Evaluation of the District Health Information System in District Kotli, Azad Jammu and Kashmir: A Retrospective Analysis

Background: It is essential to implement a high-quality electronic database for keeping important information. The District Health Information System (DHIS) is an active data-keeping system in Pakistan. This study aimed to evaluate the patients' data from the DHIS dashboard for the District Headquarters Hospital, Kotli, Azad Jammu and Kashmir (AJK). Methodology: The data was requested from the hospital administration at District Headquarters Hospital, Kotli, AJK, and the data was analyzed after permission was granted. The data was given in two forms; one was a hard copy of the data for August and September and the other was a comma-separated values file for October and November, 2023. Results: The highest frequency of patients was received in the department of emergency and trauma and the patient's median age was between 15 and 49 years. The second department was medicine with the >50 years of age. Common conditions that needed more attention were chronic obstructive pulmonary disease, acute respiratory infection, diarrhea, pneumonia, diabetes mellitus, hypertension, and ischemic heart disease. Conclusion: For nations with constrained healthcare systems and funds, primary health care (PHC) is the only viable approach for managing non-communicable diseases (NCDs). However, PHC systems intended for infectious diseases have not sufficiently adapted to the growing requirement of chronic care for NCD. Research using health information databases offers numerous benefits, such as the evaluation of large data sets and unexpected prevalence of disease in certain populations, such as a higher prevalence of disease in one gender or age group. Health information system-based data analysis or studies are less expensive and faster but lack scientific control over data collection.


Introduction
Every healthcare system should be able to comprehend the level of care it provides, and consumers should know the quality of care they receive.To meet these demands, both quantitative and qualitative data analysis are essential.The data are used to answer questions related to quality of service, monitor, and facilitate improvement in healthcare, as well as to make recommendations and decisions.We can use the same data in different ways, depending on the type of question we are looking for.The analysis of both quantitative and qualitative data is important for assessing and directing the process of change.Time series analysis is the gold standard for using data for improvement over intervals of time, which requires frequent, small-scale data collection and presentation efforts [1].
The secure and effective transfer of private health information is ensured by placing reliable data management systems in place.Healthcare professionals usually overlook the responsibility of keeping meticulous data and clinical records of patients.Therefore, it is critically important to implement highquality electronic healthcare record applications that can reduce errors caused by poor data-keeping.Medical errors are typically caused by inadequate systems for processing medical data [2].District Health Information Systems (DHIS) became active in Pakistan in 2008.It has been functional since 2009 in Punjab and other provinces.It was established with the aim of improving data quality and analyzing it to encourage evidence-based decision-making [3].
DHIS is monitored, and its data are analyzed for policy guidance by the Ministry of National Health Services Regulation and Coordination.DHIS is now digitalized to promote data flow through a management dashboard.The Pakistan Health Information System dashboard is established at the national level and housed in the Health Planning, System Strengthening, and Information Analysis Unit [4].
Managing pharmacy stock and human resource management, maintaining hospital records, infection control, and data monitoring are some of the functions of health management systems (HMSs).HMSs can help improve health delivery, for example, skilled birth attendance in China was improved, and antenatal and postnatal care was enhanced in Egypt with the help of HMS [5].DHIS was established in Pakistan with the same vision.The objective of our study was to emphasize the importance of a robust mechanism of data management at healthcare centers.A system that keeps patients' records can help to determine the burden on healthcare and evaluate the performance.The study evaluated the DHIS in phase one; both in the form of paper (hard copy) and a digital dashboard.We aimed to determine the efficacy of keeping data when the patients' records are kept in the form of paper or a digital system like DHIS.

Purpose
The study of this data will give an estimate of the burden of patients on the hospital and its capacity to accommodate the patient flow.For this purpose, we will retrospectively determine the number of services gained in the hospital by patients and the number of visitors in each department.It will also emphasize on importance of a robust data-keeping system.

Study setting
Kotli is a district administrative unit in Azad Jammu and Kashmir (AJK) covering an area of 1862 square kilometers with a population of 0.828 million (projected population 2021) which accounts for 19% of the total population of AJK.With a growth rate of 1.69, the population comprises 391,465 men and 436,580 women.There are more than 250 healthcare facilities in the district including basic health units (BHUs) and dispensaries.The burden of patients on healthcare facilities is 2977 patients per facility.The District Headquarters Hospital, Kotli is the only tertiary care facility, so it caters to the majority of first-visit patients in outpatient departments (OPDs) and patients referred from rural health centers, BHUs, and dispensaries [6].

Data
The data set that we are using is the time series data created as the baseline for the DHIS.The permission to access the data was obtained from the concerned authorities before data collection.The DHIS was introduced in Pakistan in 2007-2008 and is functional since 2009-2010.The DHIS in AJK became functional quite late but it is in use now.The system was introduced recently in District Headquarters Kotli and it is in the first phase or a trial phase.The trial phase comprised of keeping data in two forms; first in the form of paper (hard copy) for August and September and the second as a digital copy on the dashboard of DHIS for October and November 2023.

Data collection
The data was provided in the form of hard copies (paper sheets) for August and September while it was given in the form of a comma-separated values (CSV) file on a portable device for October and November (no direct access to the dashboard).For data collection, the relevant information was searched on the official documents provided by the hospital.The record contains data for outpatients of each department including medicine, surgery, pediatrics, dermatology, dentistry, eye, ear, nose throat (ENT), and orthopedics, etc.The details of infectious diseases and communicable diseases like malaria, dengue, tuberculosis (TB), and hepatitis B and C are given separately in the documents.The data is presented in the form of outpatients' department visits (number of patients) and the number of patients attended at each department.The main OPD deals with the segregation of patients into each department.The data is distributed in different ways; the first distribution is in departments; and the second distribution is outdoor and indoor patients.The third distribution is the type of disease diagnosed and the fourth is the distribution on the basis of age groups.The first age group was under one year, the second group was one to four years, and the third group was above five years.About 15 to 49 years is the fourth group and then the 50 years and older age group was the last one.As this was a baseline data entry for DHIS, two methods of data entry were used; one was data entry on hard copy as phase one and the second was data entry on the DHIS dashboard.The data was recorded from hard copies for August and September on an Excel sheet and for October and November was copied in the form of a CSV file and then transported onto an Excel sheet.

Data analysis
The number of patients depicted as the frequency of visits in each department was noted down and stratified against age groups.The maternal, newborn, and child health (MNCH) visits and family planning (FP) visits were evaluated separately.The analysis was done on an Excel sheet as the study did not aim to determine any correlation or associations.The data was described based on records given on the Excel sheet and the graphs were also made on the Excel sheet.Any necessary analysis like sum and average was performed on the Excel sheet.Due to the simple nature of the analysis, no statistical tool was applied.

Results
The data was taken from the DHIS dashboard for four months (August to November 2023) only as the DHIS dashboard is in the initial phase and limited data is available.The frequency of patients attending each department was variable (Figure 1).The emergency department received the highest number of patients followed by the department of medicine.
The detailed distribution of patients is given in Table 1.This gives an overall number of the patients who were attended at each department at the hospital.The frequency is then stratified based on the age of the patients and their gender (Table 1    The highest frequency of the patients was received at the hospital in October and November in the age group of 15 to 49 years.The attendance of males is higher than female patients. The data is stratified based on gender and age in each department for August (Figure 2).The frequency of patients received in each department is stratified based on gender and age for September (Figure 3).The data reported in every department is stratified based on gender and age for October (Figure 4).The patient data gathered for each department is stratified based on gender and age for November (Figure 5).The number of patients diagnosed with a particular disease was noted down in this (Table 2).The most frequent diseases were acute respiratory infection, peptic ulcer disease, and chronic obstructive pulmonary disease (cases of more than 4000 for each diagnosis).These were followed by diarrhea (both <5 and >5 years), asthma, and hypertension (the number of cases ranged between 2000 and 3000).Then comes diabetes mellitus (DM), ischemic heart disease (IHD), scabies, urinary tract infection, dental caries, and pneumonia (cases ranged between 1000 and 2000).Discussing the diseases that need surveillance, 150 viral hepatitis, 155 tuberculosis, and 211 cases of suspected malaria were reported.No cases of AIDS/HIV or acute flaccid paralysis were reported.

Respiratory Diseases
The hospital provides services apart from regular OPD attendance.These are immunization, FP services, maternal and newborn health which includes antenatal visits and mothers' vaccination, tuberculosisdirectly observed treatment (TB-DOTS), and birth and neonatal care (Table 3).The children under 12 months who received their first or third vaccination were 333 and 327, respectively.About 169 women received an anti-tetanus vaccine and 333 children were fully immunized.The hospital facilitated 1066 FP visits, 1356 first antenatal visits, and 632 normal deliveries.The hospital also provides laboratory services (Table 4).
Service provided  The laboratory investigations are done for regular infections as well as for communicable diseases including malaria, tuberculosis, and viral hepatitis.
The patients can be admitted to the hospital as the district headquarters has the facility for indoor admissions and services (Table 5).We could not retrieve data on indoor admissions for September.The occupancy rate was 100% in the pediatric and gynecology ward, >50% in cardiology and surgery, and 70-100% in medicine.The eye and ENT departments had a lower rate of bed occupancy (<50%).
The number of surgical procedures is mentioned in (Table 6).The list of the main diagnoses that became a reason for admission to medical or surgical wards is given in Tables 7, 8 (Appendices).

Discussion
Health system data not only furnish crucial information pertaining to healthcare utilization and expenditure but also provide substantial insights into the patterns of various diseases [7].Health systems exhibit diversity in their performance-based capabilities, which include but are not limited to the provision of essential medications, skilled birth attendance, FP services, antenatal care, and immunization.The importance of management in health systems is well-documented; however, further research is required to determine the precise role of a district as a management unit and health system management at the district level [8].The goal of the current data analysis is to look into the disease burden that the district healthcare unit is responsible for.This medical facility accommodates patients in its OPDs and offers indoor facilities for surgical procedures.Furthermore, it is equipped with a fully operational laboratory and a system for monitoring communicable diseases.Additionally, it provides FP services, antenatal care, and vaccinations for both the mother and child.
Surveys are undertaken on a global scale to estimate disease burden, identify the most prevalent diseases, and analyze disease epidemiology.For instance, the Asia-Pacific region is susceptible to the development of communicable diseases [9], and South Asia faces challenges from preventable ailments (measles, pneumonia, and diarrhea accounted for two-thirds of the roughly 3.7 million child deaths attributed to such causes in 2000).Central Asia has witnessed a 29% increase in new cases of AIDS, with India having the second-highest prevalence of AIDS and HIV [10].Asia-Pacific exhibits a higher prevalence of dengue [11].Over four months, pneumonia was responsible for 14 deaths and diarrhea was responsible for two deaths in our study population.
The global prevalence of hepatitis B is estimated to be 296 million, while hepatitis C has an additional 1.5 million cases [12].hepatitis B virus (HBV) is more prevalent among patients with liver cirrhosis in Asia and Africa (8-61%) compared to Europe, America, and Oceania (3-41%).The co-occurrence of HBV and hepatitis C virus infections exceeds 50% in countries across Asia and Africa.The primary cause of liver cirrhosis [13] is alcohol consumption, which ranges from 0% to 41% in Oceania, 16-78% in Europe, and 17-52% in America.In 2019, 229 million cases of malaria have been documented on a global scale [14].A meta-analysis encompassing research conducted between 2006 and 2021 documented a cumulative incidence of malaria amounting to 23.3% (1.68-99.79%)(19).From 1990 to 2019, the age-standardized incidence rate (ASR) decreased by an average of 0.80% annually [15].According to the WHO, the number of deaths due to malaria reached 409,000 in 2019.Children under five years (67%), pregnant females, and people living in sub-Saharan Africa (94%) and Southeast Asia (3%) were the most vulnerable populations [14].Among the diseases that need surveillance, 150 cases of viral hepatitis, 155 cases of tuberculosis, and 211 cases of suspected malaria were reported in the present data.No cases of AIDS/HIV or acute flaccid paralysis were reported.
The growth in the burden of non-communicable diseases (NCDs) over the past 10 years has created a barrier to development goals such as poverty reduction, human security, economic stability, and health fairness [16].Systemic sclerosis incidence and prevalence have increased globally [17], and multiple chronic diseases are more prevalent among women (28.4%) than among men (25.9%), and the risk increases with age [18].Of the 56.9 million deaths worldwide in 2016, an estimated 40.5 to 2 million were due to NCDs [19].In 2021, two-thirds of the deaths in Southeast Asia will be associated with NCDs.Half of the deaths occurred between 30 and 69 years of age, and cardiovascular diseases accounted for 3.9 million deaths, along with cancer, chronic respiratory diseases, and diabetes.However, there has been inconsistent progress in risk factor reduction and NCD management [20].The medicine department of the District Headquarters Hospital, Kotli, Azad Jammu and Kashmir also receives a large bulk of patients with NCDs.
Low-and middle-income nations account for 70-80% of NDC-related mortality.According to WHO NCD Country Profiles 2014, Pakistan has a double burden of NCDs and communicable diseases, with NCDs accounting for approximately half of all deaths.About 1210 homes in Nurpur Shahan were surveyed; 34.4% of people had high blood pressure or IHD.Smoking, drug use, and alcohol addiction are also risk factors [16].
In a survey in Lahore from 2018-2019, 64.5% of the respondents were women.Of the participants, high blood pressure (40.1%), diabetes (15.8%), and IHD (17.0%) were common, and the risk factors were obesity or overweight (68.8%), prehypertension (37.0%), smoking (13.6%), and alcohol use (1.8%).Age was the most important risk factor; 42.4% were between the ages of 30 and 39 years, and 23.8% were in adults aged 60 years and older [21].High prevalences of peptic ulcer disease, hypertension (HTN), DM, and IHD were reported in the present data.HTN, DM, and IHD cases also needed admission to the medical ward in some instances.
A survey of 10 cities in Pakistan found that approximately 54% of 14,531 children received vaccination, while 14% had received no vaccination.This study highlights the importance of gender equality and access to healthcare [22].According to an audit conducted in 2018, the most common diseases in Pakistan are typhoid fever, measles, tuberculosis, respiratory infections, diarrhea, and hepatitis A, B, and C. Episodes of dengue, malaria, and chikungunya occur in between.Infections of different organ systems and rabies caused by dog bites are also common [8].The United Nations Pakistan reported that diarrhea, malaria, and typhoid fever are constantly increasing in Pakistan, with 44000 cases of malaria reported only in 2022 in the southern province [23].Dengue is a serious issue in Pakistan [24].The present data also exhibited the same trend.Admissions in the medical ward were for the same diseases as mentioned above, particularly diarrhea and pneumonia in children, tuberculosis, viral hepatitis A and E, and DM-related complications in adults.
The dengue cases needed 32 admissions in August, and there were two deaths.
Most of these health conditions are managed by private-sector practitioners, including general physicians and medical specialists [8].Baseline data analysis and a comprehensive understanding of the burden of communicable and NCDs can help formulate effective policies and plans.Pakistan has a huge burden of communicable diseases, and the number is on the rise.Multiple socioeconomic and demographic factors, such as the lack of a well-developed healthcare system, poverty and illiteracy, population pressure, the burden of internally displaced and external migrants, and a lack of prevention strategies, are all factors that enhance the problem [8].Initiatives for global health and development must address socioeconomic and health-sector limitations.The management and treatment of communicable diseases should be independently determined by each nation [25].This study, apart from describing the burden on a healthcare system, also aimed to emphasize the use of DHIS.As mentioned in the methodology section, the DHIS data entry was done manually in the first phase.The details are clearly given in all sections of the DHIS forms for August.But, for September, a section of the data regarding the indoor patient details was missing, which is a sign of a lack of consistency in keeping data.In the second phase, the DHIS dashboard was introduced as an electronic database for healthcare systems.The data for October and November has a lower number of missing values (the data for the number of surgical procedures is missing) as compared to September.This is a sign that a manual data entry system has less compliance, is difficult to use, and is hard to maintain.This analysis encourages the use of electronic databases (DHIS).

Limitations
The DHIS is a novel system in Pakistan.It is actively being used in different health centers in Punjab and other provinces.Kotli is a small district in AJK, Pakistan, and it has recently adopted the DHIS.There are still certain limitations to the data, like a lack of consistency in the process, i.e., consistency in the records updated and delicate details in certain parts of DHIS.There is a lack of interest in maintaining data on the dashboard and the hospital staff probably does not realize the importance of a well-established electronic database (which is visible in the form of missing values in certain areas of DHIS).At this point, DHIS data from district Kotli is insufficient to provide a detailed picture of the burden on the healthcare system and the improvement in providing services over time.

Conclusions
For nations with constrained healthcare systems and funds, primary health care (PHC) is the only viable approach for managing NCDs.However, PHC systems intended for infectious diseases have not sufficiently adapted to the growing requirement of chronic care for NCD.Research using health information databases offers numerous benefits, such as the evaluation of large data sets and unexpected prevalence of disease in certain populations, such as a higher prevalence of disease in one gender or age group.Health information system-based data analysis or studies are less expensive and faster but lack scientific control over data collection.

FIGURE 1 :
FIGURE 1: Frequency of patients who attended each department from August 2023 to November 2023 ENT: Ear, nose, throat

FIGURE 2 :
FIGURE 2: Stratification of patients according to department, gender, and age in August 2023 ENT: Ear, nose, throat

FIGURE 3 :
FIGURE 3: Stratification of patients according to department, gender, and age in September 2023 ENT: Ear, nose, throat

FIGURE 4 :
FIGURE 4: Stratification of patients according to department, gender, and age in October 2023 ENT: Ear, nose, throat

FIGURE 5 :
FIGURE 5: Stratification of patients according to department, gender, and age in November 2023 ENT: Ear, nose, throat

10 Family
observed treatment (TB-DOTS) (from TB card TB-01) 1 Intensive-phase TB-DOTS patients 0 19 planning (FP) services/commodities provided (from FP register) and newborn health (from maternal health and obstetric registers) 1 First antenatal care visits (ANC-1) in the facility 291

TABLE 1 : Outpatient department attendance in each department at the District Headquarter Hospital
ENT: Ear, nose, throat

TABLE 2 : Distribution of patients' frequency based on diagnosis established in each patient
ENT: Ear, nose, throat

TABLE 8 : Main diagnosis in patients admitted to the surgical ward
CVA: Cerebrovascular accident; DNS: Deviated nasal septum; ENT: Ear, nose, throat