Existing Health Information Systems and Lessons from India and China

South Africa’s health information systems (HISs) are vital for modernising healthcare delivery, yet the country faces significant challenges in achieving a unified, patient-centred electronic health record (EHR) system. The current systems are fragmented, lack interoperability, and focus primarily on administrative or epidemiological data rather than supporting clinicians’ decision-making processes. This article examines South Africa’s existing HIS landscape and explores lessons from India and China to identify potential pathways for improvement.

Existing Health Information Systems in South Africa

Existing health record practices do not resemble a comprehensive HIS. They can be described as patient inventories and accounting systems (“back entry capture of paper registers” onto a computer which is not accessible or usable to clinicians) (Zharima, Griffiths, & Goudge, 2023). These systems are also not integrated in a larger system between different health providers. There is however a degree of integration on the funder level. “In other provinces where I’ve had some experience, there actually isn’t an electronic health record of any meaningful description. This is primarily because nobody can agree as to what the standards should be” (Participant 5 from Zharima, Griffiths, & Goudge, 2023). The National Department of Health (NdoH) and the Council for Scientific and Industrial Research (CSIR) reported at least 42 different HISs which supported patient administration and care in 2013. Only seven were operational in five or more provinces and of these, five were for surveillance and monitoring and only two concerned patient care (Wright, O'Mahony, & Cilliers, 2017).

Patient data is currently manually captured (handwritten) in a patient file and monitoring and evaluation (M&E) is relied on by nurses' recordings in registers (Wright, O'Mahony, & Cilliers, 2017). The eHealth Strategy states that all facilities that deliver healthcare should implement point-of-care electronic patient-based information systems and that this should be the source of all indicator data.

While there is an eHealth Strategy, there is currently no master patient index and national architecture to support a national digital HIS. The current HIS landscape is flawed with too many indicators being used for reporting purposes with no clear delineation of the health outcomes that they support. While there are some systems to record patient data, these are mostly in support of specific services or tasks, they do not form part of an integrated HIS to support patient-centered care and decision-making at the point of care. Most of the active HISs (DHIS2, EVDS / COVDATA, Tier.net, and the National Health Patient Registration System) are geared towards support at government level (strategic information from HIS pyramid) such as M&E or administration needs of the Department of Health (Wright, O'Mahony, & Cilliers, 2017). This is at odds with patient-centred care – defined as “care that is respectful of and responsive to individual patient preferences, needs, and values” (Wright, O'Mahony, & Cilliers, 2017). Research indicates that this strategic level does not have much immediate value for clinicians and subsequently it does not catalyse them to embrace it. This could explain why (the lack of patient-centred HISs) healthcare professionals are not embracing HIS as they perceive it as non-beneficial to their patients. Dehnavieh et al., (2019) substantiate this by highlighting that a lack of data ownership leaves little incentive for healthcare professionals at the lower levels of employment (who are most likely to capture information) to record and use health data. There needs to be a paradigm shift in the country towards designing digital HISs for patient care rather than for collecting epidemiological or management data. Information should support clinicians’ decisions and actions; "if it fails to do this, it is irrelevant noise" (Dehnavieh et al., 2019).

---

HISs can be divided into two major categories, whether it supports a specific ‘subject’ (such as a doctor or nurse to help them perform their duties) or whether it supports a specific ‘task’ (such as a prescription or billing system that can be used by anyone who enters data into it) (Wright, O'Mahony, & Cilliers, 2017). HIS is understood according to the tasks that they perform.

The information systems pyramid (Beaumont [n.d]) provides a tool to determine how mature HIS implementation can be. HIS are normally first developed and implemented at the operational level.

---

Fragmentation of the existing HISs being used in South Africa is another potential barrier to implementing a comprehensive HIS. This is exacerbated by the country’s dual healthcare systems. These sectors exist in parallel, operate independently, and use different approaches and systems to provide healthcare services. This results in a large public health sector that is over-utilised and under-resourced, and a smaller private health sector that is over-resourced and under-utilised. These two systems were inherited from the apartheid regime and contribute to health system fragmentation (Botha and Hendricks 2008) (Chuma & Sibiya, 2022).

The health systems’ governance and organisation of health into three levels, national, provincial and district health, further contribute to its fragmentation. This results in a heterogeneous management landscape facilitated by the national health system, nine provincial health authorities, and district health systems under each province intertwined with private healthcare facilities. Gray, Riddin, and Jugathpal (2016) show this fragmentation by indicating that the South African public sector comprises 16 tertiary hospitals, 698 specialised hospitals, 55 regional hospitals, 254 district hospitals, 282 community health centres, and 3 075 primary healthcare clinics. In contrast, the private sector in South Africa consists of 216 healthcare facilities.

Both the public and private healthcare sectors have incorporated a plethora of HISs and EHRs. Almost each of these has been developed independently of each other by diverse software and hardware vendors and are stored in a local database. The multitude of architectural bases, procedures and processes mean that these systems are often not equipped to communicate, exchange and share information amongst each other. Bukowski (2016) and Mladovsky (2020) describe fragmentation in health systems as occurring when multiple independent health service providers operate within the same area without coordination. According to McIntyre and Ataguba (2017), the fragmentation in South Africa's healthcare system is due to the use of separate, outdated, and uncoordinated health information systems. This results in inefficient delivery of health services and resources, exacerbating gaps within the health system, wasteful duplication and poor patient outcomes (Chuma & Sibiya, 2022). In addition, the absence of a standard national HIS in the health system adversely affects policies and procedures, organisations and operations in healthcare facilities, increases inefficiencies and restricts progress towards UHC (Chuma & Sibiya, 2022; Ndzimakhwe et al., 2023). Ndzimakhwe et al., (2023) propose that a smooth transition to the NHI will require an EHR platform that should be able to accommodate standard collaboration in the heterogenous landscape of healthcare providers.

Patient Level HIS: Clinical care and supporting services systems

eHealth@Joburg: A primary care EPR system is being implemented by Med-e-Mass, a private vendor in 83 facilities in the City of Johannesburg. Clinical notes are entered into the system with templates for mother and child health and non- communicable diseases. There is as yet no pharmacy module [10]. Over 500 000 patients have registered on this system (Malungana & Motsi, 2022). The facilities were this was implemented enabled connectivity via the Wide Area Network (WAN) consisting of fibre optic as the primary source or radio link, and in some cases a combination of the two. In case of power failure, the system was connected to generators, solar energy system, an Uninterrupted Power Supply (UPS) System and electrical reticulation (Joburg.org.za).

Meditech: Meditech South Africa (Pty) Ltd is a private software company that provides software solutions to healthcare organizations in SA [25]. This HER system documents patient symptoms, diagnoses, comorbidities and medical history according to Zharima et al., (2023) it can ink with operational systems such as imaging, lab and pharmacy (Zharima, Griffiths, & Goudge, 2023).

Medicom: This is developed by privately owned software vendor to integrate on-site EHRs. This system integrates data recorded in patient registration, appointment scheduling, out-patients management, trauma, in-patients management, medical records and patient billing (Zharima, Griffiths, & Goudge, 2023).

In KwaZulu-Natal, some hospitals use EPR through the Medicom or Meditech EPR systems. Hospitals in the Western Cape use the Unicare System. Hospitals in Limpopo use the Unicare or Medicom EPR systems. The EPRs can be understood as a comprehensive collection of patients’ health histories that is maintained and controlled by healthcare personnel (Wright, O'Mahony, & Cilliers, 2017). Because these different EPRs are built by various vendors with different underlying technologies, they fail to communicate and share information amongst each other. These systems have also only been implemented in a few areas, the majority of public health facilities continue to use paper-based systems (Wright, O'Mahony, & Cilliers, 2017).

TrakCare Lab: From 2008, this proprietary laboratory management information system (InterSystems Corporation) has been used by most laboratories in the National Health Laboratory Service – which is responsible for all diagnostic pathology in the public sector. Patient details are entered manually or through a barcode and are produced electronically (Wright, O'Mahony, & Cilliers, 2017).

Picture archiving and communication systems (PACS): Although many public hospitals in South Africa use Picture Archiving and Communication Systems (PACS), these systems are not functioning as well as they could be. A key issue is the lack of interoperability between different vendors' PACS systems. While digital radiology equipment uses a standard format (DICOM) for image data, PACS vendors use proprietary formats for other essential information like patient details and file management. This makes switching vendors expensive and difficult. Further problems include workflow disruptions, poor integration with existing patient information systems, the absence of national standards for PACS integration, and insufficient project management expertise. (Wright, O'Mahony, & Cilliers, 2017).

JAC Pharmacy System: This a proprietary pharmacy dispensing and stock control system which was introduced in 1999. It is now installed in a majority of hospitals in the Western Cape, and in an increasing number of Community Health Centres (CHCs), totalling 70 facilities in 2015 (Wright, O'Mahony, & Cilliers, 2017).

E-tick: This is a basic administrative system funded by the Aurum Institute which functions as a digital version of the paper-based tick register used to record patient data by healthcare providers and administrators in community health interventions. This HIT records and stores patient data on each of their visits to a facility including “names, dates, illness and treatment and service provided at the facility” (Zharima, Griffiths, & Goudge, 2023). It has only been implemented in the Ekurhuleni district.

Patient and Operational level HIS: Administration systems

CLINICOM Hospital Information System: This is used by nearly all hospitals in the Western Cape, providing patient demographic and hospital administration data. It supplies a unique patient identification number that is shared across other HIS for public-sector users throughout the Western Cape [18] (Wright, O'Mahony, & Cilliers, 2017).

Primary Health Care Information System (PHCIS): This is mostly an administrative HIS that was developed by the Western Cape government to be used in all public sector primary healthcare centres (PHCs) and CHCs in the province – except for Cape Town City. Its purpose is to centralise the registration of patients and store their patient data including tracking their visitations and outcomes. It has been integrated as a module (such as for Obstetrics and gynaecology, bookings and appointments, as well as HIV and TB monitoring). It offers demographic data as well through a unique patient identifier number (administered by CLINICOM) that is attached to a patients paper record as a bar code (Zharima, Griffiths, & Goudge, 2023).

Primary Health Care Information System (PHCIS): The "PHCIS Basic" version was designed for public community health centres and clinics in the Western Cape. It records patient demographics and uses ICD-10 codes to classify visits. The system employs a unique patient identifier (managed by CLINICOM) that is linked to the patient's physical record via a barcode. Data is then entered into the system manually. A related system, EKAPA, originally designed for HIV case management and tracking, is now being integrated into PHCIS, as both were built on the same platform) (Wright, O'Mahony, & Cilliers, 2017).

Patient Record and Health Management Information System (PREHMIS): This is a linux-based system used by the City of Cape Town in PHCs. Data capturers read patient records, select an indicator from a printed menu, and then scan the barcode into a computer (Wright, O'Mahony, & Cilliers, 2017).

Delta 9™ Hospital Information System: Little detail is provided on the company website about the functionalities of its product Unicare™ that are used in 108 institutions (hospitals and clinics) in both the public and private sector [19] (Wright, O'Mahony, & Cilliers, 2017).

Patient Administration and Billing System (PAAB): This platform as ran by a private company owned by the NdoH. While it is mainly used for administration data, a clinical data recording module has been added but it lacks the functionality to be used in an integrated manner. It also lacks linkage with the pharmacy system or laboratory results.

RxSolution: This stock control programme was funded by the US Centres for Disease Control and Prevention (CDC), and implemented in clinics and hospitals in five provinces [18] (Wright, O'Mahony, & Cilliers, 2017).

Operational and Strategic Level HIS: Monitoring and Evaluation systems.

PHC data is manually captured by nurses (usually in vertical programmes) which is aggregated by data capturers into an electronic HIS for M&E purposes for the NdoH. This process has been associated with poor data quality and a perceived high work burden from nurses. Odama et al., (2010) found no evidence "that data analysis informs any policy or programme management in individual clinics" in the Eastern Cape Province.

National Health Patient Registration System (HPRS): The HPRS is owned by the NdoH and developed by the CSIR (Zharima, Griffiths, & Goudge, 2023). This system allows identity verification and records the reason for a visit and is installed in 650 public PHC facilities countrywide (Wright, O'Mahony, & Cilliers, 2017). The system has at least 44 million people registered and is considered the most reliable source of national patient demographic data [26] (Wright, O'Mahony, & Cilliers, 2017). The HPRS uses the SA ID number and other forms of legal identification to form a Patient Registry and offers a Master Patient Index capability. However, it only captures patient demographic details (Zharima, Griffiths, & Goudge, 2023).

DHIS 2: The District Health Management Information System is responsible for the collection and analysis of routine healthcare data from all PHC and district hospitals in the public health sector (Wright, O'Mahony, & Cilliers, 2017). This is achieved though the DHIS 2 which is an open-source platform which has moved to a web-based tool to ensure health data is available as soon as it is generated (Zharima, Griffiths, & Goudge, 2023). It was developed by the Health Information Systems Program (HISP) Centre at the University of Oslo (Zharima, Griffiths, & Goudge, 2023). The National Indicator Data Set consists of about 200 indicators, of which 140 are relevant for PHC. Data is sent on monthly basis from PHC facilities to the NdoH (Wright, O'Mahony, & Cilliers, 2017). It is a tool for collection, validation, analysis, and presentation of aggregate patient-based stats and is tailored (but not limited) to integrated health information management activities (Zharima, Griffiths, & Goudge, 2023). Several weaknesses of the DHIS have emerged: Too many indicators (especially for donor-driven programmes), a misalignment of present indicators and the goals of the health sector, lack of ICT infrastructure, and a lack of experienced personnel (Wright, O'Mahony, & Cilliers, 2017). The DHIS software also stores aggregated data instead of patient level data and there is no cut-off date for data input which results in inconsistent outputs (Wright, O'Mahony, & Cilliers, 2017).

Tier.net: This is a stand-alone patient inventory system with clinical data for HIV and TB management in all public sector facilities. It was developed by WAMTech in collaboration with UCT (Zharima, Griffiths, & Goudge, 2023).

Electronic Vaccination Data System (EVDS): A national self-registration, online platform built on the HPRS code to register, record, track and monitor Covid-19 vaccination progress in the country.

The District Health Information System (DHIS), Tier.net, Health Patient Registration System and the EVDS are core national systems used across South Africa (Zharima, Griffiths, & Goudge, 2023). The National Department of Health has been involved in the development, implementation and ownership of numerous digital health information systems through collaboration with the CSIR (Zharima, Griffiths, & Goudge, 2023).

Lessons from International Models

India: Navigating Fragmentation

India’s HIS landscape faces challenges similar to South Africa, including fragmented EHRs and inadequate infrastructure. The lack of a national patient identifier has impeded the integration of various systems. However, India has made strides by adopting open-source EHRs and fostering partnerships between public and private sectors.

Key Lessons:

Standardisation: Establishing consistent data standards is essential for interoperability.

Collaboration: Building public-private partnerships can accelerate implementation and innovation.

Training: Equipping healthcare workers with digital skills is critical for adoption.

China: Regional Success, National Challenges

China adopted a three-stage approach to EHR implementation, achieving regional successes but struggling with national interoperability. Early reliance on regional systems created strong local platforms but delayed the establishment of national standards.

Key Lessons:

Phased Implementation: Starting regionally can build momentum and identify challenges before scaling nationally.

National Strategy: A cohesive national framework is crucial for long-term interoperability.

Recommendations for South Africa

Leverage Existing Systems: Build on platforms such as the HPRS and EVDS to create a more unified HIS.

Provincial Insights: Follow the Western Cape’s example of progressively building a provincial digital health ecosystem.

Open-Source Solutions: Explore the use of open-source EHRs, as successfully implemented in India, Brazil, and Mexico.

Clinician-Centric Design: Shift focus to patient-centred care by designing systems that directly support clinical decision-making.

Infrastructure Development: Prioritise investments in internet connectivity and digital infrastructure to ensure equitable access across provinces.

Conclusion

South Africa’s fragmented HIS landscape underscores the need for a paradigm shift towards integrated, clinician-friendly digital solutions. By learning from the successes and challenges of India and China, South Africa can develop a comprehensive national strategy that addresses infrastructure gaps, enables interoperability, and supports UHC. A focus on patient-centred care and collaboration between sectors will be key to achieving a strong digital health ecosystem.