7.3. Health information exchange

Since there are different use-cases for health information, there are different types of software applications functioning within the health sector. We use the term architecture for health information to describe a plan or overview of the various software applications, their specific uses and data connections. The architecture functions as a plan to coordinate the development and interoperability of various subsystems within the larger health information system. It is advisable to develop a plan that covers all components, including the areas that are currently not running any software, to be able to adequately see the requirements in terms of data sharing. These requirements should then be part of specifications for the software once it is developed or procured.

The openhealth information exchange (openHIE) is an interoperable interpretation of this architecture, with an HMIS or DHIS2 often assuming a significant role in it.The openHIE framework has been developed with a clear focus on countries in low resource settings, through the participation of several institutions and development partners, including the Oslo HISP program.

The schematic overview below shows the main elements of the openHIE framework, containing a component layer, an interoperability services layer and external systems.

The openHIE component layer covers meta or reference data (Terminology, Clients, Facilities), Personal data (Staff, Patient History) and national health statistics. The purpose is to ensure the availability of the same meta data in all systems that participate in the corresponding data exchange (e.g. indicator definitions, facility naming, coding and classification). In some cases, like the case of the Master Facility Registry, the data may also be used to provide information to the general public through a web portal. While the interoperability layer ensures data brokerage between the different systems, the external systems layer contains several sub-systems, many at point of service level, with often overlapping functional range.

There are different approaches to define an eHealth architecture. In the context of this DHIS2 guideline, we distinguish between approaches based on a 1:1 connection versus approaches based on an n:n connection (many-to-many).

7.3.1. 1:1 integration

In many countries a national HMIS is often the first system to be rolled out to a large number of facilities and to manage a large number of data on a monthly or quarterly basis. When countries start to develop their health system architecture further, DHIS2 often will be connected to some other systems. This connection is often done directly through a simple script, which automates a data transfer.

We talk of a 1:1 connection because it is limited to two systems. In the case of an LMIS/HMIS integration, one LMIS will transfer data to DHIS2 as defined in the script. This hands-on approach often represents a first step and is one of the most common use cases on the way to an interoperable openHIE architecture. However, this simplicity also brings along disadvantages: In case a second logistics system would want to transfer data to DHIS2 (e.g. commodity data for a specific disease program), a second script would have to be written, to perform this task. These two scripts would then run independently from another, resulting in two separate 1:1 connections.

7.3.2. n:n integration

A different approach is based on placing a purpose-built software to serve as an interoperability layer or BUS approach, managing the data transfer between possibly several systems on either side (n:n). This could be the case if for example you wanted to collect stock level data through different LMIS applications, and then share it to a central warehouse LMIS, the HMIS and some vertical disease programs system. The openHIE reference software to assume this role is Jembi openHIM, but systems like "MOTECH" have also been used for this purpose as will be discussed below.

While this approach may result in a higher initial effort, it promises to make further integration project easier, because the interoperability layer is being alimented with definitions and mappings that can be re-used for connecting the next systems.

In practice, there are certain challenges to this approach. It takes a considerable effort of qualified resources to activate APIs and with each new release of any involved system, data flows require re-testing and if necessary adaptations. Also, to be successful these implementation projects typically have to go through a series ofcomplex steps, such as the agreement on an interoperability approach embedded in the national eHealth strategy, the definition of data standards and sustainable maintenance structure, and attaining a stakeholder consensus on data ownership and sharing policies. There can be some long term consequences when data and systems are knitted together - it creates new roles, jobs and tasks which didn't exist before and may not have been planned for (metadata governance, complex system administration, boundary negotiators, etc.).

Example: Grameen DHIS2/CommCare middle layer in Senegal

In a Chapter 7, Integration concepts, MOTECH serves as technical middle layer between an LMIS for mobile data collection at the health facility level (CommCare) and DHIS2, allowing to define data mapping, transformation rules and data quality checks. The interface is set-up to transfers data from CommCare Supply to DHIS2 whenever data is saved into a CommCare form at facilities. For each commodity, data on consumption, available stock, losses and stock-out data is transferred from CommCare to DHIS2.

The higher initial investment of the Senegal approach hints towards a more ambitious long-term system architecture, foreseeing that the MOTECH platform may in future serve to accommodate further interoperability task. However we do not see any of the country activities tightly embedded in a text-book eHealth architecture, which would clearly define areas of priority, leading systems for each priority and the relations and resulting APIs between these different components. One may argue that interoperability projects are built on a weak foundation if there is no previous consensus on an architectural master plan. On the other hand it is also valuable to allow system initiatives to organically develop, as long as they are rooted in well-founded country needs.

7.3.3. Architecture, standards and mapping

An important element of an eHealth architecture is the inclusion of international eHealth standards. Standards are especially relevant for n:n connections, less so for direct (1:1) connections.

Some standards are on the technical level (e.g. transmission methods), other on the contents side (e.g. WHO 100 core indicators). Gradually aligning national system initiatives to these standards can give countries access to proven solutions, benefitting from medical and technological innovation.

Example: Ghana EPI

The Ghana case illustrates how the WHO EPI reporting requirements serves to define standard data in DHIS2. This standardization at the dataset and terminological level is the basis for the system integration. In the area of DHIS2, work is ongoing with WHO to develop standardized datasets, which could in the future open up new opportunities for interoperability and efficiency gains by offering some consistency of metadata across systems, and also encouraging countries to reuse existing solutions.

At the language level, there is a need to be consistent about definitions. If you have two data sources for the same data, they need to be comparable. For example, if you collect malaria data from both standard clinics and from hospitals, this data needs to describe the same thing if they need to be combined for totals and indicators. If a hospital is reporting malaria cases by sex but not age group, and other clinics are reporting by age group but not sex, this data cannot be analysed according to either of these dimensions (even though a total amount of cases can be calculated). There is thus a need to agree on uniform definitions.

In addition to uniform definitions across the various sub-systems, data exchange standards must be adopted if data is to be shared electronically. The various software applications would need this to be able to understand each other. DHIS2 is supporting several data formats for import and export, including the most relevant standard ADX. Other software applications are also supporting this, and it allows the sharing of data definitions and aggregate data between them. For DHIS2, this means it supports import of aggregate data that are supplied by other applications, such as OpenMRS (for patient management) and iHRIS (for human resources management).

A crucial element of the architecture is how organize data mapping. Typically the metadata of different systems does not match exactly. Unless an MoH has been enforcing a consequent data standard policy, different systems will have different codes and labels for a facility. one System may call it District Hospital - 123, the other system may refer to it as Malaria Treatment Centre - 15. To be able to transfer data, somewhere the information that these two facilities correspond needs to be stored.

In the case of a 1:1 connection, this mapping has to be done and maintained for every connection, in case of an n:n interoperability approach, one side of the definitions can be re-used.

In order to assure that the data can flow smoothly, you need to have clear responsibilities on both sides of the system regarding data maintenance and troubleshooting. For example, there need to be previously defined standard procedures for such activities as adding, renaming, temporarily deactivating or removing a facility on either of the two systems. Changes of database fields that are included in a transferred data record need also to be coordinated in a systematic way.