Health Management Information System

The article is incomplete. I hope to build on it when I have more to say.

Disambiguation of Terms

First of all we need to disambiguate the terms. A distinction must be made between “health management” as a governmental or societal responsibility and “healthcare” as a service provided by various facilities. Factors contributing to people’s health include good nutrition, food safety, clean water, and clean environment not just the control of diseases. Hence, health management is a broader activity. On the other hand, healthcare is concerned with services for people affected by disease, early detection of diseases, disease prevention and promotion of health of an individual.

Information systems to facilitate the delivery of healthcare services are developed for the type of facilities distinguished by the level of services it provides. Hence, we have Hospital Information Systems (HIS), Clinic information systems, Day care Information Systems and Hospice Information systems etc.. These are called Healthcare Information Systems, where care is defined as a business of service provision. This is the main subject matter of my website.

Health Management Information System (HMIS) of the Ministry of Health (MOH)

The ministry of health being an arm of the government is responsible for managing all aspects the health of its citizens through of efforts at promoting health and the prevention, detection, control of diseases.

MOH is a huge organization that oversees the county’s health issues (public health), Health Management is its core function. The information system that facilitates the function of Health management would be called Health Management Information System (HMIS). This is the subject discussed in this post.
This can be by manual or computerized means. We would imagine that there would be a vast amount of data involved and a computerized system consisting of applications that would facilitate this function would be named the Health Information Management System. It facilitates preventive activities plus early detection of disease (screening services). It also monitors disease incidence & prevalence and control (epidemiology) through Health offices at national, state level. You can get the information about this central function and how it is organized at .

However, in Malaysia like in many countries, the ministry’s facilities provides promotion of health, early detection and primary healthcare services through health clinics. To do this it uses the Wellness Information System (which has not been well developed as yet).
Healthcare is a business endeavor (not necessarily for profit) provided by various and provision of healthcare for people affected by disease. On the other hand, healthcare services are provided by both the private and public sector. The role of MOH as a ministry within the government would be to regulate and oversee the services provided.
However, if the MOH also runs its own healthcare services (care of the sick) through hospitals and clinics, information management for these would be part of the Healthcare Information Systems but would contribute to HMIS.

To carry out its strategic management function (forecasting, planning, budgeting, funding), the health ministry requires information regarding the status, trends, and future needs of health and healthcare. The information is obtained from those peripheral services. It is then gathered, stored, analyzed, and interpreted at a central office. In Malaysia, it is called the Information Documentation System (IDS) unit in the MOH head office.
The website on IDS of MOH mentions how it obtains data from the various health care facilities and health administration offices i.e., through a web application which enables those facilities and offices to submit their reports (called returns) using electronic forms via the internet.

Sources of Data

The website of Malaysian IDS mentions certain applications like THIS, CDCIS, SMRP, FOSIM etc which purportedly collects data electronically. These usually provided secondary data i.e. those that have been collated and analyzed.

However, the website glossed over how raw data was obtained. It was not mentioned how data was actually obtained. and does not even mention how they work. THIS is Total Hospital Information System. MOH implies that for hospitals and clinics that has computerized systems, reports are generated by the system. This is not quite so because those systems may not be developed to create specific reports directly. SMRP (Sistem Mengurus Rekod Pesakit) is the computerized patient registration system used in certain hospitals and clinics. CDCIS (Communicable Disease Control Information System) is a system for the management of data for the detection and prevention of communicable diseases. It has a reporting system for the notification of infectious disease known as e-Notifikasi. FOSIM is the Food Safety Information System.

Primary Sources of Data

Data is collected at the primary source of raw data and converted into ‘returns’ to MOH. This is a very tedious and laborious process which needs further explanation.
For managing the operations of healthcare delivery at its own facilities managers at MOH needs to know, among other items, the workload, case types, staffing needs, requirements for acquiring and facility maintenance. Data for workload concerns number of inpatient admissions / discharges, clinic attendances, number of deliveries, surgical operations and quantity of service items such as laboratory tests and so on radiology images. This requires each department and unit to keep registration books. These are large books maintained by middle managers or supervisors like Nursing Sisters and supervisors. Registers are kept for clinic attendances, hospital admissions, births, deaths and bed occupancy

In Malaysia, the practice is inherited from the times before independence and still used to this day. Data from them are gathered and converted into reports by Medical record officers.
Besides giving data concerning workload, data regarding disease burden (incidence, prevalence, epidemiology) can also be taken from the registration books mainly because there are columns on the pages of the books for reason for visit and diagnosis on discharge. However, the data regarding diagnosis must be copied from what the doctor writes in the medical record which is not easy. Data concerning number and cause of death is taken from death certificates. Registers are kept for some specific causes of deaths such as Maternal mortality and neonatal mortality. Labor rooms keeps a register of births and stillbirths. Operation theatres keeps a registry of all surgical operations performed.

Notification of Infectious Diseases

Data concerning epidemiology relies very much on the system for notification of disease. It is mandatory (by law) to report the occurrence or detection of a communicable disease. This has been made easier and quicker by the electronic notification system introduced in recent years. The system requires the awareness to report by doctors but often are known only when the discharge diagnosis is looked at by medical record officers.

Data From Research

For non-communicable disease, National Health Morbidity Survey by Institute for Public Health, National Institutes of Health (NIH) conducts a survey in 4-yearly cycles since the year 2011.

Disease Registries

There are also disease registries or databases which are run by MOH, professional bodies or NGOs as an ongoing, systematic collection, analysis and interpretation of disease specific data, and timely dissemination of these consolidated and processed information essential to the planning, implementation and evaluation of clinical and public health practice, to contributors to the surveillance and other interested persons. Existing ones are listed at .

National Cardiovascular Database (NCVD)


Soalan ini sering ditanya atau pelaksanaannya kerap dicadangkan oleh ramai petugas mahu pun pengurus.

Selaras tidak semestinya bermaksud mengguna aplikasi yang sama. Kalau aplikasi yang sama pun, tidak semestinya sistem (architecture) yang sama. Sesetengah fasiliti lebih sesuai mengguna sistem client-server konvensional dari sistem berasaskan web atau cloud.
Aplikasi pun perlu disesuaikan mengikut keperluan setiap fasiliti (kecil besar, primer, sekunder, tertiari).

Yang benar benar perlu menggunakan sistem dan aplikasi yang sama ialah fasiliti yang digabungkan sebagai satu kluster untuk membolehkan pesakit dijaga supaya petugas bekerja secara bergilir tempat di semua fasiliti (hospital dan klinik) didalamnya. Kesulitan yang timbul ialah jika berbeza pesakit dan petugas akan menghadapi kesulitan memahami sistem. Untuk menggunakan sistem yang sama polisi dan prosedur pun perlulah sama dan semua fasiliti diletakkan dibawah satu pengurusan.

Keseragaman dan penyelarasan yang diperlukan untuk fasiliti yang berfungsi berasingan (walaupun dibawah satu enterprise seperti hospital awam atau rangkaian hospital persendirian) adalah pada nomenklatur dan terminologi serta kaedah komunikasi yang standad seperti HL7.

Kesaragaman ini akan membolehkan data dikongsi untuk maksud kesinambungan operasi contohnya untuk rawatan ulangan, kes rujukan, dan plan penjagaaan pesakit sepanjang hayat LHR). Keseluruhan rekod pesakit tidak prlu dikongsi. Memadai dengan ringkasn kes sahaja.

Keseragaman juga memudahkan pengumpulan data untuk pusat pangkalan data, bagi tujuan strategik seperti perkiraan beban penyakit (kadar insiden, daftar penyakit), beban kerja, keperluan sumber (wang, peralatan, tenaga kerja db) dan perancangan masa depan. Untuk ini, data dihantar dari pelbagai fasiliti untuk dikumpulkan secara berpusat dalam gudang data (data warehouse) atau sistem pengurusan data bidang kesihatan HMIS.
Ketika ini, kita di Malaysia belum berjaya menetapkan kandungan data yang perlu dikongsi dan pustaka kata gunasama yang dikehendaki. Usaha sedang dibuat dan perlu ditingkatkan.

The Job of a Nurse and the Nursing Function

The Job of a Nurse and the Nursing Function

I have, for a long time, wished to write an entire article on this subject. May be a short post can be a start.

Nursing is an activity performed by all members of the community. We talk/hear about a mother nursing her child, daughters nursing their parents in their old age and wives nursing their debilitated husbands. Nor is nursing confined to women. We read about husbands nursing their wives back to health. In fact, stories had been written of a whole a community nursing an injured soldier. In Malay the word ‘rawat’ means ‘to take care of’. A synonym is ‘menjaga’ which means to do a day and night vigil to look after a sick person. It includes performing tasks to provide comfort, to assist in the performance of basic activities of daily living and to give hope.
At a certain point in history, groups of women take on the task of nursing as a defined activity which later became important enough to be recognized as a profession. The nurse then becomes a member of the healthcare team, joining other healthcare professionals and complementing them by providing ‘nursing’.

Yet, today, the job of a nurse has evolved in such a way as to expand beyond her/his role to include those tasks other than nursing. She/he has taken on or has been given additional tasks in the care of sick persons as well as in health promotion, disease prevention, early detection of diseases/illnesses/health problems and in rehabilitation. Currently, she/he is expected to perform parts of the tasks of the doctor, the pharmacist, the rehabilitation professional, the phlebotomist and other professions not to mention that of porters/orderlies. Included in these is the recording of data. On top of that, they are also saddled with administrative and managerial tasks.
Why does the job of the nurse encompass so much responsibilities? This stems from the tradition of the nurse being on a 24-hour vigil (‘berjaga’ means ‘not to sleep’). The healthcare service has been designed so that (more so in in-patient care) the nurse is there by the side of the patient and within the location allocated to her/him all the time. To achieve this, nurses work in continuous shifts. Somehow, it is thought that at night there is less work and the nurse can work a longer shift (to keep a vigil is after all a sacrifice expected of a carer).

Much of the work that is not necessarily ‘nursing’ in nature is given to the nurse because she is always there. The first of this is observation and monitoring which, by nature, are continual. Dispensing medication is her/her role because we do not expect pharmacists to come in at night, do we? Who is more appropriate to teach, observe and cajole patients to do various physiotherapy exercises than a nurse? After all it is simple and within their capability. If the nurse can withdraw blood, who needs a phlebotomist. Somehow, porters are always short in supply, it is not beneath the nurse to push a patient. It is better because she/he can keep watch on the patient. The list goes on and on.
To be part of the health-care team effectively, the nursing profession need to reconcile with these needs and arrangements. They should be proud to take on the responsibility of executing the key components of the overall care plan instead of complaining of being the ‘hand-maiden of the doctor’. Looking at it that way means that they are servants also of all other health care professionals mentioned above. They must also acquire sufficient knowledge and skills to do so.

On the other hand, health care service managers must recognize the importance and gravity of the nursing job. Numbers of staff assigned to various services must commiserate with the amount and complexity of the tasks to be performed. The contribution of nurses must be compensated equitably.
In modern healthcare practice, the role of the nurse goes beyond ‘nursing’. The difference between the job of a nurse and the function of nursing needs to be understood.

Tugas Seorang Jururawat dan Fungsi Merawat

Saya telah sekian lama bercita cita menulis artikel mengenai topik ini. Mungkin sebagai permulaan, pos yang pendek ini mencukupi.
Dalam Bahasa Melayu ‘merawat’ sinonim dengan ‘menjaga’ yang bermaksud melegakan tubuh serta sanubari seseorang, membantu yang kehilangan upaya menjaga dirinya dan membina semula semangat, sepanjang hari dan malam.
Merawat adalah suatu aktiviti yang dilakukan oleh ramai orang dalam kalangan ahli masyarakat. Kita selalu bercakap atau mendengar mengenai emak menjaga anaknya, anak menjaga ibu bapa yang sudah tua, dan isteri menjaga suami yang hilang upaya. Namun perbuatan merawat tidak terhad sebagai tugas wanita sahaja. Kita pernah membaca kisah suami merawat isterinya yang sakit hingga kembali sihat. Malah, kita juga biasa dengan cerita sekumpulan orang atau komuniti yang merawat pejuang yang cedera di medan perang secara rahsia tanpa menghiraukan keselamatan sendiri.

Pada suatu ketika dalam aliran sejarah, terdapat kumpulan wanita yang menjadikan kerja merawat sebagai suatu aktiviti tersendiri hingga kemudiannya dianggap masyarakat cukup penting untuk diambil kira sebagai satu profesion. Perawat menjadi ahli dalam pasukan yang memberi khidmat kesihatan dan dipanggil sebagai Jururawat, (juru bermaksud ‘pakar’ dalam bidangnya) lalu berdamping dan bekerjasama dengan para profesional lain dengan memanfaatkan kesanggupan dan kebolehan unik yang disebut sebagi ‘merawat’.

Namun, ketika ini, tugas seorang jururawat telah berkembang sehingga merangkumi tugas tugas lain diluar kemahiran hakikinya. Skop bidang kejururawatan kIni termasuk penjagaan orang yang sakit, mempromosi kesihatan dalam kalangan masyarakat, mencegah penyakit, mengenalpasti masalah kesihatan diperingkat awal, dan melangsungkan aktiviti pemulihan. Oleh itu jururawat diharapkan dan diberi kepercayaan menjalankan sebahagian tugas tugas dalam bidang kemahiran doktor, juru farmasi, jurupulih, petugas mengambil darah termasuklah tugas tugas ahli profesion lain (belum diambil kira lagi tugas tugas atenden). Untuk semua ini jururawat diwajibkan merekod data mengenai semua aktiviti yang dilakukan. Selain dari itu beban kerja ditambah pula dengan pelbagai tugas pentadbiran dan pengurusan.

Kenapa tugas jururawat mengandungi begitu banyak kewajipan? Ianya timbul dari peranan tradisi perawat yang tugasnya berterusan 24 jam – siang dan malam (‘berjaga’ maksudnya ‘ langsung tidak tidur’). Perkhidmatan penyampaian khidmat kesihatan direkabentuk (terutama untuk penjagaan pesakit dalam tetapi tidak kurang juga untuk perkhidmatan lain) supaya jururawat sentiasa berada bersama pesakit. Untuk menhadirkan keadaan ini, juruwat perlu bekerja secara syif supaya tugas kejururawatan dapat dibuat terus menerus. Entah bagaimana, kerja syif malam dianggap kurang berat hinggakan tempohnya ditetapkan lebih panjang (mungkin kerana berjaga malam itu satu pengorbanan yang sanggup dipikul oleh penjaga).

Oleh itu, kerja kerja yang bukan tugas hakiki ‘merawat’ diberi kepada jururawat kerana meraka sentiasa berada bersama orang yang dijaga (tidak seperti doktor dan petugas lain). Tugas tambahan utama ialah pemerhatian dan pemantauan (termasuk merekodkan dalam carta) kerana tugas ini berbentuk berterusan. Memberi ubat juga menjadi tugas jururawat. Tak kan kita hendak menyuruh ahli farmasi datang waktu malam? Siapa yang lebih sesuai untuk mengajar, memerhati dan memujuk pesakit melakukan aktiviti pemulihan jika tidak jururawat? Bukankah itu sesuatu yang mudah dan boleh dilakukan oleh jururawat? Kalau jururawat boleh mengambil sampel darah mengapa hendak panggil petugas pengambil darah? Jika porter tiada, setakat menolak pesakit tidak merendahkan martabat seorang juruwat, tidakkah begitu? Lagi pun, ini lebih baik kerana dia boleh memerhati pesakit yang dihantar atau dipindahkan. Senarai tugas yang dipikul jururawat sentiasa bertambah tanpa had.

Untuk menjadi sebahagian dari pasukan penyampai khidmat kesihatan secara berkesan, profesion jururawat perlu menerima hakikat keperluan dan aturan yang disebut diatas. Jururawat harus bangga mengambil tanggung jawab melaksanakan komponen penting dalam melangsaikan plan penjagaan pesakit yang menyeluruh. Tak usahlah menganggap diri sebagai orang suruhan doktor. Kalau bersikap begini jadilah jururawat sebagai orang suruhan para ahli profesion yang lain juga (seperti disebut diatas). Sebaliknya juruawat hendaklah melengkapkan diri dengan ilmu dam kemahiran yang diperlukan untuk memikul tugas ini.

Bagi pihak pengurus perkhidmatan pemberian khidmat kesihatan pula, mereka perlulah menghargai kepentingan dan betapa beratnya usaha jururawat dalam menjalankan tugasnaya. Bilangan petugas yang diagihkan kepada perkhidmatan tertentu perlu setimpal denagn kuantiti dan kepayahan tugas tugas yang perlu dibuat. Imbuhannya pula perlu setimpal dan saksama.

Dalam amalan kerja pemeberian khidmat penjagaan kesihatan moden, bidang tugas seorang jururawat melangkaui tugas hakiki ‘merawat”. Hakikat perbezaan antara ‘tugas jururawat’ dan fungsi ‘merawat’ ini perlu difahami.
Terdapat pula bahaya kecenderungan terlebih memberi perhatian kepada tugas tugas bukan hakiki hinggakan mengabaikan tugas ‘merawat’ dan ‘menjaga’. Namun itu cerita panjang, yang perlu dibincang di waktu lain.

Di kesempatan ini saya mengambil peluang memperkenalkan artikel dalam laman web saya mengenai pemerhatian dan pemantauan tugas yang sebahagian besar dipikul jururawat..

Apa Ada Pada Nama – HIS atau EMR

Mengikut pendita Shakespeare, bunga ros dipanggil dengan apa jua nama masih berbau harum. Ya, kalau bunga ros dipanggil bunga mawar ia masih wangi. Namun jika bunga melor dipanggil bunga ros, lainlah wanginya. Begitulah dengan nama HIS atau EMR.

Ketika sistem pengurusan maklumat penjagaan kesihatan berkomputer dimulakan di Malaysia dengan pelaksanaannya di Hospital Selayang (1999) nama yang digunakan ialah ‘Total Hospital Information System’ atau ‘Sistem Maklumat Hospital Lengkap’. Nama yang sama digunakan di Hospital Putra Jaya, Serdang, Ampang, Sugei Buloh dan banyak agi hospital. Nama ini menekankan niat untuk menggunakan Teknologi Maklumat (Information Technology) secara menyeluruh iaitu untuk memudahkan kerja bagi semua fungsi dan di semua unit, menggantikan sistem sebelum itu. Malah pemberi khimat di Hospital Selayang sangat sangat menghargai bagaimana sistem maklumat hospital memudahkan kerja kerja mereka.

Namun baru baru ini, Kementrian Kesihatan telah mengutarakan cadangan untuk melaksanakan Rekod Perubatan Elektronik (Electronic Medical Record) di seluruh negara dengan kadar cepat (“…fast-track EMR implementation across MOH hospitals and clinics nationwide..”). Bila saya merungut tentang penggunaan nama, yang saya anggap salah, ada orang menjawab “biarlah apa nama jua pun asal sistem merekod atas kertas digantikan”. Jawapan ini menunjukkan salah faham mengenai mengapa kita menggunakan sistem berkomputer. Teknologi maklumat digunakan dalam bidang perkhidmatan penjagaan kesihatan (seperti juga yang digunakan dalam bidang lain) adalah untuk memudahkan kerja dan menoptimumkan penggunaan data sebagai sumber yang berharga.

Rekod perubatan adalah catatan apa yang dibuat dan apa yang berlaku keatas pesakit mengikut tarikh dan masa (kronologi). Kalau komputer digunakan sekadar untuk tujuan itu, aplikasi paling sesuai adalah aplikasi pemproses perkataan (word processor) seperti Microsoft Word. Sebaliknya, jika kita hendak gunakan teknologi maklumat untuk membantu kita membuat kerja, kandungan sistem akan terdiri dari sistem kecil atau modul untuk perkhidmatan klinikal, bantuan klinikal dan juga pengurusan. Struktur sistem juga menjadi kompleks dan memerlukan usaha, kepakaran dan belanja yang tinggi untuk mencipta dan melaksanakannya.

Mereka yang menggunakan istilah “Sistem EMR” kerap berkata itu hanya nama, maksud sebenarnya ialah sistem yang komprehensif (nama begitu dugunakan kerana popular). Namun dek kerana nama yang dipakai, fikiran mereka menjadi celaru. Mereka membina dengan menukar borang kertas kepada borang elektronik, lalu menjadikan mencipta borang sebagai usaha utama (tanpa memikirkan bagaimana data diataurkan dalam pangkalan data). Lepas itu, mereka hairan dan berkata kita ada begitu banyak data, kenapa tiada orang hendak mengalikannya?

Kerana masih terbawa bawa dengn konsep mencatat data (documentation), mereka berpendapat sistemnya sangat mudah dan harganya pun sepatutnya murah. Baru baru ini saya mendapat tahu, ada sebuah hospital universiti menganugerahkan tender sistem maklumat hospital lengkap (yang mereka panggil ‘EMR’) dengan harga RM12 juta. Yang saya tahu, harga termurah Sistem Maklumat Hospital adalah lebih kurang RM40 juta.

Bila berinteraksi dengan pegawai di Kementerian Kesihatan mahu pun di universiti, pepatah Melayu “Hanya jauhari mengenal manikam’ terlintas dibenak hati saya.

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