Improvement axes identification for the components and the information flow of a hospital information system: A case Study

— Hospital Information System is the most fragile component of the health care system in the countries in development process. The modernization of the health care system does not integrate a rigid reflection on the installation of these tools into the hospital, which remain foreign with the strategies of these countries. This article aims at studying the case of a hospital Information system by schematizing the distribution of its components as well as its flow of information in the form of two complementary cartographies, a functional cartography and an information flow cartography, so this study's main objective is to reveal the axes of improvement of this system, by studying it, while focusing themselves on the transfer of information in the hospital institution which is the object of our study, to demonstrate this objective we have developed rich and flexible scenarios in the form of flowchart, that can also incorporate descriptions of users and their current and potential use of the information system. The formalization of the cartographies, in our case, enters in an improvement approach of the information system.

The best mode of answer to our principal question seemed to us to be pedagogical tool, of use simple and not very consuming time. This device was to make it possible to carry out both a diagnosis of the situation of the HIS. To have a complete view of the system and its components, we had recourse to the discussions with the IT staff, so we could make visits to the various services, which are using the HIS (laboratory, pharmacy, admission office) To carry out the questionnaire of defining and diagnosing the system, we took as a starting point a diagnosis tool of the maturity of information systems [2], this tool is aimed at managers of medical-social institutions and services, who are managing one or more establishments/services. It can allow them:  To analyse in an autonomous way maturity of their Information system current (level of cover, use, level of satisfaction)  To obtain a first vision prioritized of the projects IS to carry out  To evaluate the capacity to deploy a project IS For the information sheets, we based ourselves on questions defining the functionalities of the modules of the system, as well as on the interactions [6] between the different modules and the type of information exchanged.

A. Presentation of the studied HIS: Definition and diagnostic of the information system hospital of the hospital institution
The collection of knowledge and information is carried out based on individual and collective interviews at the university hospital center. We have analysed the system to identify changes and improvements.
The definition in Table I and the diagnostic in Table II of the HIS of the university hospital center were made by referring to the persons in charge of informatics and statistical department, with the aim of determining the characteristics and the general information of the system and to provide information on its state and its maturity. Table I gathers information defining the information system, in terms of objectives, components, and the functional perimeter...

Features / General
Under which objectives did you make the decision to implement the HIS?
Computerization of the circuit of the patient since his admission in the center to its exit for better guaranteeing a traceability of information and a continuity of the care and thus to have a structured, interoperable and homologated computerized patient record. How long has the HIS been in the implementation phase? We estimate less than two years The following table provides a general diagnosis of the state of the existing HIS and its level of maturity, the answers to the questions presented below, gave us ideas on the nature of the questions to pose, staff to be questioned, possible sources of information, and ideas about encountered problems of the system ...; All this to bring out the necessary information concerning the components of the system.

Yes
Has the formations been the object of an evaluation? Yes Is the ergonomics of the tool satisfactory?
Yes, but few of the functions are concerned with an improvement of ergonomics Has the added-value of the tool to the work conditions of the professionals medical and others been noted? Yes Has the contribution of the tool to the optimization of the overall process of the assumption of responsibility of the patient been noted?

Yes
Which is the level of use of the deployed tool? (number of actors using the system on the full number of actors concerned) The tool is used almost systematically Are a functional or / and technical abnormalities persistent? Yes, blocking anomalies persist What are the problems or the failures already met on the level of the HIS and its components?
1) Functionality not adapted to the context of Hospital center, it was necessary to remodel the business part e.g. Billing module.
2) The application of the HIS is in foreign language and this presents a problem during the seizure of information for the staff of the hospital and at the time of the resolution of the problems by staff of the IT department.
3) The HIS conceived by the editor is not adapted to the volume of the hospital center, because it was developed for the smaller hospital institutions. Presentation of the sample In order to map the existing information system, by putting first the interactions between its modules, an information sheet on each module was disseminated to the IT and statistical service staff. These information sheets have the same questions for the various modules, each technician or engineer filled us the card of the module which it pilots. Table III summarizes some information that defines each module. This information is gathered using the fact sheets presenting the following questions (two types of questions, open and with choices):  General objective of design of the module (reason to be designed);  Principal features of the module;  Users & beneficiaries of the module;  Contributions (the output data of this module will be used for what?);  Module and upstream processes (What modules that provide their output elements to be used as input data for this module?);  Input data (information sheets, reports, results);  Modules and downstream processes (What modules that will use the resulting output of this module as input data?);  Output data (information, forms, reports, results);  Observations and areas of progress (concerning module);  What problems have already been encountered in the HIS and its components?  Table IV and V present the problems and difficulties [8] pronounced by IT staff (during our study, by our own observations, and by responses from the pilots of the HIS modules), the problems are distributed on three levels [9], for each module presenting failures, the levels are the following:  The strategic level, which corresponds to design problems;  The tactical level that corresponds to the network use;  Operational level which relates to piloting.

Foreign language
It remains to be mentioned that all the information system application is in foreign language (Spanish), so the operational problem in relation to the language used, is a problem present for all modules.
Our returns on the state of the computer equipment or IT infrastructure of the hospital are generally negative, The IT staff confirms that the number of computers, printers and means of communication (Tel, Fax) is weak compared to the need and the number of the users and staff of the hospital, and the estimate of the needs about server has not been solid because server capacity does not fully meet the requirements and volume of the hospital being studied. Despite all this we can't propose improvements in this regard, because we have not done a detailed study (statistics, which lists the number of each equipment), which will enable us to highlight action plans directly affecting the system infrastructure. Then our contribution will be on the functional level of the information system, and not directly on the physical architecture level.

III. RESULTS PRESENTATION
Considering the information sheets of the various system modules, we have schematized the information system, what enabled us to reveal the connections between the modules, and to create a unified diagram, which considers the interactions between the various modules constituting the existing HIS. Those are two functional cartographies, describing the structuring of the information system into communicating functional blocks (first the existing system Fig.1, then the target system Fig.2 (after a reorganization of the existing system, a posteriori analysis and specification)), that's means the modules allowing to support business processes, by taking into account the dynamics of the processes, so that at the end having a cartography of flow of information (Fig.3) presenting the entries and the outputs of each module. Therefore, our goal is to present mesoscopic [9] cartographies and scenarios which incorporate the entities in the form of packages and constitutes an intermediate level between the macroscopic one and the microscopic one. Finally, it is to note that we realized these schemas using Edraw Max software (diagram software that makes it possible to create flow diagrams, network diagrams, building plans, scientific illustrations, UML diagrams, workflows, Directional maps and database diagram.).
We have demonstrated our work by presenting possible scenarios in an easy form to read, consisting of multiple steps, for our case those scenarios are constituted by several activities describing their steps without considering the time notion, to define those scenarios we used to present them into flowcharts of our final Information system. We preferred to build our scenarios in a form of flowchart, which is easy to follow and it's more representative, and this is the main objective of a scenario, as mentioned by Carroll [5] as definition: "The defining property of a scenario is that it projects a concrete description of activities that the user engages in when performing a specific task, a description sufficiently detailed so that design implications can be inferred and reasoned about. Using scenarios in system development helps keep the future use of the envisioned system in view as the system is designed and implemented; it makes use concrete -which makes it easier to discuss use and to design use." We have built our scenarios, as shown in Fig.4 to 12 based on the cartographies, questionnaires and our proper experience inside the Hospital.
The table below presents a reading key for all the schemas (cartographies and scenarios).

IV. ANALYSIS AND RESULTS DISCUSSION
Whatever the studied models, that they act of applications dedicated to a problem given on the HIS or of an overall methodology, the design and the piloting of the HIS consist in determining the structure and the means which compose it, i.e., of making an analysis and specification, it is what we adopted like method at the time of our study.
Among the internal components of the existing HIS, as shown in Fig. 1 and of any system the database layer consisting of a database management system. This layer allows the access and the storage of the necessary data to the tools belonging to the different layers of the environment. Our contribution on this level is related to the exploitation of the database, we know all that information untreated does not have any sense, it is for that we thought to add two modules: module of continuous improvement and module Indicators OLAP and decision making.
Table VII presents the components added or modified in the functional cartography of the target HIS, as shown in Fig. 2, these components are presented in the same way as the modules grouped previously in Table III, presenting the module, its design objective, Its features or functionality, the users and its contributions for the HIS and the hospital institution. The HIS changes can be grouped into 4 themes:  A different structure: in addition to the old distribution of modules, we will have a subsystem made up of the modules dedicated to the assumption of responsibility of the patient, and another subsystem made up of modules dedicated to the evolution of the management systems;  Introduction of new technologies: Intranet, virtual boxes for ideas and for claims ... use of a pneumatic system for the distribution of medicines, balance sheets or analyzes (HIS flowchart with information flow);  A search for rationalization of flows: no unit of care will be present among the medical-technical modules;  A different management of evolution: with the introduction of new rules of management like the modules of evolution.
Speaking of the maturity level of the existing information system, and since we are based on the "ANAP" guide [2], for the design of our questionnaire, Linked to the general diagnosis and maturity level of the system, we must say that according to the five maturity levels defined by ANAP [1], as shown in Table VIII , The existing HIS is in the third maturity level, Because at this level practices are standardized and adapted with mastery of the internal repository as well as a centralization of knowledge and practices where the organization has a strategic plan as well as a planning of the process improvements.
Speaking now of the HIS after modification and improvement we can conclude that the latter can be at the 4th level of maturity, because using the new system the organization will be able to measure qualitatively and quantitatively the objectives of the project and to adjust them. The general objectives of accompanying adapted to the context and the accepted population are not formalized Level 2 The general objectives are specified and broken down into operational objectives at the structural level Level 3 The operational objectives give rise to an action plan implemented at the structural level Level 4 A policy of continuous improvement is organized and implemented (multidisciplinary analysis of the actions implemented and improvement plan deployed) Level 5 The impact of the policy of continuous improvement of benefits is identified and measured From another point of view of the WHO [11] and per the Capability Maturity Model (CMM), the maturity level found for the existing HIS can be parallel to Level 3 of the CMM, which is the level defined where the process is defined/confirmed as a standard business process, as well as the HIS level after modification can be parallel to level 4, which is Managed, this level when the process is managed per the metrics described in level 3, that is, data collection and analysis.
According to the two functional cartographies we can say that the detailed analysis of the results shows that existing cartography (Fig.1) is not satisfactory from an organizational point of view because it does not make it possible to view the connections between the modules, which can cause communication problems. Indeed, the organization of the existing HIS required the distribution of the modules in the form of packs for better visibility and to form solid links between the modules and sub-systems of the HIS.
Target cartography (Fig.2) of the HIS makes it possible to obtain a 100% rate of interaction between the units (unit of the care, unit of supports and unit of management), 100% of the orders and flows are assured, while allowing the maximum of connections between modules, to get closer to the reality of the hospital institution (which is a complex socio-technical system). In addition, the new cartography makes it possible to ensure a positive evolution and an improvement of the HIS, by exploiting the database (which did not have outputs for the existing HIS).
The third cartography, of information flows (Fig.3), is made while being based on the functional cartography of the target system, to have a general sight which gathers the various components of the existing system, besides the components added or modified in the second cartography.
Our goal was, thereby, to develop rich and flexible scenarios and concepts that can incorporate descriptions of users and their current and potential use of the information system. As a schematic description of what users do and experience when using this system, scenarios are such rich description of the human activities that can augment the comprehension of the system and present a simple demonstration of our work, the scenarios above ( Fig.4 to 12), in the form of flowchart, were developed based on the cartography of information flows of the new HIS and the most frequently encountered task lists of the system.
Finally, we should say that this system must be technically approved, that is why we intend in future work to make an application of the latter, to ensure the smooth functioning of the improvements made.

V. CONCLUSION AND FUTURE WORK
The system that we studied at the time of this research allows the automation of the statement of the constants and of the care; it is a little an improved "placard". The use of this system by the staff, contributes to the improvement of the quality of the care by influencing certain factors like the security, the efficiency, the saving of time. It is possible to computerize the care process, planning care, always with the aim of improving the quality of care, this also saves time and increases safety, but this type of system allows the collection of precise and reliable information on the activities of hospitals. The computerization of the care approach, of the care planning, the transitions will thereby play a primordial role in the evaluation of the practices of the hospital institutions and thus on the improvement of the care quality. Improving the quality of care does not only depend on its assessment but also on a regular contribution of knowledge, a handing-over in question. The best way to reach this is to be able to consult databases quickly, to be able to exchange on the practices (What is done elsewhere, what are the consequences). A tool is at our disposal; it is well-sure the Internet network. There too experiments developed: Sites appeared, of the hospitals installed connections to Internet in the care rooms especially for medical staff. But everything remains to be done so that all the staff can get the best part from it (whether in training or in practice), we also speak about the Intranet which allows a more evolutionary communication and in real time more than the tools classic (e-mail). A new tool is at our disposal, it's to us to use it as efficiently as possible and to set its limits.