Public Health Care Database

2016 International Innovations Awards submission
County Medical Office of Health St. Andrew/St. David, Ministry of Health, Trinidad and Tobago


INTRODUCTION

In the Republic of Trinidad and Tobago, the Ministry of Health is the national authority charged with oversight of the entire health care system. The prevention of diseases, diagnoses, treatment of illnesses and injuries in human beings form the subject matter of health care. Health care delivery includes providing primary, secondary and tertiary health care. The Public Health Department (PHD) is an agent of primary health care. This is the basic first level of contact between the community and the health system.

The administration of health care services in Trinidad and Tobago is decentralised geographically into regional health authorities. The Eastern Regional Health Authority (ERHA) assumes responsibility for two Counties on the island: St. Andrew/ St. David and Nariva/Mayaro. The PHD falls under the jurisdiction of the County Medical Officer of Health St. Andrew/ St. David, and is responsible for a variety of duties including but not limited to:
  • Registration of food premises, which entails inspection and monitoring for compliance in accordance with the Public Health Ordinance
  • Registration of food handlers including fixed and itinerant vendors
  • Routine food sampling
  • Routine water sampling
  • Ante and post mortem meat inspections
  • Processing applications to vend over-the-counter-drugs
  • Investigation of environmental complaints received at office from members of the public and referred from the Ombudsman, the MOH and the Municipal Authority
  • Processing of water applications from the Water and Sewerage Authority
  • Investigation of infectious and vector-borne diseases – dengue, leptospirosis, H1N1, chikungunya, cholera, salmonellosis, shigellosis, etc.
  • Vector control
  • Inspection of public buildings including schools, disaster shelters, market places,  etc.
  • Health education campaigns
  • Prosecution of matters under the Public Health Ordinance, Litter Act, Yellow Fever  Regulations.
  • Inspection of funeral parlours/crematoriums
  • Inspection of beauty salons, tattoo parlours and body piercing shops
  • Routine farm inspections
  • Processing of building plans referred from the Municipal Authority
  • Advising external agencies on public health hatters
The Public Health Ordinance (PHO) requires food handlers and food premises to be registered by the 31st of March annually with the Local Health Authority. This process involves submitting an information profile as scheduled by the PHO. The yearly submission of these schedules floods public health offices throughout the country each year. County St. Andrew/St. David registered 2725 food handlers last year and 812 food premises. Under the PHO each food handler submits an application for the registration of premises and the registration of the food handler. Certificates and badges are awarded if the food handler or food premises meets the requirements for certification.

Conducting business at a typical government office usually conjures up images of long lines as clerical staff record and look up information in large tomes or registers. Prior to the implementation of the new system this was a close portrayal of daily experience. Registering a food business with ten employees could take approximately thirty minutes at the front desk as details for the premises and every employee was recorded firstly on application forms, payment slips and then into the office registers. The genesis of the database was to significantly reduce the time spent by clients at the counter when registering food handlers and or food premises.

THE PUBLIC HEALTH DEPARTMENT COUNTY ST. ANDREW/ST. DAVID CLIENT DATABASE

Goal: To improve departmental efficiency and client satisfaction.

Objectives:
  • Reduce the length of time to process clients registering yearly
  • Minimize inaccuracies in information for certification
  • Eliminate file duplication
  • Remove information loss resulting from lacking physical copies of client information
  • Reduce physical storage space necessary for PHD data
  • Facilitate data generation and tabulation for reports
  • Minimize the repetitiveness of reporting across multiple agencies
  • Produce reports in “real time”
  • Secure sensitive data
  •  Improve the ability of management to determine the status of multiple Public Health activities  and evaluate performance
According to Laudon and Laudon in their book Management Information Systems: A Contemporary Perspective, an information system is “a set of procedures that collects (or retrieves), processes, stores, and disseminates information to support decision making and control”. The St. Andrew/St. David Client database primarily functions as a transaction processing system, which simply records the routine transactions needed to conduct day-to-day business.

Data is entered into the system via the client service counter where the administrative aspect of the department occurs. Various types of applications are registered in the system and disseminated to the relevant Public Health Inspectors (PHI). The PHI then investigates and inputs electronic reports. For example, a food handler may apply for registration of his food premises and his application is placed into the database. Then, the PHI subsequently submit a report after their inspection of said premises saying whether or not it is recommended for approval and on what grounds. Upon logging into the system it alerts you about what is new, as well as if you have outstanding reports. In addition to processing data related to everyday department transaction the database can be used to facilitate planning and decision-making. It can be filtered by key fields to determine trends, highlight locals of public health significance and other demographical data from clients.

DEVELOPMENT

On 4 September 2012, Dr Mark Dookeran PhD, Food Science and Technology assumed duties as Public Health Inspector III of the Public Health Department County St. Andrew/St. David.  During discussions with Mr Raughn Gordon, Public Health Inspector II (Food Safety), the idea of a computerised registration process for the various activities at the Public Health Department began. Despite the lack of technical personnel, the development process maintained fundamental elements of developing a database management system.

1. Analysis - Model the application from the perspective of the real world
Mr Gordon recognised that the majority of clients and their specifics remained the same each year. The PHO set the required information fields, which have several schedules attached and did not change. If this information had been previously stored, clients could simply confirm that no changes have been made rather than having to resubmit information, thereby cutting the registration time. Information was also stored in multiple registers resulting in duplication, which caused difficulty when attempting to retrieve information. Mr Gordon envisioned a transaction process similar to that of a bank, while Dr Dookeran imagined an office where information was available “at your fingertips”.

2. Design - Decide how to build the application from the analysis
At this point neither officer was exactly sure how the initiative would be accomplished, as the department did not have the required technical expertise to facilitate a project of this nature. However, the decision was made to begin computerising data in County St. Andrew/St. David. To this end, the Public Health Inspector III requested additional clerical staff to assist the department, and Mr Raymond Charles - Temporary Clerical Officer was assigned to the department. He began the development of what is currently  the Public Health Inspectorate County St. Andrew/St. David Client Database, otherwise known as “the database”. 

3.  Implementation - Write the actual database and programming code
Development began using the Microsoft Excel program but was quickly switched to Microsoft Access as it was better suited for data manipulation. Despite his lack of technical knowledge, Mr Charles acquired and read the book “Databases for Dummies” from the popular “...for dummies” series. Utilising the coding languages Visual Basic for Applications (VBA) and Structured Query Language (SQL), he was able to begin structuring the database focusing on food handlers and food premises.

4.  Data conversion - Populate the application database with available data
Data was entered manually from the office filing system, via reports from the desks of the Public Health Inspectors and also retrieved live as customers came to the front desk on a daily basis. This was a tedious process that was facilitated by an on-the-job trainee from the then Ministry of Science and Technology. The manual process revealed several duplicate files and errors in the data that was originally captured.

5.  Testing - Ensure that the application is suitable for actual use
The initial version of the constructed database did not pass alpha testing when rolled out in December 2012 and had to be scrapped. This preliminary process was not easily executed at the counter and had to be completely recoded. A second version was created in February 2013, and when alpha testing was successful the initiative proceeded to beta testing using staff members at the department. Once this was successful, the database was launched and has been continuously upgraded as end users in the department detect flaws and suggest improvements. Other service components of the Public Health Department such as environmental complaints, water connection applications, and dengue case investigations will be added later on.

6.  Training - Help users master the new application
Training was conducted in two parts; a tutorial session was held for clerical staff, and a separate session for the technical staff. Following the sessions, staff were introduced to the system and given sample data to enter and manipulate. The integration was successful, and even members who were not computer literate were able to navigate the database via the switchboard that has been set up as a user interface.

7.  Maintenance - Preserve the soundness of the application over the long term
The database is now part of everyday life at the office and the system’s information is archived at the end of every calendar year. Archival is necessary to avoid clutter and slowing of processing speeds. The system itself is stored on a server housed at the Information System/Information Technology department of the ERHA.

RESULTS

As previously mentioned this project was originally geared towards improving service management, however, the final results have exceeded original expectations and include:
  • Prior to implementation of the system, a client who had 10-15 staff could spend approximately 30 minutes filling out the necessary documents in triplicate to register the company and employees. This has been reduced to a period of less than 10 minutes. 
  • Due to its ability to auto correct errors, the system minimises inaccuracies in information and has almost completely eliminated file duplication.
  • Information is backed up on a server and therefore can always be retrieved.
  • Many files are no longer physically stored but exist in softcopy only.
  • System alerts can assist staff in providing timely report submissions and meeting important deadlines.
  • Information can be automatically generated for reporting and analysis in various formats, and duplicates are easily produced for dissemination and to update clients.
  • The database is completely password protected. Unlimited access is only granted to senior  staff.
  • The Department head has a complete view of the activity status in the county, similar to that of a marketing dashboard in corporate environments.
  • The office no longer has the volume of clients visiting on an “office day” for updates on their issues. This has decreased as status updates can be easily retrieved from the system with or without the presence of an officer. 

OBSTACLES TO IMPLEMENTATION
  • Aside from having a specific goal, there was little formality and structure in the project development. It started as a discussion between two senior Public Health Inspectors (PHIs) and evolved into what it is today. At the time of the initial discussions, there were only four desktop units in the department. This proved challenging as the units would be necessary to input data at the counter and from the desks of individual PHIs. Fortunately, the department was already carded to receive desktop computers for all PHIs. This was eventually fulfilled by the MOH and and two additional computers were received from the ERHA to use at the front desk.
  • It goes without saying that this project would have been greatly facilitated by expert input. Looking back as a department, special mention must be made of Mr Raymond Charles who is still employed as temporary clerical officer. Mr Charles had understood that he was being sent to the Public Health Department to do data entry. Realising upon his arrival that there was no system in which to enter the data, he proceeded to build one by teaching himself to code.
  • This system has significantly impacted the culture of the department and not all members of staff bought into the idea initially. The database represented a great change that had to be managed  by senior staff in the department. Not all members of the department were computer literate, therefore they were understandably concerned about their ability to use the new system. Mr Charles conducted training sessions to acquaint the staff with the new system and resistance was gradually overcome as the staff began to realize its benefits.

EVALUATION

The system has not been formally evaluated. It is considered to be in a state of beta testing whereby feedback from the department is still used to make alterations and/or upgrades to the system on a continuous basis. The Quality Department of the ERHA has examined the system and is exploring the potential for applying it to other departments such as the casualty area at the Sangre Grande Hospital, as well as to link it to the ERHA’s Geographic Information System located in the Public Health Observatory. The database is at a stage where the potential of this system and how it can impact other areas is still being explored. Many of our clients have expressed pleasure with the new and faster system.


OPPORTUNITIES
  • With the advent of the Zika virus in the region, the Public Health Inspectorate County STAD began planning for an aggressive campaign to prevent the possibility of a county outbreak. Recognizing pregnant women as a vulnerable population, the database is being used to identify geographical clusters of potential mothers and help identify insanitary areas to be targeted for intervention and treatment. It has similarly been used to target areas for specific Health Education Campaigns.
  • “Going Green”- The database has of course significantly reduced the amount of paper used within the department, and every day the ideal of going completely “paperless” seems more and more attainable.
  • There is potential for the database to be used in other departments. By linking more areas within the organisation, the highly structured information provided by these systems could enable managers to better evaluate the outputs and performance. It may also help target service gaps and other internal errors.
  • At present, Public Health Inspectors who are field officers are only able to update the system at the office. However, the system has potential for remote accessibility. This would mean Inspectors could complete and submit updated reports while conducting inspections in the field without returning to base.
  • In addition to the ERHA, several other counties are interested in the possibility of replicating the system. This would not only provide greater uniformity in national reporting but could potentially give relevant authorities in the centralised Ministry of Health immediate access to nationwide public health statistical data.
  • The database can be used for disease surveillance, which involves monitoring disease spread in order to establish patterns of progression, and predict, observe and minimize the harm caused by outbreak, epidemic and pandemic situations. With the outbreak of any disease, health care professionals are primarily concerned with breaking transmission of the disease. Information is crucial here in being able to identify the case, map the progression of the disease and target vulnerable areas, which will play an important role in being able to manage outbreaks.
CONCLUSION

This has been an incredible journey for the staff of the Public Health Department and successes of the system continues to motive them to find new uses, applications and ways in which it could improve. Management of Information Systems and Database Management is a popular concept in today’s corporate world. Retail giants such as Walmart and Target are using information systems for everything, from online shopping to marketing campaigns. Statisticians are able to predict consumer behaviour/lifestyle based on observing data collected from how customers shop (Lubin, Gus 2012). With each new disease outbreak worldwide, health officials continue to seek innovative means of breaking transmission and preventing the spread of these diseases in mankind. County St. Andrew/St. David has just scratched the surface of a concept that if explored may have potential to meaningfully impact disease control and the way health services are administered in this country.
REFERENCES

Laudon, Kenneth C., and Jane P. Laudon. Management Information Systems: A  Contemporary Perspective. New York: Macmillan Pub., 1991.

Lubin, Gus. “The Incredible Story Of How Target Exposed A Teen Girl’s Pregnancy.” Business Insider. Business Insider, Inc, 16 Feb. 2012. Web. 12 Mar. 2016.