eGovernment for Development
eHealth Case Study No.3
MINPHIS: Improving Patient Data in a Nigerian Hospital
Case Study Author
Adekunle Oluseyi Afolabi ( aoafolabi@yahoo.com )
Application
Since 1991, a computerised system for storing and reporting patient record data has been under operation and refinement in the Obafemi Awolowo University Teaching Hospital (based in Ile-Ife, Nigeria). The system has been christened MINPHIS: Made in Nigeria Primary Health care and Hospital Information System.
Application Description
The MINPHIS application keeps patient records and generates various reports for health management and research purposes. The reports include the patient status, medical history and admissions plus indicators like length of stay per patient, discharge summaries, mortality and morbidity data, and operations. The application can answer ad hoc queries from medical researchers (e.g. cases of cholera for a period per geographical location for specific age group or sex or both). It can also provide performance information relevant to particular health care professionals, such as the mortality rates for patients treated by a particular staff member. Such information can be used for self-appraisal by medical staff, or for formal appraisal by hospital managers.
The intention is to extend the system to encompass both the three tiers of the Nigerian health system in order to provide a total patient health data application.
Role of ICT
The records system currently uses a minimum of Pentium III with 128MB RAM and 10GB hard disk capacity. The operating system is Windows 2000. The MINPHIS software package has been custom-built.
Application Drivers/Purpose
The initial driver for the project came from an academic from the University of Kuopio, Finland who wanted to understand the work of computer systems developers in developing countries: how they can contribute to social development and how their work differs from that of developers in industrialised countries. In tackling this, he decided to engage in a software development project in Nigeria. This particular project emerged as a collaborative initiative hosted by the Obafemi Awolowo University's Computer Science and Engineering department (Health Informatics group), which advised the Finnish researcher to work within the University's Teaching Hospital. The project had the stated purpose of producing the clinical-based patient information that is required for effective health care management and health care research. The underlying goal of the system is to improve health care delivery in Nigeria.
Stakeholders
The developmental stakeholders for the system are those just identified above: external and internal academics plus hospital staff. Within the hospital, health records personnel are the key operational stakeholders alongside hospital management staff. Medical personnel and patients are also affected by the system.
Health and the Poor
The system has no direct impact on the poor. However, poor women and men form the majority of the patients whose data is used by managers and policy-makers to try to improve health planning decisions. If those decisions can be improved - for example about which disease categories need more attention and resourcing - then the poor should be beneficiaries.
Impact: Costs and Benefits
The bulk of costs for development of this system have been incurred through staff time that has not been explicitly costed, but which represents many person-years of effort. The system also requires a significant hardware infrastructure to be in place which, again, has not been explicitly costed against the project. Software development tool costs are estimated at around US$6,000. The main resources - hardware, software and some human resource inputs - were provided by the Academy of Finland through the INDEHELA-Methods project.
The system has helped to improve the quality of patient data which, in turn, has been used through reporting to improve the quality of decision-making. This should have helped in planning, for example to understand which disease categories to priorities for attention, or to understand the availability and requirements for particular drugs. It should help in research, for example to identify trends in patient health and care. And it has been used in resource management decisions, by improving the understanding of indicators such as the number of consultations per day handled by medical professionals, the number of patients per ward, the number of professionals who fail to write discharge summaries for their patients, etc. The availability of such performance information should also have helped focus the minds of health professionals on their own performance. As noted below, though, levels of use and institutionalisation of the system are still somewhat limited.
Evaluation: Failure or Success?
There have been two evaluations of the system; first in the 1990s and then more recently. The first evaluation found that MINPHIS was useful but should be expanded to give more clinical benefits. The second evaluation reported that MINPHIS was under-utilised and was more like a 'status symbol' at the hospital. It should therefore be categorised as a partial success/partial failure. The MINPHIS package is now on the market, and at least four other tertiary hospitals in Nigeria have implemented it.
Enablers/Critical Success Factors
- Committed hybrid team . This e-health application has benefited from the commitment and focus of the project team who, despite conflicts of interest at times, have tried to stay attentive to the production of the information system. The team's hybrid profile has also helped, covering both health and IT capabilities with all groups involved in system development: the IT specialists took overall responsibility for developing, implementing and maintaining the system; health care professionals helped with clinical validation of the system; and health records officers tested the system with real patient data to ensure that it matched against manual reporting.
- Interested users . This e-health system has benefited from a group of stakeholders who actually wanted to use the system and its outputs. These include the health records officers who are the main system users and who have found their work upskilled and more professionalised, and health researchers who use the system from time to time to answer queries.
Constraints/Challenges
- Conflicts of interest . eHealth systems often bring together a variety of different institutions. In this case there were local and overseas institutions; and there were health and IT institutions. Each one of these institutions had different goals, and even within the institutions, individuals had different interests. Some saw the project as a research opportunity, others saw it as a practical tool, others saw it as a 'cash cow', and yet others saw it as a stepping stone to creating regional centres of excellence in training or in information systems development or in information systems research. With each party pulling in rather different directions, the overall health focus of the project could easily get lost.
- Time and money . Allowing a longer time period for an e-health application can be very positive: it can allow an incremental approach that minimises risks of failure. However, this project also showed the downsides of long timescales. Over time the members of the pioneering team of system developers got promoted within their institutions. They had to spend more time on administration and management with limited time to devote to system development. This would have been manageable except for the fact that the project had no funding with which to buy in professional systems development help. This caused further delays and, as technology moved on, when additional IT professionals were hired to help, it generally made sense for them to start the system all over from scratch. The project also faced the problem of turnover among managerial staff in the institutions involved, leading to a lack of continuity in project management.
Recommendations
- Invest in aligning interests . eHealth projects can be derailed by the conflicting interests of different stakeholders. A starting point for such projects, then, should be an understanding of the individual interests of stakeholders and an attempt to map those onto the formal health-related objectives of the e-health application. Individual and application interests cannot necessarily be fully aligned, but at least stakeholders can be helped to realise that their individual goals - money-making, or achieving recognition - are unlikely to be achieved if the system is not developed. In all, there needs to be a good amount of effort invested on the soft side of the e-health project: building trust, facilitating more open and honest communication, and understanding the mechanisms of negotiation and compromise.
Further Information
Health Informatics Group, Computer Science & Engineering Department, Obafemi Awolowo University, Ile-Ife, Nigeria ( minphis@oauife.edu.ng ).
Case Details
Case Editor : Richard Heeks.
Author Data Sources/Role : System Development Role.
Outcome : Partial Success/Partial Failure.
Region : West Africa. Start Date : 1991. Submission Date : January 2004.