care system.

With computerized data entry a clerk with limited experience may enter codes in a data base by
selecting from menu options that may not match the exact terminology used by the physician.

(c) Potential sources of Errors in recording clinical data

▪ Misinformation from the patients

▪ Quality of clinical findings
▪ Errors in recording patients’ data by providers
▪ Personnel errors during the recording of diagnostic tests
▪ Inaccurate interpretation of tests/results
(d) Intentional recording and reporting of false errors

One of the greatest fear of users is that information system will monitor employees work and that
repercussions will occur if the employees do not attain a particular level of performance indicator.

Sometimes the health system is set up in such a way that reporting accurate data acts as a
disincentive.

Physicians at times deliberatively mis-record patient data to avoid litigation.

Errors in processing data

Errors occur during the transfer and aggregation of data at all levels of the information system.
Manual processing which is common in most developing countries involve tedious computation
that often result in errors. Corrections are rarely made for missing reports.

If computers are available, data processing operations typically involve a serious of basic steps
each of which is suitable to possible introduction of errors;

▪ Editing
▪ Coding
▪ Data entry
▪ Tabulation

(a) Editing

Registers and forms are edited to correct inconsistencies and eliminate omissions. During this stage
managers need to make decisions about treatment of “unknown” responses in the raw data.

Where information is lacking on one variable, can a reasonable entry be estimated based on other
information supplied in the form?
(b) Coding

It is the conversion of entries on forms or registers into symbols. While many coding procedures
are relatively simple, involving classification of individuals by sex (male, female), by location
(village x, village y), reason for risk (preventive, curative) and so on, some coding procedures are
complicated and have the potential for significant errors.

For instance, when classifying causes of death according to International Statistical classification
of Diseases 10th Revision (ICD 10) categories, it is relatively easy to confuse the coding of disease
A37.0 (whooping cough due to Bordetella pertussis) with that of category A37.1 (whooping cough
due to Bordetella parakeratosis)

(c) Data entry

Data entry refers to the means of transfer of the data from the original document to the computer.
For manual data entry into the computer, many institutions perform double entry to reduce errors.
With double entry a computer program accepts the record only if the clerk has entered it exactly
the same way. This procedure minimizes the introduction of errors due to typing mistakes.

(d)Tabulation

A final step entails re-arranging the data in order to provide the most useful charts and figures for
decision makers. The potential for errors is significant if the programmer provides incorrect
instructions (to the computer) for the required tabulation. For instance, a program manager might
request for information on the number of ANC visits in District X (a rural accessible area) in 2000.

The programmer might incorrectly insert the code for District Y (an urban area of high access) for
2001.

Without reviewing the coding from the programming, the program manager might recognize that
District X and Y were confused, but unlikely to know that the years 2000 and 2001 were also
tabulated erroneously.
Common threats to data quality

• Double counting

o Within service

o Across service

• Incomplete records

• Incorrect data

• Inconsistent procedure for data capture

What can be done to ensure data quality?

The following strategies can help to ensure high quality data at low cost.

(a) Keep the design of the information system as simple as possible

Operational cards, registers and forms should be designed in a simple manner with clear
instructions. Valid, sensitive and specific instructions MUST be selected to increase data quality.
It is also important to minimize the number of levels in the information system in orders to avoid
errors during the transfer and processing of data.

In general, the collector and the user of data should be as close as possible. Indeed, in action led
information systems, the collectors and users of data may be the same people. This will reduce
errors in handling data and will improve decision making process as data is more likely to be
meaningful to the person who collects them.

(b) Involve users in the design of the system

Involving users in the design of the system is an incentive in two ways: -

i. It helps develop an information system that is best suited to the user

ii. It increases ownership of the system

While involving users takes more time, it promotes a general understanding of the system and
improves the quality of the data produced. Furthermore, it ensures that the data collected is
relevant.

(c) Design of the data collection instruments

What is quality assessment?

• Quality assessment refers to the process of evaluating the services being offered

• Quality assessment is a tool that can be used to determine effectiveness and efficiency of
the services being offered

Why is it important to do a quality assessment?

1. To sustain clients/ services

2. To attract potential new clients

3. To revise or modify service delivery vis a vis targets and strategy

2. Presentation of data
In most clinics or health facilities data are gathered on immunization, Antenatal care growth
monitoring and morbidity every month. The collection of data becomes more meaningful if
analysis is done regularly and locally. Furthermore, presentations of data in the form of tables,
charts will enhance insight into what is going on in the catchment population with respect to
clinic utilization. In statistics, data are classified into qualitative and quantitative data.
Qualitative data cannot be counted. A collection of quantitative data in its original form is called
raw data

a) To analyze these data, we obtain a frequency distribution and grouped into categories,
age, classes (range of values) or tables.
b) A slightly more complicated way of presenting data is through contingency table. A
contingency table shows the relationship of two or more variables. E.g., age and sex of
patients with blood diarrhea or
c) One step further is the analysis to produce a graph of the data presented in tables, graphs,
provides more insight into frequency distributions and are easier to read.
d) Data can be summarized by measures of central tendency, mean, mode and median.
e) Data on deaths and births can be done using the mortality and fertility rates.

Data interpretation

Interpretation involves putting the findings of the study/ data into perspective and making
appropriate recommendations.

3. Data Quality Audit:

The goal of the Data Quality Audit (DQA) is to assure that management of services and
allocation of resources (funding) are based on sound and accurate data. The specific domain
areas include;
 ➢ Assess the quality of, accuracy, timeliness of service data and reporting system.
➢ Audit the reported figures given by the institution and estimate the national verification
factor (VF), recounted/ reported service data.

What is auditing?

Auditing is essentially examination of book of accounts. For example, ideally on EPI the book of
accounts are the various data collection tools in use ledger books, bin cards, tally and summary
sheets and immunization register.

It is an independent examination and expression of opinion on the financial statements of an

entity by an appointed auditor. Without independence it is not auditing

Auditors examine every document or voucher which support any transaction in a business e.g.,
receipts, logbooks and letters of representation. Auditing covers even behaviors of staff, their
professional qualifications and responsibility to duties e.g.

• A qualified nurse or health records and information officers who are negligent to duties
or
• Unqualified staffs dealing with work beyond their scope.
• Staff using KEPI fridge as a table, cupboards, vehicles, computers used for personal use.

Some advantages of Auditing

• Able to detect fraud

• Prevention of errors
• An “unqualified report” (opinion) can boost morale of accounting staff.
• An “unqualified report” (opinion) can be used to raise finance from banks or
development partners.
What must we do?

• Ensure that all reports are available and complete tally sheets ledger books, summary
sheets, bin cards, supervisory books for the audit year and current year.
• Ensure that all the data analyzed are accurate though for the report not submitted nothing
can be done.
• Have proper answers to the difference in data submitted since this may affect the
verification factor confidence interval.
• Ensure the consistency of the data and denominators used.
• Strengthen monitoring completeness and timeliness of reports at district, provincial and
national levels.
• Encourage regular written feedback
• Have old reports and forms properly kept and ready for verifications.
• Report missing data and why so.
• Ensure the retention of all health records for at least ten years (10) as stipulated in the
national policy.

What we must not do?

• Inflate our data or reports

• Be fraudulent e.g., same ink, fresh ink
• Missing reports should not be re-written – may result in a “zero score”
• Keep our offices locked or say the staff with the key not available.
• Fail or sabotage the DQA verification exercise.

4. DATA SECURITY
Backup

Def: - Computer security - protection method whereby several duplicate data files are stored on
Secondary Storage Devices in the event a catastrophic event damages the computer's main file
storage system. It is advisable to store backup data files in different locations to guard against
loss in the event of a fire, theft, or other unplanned event. Backup require two types, one to be
backup on even days and the other on old day. The storage device required to be stored far from
the main storage (server/computer) or operation office. Reports also can be backed-up on
institutional email.

Note: - Backup and Recovery: The goal will be to back up the data from any system on a daily
basis. Backup media could be external hard disk, Organizational email account, flash disk,
diskette, petition hard disk so that it will be available in the event of catastrophic failure.
Storage

Def: - The retention of data in any form, usually for the purpose of orderly retrieval and
documentation. A device consisting of electronic, electrostatic, electrical, hardware or other
elements into which data may be entered, and from which data may be obtained as desired.
Storage facilities varies depending on the size of the institution and workload in a facility you
require to have a folder or file, shelves, filling cabinet, box file or lockable cupboard to enable
you secure the documents. While in a large institution and district you require to have a memory
stick (Flash disk), Camera and PDAs you require to have a memory card, external hard drive,
RW-CD, R-CD, Cabinet, shelve and lockable cupboard. The storage device/documents required
to be stored far from the main office storage especially sensitive/vital documents.

Network Operations

Take all necessary precautions to prevent any destructive or malicious program (virus) from
being introduced to the system. Employ appropriate measures to detect virus infection and
employ all appropriate resources to efficiently disinfect any affected systems as quickly as
possible.

Computer Virus Prevention,

Detection, and Disinfection: The goal of the system will be to maintain updated virus protection
from a reputable source. Any and all viruses found will be quarantined or the virus will be
deleted. Every organization are required to run and maintain their own anti-virus software from
an approved source on all computers that have access to the HMIS system.

Records

Def: - any written document about in professional relationship with a health worker. Written
accounts of acts, transactions, or instruments that are drawn up pursuant to legal authority by an
appropriate officer and appointed to be retained as memorials or permanent evidence of matters
to which they are related.

Patient records is not a public record and its should be kept strictly confidential but can be
release only under sustain circumstance especially through patient consent (implicit, explicit),
court order, when it exist a high duty than a lower duty, when there is infectious or notifiable
disease. A public record is a document that has been filed with, or furnished by, a governmental
agency and is available to the public for inspection. For example, title of record to property is an
ownership interest that has been duly filed in the office of public land records. The term record
also applies to the formal, written account of a case, which contains the history of actions taken,
papers filed, rulings made, and all written opinions.
Data Security

Secure access to physical areas containing equipment, data, and software. Strictly safeguard all
data including client-identifying information in accordance with the latest technology available
and securely protect it to the maximum extent possible. Maintain and administer central and
backup server operations including security procedures and maintain backups of the system to
prevent the loss of data. Monitor access to all systems that could potentially reveal a violation of
information security protocols. Maintain and audit accurate logs of all changes made to the
information contained within the database.

Issue all User IDs and passwords for HMIS users through Technical Administrator. Only
designated Technical Administrators may request and receive HMIS passwords and User IDs
from Central level. Periodically change of passwords for security purposes. Not release data to
any person, agency, or organization without the client’s authorization and following the
procedures for the release of data. Any database at all level should not be handle by many people
have limited persons with right persons to handle the database which assist improve security and
management of database.

In the event of manual or use of files or folders data security is paramount and file must be filed
in a permanent building with fire extinguishers, exit doors, big bill board showing “No
smoking”, filing rooms should have well ventilated, filling equipment should be raised in case of
linkage or flood. doors and windows should be grilled. All patients/clients records and
information MUST not be access by un authorized (persons not directly handling the
patients/clients

Limit HMIS access to authorized users and follow all protocols of monitoring those users.
Provide names of all staff members who have access to the Records Unit and certify that such
staff are competent to have access to this information according to the provisions.

Preventive maintenance

Any machines, devices or equipment require regular preventive maintenance to improve

efficiency and durability.

• Files/folders requires: -
o dusting, and permanently filling of loose notes
o weeding of inactive notes/records
o during filling it require support file to stand upright
o keep on a dry and cool place
• CDS, Flash disk, Memory cards, diskette
o Place on a rag or album o Keep on a dry and cool place
o Its fragile so handle with care.
o Observe proper removal and inserting the device into the electronic machine.
 • Computers, laptop, printers, PDAs, Cameras, Duplo machines
o Its fragile so handle with care
o Read manufacture instruction while installing and assembling
o Keep on a dry and cool place
o Place on firm workstation, raise from surfaces and should not be placed at the
edge of the workstation
o Always wipe the equipment and workstations with dry clean clothing
o Once a quarterly or six months do major flow up the dusty.
o Avoid opening of equipment regularly, but it required trained technician
o Avoid using oily and wet hands on a keyboard and monitor
o Avoid taking tea, water, office pin near the keyboard
o Follow the right procedure of warm booting and shutting down the
devices/machines
o Proper connection of cables
• Other general equipment – shelves, rags, workstations
o Wipe the duty
o Painting and avoid spilling water on the surfaces
o Reinforce/support or acquire new shelves, workstation or rags
o Apply oil to parts with wheels

DHIS2
The District Health Information System Software (DHIS) is a free and open-source database and
application for collecting, processing, and analyzing health information, and whose development
and implementation was started in 1998 by the Health Information System Programme (HISP)
based in South Africa.

The overall objective of DHIS2 implementation is to be able to generate, analyze and

disseminate health information to facilitate effective policy formulation, management, planning,
budgeting, implementation, monitoring and evaluation of health services and program
interventions in the health sector. DHIS2 is able to support collection and analysis of routine
health services data, as well as non-routine data such as population estimates, facility workload
and survey data. Currently this data is collected by means of a paper-based system of registers,
tally sheets, and monthly data collation forms at each health facility. The collated monthly data is
either entered directly into the web-based DHIS2 or sent to the district level where is entered on
to the web-based DHIS2 software, then analyzed in the system. The web-based DHIS2 is
intended to capture health facility service delivery data and allow analysis at that level,
promoting data use at all levels for decision making.
DHIS2 is configured to allow the generation of reports, which can be either standard or
customized to meet the user requirements; and to also carry out data quality analysis and provide
a dashboard for monitoring and evaluation of health programs’ indicators. The essential reports
have already been built into the system and are immediately available for review at all levels i.e.,
by the health facility, district, province and national health departments. Data quality is
addressed through mechanisms incorporated into the data collection process and functions within
the DHIS software. Another advantage of the DHIS2 platform is its very modular web interface
which allows for easy incorporation of various modules, enabling easier replication of the
complex paper reporting formats that are unique to each country of implementation

Objectives of the District Health Information System 2 in Kenya

i. Calculation of indicators - Many indicators are based on numerators and

denominators from different data sources. DHS2 aims at integrating more data
source; hence more indicators can be generated from the central repository.
ii. Reduce manual processing and entering of the data - With different data at the same
place, there is no need to manually to extract and process indicators or reenter data in
to the data warehouse. This due to its ability to provide inter-operability between
systems of different data type.
iii. Streamline and simplify health information systems.
iv. Reduce redundancies - DHIS2 reduces the overlapping redundant data that is usually
collected by various parallel systems.
v. Improve organizational aspects - If all data can be handled by one unit in the ministry
of health instead of various sub systems maintained by different health programs, this
one unit can be professionalized.
vi. Integration of vertical programs. - An integrated database containing data from
various sources become more valuable and useful than fragmented and isolated ones.
For instance, when analysis of epidemiological data is combined with specialized data
will give a more complete picture of the situation
Some other challenges that have faced the deployment of the web-based DHIS2 in the country
include:

1. Connectivity: The strength of Internet connectivity varies widely in Kenya. Some regions
also have less access to electricity and mobile telephony. It is 29 thus difficult to
implement direct data entry by health facilities till the infrastructure at these levels in
enhanced.
2. Capacity: User capacity to use DHIS2 effectively has also been a challenge because of
the limited availability of skilled ICT work force in the health sector.
3. Stakeholders: There is continuous need to take care of all stakeholders’ needs in the
system, and at the same time avoid introducing redundant tools that risk overloading the
system. This has necessitated the development of standardized tools which take into
account the reporting needs of the various stakeholders – a challenging task which is still
ongoing.
4. Capital: While the project was heavily donor funded, there is need to find ways to blend
private and public resources in ways that would be sustainable.
5. Onset of Devolved counties – this has slowed down the rollout of training to users which
is necessary to ensure ease of system use. Moreover, the new structures at the counties
means that some of the DHIS2 district champions have had their roles redefined slowing
down use even further.

It is interesting to however note that the above challenges have not dampened the process of
scaling up use of DHIS2 in Kenya.

DHIS2 implemented in Kenya is comprehensively addressing the need for quality routine health
data in the following ways:

• The inbuilt validation rules and data quality checks have improved overall data quality.
• Use of the cloud-based Central Server ensures that changes made in the system are
available immediately to all user, and this setting also ensures that DHIS2 is available on
a 24/7 basis.
• Previously some of the HIS data was contained in parallel, mostly donor sponsored
systems which were not easily accessible to potential users; the DHIS2 data is however
web-based and all interested users can now use web browsers to access HIS reports from
any location.
• The implementation HTML5 standard allowing for offline data entry has made use of
DHIS2 a reality even in rural parts of Kenya with poor internet connectivity.
Design of DHIS

All data in one place – a central repository

▪ Supports collection of many different data sets (and can easily expand to new data
requirements)

▪ Automated import from other systems like MFL, EMR, HR, Logistics etc. (planned
for)

▪ Avoid duplicate systems for data collection and storage

Easy access to data to all online users

▪ Wherever you are, as long as you have Internet and a username you can access the
latest data

▪ DHIS 2 becomes a data centre for all stakeholders with access

Pre-defined analysis tools shared by all users

▪ both one click reports and custom data analysis

▪ targeting different needs and skills

▪ User-defined dashboards to give a quick overview of the latest data

▪ GIS interface to all the data

Data aggregation to any level or period

▪ While data is collected and stored monthly by health facility, a report can show quarterly
or yearly values by any level in the hierarchy

Built in support for definition and calculation of indicators (coverage, incidence rates etc.)

▪ Often referred to as “calculated indicators”

▪ Makes use of population and other denominator data already in the system

All reports and analysis tools support indicators and allow for analysis and comparisons
across areas and over time

▪ Instead of looking only at raw numbers or doing manual calculations in Excel

Many output formats are supported; html, pdf, excel, jasper reports
DHIS Browsers

The DHIS 2 is a web-based application and is available in an Internet browser when you have
Internet connection.

The recommended browsers are: -

▪ Google Chrome
▪ Mozilla 8
▪ Internet Explorer 9 and above

Principles of DHIS Reporting

There two types of reports: -

o Standardized -One-click

o Dynamic-enhanced deep analysis

− Facilitates users with different levels of experience

− Facilitates requirements for fixed reports as well as deep analysis

Online system enables horizontal comparison

Feedback reports are available immediately

Possible to compare performance across organization unit

Types of Reports

(a) Standardized

• Standard Report

• Dataset Report

• Reporting Rate Summaries

• Report table

• Resources
(b) Dynamic

Pivot Table

Organization Unit Distribution Report

Tally sheet

DHIS in the Kenyan context

DHIS was introduced in Kenya in 2010 and piloted in Coast in January 2011

National Roll out was from May-October 2011

Rationale for DHIS adoption in Kenya

▪ Multiplicity of HIS/M&E systems

▪ Inability to authoritatively state level of sector performance
▪ Difficulty determining intra-district reporting rates
▪ Limited analysis with often conflicting statistics
▪ Limited capacity of excel based databases
▪ Overall erosion of trust in the existing system

DHIS2 supports different facets of the information cycle including:

▪ Collecting data.
▪ Running quality checks.
▪ Data access at multiple levels.
▪ Reporting.
▪ Making graphs and maps and other forms of analysis.
▪ Enabling comparison across time (for example, previous months) and space (for example,
across facilities and districts).
▪ See trends (displaying data in time series to see their min and max levels).
Benefits of DHIS

1. Provide a comprehensive HIS solution based on data warehousing principles and a

modular structure which can easily be customized to the different needs of the health
systems - and supports the idea of an integrated HIS at all levels of the health hierarchy.

2. Customization and local adaptation through the user interface. No programming required
to start using DHIS 2 in a new setting (country, region, district etc.).

3. Provide data entry tools which can either be in the form of standard lists or tables, or can
be customized to replicate paper forms.

4. Provide different kinds of tools for data validation and improvement of data quality.

5. Provide easy to use - one-click reports with charts and tables for selected indicators or
summary reports using the design of the data collection tools. Integration with popular
external report design tools like iReport and BIRT allows super-users to flexibly add more
custom reports accessible to all users.

6. Flexible and dynamic (on-the-fly) data analysis in the Data Visualize and the GIS
modules.

7. A user-specific dashboard for quick access to the relevant monitoring and evaluation tools
including indicator charts and links to favorite reports, maps and other key resources in the
system.

8. Easy to use user-interfaces for metadata management e.g., for adding/editing datasets or
health facilities. No programming needed to set up the system in a new setting.

9. Functionality to design and modify calculated indicator formulas.

10. User management module for passwords, security, and fine-grained access control (user
roles).

11. Messages can be sent to system users for feedback and notifications. Messages can also be
delivered to email and SMS.

12. Users can share and discuss their data in charts and reports using Interpretations, enabling
an active information-driven user community.
 13. Functionalities of export-import of data and metadata, supporting synchronization of
offline installations as well as interoperability with other applications.

14. Integration with other software systems – using the DHIS 2 Web-API and the Integration
Engine.

15. Further modules can be developed and integrated as per user needs, either as part of the
DHIS 2 portal user interface or a more loosely-coupled external application interacting
through the DHIS 2 Web-API.

Practical session recommended

MASTER FACILITY LIST

The MFL is the official list of all the facilities operating in Kenya, and is maintained by the
SCHMT through the SCHRIO.

• The MFL is found on www.ehealth.or.ke/facilitylogin

• The MFL has a unique code for each facility
• The MFL contains permanent and semi-permanent bio-data on each facility:
• Permanent data is that which does not change – name, directions to locate the facility, geo-
codes, etc.

The MFL has two official sites: -

1. Log-in site- This site requires a username and a password to get in. It is only
authorized personnel who can get into the Login site.
2. Public Site- This available for everyone to view and does not require to Login

Explain functions of the different Menus of MFL

Home Menu: - Provides a quick and faster method for searching of facilities and contacts.

Facilities Menu: - Provides for advanced filter-based facility and contact searching, editing and

adding of new facility to the MFL

Admin Offices: -This menu item is used to provide all facility contacts

Reports: - This menu item gives summarized reports about facilities

System: - The system menu item is primarily used for system configuration and
 administration

Master Community Unit List (MCUL) Practical session recommended

Other applications of ICT

ELECTRONIC MEDICAL RECORDS

INTRODUCTION

Paper-based records have been in existence for centuries and their gradual replacement by
computer-based records has been slowly underway for over twenty years in western healthcare
systems. Computerized information systems have not achieved the same degree of penetration in
healthcare as that seen in other sectors such as finance, transport and the manufacturing and retail
industries. Further, deployment has varied greatly from country to country and from specialty to
specialty and in many cases has revolved around local systems designed for local use. National
penetration of EMRs may have reached over 90% in primary care practices in Norway, Sweden
and Denmark (2003), but has been limited to 17% of physician office practices in the USA (2001-
2003). Those EMR systems that have been implemented however have been used mainly for
administrative rather than clinical purposes.

• Electronic medical record systems lie at the center of any computerized health information
system. Without them other modern technologies such as decision support systems cannot
be effectively integrated into routine clinical workflow. The paperless, interoperable,
multi-provider, multi-specialty, multi-discipline computerized medical record, which has
been a goal for many researchers, healthcare professionals, administrators and politicians
for the past 20+ years, is however about to become reality in many western countries.
• In Kenya, the Division of Health Information Systems (HIS) has recognized the need to
improve the use of ICT in health. Under Strategic Objective Five of the HIS Strategic Plan
2009-2014, the HIS aims to strengthen the use and application of information and
communication technology, in data management. Tethered to this objective is the need to
have standardized and interoperable ICT Applications, including Electronic Medical
Records. It is with this objective in mind that the Ministries of Health, through the HIS,
embarked on a process of standardization of EMRs in Kenya. Electronic Medical Record
 (EMR) systems are increasingly being adopted in Kenya to improve medical record
management, health program management, and the quality of patient care.

WHAT IS AN EMR?

• EMR is an acronym for Electronic Medical Records. This refers to a paperless, digital
and computerized system of maintaining patient data, designed to increase the efficiency
and reduce documentation errors by streamlining the process. It can also be defined as a
longitudinal collection of electronic health information that provides immediate,
authorized access to person and population level data to support efficient health services
delivery process.

CURRENT SITUATION ON THE USE OF ELECTRONIC MEDICAL RECORDS IN

KENYA TODAY.

• Implementing EMR is a complex, expensive investment that has created a demand for
Healthcare IT professionals and accounts for a growing segment of the healthcare
workforce. Just like any other record keeping, moving patients' records from paper and
physical filing systems to computers and their super storage capabilities creates great
efficiencies for patients and their health care providers, as well as health payment systems
• In 2001 the Department of Medicine and Child Health and Pediatrics at Moi University,
Eldoret and the department of internal Medicine and Geriatrics at the Indiana University
school of Medicine in collaboration with the Moi Teaching and referral Hospital in Eldoret,
Kenya, established the academic Model for Prevention and treatment of HIV/AIDS
(AMPATH). Its medical records in Sub Saharan Africa are the first electronic medical
record system for the Comprehensive management of the clinical care of patients infected
with HIV. This system is composed of both paper-based and electronic records, has led to
uniformity in data collection and facilitated the retrieval of patient data for clinical care
and research.
• Other health facilities in the region both GOK and Private that have implemented the
EMR in Kenya include Aga Khan Teaching and Referral Hospital, The Nairobi Hospital,
Kisii Level 5 Hospital, MP Shah Hospital, Jaramogi Oginga Odinga Teaching and
Referral Hospital, Coast Provincial general Hospital, Naivasha District Hospital among
others.
 • It has been observed that facilities that have embraced EMR have shown remarkable
improvement in revenue collection as every activity is accounted for. It has also tools for
stock control and supply chain management. This results in efficient use of resources as
health care providers become more accountable and audit trail is possible i.e., every
action done in the system can be traceable to the real user.
• Some of the notable challenges with the EMR may include high cost of setting the
infrastructure and maintenance of the system, lack of standardization of EMR in Kenya,
computer viruses, and literacy level among users. Due to fear, change is considered a threat
yet without adequate involvement of the users of the system, the project can never be
developed.

ADVANTAGES AND DISADVANTAGES OF USING ELECTRONIC MEDICAL

RECORDS.

• By making it easier to use and share information, EMRs can help health care providers do
a better job of managing patient care. When fully functional and exchangeable, the
benefits of EMRs offer far more than a paper record can. Some of the benefits include the
ones discussed below:

• Money is saved by using electronic medical records; not just the cost of paper and file
folders, but the cost of labor and space, too. In any business, time equals money. The
efficiencies created by simply typing a few identifying keystrokes to retrieve a patient's
record as opposed to staring at thousands of file folders, filing and refilling them -- saves
a doctor's practice or a hospital many thousands of shillings. That's even taking the cost
of the electronic system into account.

• Another benefit is safety. In the past, the way a doctor obtained your health history was
by asking you. Each time you visited a new doctor's office, you filled out forms about
your history, including previous surgeries, or the drugs you take on a regular basis. If you
forgot a piece of information, or if you didn't write it down because it seemed
unimportant to you, then your doctor didn't have that piece of your medical puzzle to
work with.
• However, when doctors share records electronically, your new doctor only needs to ask
your name, birth date, and possibly another piece of identifying information. She can then
pull up your records from their electronic storage space. All of the information he needs
to see will be there in full. When it comes time to diagnose you, it might be important to
him to learn that you are taking a certain kind of medication, or even an herbal
supplement -- any information shared with a previous doctor. Diagnosis and treatment
decisions might be altered based on that information, which is far more complete than
what you might have written down on paper.

• In the past, when a doctor closed his practice, retired, moved, or even died, patient
records could easily get lost or relocated, making it impossible for patients to get the
records they needed to take to a new doctor. Keeping these records electronically,
especially in the cases where patients can also gain access to them, means the patient
won't be left without the records she may need.

• EMRs save space. Instead of keeping huge paper files on patients, all records are kept on
computer files. Though someone must store these records in computers, this still
represents a small percentage of the space required to store physical records.

• Electronic medical records may save time as well. Though faxing and email assisted one
doctor to get information from another doctor or a laboratory, there was generally a wait
time. When a doctor has instant access to all of a patient’s information, including things
like x-rays, lab tests, and information about prescriptions or allergies, he or she is
empowered to act right away, thus saving time.
• Many doctors are often considered to have undecipherable handwriting, and though this
is a generalization, unclear writing can lead to mistakes. Typed information is less likely
to create misunderstandings.
• One concern about the use of electronic medical records is that doctors may have a
significant learning curve when these programs are first employed. A poor typist may
actually take a long time to input information. Doctors often have to be their own medical
clerks especially during an office visit, and a doctor distracted by confusing technology
may not be as alert to a patient’s symptoms or needs.
• There is no single electronic medical records source or system, so different hospitals and
individual clinicians are not all using the same program. This negates the possibility of
instant information for all on the medical team, since one program may not mesh with
another.
• Some patients express concern that electronic medical records might be hacked and
exploited by others. Misuse of private medical information could create problems for
people who have conditions they wish to keep private.

CONCLUSION

• Despite these concerns, it appears many doctors and hospitals are now attempting to use
electronic medical records. It remains unclear how long it will take for old files with long
medical histories to be updated into electronic means. It also seems that employing
electronic means to store data still requires some thought so that information and systems
are uniform.
• The Government of Kenya has come up with the national guidelines and standards for the
implementation of Electronic Medical Records which will spearhead the growth in the
country. Working with the implementing partners, health facilities like Rwambwa Health
Centre in Siaya, Awendo Sub-District Hospital in Migori have embraced the EMR and
effective and efficient management of health care system has been realized in these
facilities.

GIS

What is a GIS?

Definition:

• It is a computer system capable of capturing, storing analyzing and displaying

geographically referenced information i.e., data identified according to location.

• Information system designed to work with data referenced by spatial coordinates collected
through the Global positioning system (GPS)
Components of a GIS

• Hardware: Computer, Network, printer, Plotter, digitiser

• Software: Database management system, statistical analysis system, map digitising

system, geographic analysis system

• Data: The data that is input into the system in various forms such as maps, reports etc.

• People: People working with a GIS such as data entry staff, surveyors, IT administrators
etc.

• Processes/Methods: Includes processes such as overlaying, digital mapping, visual

displaying, interpolation etc.

Why use GIS?

• Ability to assimilate divergent sources of data

• both spatial and non-spatial

• Visualisation impact-what is where

• Analytical capability e.g., showing trends

• Overlaying of data (use of different layers)

• Modelling-What if? Sharing of information

Remind participants about the John Snow experiment where John snow by use of geographic
coordinates was able map out the houses of people that had cholera and through this, he was able
to isolate the circumstances that seemed to favour the spread of cholera, key among them being
poor sanitation and refuse disposal.

The importance of GIS in healthcare: -

• GIS helps in visualising data e.g.; in surveillance you are able to locate and monitor trends.

• Helps to identify the areas of greatest health needs to enable decision makers to prioritise
resources.

• Also, one may map conditions before and after action or event to see the impact. A SCHMT
might map the change in the spread of a disease before and after an epidemic.
 • Modelling enables one to see what if situations in comparison to new features in a location
e.g., new road, new market, health facility etc.

• We can also use different layers of presentation such as geographic, health facility
coverage, population etc. and this can aid in visualisation for decision making

Data presentation

Purpose of data presentation

• Identify patterns and trends within the data

• Summarize results of data analysis

• Communicate information to others

– Periodic data summaries

– Investigation reports

– Slide presentations and posters

– Scientific publications

Choosing the most appropriate format for displaying data depends on:

• Variable type

• Purpose of the data presentation

• Complexity of the data

• Ease of interpretation

• Effectiveness of conveying your message

Data is presented differently depending on variable type

1. Qualitative or Categorical variables cannot be measured numerically. Instead, they are

divided into non-numerical categories. Examples of qualitative variables include hair color,
occupation, region.

Qualitative variables are further divided into 2 categories:

(a) Nominal variables are those whose categories are labels or names that don’t have an inherent
order. For example, Nationality – Ugandan, Kenyan, and Tanzanian.

(b) Ordinal variables are those whose categories are non-numerical, but still have some order to
them. Think of the word “order” to help you remember. For example, Severity of illness—mild,
moderate, severe

2. Quantitative variable. Think of the word quantity. Quantitative variables can be

measured numerically.

(a) Discrete variable. These variables are measured as whole numbers. For example, Count
Data – 1, 2, 3, 4… n such as number of cups of tea consumed.

(b) Continuous variable. These variables can have numerical measurements in between
whole numbers. For example, height can be 175.15 cm.
Data can be presented in

• Tables

• Bar Charts

• Histograms

• Line Graphs

• Scatter plots

• Maps

• Pie Charts

• Box plots

• Frequency Polygons

• Tables, charts, and maps are common ways to display data

• Presented data should be clear, meaningful, and easy to interpret
• Effective visual displays avoid unnecessary or distracting features
Data Warehouse
A data warehouse is a type of data management system that is designed to enable and support
business intelligence (BI) activities, especially analytics. Data warehouses are solely intended to
perform queries and analysis and often contain large amounts of historical data. The data within
a data warehouse is usually derived from a wide range of sources such as application log files
and transaction applications.

A data warehouse centralizes and consolidates large amounts of data from multiple sources. Its
analytical capabilities allow organizations to derive valuable business insights from their data to
improve decision-making. Over time, it builds a historical record that can be invaluable to data
scientists and business analysts. Because of these capabilities, a data warehouse can be
considered an organization’s “single source of truth.”

Benefits of data warehouse

1. A Data Warehouse Delivers Enhanced Business Intelligence - By providing data from

various sources, managers and executives will no longer need to make business decisions
based on limited data or their gut. In addition, “data warehouses and related BI can be
applied directly to business processes including marketing segmentation, inventory
management, financial management, and sales.”
2. A Data Warehouse Saves Time - Since business users can quickly access critical data
from a number of sources—all in one place—they can rapidly make informed decisions
on key initiatives. They won’t waste precious time retrieving data from multiple sources.
3. A Data Warehouse Enhances Data Quality and Consistency - A data
warehouse implementation includes the conversion of data from numerous source
systems into a common format. Since each data from the various departments is
standardized, each department will produce results that are in line with all the other
departments. So, you can have more confidence in the accuracy of your data. And
accurate data is the basis for strong business decisions.
4. A Data Warehouse Provides Historical Intelligence - A data warehouse stores large
amounts of historical data so you can analyze different time periods and trends in order to
make future predictions. Such data typically cannot be stored in a transactional database
or used to generate reports from a transactional system.
 5. A Data Warehouse Generates a High Return of investment - Finally, the piece de
resistance—return on investment. Companies that have implemented data warehouses
and complementary BI systems have generated more revenue and saved more money
than companies that haven’t invested in BI systems and data warehouses.
6. And that should be reason enough for senior management to jump on the data warehouse
bandwagon.

Exercise

Discuss the application of computers in HIS