Health Information

HEALTH INFORMATION

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Introduction

· Health information is an integral part of the national health system.

· It is a basic tool of management and a key input for the progress of any society.

· A health information system is defined as: "a mechanism for the collection, processing, analysis and transmission of information required for organizing and operating health services, and also for research and training".

· The primary objective of a health information system is to provide reliable, relevant, up-to-date, adequate, timely and reasonably complete information for health managers at all levels (Le., central, intermediate and local), and at the sharing of technical and scientific (including bibliographical) information by all health personnel participating in the health services of a country and also to provide at periodic intervals, data that will show the general performance of the health services and to assist planners in studying their current functioning and trends in demand and work load.

· Unfortunately, it is still very difficult to get the information where it matters most – i.e., at the community level. It is conceded that no country at the present time has such a thoughtfully constructed system of health information in operation, but the concept is receiving much attention.

· The whole science of health statistics has undergone considerable changes in the past two decades. In 1973, the World Health Assembly stressed the need for complete reconstruction of the health information systems.

· Health information is an integral part of the national health system. It is a basic tool of management and a key input for the progress of any society.

Components

The health information system is composed of several related subsystems. A comprehensive health information system requires information and indicators on the following subjects:-

Demography and vital events

o Environmental health statistics

o Health status (mortality, morbidity, disability, and quality of life)

o Health resources (facilities, beds, manpower)

o Utilization and non-utilization of health services (attendance, admissions, waiting lists)

o Indices of outcome of medical care

o Financial statistics (cost, expenditure) related to the particular objective

Uses

The important uses to which health information may be applied are:

To measure the health status of the people and to quantify their health problems and medical and health care needs
Local, national and international comparisons of health status. For such comparisons the data need to be subjected to rigorous standardization and quality control.
Planning, administration and effective management of health services and programmes
Assessing whether health services are accomplishing their objectives in terms of their effectiveness and efficiency
Assessing the attitudes and degree of satisfaction of the beneficiaries with the health system, and
Research into particular problems of health and disease

Sources

The lifeblood of a health information system is the routine health statistics.
Information requirements will vary according to the administrative level at which planning is envisaged. For example, the information requirements of a public health administrator will be different from the information requirements of a hospital administrator. These different contexts require different sources of information like:-

1. Census –

The census is an important source of health information.
It is taken in most countries of the world at regular intervals, usually of 10 years.
A census is defined by the United Nations as "the total process of collecting, compiling and publishing demographic, economic and social data pertaining at a specified time or times, to all persons in a country or delimited territory".
Census is a massive undertaking to contact every member of the population in a given time and collect a variety of information.
It needs considerable organization, a vast preparation and several years to analyse the results.
This is the main drawback of census as a data source - i.e., the full results are usually not available quickly.
The first regular census in India was taken in 1881, and others took place at 10-year intervals.
The last census was held in March 2001.
The census is usually conducted at the end of the first quarter of the first year in each decade, the reason being, most people are usually resident in their own homes during that period.
The legal basis of the census is provided by the Census Act of 1948.
The supreme officer who directs, guides and operates the census is the Census Commissioner for India.
Although the primary function of census is to provide demographic information such as total count of population and its breakdown into groups and subgroups such as age and sex distribution, it represents only a small part of the total information collected.
The census contains a mine of information on subjects not only demographic, but also social and economic characteristics of the people, the conditions under which they live, how they work, their income and other basic information.
These data provide a frame of reference and base line for planning, action and research not only in the field of medicine, human ecology and social sciences but in the entire governmental system.
Population census provides basic data (such as population by age and sex) needed to compute vital statistical rates, and other health, demographic and socio-economic indicators. Without census data, it is not possible to obtain quantified health, demographic and socio-economic indicators.

2. Registration of vital events –

Whereas census is an intermittent counting of population, registration of vital events (e.g., births, deaths) keeps a continuous check on demographic changes.
If registration of vital events is complete and accurate, it can serve as a reliable source of health information.
Much importance is therefore given to the registration of vital events in all countries.
It is the precursor of health statistics. Over the years, it has dominated the health information system.
The United Nations defines a vital events registration system as including "legal. registration, statistical recording and reporting of the occurrence of, and the collection, compilation, presentation, analysis and distribution of statistics pertaining to vital events, i.e live births, deaths, foetal deaths, marriages, divorces, adoptions, legitimations, recognitions, annulments and legal separations".
Registration of vital events has been the foundation of vital statistics.
India has a long tradition of registration of births and deaths. In 1873, the Govt. of India had passed the Births, Deaths and Marriages Registration Act, but the Act provided only for voluntary registration.
Subsequently, individual States like Tamil Nadu, Karnataka and Assam passed their own Acts.
However, the Registration system in India tended to be very unreliable, the data being grossly deficient in regard to accuracy, timeliness, completeness and coverage.
The extent of under-registration in some States ranged from 38 to 97 per cent in respect of births, and 3 to 83 per cent in case of deaths. This is because of illiteracy, ignorance, lack of concern and motivation.
There are also other reasons such as lack of uniformity in the collection, compilation and transmission of data which is different for rural and urban areas, and multiple registration agencies (e.g., health agency, panchayat agency, police agency and revenue agency).

3. Sample Registration System (SRS) –

Since civil registration is deficient in India, a Sample Registration System (SRS) was initiated in the mid-1960s to provide reliable estimates of birth and death rates at the National and State levels.
The SRS is a dual-record system, consisting of continuous enumeration of births and deaths by an enumerator and an independent survey every 6 months by an investigator supervisor.
The half-yearly survey, in addition to serving as an independent check on the events recorded by the enumerator, produces the denominator required for computing rates.
The SRS, now covers the entire country. It is a major source of health information.
Since the introduction of this system, more reliable information on birth and death rates, age-specific fertility and mortality rates, infant and adult mortality, etc. have become available.

4. Notification of diseases –

Historically notification of infectious diseases was the first health, information sub-system to be established.
The primary purpose of notification is to effect prevention and/or control of the disease.
Notification is also a valuable source of morbidity data Le., the incidence and distribution of certain specified diseases which are notifiable.
Lists of notifiable diseases vary from "Country to country, and also within the same country between the States and between urban and rural areas.
Usually diseases which are considered to be serious menaces to public health are included in the list of notifiable diseases.
Notification system is usually operative through certain legal Acts (e.g., Madras Public Health Act, 1930).
Some State Governments in India do not have any specific Act, except invoking the Epidemic Diseases Act 'of 1897, and extending the same from year to year.
The notification system is linked up with the vital statistics machinery and the reporter is often the village chowkidar or headman.
With the introduction of village Health Guides and multipurpose workers, the reporting responsibility is now shifted from the village chowkidar to the health workers. Since the legal provision is an essential prerequisite for any notification system, the enactment of a uniform Act similar to the Registration of Births and Deaths Act, 1969 is deemed necessary for any improvement in the notification system in India.
At the international level, the following diseases are notifiable to WHO in Geneva under the International Health Regulations (IHR), viz. cholera, plague and yellow fever.
A few others - louse-borne typhus, relapsing fever, polio, influenza, malaria, rabies and salmonellosis' are subject to international surveillance.
This information is published by WHO on a world-wide basis.
The Expert Committee on Health Statistics in its third Report (11) recommended that yearly data of notification should be detailed by age and sex.
Although notification is an important source of health information, it is common knowledge that it suffers from serious limitations

Notification covers only a small part of the total sickness in the community
The system suffers from a good deal of under-reporting
Many cases especially atypical and subclinical cases escape notification due to non recognition, e.g., rubella, non-paralytic polio, etc. The accuracy of diagnosis and thereby of notification depends upon the availability of facilities for bacteriological, Virological and serological examination. The lack of such facilities in the rural areas of India also works against the correct reporting of the causes of sickness.

In spite of the above limitations, notification provides valuable information about fluctuations in disease frequency.
It also provides early warning about new occurrences or outbreaks of disease.
The concept of notification has been extended to many non-communicable diseases and conditions notably cancer, congenital malformations, mental illness, stroke and handicapped persons.

5. Hospital records –

In a country like India, where registration of vital events is defective and notification of infectious diseases extremely inadequate, hospital data constitute a basic and primary source of information about diseases prevalent in the community.
The eighth report of the WHO Expert Committee on Statistics recommended that hospital statistics be regarded in all countries as an integral and basic part of the national statistical programme.
The main drawbacks of hospital data are

They constitute only the "tip of the iceberg" i.e they provide information on only those patients who seek medical care, but not on a representative sample of the population. Mild cases" may not attend hospitals; subclinical cases are always missed
The admission policy may vary from hospital to hospital; therefore hospital statistics tend to be highly selective
Population served by a hospital (population at risk) cannot be defined.
There are no precise boundaries to the catchment area of a hospital. In effect, hospital statistics provide only the numerator (i.e., the cases), not the denominator. Extrapolation of hospital data to an entire community is highly conjectural in estimating frequency rates of disease. Therefore, hospital statistics are considered a poor guide to the estimation of disease frequency in a community.

In spite of the above limitations, a lot of useful information about health care activities and utilization can be derived from hospital records. For example, hospital discharge sheets contain much useful information on diagnosis, medical and surgical procedures, complications, length of stay, laboratory data, etc.
A study of hospital data provides information on the following aspects: (a) geographic sources of patients (b) age and sex distribution of different diseases and duration of hospital stay (c) distribution of diagnosis (d) association between different diseases (e) the period between disease and hospital admission (f) the distribution of patients according to different social and biological characteristics, and (g) the cost of hospital care.
Such information may be of great value in the planning of health care services.
Indices such as bed occupancy rates, duration of stay, and cost-effectiveness of treatment policies are useful in monitoring the use of hospital facilities.
For the development of hospital statistics, the importance of establishing a medical record department in each hospital cannot be over emphasised.
It is now felt that computerization of medical records will enable medical care to be more effectively rendered, better planned, and better evaluated.

6. Disease Registers –

The term "registration" implies something more than "notification".
A register requires that a permanent record be established, that the cases be followed up, and that basic statistical tabulations be prepared both on frequency and on survival. In addition, the patients on a register should frequently be the subjects of special studies.
Morbidity registers exist only for certain diseases and conditions such as stroke, myocardial infarction, cancer, blindness, congenital defects and congenital rubella. Tuberculosis and leprosy are also registered in many countries where they are common.
Morbidity registers are a valuable source of information as to the duration of illness, case fatality and survival.
These registers allow follow-up of patients and provide a continuous account of the frequency of disease in the community.
Even in the absence of a defined population base, useful information may be obtained from registers on the natural course of disease, especially chronic disease in different parts of the world.
If the reporting system is effective and the coverage is on a national or representative basis, the register can provide useful data on morbidity from the particular diseases, treatment given and disease-specific mortality.

7. Record Linkage –

The term record linkage is used to describe the process of bringing together records relating to one individual (or to one family), the records originating in different times or places.
The term medical record linkage implies the assembly and maintenance for each individual in a population, of a file of the more important records relating to his health.
The events commonly recorded are birth, marriage, death, hospital admission and discharge.
Other useful data might also be included such as sickness absence from work, prophylactic procedures, use of social services, etc. Record linkage is a particularly suitable method of studying associations between diseases; these associations may have aetiological significance.
The main problem with record linkage is the volume of data that can accumulate.
Therefore in practice record linkage has been applied only on a limited scale e.g., twin studies, measurement of morbidity, chronic disease epidemiology and family and genetic studies.
At the moment, record linkage is beyond the reach of many developing countries.

8. Epidemiological surveillance –

In many countries, where particular diseases are endemic, special control/eradication programmes have been instituted, as for example national disease control programmes against malaria, tuberculosis, leprosy, filariasis, etc. As part of these programmes, surveillance systems are often set up (e.g., malaria) to report on the occurrence of new cases and on efforts to control the diseases (e.g., immunizations performed).
These programmes have yielded considerable morbidity and mortality data for the specific diseases.

9. Other health service records –

A lot of information is also found in the records of hospital outpatient departments, primary health centres and subcentres, polyclinics, private practitioners, mother and child health centres, school health records, diabetic and hypertensive clinics, etc. For example, records in MCH centres provide information ab9ut birth weight, weight, height, arm-circumference, immunization, disease specific mortality and morbidity.
However, the drawback with this kind of data is that it relates only to a certain segment of the general population.
Further the data generated by these records are mostly kept for administrative purposes rather than for monitoring.

10. Environmental health data –

Another area in which information is generally lacking is that relating to the environment.
Health statistics are now sought to provide data on various aspects of air, water and noise pollution; harmful food additives; industrial toxicants, inadequate waste disposal and other aspects of the combination of population explosion with increased production and consumption of material goods.
Environmental data can be helpful in the identification and quantification of factors causative of disease.
Collection of environmental data remains a major problem for the future.

11. Health manpower statistics –

Information on health manpower is by no means least in importance. Such information relates to the number of physicians (by age, sex, speciality and place of work), dentists (classified in the same way), pharmacists, veterenarians, hospital nurses, medical technicians, etc.
Their records are maintained by the State medical/dental/nursing councils and the Directorates of Medical Education.
The census also provides information about occupation.
The Institute of Applied Manpower Research attempts estimates of manpower, taking into account different sources of data, mortality and outturn of qualified persons from the different institutions.
The Planning Commission also gives estimates of active doctors for different States. Regarding medical education, statistics of numbers admitted, numbers qualified, are given every year in "Health Information of India", and published by the Govt. of India, in the Ministry of Health & Family Welfare.

12. Population surveys –

A health information system should be population-based.
The routine statistics collected from the above sources do not provide all the information about health and disease in the community.
This calls for population surveys to supplement the routinely collected statistics.
The importance of surveys is heightened by the fact that there are no cause-of-death statistics in India and the statistics available for cholera, plague, respiratory diseases, fevers and diarrhoea are of no use for public health administration.
The term "health surveys" is used for surveys relating to any aspect of health - morbidity, mortality, nutritional status, etc. When the main variable to be studied is disease suffered by the people, the survey is referred to as "morbidity survey". Broadly, the following types of surveys would be covered under health survey:

Surveys for evaluating the health status of a population that is community diagnosis of problems of health and disease. It is information about the distribution of these problems over time and space that provides the fundamental basis for planning and developing needed services.
Surveys for investigation of factors affecting health and disease, e.g., environment, occupation, income, circumstances associated with the onset of illness, etc. These surveys are helpful for studying the natural history of disease, and obtaining more information about disease aetiology and risk factors; and surveys relating to administration of health services, e.g., use of health services, expenditure on health, evaluation of population health needs and unmet needs, evaluation of medical care, etc.
Population surveys can be conducted in almost any setting; sampling techniques have been developed so that estimates at any level of precision desired within the constraints of available resources can be achieved. Health surveys may be cross-sectional or longitudinal; descriptive or analytic or both. Health surveys on a permanent basis are in operation in only a few countries, viz. in Japan since 1953, USA since 1957 and UK since 1971. General health surveys on a national basis have not yet been attempted in India, although the first methodological general health survey was carried out in Singur Health Centre by Lal and Seal in 1944-46.

Survey methods –

From the point of view of the method employed for data collection, health surveys can be broadly classified into 4 types:

Health interview (face-to-face) survey
Health examination survey
Health records survey
Mailed questionnaire survey

Each method has its advantages and disadvantages.
When information about morbidity is needed,
Health examination surveys generally provide more valid information than health interview surveys.
The survey is carried out by teams consisting of doctors, technicians and interviewers.
The main disadvantage of a health examination survey is that it is expensive and-cannot be carried out on an extensive scale.
The method also requires consideration of providing treatment to people found suffering from certain diseases.
The health interview (face-to-face) survey is an invaluable method of measuring subjective phenomena such as perceived morbidity, disability and impairment; economic loss due to illness, expenditure incurred on medical care; opinions, beliefs and attitudes; and some Behavioural characteristics.
It has also the advantage of giving population-based data.
The National Sample Survey Organization in India has been active in conducting interview surveys; these surveys have provided some country-wide data on general morbidity, family planning and vital. Events, but the morbidity data is not reliable because of the limitation of the interview method.
This is why interviews are often combined with health examination surveys and/or laboratory measurements.
An alternative method of measuring subjective phenomena is the self-administered Questionnaire, i.e a questionnaire without an interviewer.
The use of questionnaires is simpler and cheaper, and they may be sent, for example, by mail to persons sampled from a given target population.
A certain level of education, and skill is expected from the respondents when a questionnaire is administered.
There is usually a high rate of non-response.
Health records survey involves collection of data from health service records.
This is obviously the cheapest method of collecting data. This method has several disadvantages: (a) the estimates obtained from the records are not population based (b)reliability of data is open to question, and (c) lack of uniform procedures and standardization in the recording of data.
Unless the aim of survey is to derive information from a special group (e.g., school children or a particular occupational group), the household is the most common sampling unit. It is one that allows for the collection of most social, economic and health information in a convenient way.
The size of the sample, necessary for a household survey, depends upon the measurement being taken and the degree of precision needed. Many national samples typically cover between 5,000 to 10,000 households.
This is usually considered adequate for providing national estimates on such variables as health care status, anthropometric measurements, food consumption, income, expenditure, housing, literacy, etc.
Surveys carried out by either single or repeat visits provide direct estimates of vital events.
A single survey obtains the necessary information retrospectively and is subject to problems of recall and omission. Follow-up surveys on the same households within short intervals (e.g., 6 months) appear to provide more accurate estimates of vital events, but may be too expensive for monitoring purposes.
Data must be gathered under standardized conditions with quality control.
The collection of data should be limited to those items for which there is a clearly defined use or need; the fact that data might be of interest or use to someone, someday, somewhere is not a valid reason for collecting them.
The data that is collected should be transformed into information by reducing them, summarising them and adjusting them for variations in the age and sex composition of the population so that comparisons over time and place are possible.

13. Other routine statistics related to health –

The following list, which is not comprehensive, merely serves to give examples of sources of data that have already been put to good use by epidemiologists
Demographic: In addition to routine census data, statistics on such other demographic phenomena as population density, movement and educational level.
Economic: consumption of such consumer goods as tobacco, dietary fats and domestic coal; sales of drugs and remedies; information concerning per capita income; employment and unemployment data.
Social security schemes: medical insurance schemes make it possible to study the occurrence of illnesses in the insured population.
Other useful data comprise sickness absence, sickness and disability benefit rates.

14. Non-quantifiable information –

Hitherto, the health information system concentrated mainly on quantifiable -(statistical) data.
Health planners and decision makers require a lot of non-quantifiable information, for instance, information on health policies, health legislation, public attitudes, programme costs, procedures and technology.
In other words, a health information system has multidisciplinary inputs.
There should be proper storage, processing and dissemination of information.