Sustainability of health information systems in developing countries: the case of Fiji.
Abstract: This paper examines the future sustainability of the Fijian Ministry of Health's (MoH) information and communication technology (ITC) system for patient management (PArIS). PArIS was developed with AusAID funding and, as the owner of the system, AusAID has no commercial competence or interest in further development of the system. Thus, the question that arises is: should Fiji adopt a commercially available patient administration system or retain the existing PATIS? In-depth consultations with senior executives and line managers of units that were major users of PATIS were undertaken. Semi-structured interviews and focus group discussion approaches were utilised. The consensus or majority views of the users were that the existing PATIS performed more than adequately. The future sustainability of the system is threatened by the lack of investment in resources (e.g. hardware maintenance and human resources) required to keep the system operating at its optimum. It was found that PATIS provides Fiji with a satisfactory patient administration system. The identified problems with the system are not related to the application per se but rather to an under-investment in resources for its utilisation.

Keywords (MeSH): Fiji; Medical Informatics; Health Information Technology; Patients; Organization and Administration

Supplementary Terms: Patient Administration Systems
Article Type: Report
Subject: Sustainable development
Developing countries
Medical informatics
Authors: Soar, Jeffrey
Gow, Jeff
Caniogo, Vili
Pub Date: 10/01/2012
Publication: Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Health Information Management Association of Australia Ltd. ISSN: 1833-3583
Issue: Date: Oct, 2012 Source Volume: 41 Source Issue: 3
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Code: 0DEVE Developing Countries
Accession Number: 308004950
Full Text: Introduction and background

The application of information and communication technology (ICT) in healthcare is being used in many new and interesting ways, including telehealth, telemedicine, clinician decision-support, evidence-based care, evidence-based policy, workforce productivity management, access to training materials, quality and practice guidelines, access to the world's health knowledge and consumer empowerment (World Health Organization [WHO] 2008). ICT has become a key tool for executive-level decision making, particularly for resource deployment. Decisions on ICT investment need to be based upon sound business cases, which are able to be made for certain applications of many new technologies (Ayres, Soar & Conrick 2006). Technologies such as the Internet, mobile phones and personal digital assistants can also be used to great advantage to communicate and collect information. The use of satellite technologies, in particular, will significantly increase access to broadband at decreased cost, and will improve penetration (Lee, Marcu & Lee 2011). An additional benefit is that ICTs can be used for multiple purposes, ranging from the registration of births to teleconsultation and open learning. ICT offers the ability to dissociate time and distance from learning activities and the ability of learners to study on the job while they deliver services. ICT provides the means to address many of the reforms that have been embraced internationally but are yet to be fully implemented in Fiji. These include:

* Strengthening the nexus between research evidence and healthcare planning, policy and practice to enable planning and resource deployment needs to be based on epidemiology research. To this end an intranet can provide a readily accessible repository of best-practice clinical guidelines.

* Improving safety and quality, because many adverse events such as medication problems arise from inadequate or poor quality information for prescribing and administration. The use of a health information system (HIS) can address these as well as provide reporting for quality assurance processes.

* Increasing workforce efficiency and productivity, as ICT can provide the tools to reduce effort in areas such as searching for patient data, obtaining diagnostic results and reducing duplication of services such as scans through better sharing of previous results. It can also help manage waiting lists and waiting times, ensuring maximum productivity from resources such as operating theatres.

Healthcare systems are under pressure around the world (WHO 2000; McKee 2010). These pressures include or derive from:

* New and expensive treatments such as endoscopes and medications.

* Workforce shortages. This applies across most disciplines but is particularly acute in developing countries whose health workforce is often 'poached' by developed countries.

* Safety and quality. There has been recognition that hospitals are not always safe places to be, with avoidable deaths often exceeding those from other causes of premature deaths.

* Fragmentation. Most health services have an episode and provider focus rather than an holistic, longitudinal focus on patients and maintaining or improving their wellness.

* Funding. Healthcare continues to increase its share of gross domestic product (GDP), primarily through pressures of increasing demand, increases in chronic illness and the cost of new treatments, medications and medical technologies.

* Ageing of populations. This is associated with an older age of women when having a first child, smaller families and increased longevity.

Fiji: its health system and its health information assets

The whole system of government was thrown into upheaval by the military coup in 2006. Subsequent events, in particular the diplomatic isolation of Fiji and the global financial crisis (GFC) have had a dramatic effect on the Fijian economy and the fiscal position of Government. In 2007, GDP fell by 0.9% and again fell by 3.0% in 2009 (World Bank 2011). This has impacted adversely on Government revenues particularly, and it has run budget deficits in the range of 3 to 4% of GDP over the past five years (World Bank 2011). Total Government health expenditure in Fiji is low by world standards. It has varied between 2.5% and 3.5% of GDP over the past 15 years (Fiji Ministry of Health [MoH] 2010) and currently trending lower. The proportion of Government expenditure in Fiji on health has varied between 9% and 11% over that same time period (Fiji MoH 2010). In 2009, the Government announced two measures that adversely impacted upon the health system: (a) a cut of 50% to the operational budget of all Government agencies including health and (b) a decree that public servants had to retire at age 55 years, which has removed a very large number of senior and middle level staff out of the health system (Freeman & Sutton 2010).

Fiji has some key health information assets that would be the envy of more developed nations. These include a unique patient identity number, known as the national health number (NHN), and the seamless sharing of patient information between facilities (Fiji MoH 2009). These are valuable assets as they form the essential foundation for best-practice in health information management, which is unusual to see in lesser developed countries like Fiji (AusAID 2008).

Fiji Ministry of Health ICT

The Fiji MoH has become a leading government ministry in the introduction of ICT through its desire to have information available to support informed decision-making, business needs and improved service to the general public (Fiji MoH 2008). The MoH ICT infrastructure is comprised of numerous small to medium Local Area Networks situated at MoH facilities throughout Fiji and a Wide Area Network linking major facilities in Suva, Lautoka and Labasa (Fiji Health Sector Improvement Project [FHSIP] 2007). Major areas of computer utilisation are: human resources post processing; secretarial support; patient information system (PATIS); financial management information system (FMIS); human resources information system (HRIS); Open Learning Centre (POLHN); and management--correspondence and email services.

Patient information systems (PATIS)

PATIS was originally developed following a request from the Government of Samoa to the Government of Australia in 1996 for assistance with a health information system, and a subsequent request from the Government of Fiji. PATIS was developed through AusAID support for the Pacific nations, is written in Microsoft Access, and uses the SQL server database management system for patient information collection and dissemination (AusAID 2003). By providing funding for its development, AusAID is technically the owner of PATIS, and has offered to make it freely available to other Pacific nations. PATIS currently has limited technical support for sustainability, and no sustainable inter-country coordination. PATIS is a low-cost application software system that provides functionality generally found in commercial patient administration systems (PAS) modules of a HIS. There have been significant enhancements to Fiji's PATIS, which now has functionality usually only provided by specialised clinical system modules.

The rollout of PATIS has been limited to hospital usage and some health centres, and, for the current time, it is considered completed. However, is still incomplete, especially in the outer islands. A further disappointment is that it is paper-based and not networked. Insufficient staff available and trained in computer entry hinders its transformation into a more dynamic and potentially powerful management and research tool (Freeman & Sutton 2010). A database at headquarters has been finalised but not yet rolled out to hospitals and health centres.

Research problem

Fiji's MoH and, in particular, its HIS are under significant pressure in the face of the current economic situation, rising costs, and rapid changes in technology. The MoH has had decreases in their ICT budget over the past few years, which has led to difficulties in maintaining and replacing hardware. Due to investments by AusAID, the HIS has developed and grown. However, the ongoing assistance with ICT funding from AusAID is not likely to be continued so it is critically important that all key stakeholders reassess the sustainability of such systems. Increasing the internal ICT capacity of the MoH is essential, through an increase in numbers and skills of staff, if the current health ICT infrastructure is to be maintained and sustained for the future. It is tempting to see ICT as an expensive and ever-demanding cost rather than a strategic investment that will deliver value in excess of the cost of investment. This requires ICT to be viewed and managed from a strategic level, for investments to be based upon business cases, and for there to be recognition of ICT as an essential infrastructure to enable quality healthcare and effective use of resources. To date, the MoH Directors have not been well-equipped by ICT. An executive information system (EIS) would be one way to provide information for evidence-based decision making that would demonstrate the value of quality information and identify the current shortcomings in MoH systems.

The commercial value of the intellectual property of PATIS is not clear. While Fiji and Samoa derive great value from it, there may not be market opportunities. PATIS will need further capital investment to move it to a more modern technology platform. There is a range of products now on the market with modern software tools already developed, which have a large user-base and are well supported by vendors. AusAID could test the market through a call for expressions of interest in commercialising the product. The interests of existing users such as Fiji and Samoa would need to be protected.

Given the situation, this study aimed to answer the following eight research questions and discover what evidence is available to support the sustainability of the MoH's health information and ICT systems, and in particular:

1. What is the MoH's ability and willingness to continue to pay the annual maintenance fees for all software packages and therefore have access to upgrades?

2. What is the MoH's ability and preparedness to fund hardware maintenance and to plan and finance replacements?

3. What is the robustness and sustainability of PATIS, given that it is not a proprietary software system?

4. How sustainable are the software systems?

5. How sustainable are the hardware platforms and associated equipment?

6. What are the risks to sustainability and the 'future proofing' of the MoH's core ICT systems, including in particular the FMIS, HRIS and PATIS?

7. What is the sustainability of the MoH's ICT systems within the context of the Government of Fiji's ICT services and platform(s) both existing and those short-term developments that can be relied upon to happen?

8. What are the risks to the other infrastructure without which modern ICT cannot effectively operate, such as telecom services and reliable power sources?

The focus of the research was particularly, but not only, on the ICT systems funded by the Fiji Health Sector Improvement Program (FHSIP). To this end, an analysis of the evidence and assessments was undertaken, which examined: sustainability of software systems; sustainability of hardware platforms and associated equipment; risks to sustainability; and 'future proofing' of the MoH's core ICT systems, including in particular the FMIS, HRIS and PATIS.

Further, an examination of the sustainability of the MoH's ICT systems within the context of the Government of Fiji's ICT services and platform(s), both existing and those short-term developments that can be relied upon to happen; other infrastructure without which modern ICT cannot effectively operate, such as telecom services and reliable power sources; and the general ICT environment in Fiji. This will enable conclusions to be reached regarding the sustainability of the MoH's ICT systems and make practical recommendations for any actions needed to bring that sustainability to an acceptable level, if appropriate. Some of these specific measurable outcomes included reporting the sustainability of each of the MoH's ICT systems, with particular but not exclusive emphasis on those systems funded by FHSIP. A further aim was to advise on risks to sustainability and recommendations of practical actions that should be taken to provide a reasonable level of sustainability.

Previous reviews of PATIS

The background for this current study included reviewing work previously undertaken regarding the sustainability and suitability of PATIS and MoH information and ICT systems. Some of the recommendations of previous reviews have been successfully implemented, and others are still under development, while some may need to be revisited.

2002-2003 Review of Sustainable Options for Future Implementation, Maintenance and Enhancement of PATIS

A Review of Sustainability Options for Future Implementation, Maintenance and Enhancement of PATIS (AusAID 2003) was commissioned by AusAID, undertaken in 2002 and finalised in 2003. Some of the key recommendations included:

* that PATIS implementation continue with AusAID support (rather than considering replacement of PATIS)

* formal PATIS coordinating arrangements be established between Fiji and Samoa

* consideration be given to the acquisition of a report generation software tool (such as Crystal Reports)

* best practice for software development and ICT management be adopted including: adherence to standards; adherence to common code across all user sites; compiled code only to be provided to sites; coordination of enhancement requests and new releases; user group(s) be established; project management rigour to be applied; and separation of the ICT roles of implementation, maintenance and enhancement.

2005 Sustainability Review

Recommendations from the PATIS Sustainability External Peer Review relevant to this current study include (Fiji Health Sector Improvement Project [FHSIP] 2005):

* Investigate expanding the current ICT outsourcing contractor's role to provide a Ministry-wide help-desk service and ICT management support.

* An appropriate ICT recurrent budget for maintenance, replacement and support be allocated.

* Investigate the development of a data interchange facility based on HL7 standards into PATIS.

* Establish a computer training room in each division.

* Limit PATIS releases to one or two annually.

* Develop and maintain PATIS user documents (user and training manuals).

2007 Strategic Plan for Information Technology

In August 2007, a five-year strategic plan for information technology for the Fijian MoH was completed (Fiji Health Sector Improvement Project [FHSIP] 2007). Goals and recommendations relevant to this current study include:

* MoH must re-structure the ICT Department, employ an ICT Manager and develop an ICT policy.

* Technology will be leveraged effectively in terms of thin client technology, development of intranet and an executive information system (EIS), improvements to back-up systems, helpdesk, disaster recovery and business continuity.

* Existing applications data need to be integrated into forming an EIS. To do this requires connectivity and a rollout to sub-divisional medical officers and health centres of PATIS, FMIS, HRIS with the provision for security and confidentiality of patient information.

* Enhance knowledge management by adopting a standard operating environment, investigate baseline architecture training requirements for MOH employees and ensure greater access to the latest knowledge and evidence-based clinical guidelines for improved decision making, and in addition, to develop a knowledge and skill inventory of existing and needed emerging requirements.

* Current support systems need to be improved in terms of hardware and application support contracts with an option to outsource partial or complete ICT systems and services for the sustainability of systems. Quality assurance and asset management systems need to be developed.

Method

At the commencement of the study a literature search and review of previous reports and other background material was conducted on HIS generally and PATIS in particular. Initial briefings were conducted with Australian funders and senior Fijian MoH officials. The purpose of the briefings was to identify the scope of the study, discuss desired outcomes, the deliverables expected from the process and the timeframe. Following these activities, the research protocol was developed with its centrepiece the draft survey instrument for data collection purposes. The tool was pre-tested and a structured survey instrument was administered to a group of health system professionals in Fiji during 2009. The instrument explored these professionals' knowledge of ICT generally, and their experiences with PATIS specifically.

Respondents

The survey frame was drawn from middle and senior managers and senior executives in the Fiji MoH. The respondents were a random group of 25 health system stakeholders out of a larger group of 50 potential interviewees. The potential interviewees were identified in consultation with senior Ministry officials. The respondents were interviewed using a semi-structured interview approach. A focus group involving 22 people was also held later, at which the interim findings were presented, discussed and interpreted. All participants approached willingly participated in the study.

Instruments and procedure

The survey instrument consisted of a semi-structured interview guide, which was used to informally guide in-depth interviews with participants. Senior executives, who were interviewed by one of the authors with

many years experience in survey work, were also asked some additional questions of a higher order. A pilot test of the survey instrument was conducted with two MoH staff members who did not participate in the subsequent formal interview process. This pilot found that the instrument was well designed and clearly understood by stakeholders. (Appendix 1 refers).

Data analysis

Results of data collected from the in-depth interviews were compiled and analysed and thematic analysis of the collected data was conducted. The focus of the analysis was to outline the views of the vast majority of participants, which, in accordance with traditional Fijian custom, are arrived at via consensus.

Focus group discussion

Following the thematic data analysis there was a collective feedback session to all respondents to ensure that the interpretations and views expressed in the interviews were accurately captured. These consultations were to validate the preliminary results with the respondents to further discuss and confirm the initial findings.

A draft report that collated the consensus view of the vast majority was compiled following the focus group discussions and this was distributed to all participants for comments and/or correction. Following a period for comments to be submitted, these were then incorporated into the final report.

Results

The results are an amalgamation of the two consultation processes outlined in the previous section, as well as a considered assessment of the responses by the study authors. The consensus views of the vast majority of study participants are presented using the eight research questions outlined earlier.

MoH's ability and willingness to pay annual maintenance fees for software packages and upgrades

Ability and willingness to pay is related to the priority given to information and ICT, and to whether ICT is seen as a cost to be controlled or a strategic investment that will deliver savings and benefits across the MoH. There are currently proposals for investment in ICT before the ISMWG (IS Management Working Group) of the MoH.

The recent establishment of the ISMWG is a positive indication of the MoH's willingness to take stronger control of its ICT. The ISMWG is currently a temporary body, and it will be essential for the ISMWG to establish a permanent governance body to take over from it. The willingness of the MoH to invest in ICT is likely to be enhanced through:

* development of an EIS and/or intranet that delivers timely and high quality information to the MoH Executive that will assist in their planning and decision-making

* presentations to the Executive of detailed, costed business cases for investment in ICT that clearly identify the opportunity cost of not investing, the return on investment (ROI) and the payback period. There are currently some powerful business cases that could provide short-term returns if they were funded in a timely way.

Is there adequacy of ICT staffing (and/or external contracts) for hardware and software support? Internal ICT staffing levels are inadequate for sustainability. A proposal has been presented to ISMWG by the MoH ICT Manager for a total establishment increase of 50%. That would appear to be a minimum level for sustainability let alone an extension of activities. Additional staff will need to be engaged for projects such as applications development work or this will need to be contracted out. For sustainability, all these positions need to be permanent, especially given the demands for experienced ICT staff in the market. The arrangements with external suppliers for second and third tier ICT support appear to be sustainable in terms of cost and value for money.

MoH's ability and preparedness to fund hardware maintenance and to plan and finance replacements

The establishment of the ISMWG is a positive step in providing a forum for advocating investment and a channel to the MoH Executive. The ISMWG is developing a schedule of urgent investment and future budgets for ICT. If agreed to, the budgets developed by the ICT Manager will provide a minimum level of capital funds for required new hardware. There is a need to identify additional funds required to sustain existing hardware.

Robustness and sustainability of PATIS as a nonproprietary software system

The difficulties with PATIS utilisation appear to have little to do with the application per se and instead relate to training, support, availability and maintenance of hardware.

Sustainability of the software systems

There are no particular issues of sustainability with the applications including PATIS, HRIS and FMIS. Some of the inherent limitations of Microsoft Access are overcome through using SQL-Server as the database. Both Microsoft Access and SQL-Server are still current application platforms that are vendor-supported. The particular versions of Microsoft Access and SQL-Server used in PATIS are several versions-old and need to be upgraded to the latest versions. This migration needs to be funded and contracted to the outsourced supplier, as this is not straightforward and changes need to be made to the PATIS application to allow this.

Sustainability of hardware platforms and equipment

Much of the MoH hardware is obsolete and needs to be fully replaced. A budget for new hardware has been developed by the ICT Manager for ISMWG and this needs to be fully funded; servers should be rationalised and consideration given to a storage management system. A budget will be developed by the ICT Manager for ISMWG for maintenance of existing hardware.

Telecommunications in the form of failure in the dialup lines are a major cause of replication problems. All PATIS sites need to be migrated to reliable broadband. The approximate cost of this upgrade needs to have resources allocated for its implementation.

Risks to sustainability and 'future proofing' MoH's core ICT systems, including FMIS, HRIS and PATIS

'Future-proofing' implies that systems will be adaptable to changing circumstances, including changes in technology, organisational structure, and business processes. There is nothing to indicate the existing applications are not suitable for the foreseeable future in the MoH. The issues and problems are largely unrelated to the applications per se but relate more to training, policy and resourcing.

Sustainability of MoH's ICT systems within the context of its ICT services and platforms

A government-owned provider such as GovICT should be considered as a potential provider of outsourced support. This does not relieve the MoH of the need to retain quality in-house ICT staff for strategy, policy, management, contract management, business analysis and first-tier support for users and PCs.

Risks to other infrastructure that modern ICT depends on

There are many other issues (e.g. inconsistent power supply in outlying islands), which are outside the control of MoH; generally, the infrastructure of Fiji is robust in the main centres and continually improving.

Discussion and further analysis

There were several areas for improvement identified to strengthen Fiji's capacity to manage information and technology strategically. A fundamental need is to promote the value of information as a strategic resource for improved quality, safety, productivity and efficiency of healthcare. PATIS appears to be appropriate for the needs of the Fiji health system as it is designed specifically for the models of healthcare delivery common in the Pacific. There are issues and problems associated with the system but all of these appear to be manageable and not directly related to the PATIS application. They are mostly related to inadequacies in technical support, telecommunications, training and equipment. Each of these issues needs to be investigated, a costed plan developed to address the more urgent issues, and funds obtained to implement the changes.

The benefits of PATIS are still yet to be fully realised by many areas of the MoH. If Fiji MoH was a so-called 'greenfield site' then it would be advised to consider PATIS against one of the many healthcare information systems from the market that are fully supported by their vendors. There is not, therefore, a business case for replacement of PATIS. A replacement would incur significant capital cost, as well as higher recurrent costs with licensing than PATIS. There would also be the disruption involved in a major project to replace it. Despite this, other issues of ongoing concern identified by the authors from the literature include:

* There are different versions of the software in Samoa and Fiji, with no arrangements in place for sharing in the cost of support and enhancement.

* None of the other Pacific Island nations have adopted PATIS and both the Solomon Islands and Tongan Ministries of Health have implemented commercial healthcare information systems.

* There is inadequate in-house support in Fiji, as the PATIS support desk is reported to receive around 60 calls per day, which is not sustainable given their resources.

* There is a lack of training across sites, and particularly computers for training.

* PATIS is not yet implemented across all sites, which means that these sites do not gain the benefits of PATIS, and it imposes an overhead of managing both electronic and manual data systems.

* Incomplete and inaccurate data result from PATIS users' failure to maintain up-to-date data.

* The PATIS user group needs to be re-established and to prioritise an annual budget for enhancements and maintenance to the current application.

* PATIS training might be assisted if the product was provided to the Fiji School of Nursing, Fiji School of Medicine and University of the South Pacific for inclusion in relevant courses.

Outsourcing of support

PATIS second- and third-tier support is being provided by a private supplier, and the costs and usage do not seem to be excessive. GovICT is another option for back-up support of PATIS. There are plans for GovICT to be commercialised and this has already reportedly stimulated a service culture within GovICT. In terms of economies of scale, GovICT should be considered as a potential ICT services supplier to the MoH.

Alternatives to PATIS

It is difficult to find a business case for replacement of PATIS, as an alternative may give less functionality than currently exists; PATIS offers more than the functionality found in most PAS, including, for example, dental and pregnancy and birth modules. The Fiji MoH would incur significant costs, risk and organisational disruption if they changed to a new system, with possibly less functionality than exists now in PATIS. Now that PATIS has been embedded within the Fiji MoH, it is relatively low cost to maintain, and has a low number of reported problems with its functionality. The problems that are reported appear to be unrelated to the application per se and, consequently, would still be there if a different system was adopted. A replacement project would take several years and consume significant management attention and diversion of resources.

As core business processes have not fundamentally changed in healthcare around the world, nor in Fiji, PATIS remains a viable tool for the MoH for the foreseeable future. The PATIS database has huge potential to be at the core of a knowledge-driven health service for Fiji. It could aid in identifying areas of poor health, provide data for geospatial information systems that can map disease, vectors and health-status, and inform targeting of services, interventions and investment in health facilities. PATIS data are likely also to be of interest to researchers and may even have commercial value. Naturally, data would need to be de-identified so that an individual's privacy can be protected, but some of the data could be linked to web-based databases to allow searching within a secure environment.

PATIS IP and AusAID

For AusAID, the issue of ownership of the IP is still unresolved. Systems development and support is not part of the mission and core business of AusAID. They acknowledge that software development and support is best done by entities for whom this is their core function.

The value of the PATIS IP is not clear and needs to be market-tested. Whether PATIS is an option for other nations would depend upon their own analysis of the costs and benefits of it in relation to available products on the market. While Fiji and Samoa derive value from PATIS, there may not be market opportunities. To date, none of the other Pacific nations have adopted PATIS and the Solomon Islands and Tonga have both purchased commercially-developed and vendor-supported products.

Conclusion

PATIS is currently delivering health information system functionality that is benefiting the people of Fiji. Available commercial products may be more expensive, and may deliver less functionality than PATIS. PATIS sustainability is related to funding for enhancements, technical support, training and telecommunications. There appear to be few significant problems with the PATIS software per se. PATIS needs to be fully implemented across Fiji and adequate budget provided for support, hardware acquisition and for telecommunication and power problems to be resolved.

PATIS appears to be appropriate for the needs of Fiji's health system. However, the potential benefits of PATIS are still yet to be fully realised. There is not a business case for replacement of PATIS. A replacement would incur capital cost and be likely to have a higher recurrent cost than PATIS. There would also be the disruption involved in a major project to replace it. In addition most commercially available replacement patient administration systems would deliver less functionality than PATIS, which has a broader range of functionality. PAS systems cover patient registration, admission, transfer and separation. PATIS provides this functionality plus some of that found across other modules of a more comprehensive clinical information system, including dental and pregnancy and birth modules as examples.

The advantages of PATIS IP include a unique patient identity number and seamless sharing of patient information between facilities. These valuable components form the essential foundation for best-practice in health information management. Fiji makes good use of a patient management system that appears to meet the needs of healthcare information. However, by any comparison with like organisations, the MoH appears to be grossly understaffed.

Note: Throughout this paper the abbreviation HIS refers to 'Health Information System' although it also frequently stands for 'Health Information Service' in other publications.

Appendix 1

Survey instrument

The semi-structured interview instrument was used to informally guide in-depth interviews with participants. In addition, an enhanced version was used with more senior managers and executives. It is reproduced below.

General guide to facilitate dialogue

Thank you for your time. I have been engaged to review the sustainability of the MoH's health information systems, including ICT systems and in particular PATIS.

1. What are your roles and responsibilities?

2. How do you interact with the MoH's information systems?

3. What do you feel are the key issues/problems/areas for improvement with the MoH's information systems?

4. (for each one) Why do you feel that?

5. What do you feel should happen (to address each issue)?

6. Who should do that?

7. If you were doing this review, what might you look into?

8. What recommendations do you feel should be in the report?

9. What other questions should I be asking?

10. Who else should I talk to?

Please email me with any other thoughts you might have. Additional questions for executives

1. What information do you (and/or your staff) not receive that you would like to have access to?

2. What is the impact of not having that information?

3. Are there occasions of waste (materials or time) or failure of service delivery due to delays in information processing or availability of information?

4. What are your major frustrations that might be linked to processes, information access or information flow?

Acknowledgements

This research was supported by funding from AusAID, the Australian Government Overseas Aid Program. The authors would like to thank Vicki Bennett for reading through an earlier version of this manuscript and making helpful suggestions.

References

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AusAID (2008). Situational analysis of the Fiji health sector. Canberra, AusAID.

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Fiji Health Sector Improvement Project (FHSIP) (2005). PATIS sustainability external peer review. Suva, Fiji Health Sector Improvement Program.

Fiji Health Sector Improvement Project (FHSIP) (2007). Five year strategic plan for information technology for Ministry of Health --Fiji. Suva, SPNS.

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Fiji Ministry of Health (2009), Fiji health information system: Review and assessment. Suva, Fiji Ministry of Health and Health Metrics Network, WHO.

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Freeman, P. and Sutton, R. (2010). Fiji health sector improvement project (FHSIP)--independent completion report. Canberra, AusAID Health Resource Facility.

Lee, S., Marcu, M. and Lee, S. (2011). An empirical analysis of fixed and mobile broadband diffusion. Information Economics and Policy 23(3/4): 227-233.

McKee, M. (2010). The world health report 2000: 10 years on. Health Policy and Planning 25(5): 346-348.

World Bank (2011). World Bank country statistics--Fiji. Available at: http://data.worldbank.org/country/fiji (accessed 23 November 2011).

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Corresponding Author

Jeffrey Soar BA(Hons), GDipDataProc, GDipEd, Med, PhD

Professor and Director

Collaboration for Ageing & Aged Care Informatics

School of Information Systems

University of Southern Queensland

Toowoomba QLD 4350

AUSTRALIA

Tel: +61 400 746 65 7

Fax: + 61 7 4631 5594

email: soar@usq.edu.au

Jeff Gow BAgEc(Hons), MEc, PhD

Professor of Economics

School of Accounting, Economics and Finance

University of Southern Queensland

Toowoomba QLD 4350

AUSTRALIA

email: gowj@usq.edu.au

Vili Caniogo BA, MPubPol

ICT Project Manager

Honiara, Solomon Islands

email: vilimas2@yahoo.com
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