CFP: Theory-driven Interventions in Health care using Health Information Systems

Calls for Papers (special): International Journal of User-Driven Healthcare (IJUDH)
Special Issue On: Theory-driven Interventions in Health care using Health Information Systems

Submission Due Date
2/1/2013 (Extended to 1st March, 2013)

Guest Editors
Saptarshi Purkayastha, Norwegian University of Science and Technology, Norway
Knut Staring, University of Oslo, Norway

Introduction
Theory-driven evaluation came to prominence only a few decades ago with the appearance of Chen’s 1990 book Theory-Driven Evaluations. Since that time, the approach has attracted many supporters as well as detractors. At its core, theory-driven evaluation has two vital components, one conceptual, one empirical. Conceptually, theory-driven evaluations should explicate a program theory or model. Empirically, theory-driven evaluations seek to investigate how programs cause intended or observed outcomes.
Yet, limiting theory to evaluations is somewhat futile, because usually some theory as basis for a “hypothesis” (unless the research is using a grounded approach) is what drives interventions in the first place. For instance, some health information system (HIS) interventions aim to provide information about health system practices towards meeting the Millennium Development Goals (MDGs). A great number of theoretical lenses drive Information Systems (IS) interventions, and there have been attempts at collecting overviews of such theories, e.g., http://istheory.byu.edu. However, even though that list is quite comprehensive, it is not exhaustive – for example, it leaves out important perspectives from design science and information infrastructure theory.
In this special issue we seek to showcase papers that are driven by theory – in planning, in action, in diagnosis and in evaluations. Theory-driven interventions is used here to distinguish from report-style papers, position papers or papers that draw concepts purely from observations without theoretical basis prior to intervention.

Objective
The special issue would like to highlight studies in HIS that focus on doing IS interventions with a theory in mind or with knowledge building/testing in mind. The studies in the special issue would like to explain the phenomenon of IS intervention through IS theory, yet allow medical researchers/practitioners to connect with them. These studies will help medical informaticians or public health practitioners to realize the importance of existing abstracted knowledge (theory) and consider appropriate theoretical lenses for HIS interventions.

Recommended Topics
Suggested topics for discussion include (but are not limited to) the following:
- Participatory action-research as a bottom up strategy to problem solving and achieving change in healthcare
- Distinguishing end-users from super-users and theorizing their views in HIS
- Institutionalization of IS within healthcare practices
- Design science perspectives on HIS
- Interventions that deal with structures in health systems and their evolution
- Efforts at scaling interventions and information infrastructure
- Quantity of knowledge absorption, quantity of knowledge transfer, innovation in HIS
- User satisfaction, performance, perception, behaviour, usage as in Cognitive dissonance theory
- Dynamics of social construction and performance of illness through user-driven healthcare practices
- Capabilities, absorptive capacity, environmental turbulence, agility as in Dynamic Capabilities Theory
- Resource Importance, Alternatives, Discretion as in Resource Dependency Theory
- Speech acts, Communicative action as in Language Action Perspectives when HIS systems capture patient narratives or clinician notes or communication in health systems
- Fit-Viability Model of IS interventions on Health systems
- Bridging the gap between what we know and what is knowable in clinical practice

Submission Procedure
Researchers and practitioners are invited to submit papers (over email to the guest editors) for this special theme issue on or before March 1, 2013. All submissions must be original and should not be under review by another publication. Interested authors should consult the journal’s guidelines for the manuscript submissions at: http://www.igi-global.com/Files/AuthorEditor/guidelinessubmission.pdf. Submitted papers should not be more than 8000 words inclusive of abstract, tables and references. All submitted papers will be reviewed by 2 reviewers on a double-blind basis. Papers must follow APA style for reference citations.

We also request interested authors to send an abstract as soon as possible for discussion.
All submissions and inquiries should be directed to the attention of:

Saptarshi Purkayastha	Knut Staring
Norwegian University of Science & Technology	University of Oslo, Norway
E-mail: saptarsp (at) idi<dot>ntnu.no	E-mail: knutst (at) ifi<dot>uio.no

EMR at JSS Bilaspur – In pursuit of happyness

Over the last 3yrs, I have travelled across the world and looked at 100+ health facilities of different scales. My last encounter with a health facility in rural Bilaspur was very different. Having looked at systems of practice in a variety of health facilities including subcenters, private clinics, primary health centers, community health centers, district hospitals, tertiary hospitals and super-specialty hospitals, each of these places have different characteristics. What makes Jan Swasthya Sahyog (JSS), situated in rural Bilaspur in Chattisgarh special is the motivation levels among all the staff at the health facility. This includes clinicians, nurses, technicians and computer operators… And the motivation of these people stems from the fact that they still believe in care, rather than just providing health services. I use “still” because in my worldview of health facilities, most often I see people missing out on the “care” from the notion of health-care.

My visit to JSS was for volunteer work that I have been doing over the last few months to see an Electronic Medical Record (EMR) system to be setup at JSS. Over 100 volunteers across the world have come together in this pursuit to build an EMR system that is easy to use, suited to low-resource settings and can help improve work of the providers as well as help provide better services to patients. JSS was founded 15yrs back by post-graduates doctors of All India Institute of Medical Sciences (AIIMS), India’s most prestigious medical school and hospital to provide healthcare to people who are deprived from it because of poverty, neglect and lack of development. And when I visited JSS on Christmas 2011, I could see the savior work done by JSS for the many people who come from far-flung places because they are treated with dignity and care.

The EMR system broadly from interviews and discussions with some doctors, nurses, other staff and my interpretation of the context needs to do the following:

1. Help to improve efficiency in use of resources and providing patient care
2. Help to maintain correct medical practices through validations
3. Help to understand who, what, why is being treated at JSS

EMRs or for that matter any computerization process advertises many-fold benefits. Technology is most often considered the silver bullet that will solve all problems. From my experience this is rarely the case. So these 3 points might provide a guiding path to decisions that we make in the design of the EMR. In the design of the EMR, just like JSS we have to put “care” at the forefront of our efforts rather than technology prowess. Thus, this system is envisaged to be a point-of-care systems where providers will look up records and use the system to provide “care”.

The other very unique thing about JSS is that is it rooted in the locale of the context. Having seen other health facilities setup by “change-makers-coming-from-the-outside”, JSS is uniquely very much part of the context. This is one of the reasons I see why people come from more than 100kms away to JSS for treatment. People view JSS as locals and one among their own. This is one aspect that I think the EMR system should incorporate. It should embody in itself the locale. By locale, I mean the local practices, language, usability… among other things.

I would say we have some lofty goals for the EMR. One that the project lead calls as “Linux of EMRs”, but in my opinion even if we achieve more humble ends, like not causing burden to providers and patients that would make me happy. It is this pursuit that drives me to work towards this cause. I call it a pursuit because I realize this is not something that is a stagnant phenomenon. It will change with every small change that we make. Every morning it is this pursuit of happyness that drives me to understand what an EMR system would be of use at JSS.

Integrated e-Health Infrastructures

In a bid to bring together a network of international agencies working in the field health information systems - University of Oslo, NORAD, OpenMRS, WHO, HMN, Society for Health Information Systems Programs (HISP India), the National Health Systems Resource Center (NHSRC) has convened an “International HMIS Workshop on Integrated e-Health Architectures”. NHSRC, Delhi is an institution setup by the Ministry of Health to provide technical assistance to NRHM on various areas including HMIS.

We met in Goa from 26th to 30th July, 2009 and exchanged ideas on how we can build on integrated e-health infrastructure. Discussions ranged from what applications to integrate and different ways to inter-operate. Some were standard ways to interoperate while others were “not-so-standard” ways to interoperate. The most important thing was that everyone was part of the discussion and the next few weeks to months will be interesting to watch how the integration work goes forward.

The Gujarat state representatives: Mr. KK Panchal, Dr. Avashia and Sangeeta also presented their ideas on integration. I was pleasantly surprised that state representatives were for once clear about what they were expecting. Eventhough it was not very clear how, they knew what they wanted as the final product. They were also ready to bring the different parties (software-MNCs and government) together on the table for integration.

But for me what is more interesting was the way the participants shared their thoughts and philosophy of integration outside the domain of software and technology.

I have promised myself that I will be blogging atleast 3 times a week… and will be sharing a lot more of the thoughts that were shared in the workshop. A lot about what we have been working on and how we are planning to move forward in bringing a change in health informatics.

The Mobile Phone Tool for Indian HMIS

As you have already found out, I haven’t been blogging lately because of the travel and development work I have been doing for HISP India. One of the new developments that I have been working over the last 3 months is a mobile phone application for routine health data collection, obscurely called “Mobile-SCDRT”. Its a Java ME MIDP that runs on all those commodity mobile phones and is used by a community health Sub-Center for Data Reporting and Transmission (SCDRT). Now you know where that obscure acronym came from and I am unsure who gave it that “wanna-be” name.

That apart, the mobile application is being deployed part of a pilot in the 5 states of Himachal Pradesh, Kerala, Rajasthan, Nagaland and Gujarat. As part of the pilot 200 health workers from the above states receive a Nokia 3110c mobile phone with the application installed and use the application to report the routine health-related data that is collected by the Government of India as part of Health Management Information System (HMIS).

The following is an architectural overview of how the application works for those of you interested in the technical details:

So, DHIS2 is where the data gets added after being sent from the mobile phone and in DHIS2 you can do all the analysis and “use of data” for health program decisions. There are other nitty-gritty details of the application and lots of new learnings for me, but I’ll leave that to another blog entry for another day.

We have started the pilot in 2 states: Himachal Pradesh and Kerala. Its been running for close to a month now in these 2 states and from the looks of it, people are happy and excited to use it. Recalling an incident from the launch in Kerala:- When just about 15 minutes of looking into the application, a JPHN (Junior Public Health Nurse - as health workers are called in Kerala) could explain the whole application, its use and reporting procedure to her colleagues better than most of us could. It was a wonderful and humbling experience for us to see that people were so much wanting to use the application and learnt it so quickly. It was satisfying to see that it was helping the health worker to make her reporting process more efficient. What was more rewarding for her, as I understand now, was the job perk that she thought she got in the mobile phone. The mobile phone was not just a tool for reporting, but also something that she would use for calls and show it to her kids and family. Few JPHNs were instantly taking photographs of our launch using the mobile phones we provided. I hope I can have many such satisfying moments through my work in health informatics.

But not everything was perfect in all this. I for one realized, that logistics required for a project of this magnitude is not an easy job. Having a team of people in the state and within us at Delhi is a challenge. Discussions of inefficiencies and incapability of the team is a burden in itself to manage. Not everyone may have the goal to change the world and some might even be in it for the money. As for the logistics, we learnt early in the pilot at Himachal Pradesh that a “Step-by-Step” reference manual on using the application was a necessity for the health worker which she can refer to, when she’s at her home and using the application to report. Then there was the purchase of state-specific SIM cards and allocating mobile phone numbers to each health-worker and her reporting office. All this requires lots of planning and managing the logistics and repeated changing of plans has been a tough one for me.

The technical preparation of installing the application, creating the database and installing the server at the primary health centers, block hospitals and district health offices have also been somewhat of a mismanagement. Its been a complex process involving people with different work cultures and behaviors. But in the end the 2 pilots have been successful because its been an opportunity for health workers to report data more efficiently. Final results of the pilot await us, but the start has been great!

Realpolitik of Health Management Information System

HMIS or Health Management Information System has been quite a buzz-word around the Indian health machinery for sometime now. Its just that health-workers are now starting to understand. From the lay-man’s point-of-view, HMIS is a system of managing health related information. It is the process of collecting health-related data, making sense of that data to become information, understanding the relevance of information and making plans on how to use the information.

HMIS being an information system, surely has the scope of being managed through computers and it is done pan-India using an application called DHIS 2 (District Health Information Software v2). DHIS2 is an open-source Java web application and it is free for anyone to use. Free as in Freedom and free as in beer. And this has caused a stir of sorts because there aren’t a lot of things that you get free in life. I am sure some philosopher’s would be quick to tell me that nothing in life is free and so its true with DHIS as well!! But its for fact, cheaper than most other pieces of software competing in the HMIS space.

But we are not here to talk about DHIS, we are here to know the realpolitik of HMIS. Since NRHM (National Rural Health Mission) has poured in money into the health sector, lot of things have changed. It has improved health infrastructure, changed government’s outlook towards public health, generated employment and done a lot more. But it has also brought in realpolitik.

Realpolitik is a theory of politics that focuses on considerations of power, not ideals, morals, or principles. Its “real” instead of “idealistic” and that is sometimes not a bad thing. Politics, in-fact isn’t a bad thing at all!! Health forever has been idealistic, doctors forever revered as people who save lives and government health machinery thought as part of goodwill governance. With these ideals, the Constitution of India enlists “Health as a state matter”. But who has the money and who gives the money, when we are talking about health??

Software systems have enormously increased the reach and speed of information exchange and data collection for health. DHIS2 and pro-HMIS crowd has created a nation-wide awareness on the usefulness of software systems for health monitoring. This has led to a power struggle within different groups not just within the government, but NGOs working in the health sector and consulting groups that work with the states. The power game has just begun with software and technology proving as powerful weapons for whosoever wants to use it. In this hype for HMIS, simple portals that capture data for national level have fetched huge chunks of money and each day additional money is spent on building many more such systems. Then there is the power struggle to capture the market on who trains the cadre of health workers on these new technological advances that has somehow no relevance on health services.

I am just starting to see the “realpolitik”, which is definitely not bad as an ideology... Its just that health always seemed like a noble cause. I am now seeing it as a realist.

Working for HISP India on Health Informatics

I haven't been blogging for quite a while now, but the reason is partly because I'm moving into a new job and also not getting enough motivation to blog. But I thought it's a good time that I start to blogging again and what better topic that introducing my new job.

I have joined HISP India (Health Information System Programme) as a Director of Research and Development. I will be working with the National Health Systems Resource Center (NHSRC), a part of the Ministry of Health & Family Welfare of India. Our primary job at the moment is Health Management Information System (HMIS) for the National Rural Health Mission (NRHM). I know it sounds like a lot of abbreviations, but thats the thing about government organizations I guess!!

My primary test starts with a pilot test of a mobile application for data entry for DHIS 2. I will in the next few weeks talk about DHIS 2, but also talk about other research areas that I will be working on and hopefully get ideas from you guys on how I could improve the health of people in rural India through technology. Lots more to talk about, but may be more in the next few weeks on all technology