Is the routine health information system ready to support the planned national health insurance scheme in South Africa?

Implementation of a National Health Insurance (NHI) in South Africa requires a reliable, standardized health information system that supports Diagnosis-Related Groupers for reimbursements and resource management. We assessed the quality of inpatient health records, the availability of standard discharge summaries and coded clinical data and the congruence between inpatient health records and discharge summaries in public-sector hospitals to support the NHI implementation in terms of reimbursement and resource management. We undertook a cross-sectional health-records review from 45 representative public hospitals consisting of seven tertiary, 10 regional and 28 district hospitals in 10 NHI pilot districts representing all nine provinces. Data were abstracted from a randomly selected sample of 5795 inpatient health records from the surgical, medical, obstetrics and gynaecology, paediatrics and psychiatry departments. Quality was assessed for 10 pre-defined data elements relevant to NHI reimbursements, by comparing information in source registers, patient folders and discharge summaries for patients admitted in March and July 2015. Cohen's/Fleiss' kappa coefficients (κ) were used to measure agreements between the sources. While 3768 (65%) of the 5795 inpatient-level records contained a discharge summary, less than 835 (15%) of diagnoses were coded using ICD-10 codes. Despite most of the records having correct patient identifiers [κ: 0.92; 95% confidence interval (CI) 0.91-0.93], significant inconsistencies were observed between the registers, patient folders and discharge summaries for some data elements: attending physician's signature (κ: 0.71; 95% CI 0.67-0.75); results of the investigation (κ: 0.71; 95% CI 0.69-0.74); patient's age (κ: 0.72; 95% CI 0.70-0.74); and discharge diagnosis (κ: 0.92; 95% CI 0.90-0.94). The strength of agreement for all elements was statistically significant (P-value ≤ 0.001). The absence of coded inpatient diagnoses and identified data inaccuracies indicates that existing routine health information systems in public-sector hospitals in the NHI pilot districts are not yet able to sufficiently support reimbursements and resource management. Institutional capacity is needed to undertake diagnostic coding, improve data quality and ensure that a standard discharge summary is completed for every inpatient.

Availability and quality of routine morbidity data: review of studies in South Africa.

OBJECTIVES: Routine health information systems (RHISs) provide data that are vital for planning and monitoring individual health. Data from RHISs could also be used for purposes for which they were not originally intended, provided that the data are of sufficient quality. For example, morbidity data could be used to inform burden of disease estimations, which serve as important evidence to prioritize interventions and promote health. The objective of this study was to identify and assess published quantitative assessments of data quality related to patient morbidity in RHISs in use in South Africa. MATERIALS AND METHODS: We conducted a review of literature published between 1994 and 2014 that assessed the quality of data in RHISs in South Africa. World Health Organization (WHO) data quality components were used as the assessment criteria. RESULTS: Of 420 references identified, 11 studies met the inclusion criteria. The studies were limited to tuberculosis and HIV. No study reported more than 3 WHO data quality components or provided a quantitative assessment of quality that could be used for burden of disease estimation. DISCUSSION: The included studies had limited geographical focus and evaluated different source data at different levels of the information system. All studies reported poor data quality. CONCLUSION: This review confirmed concerns about the quality of data in RHISs, and highlighted the need for a comprehensive evaluation of the quality of patient-level morbidity data in RHISs in South Africa.

Routine Health Information Systems in South Africa--Opportunities for Improvement.

A recurring theme in published studies is the need for the appropriate human and other resources to support routine health information system (RHIS) implementation. While training in the use of specific RHIS and the availability of the required resources for implementation are essential for all users, other factors such as managers' understanding of the role of RHIS in supporting health services; the ability to interpret RHIS data; and a focus on data quality are further requirements for effective RHIS implementation.

Special People in Routine Health Information Systems Implementation in South Africa.

An analysis of roles and decision making structures to facilitate routine health information system (RHIS) implementation and use in public health facilities in South Africa identified a wide range of stakeholders in these processes. Two broad categories of RHIS 'special people' are analysed, i.e. leaders (administrative and/or clinical) and bridgers/support staff. In addition to health system personnel with specific responsibility for RHIS, users with an interest in effective use of RHIS and RHIS outputs, and staff of external system and/or service providers, can play significant roles in RHIS implementation and use.

A multi-method study of factors associated with hospital information system success in South Africa.

A combination of interpretivist and positivist techniques was used to develop and refine a conceptual model of factors associated with computerised hospital information system (CHIS) success in South Africa. Data from three case studies of CHIS use in level 2 public sector hospitals were combined to develop a conceptual model containing seven factors associated with CHIS success at hospital level. This conceptual model formed the basis of a fourth case study which aimed to confirm and refine the initial conceptual model. In the third phase of the study, a survey of CHIS use was conducted in 30 hospitals across two South African provinces, each using one of three different CHISs. Relationships between hospital-level factors of the conceptual model and user assessment of CHIS success were examined. A revised conceptual model of CHIS use was developed on the basis of the survey results. The use of a multi-method approach made it possible to generalise results from the case studies to multiple CHIS implementations in two provinces.

Factors associated with health information system success: results of a survey of hospitals in South Africa.

A survey of computerised hospital information system (CHIS) use was conducted in two South African provinces, in order to test a conceptual model of CHIS use developed in previous phases of this study. Relationships between factors of the conceptual model and user assessment of CHIS success; and between pairs of conceptual model factors, were derived from the survey data. The results confirmed that factors of the conceptual model were associated with CHIS success. Analysis of the relationships between factors yielded results which supported some of the conceptual model relationships, and were inconclusive for others. None of the conceptual model relationships was contradicted by the survey results. Further investigation is required to demonstrate statistical relationships between factors of the conceptual model more conclusively. The results to date support arguments for the applicability of the conceptual model of CHIS use beyond the study hospitals to other level 1 and level 2 hospitals in South Africa.

A conceptual model of computerised hospital information system (CHIS) use in South Africa.

The aim of this project is to contribute to limiting the risk of CHIS (computerised hospital information system) failure by identifying factors which are associated with the successful implementation of CHISs in district and regional hospitals in South Africa (SA). Case studies were conducted in four regional hospitals in the Western Cape province of SA to obtain data about user perceptions of the success or lack of success of the CHISs in use. A conceptual model of CHIS use has been developed based on the results of the case studies, in order to assist in the interpretation of the differing experiences across the hospitals. Key factors in the conceptual model are perception of usefulness of the CHIS and management commitment to ensuring CHIS success, which in turn are related to effective use of CHIS and/or CHIS outputs, and allocation of resources for CHIS further development. Further development of the model will be influenced by the next phase of this project: a survey of district and regional hospitals in two SA provinces.

Modelling the effect of limited or vulnerable resources on the use of computerised hospital information systems (CHISs) in South Africa.

A conceptual model of computerised hospital information system (CHIS) use has been developed, based on the results of case studies in four South African regional (level 2) hospitals, interviews with local experts, and related work on modelling and evaluation of health information systems. In addition to factors within hospitals, factors which reflect the decisionmaking and resource allocation processes at provincial level have also been included in the model. The applicability of the model is demonstrated through an analysis of the effects of limited or vulnerable resources on CHIS implementation and use at hospital level. Some potential approaches to overcoming these effects are suggested.

A consumer decision support system for common health ailments in South Africa.

Access to health services is difficult in many rural areas of South Africa. A basic computerised decision support system (CDSS) has been developed to assist consumers to reduce the number of unnecessary visits to health care facilities. Consumers are prompted to enter details of their symptoms, and the CDSS assesses the likelihood of their suffering from one of ten common ailments, such as tuberculosis or hypertension. Advice is given on whether the consumer should seek care from a health care professional.