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Hospital Management Information Systems in Health Sector and

Development in Turkey

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Year: 2017
Journal of Current Researches
on Health Sector
Volume: 7
(J o C R e H e S)
Issue: 1 www.stracademy.com/jocheres
ISSN: 2547-9636

Hospital Management Information Systems in Health Sector and

Development in Turkey
Demokaan DEMİREL1
Keywords Abstract
Health Sector, Information systems play an important role in the production, sharing, storage and
Information transmission of information in various fields. Hospital information management
System, Hospital systems used in the health sector actively meet the needs of physicians,
Information administrators, and patients in institutional processes. Hospital information
Management management systems ensure that data are collected in a correct, complete and
System,
interdependent manner. Hospital information management systems started to be
Institutional
Efficiency, used in the 1960s. These systems can be classified as integrated and modular
Turkey. systems. Integrated information systems are divided into hospital general
information system, clinical information systems, management information system,
and a database management system. In another classification, hospital management
information systems are seen to include resource utilization and programming,
financial management, materials and facility management and staff management
systems. Hospital management information systems have purposes such as
providing patient satisfaction, strengthening internal communication networks,
reducing costs, and reliably storing data in a digital environment. The development
of hospital information management systems in Turkey is based on the Health
Information Systems Project, which was supported by the World Bank in 1990 and
conducted by the Ministry of Health. The use of hospital information systems in
health institutions has become increasingly widespread with the studies conducted
under the leadership and coordination of the Ministry of Health after 2000 years.
The purpose of this study is to evaluate the development and functions of the
hospital information management systems in the health sector by acting from the
Article History Turkish case. The study first examined the development and types of hospital
Received information management systems. The purposes of the usage and benefits of these
1 June, 2016 systems have been referred to the study. In the second part of the study, the
Accepted development and components of hospital management information systems in
10 June, 2016 Turkey are evaluated.

1. Introduction
The conditions that enable global competition in the information society are the
development of communication technologies and the importance of the
administrative information flows and the inter-institutional communication
networks. Therefore, more emphasis is placed on information systems in the

1Corresponding Author. Asist. Prof. Dr., Ömer Halisdemir University, Faculty of Economy and
Administrative Sciences, Public Administration Department, demokaand@gmail.com
competitive presentation of public services. Information systems are one of the
means by which public institutions can save economic indicators, such as time and
cost. Since the 1960s, the use of information systems in the health sector has
become widespread. Health care is a priority in ensuring the social well-being and
protecting the public interest. Especially in the presentation of preventive and
curative health services, it is seen those information systems to provide greater
convenience to patients and physicians through an electronic database. The role
and importance of information systems in the health sector have increased in an
intra-institutional correspondence, the supply of materials, and in-house and inter-
institutional information transfers to health care staff. Information systems clearly
show the results of institutional performance of healthcare institutions in the
sector as well as disease statistics. It is possible to make various determinations of
the data provided by the information systems about the success rate of the
institutional service delivery.
Hospital management information systems provide an institutional framework
consisting of different information about the medical, financial and managerial
functions of a particular hospital. The first applications of these systems are
limited to, the recording of patient information and the billing of health services
offered. Today, new modules have been added to patient management information
systems such as appointment over the internet, follow-up patients, and request
analysis and display results. Thus, it has become possible for doctors to transmit
their requests directly to the laboratories via automation systems and to monitor
the results online. In this respect, the main problem of the study is to define the
role of hospital management information systems within the functional context.
The purpose of the study is to evaluate the development in Turkey qualitatively by
setting out the importance and advantages of the hospital management
information systems in the health sector. In the first part of the study, the
development and types of hospital management information systems are
discussed. It is revealed how the system has followed a developmental line from
the 1960s to the present day. In addition, sub-systems covered by hospital
management information systems are addressed. In the second part, the purpose
of hospital management information systems in health institutions is explained.
The benefits provided by the management information systems in the health
sector are explained. The last part of the study examines the studies on the use and
development of hospital management information systems in Turkey. It is depicted
how the Health Information Systems Project, initiated by the Ministry of Health
initiatives in the 1990s, has been developed with the works of 2000 and later. The
basic components of hospital management information systems used in Turkey are
also mentioned.
2. Development and Types of Hospital Information Management Systems
Information systems include all the expert workforce, computer networks, system
models and system information required to perform various functions such as
collection, processing, storage, access and distribution of information. It is possible
to see information systems as systems that aim to provide accurate, up-to-date
information where and when they are needed (Bengshir, 1996: 14). The
performance of information management systems is closely linked to the current

38 Demirel, D. (2017). Hospital Management Information Systems in Health Sector and

Development in Turkey
features of the software, hardware, and data. Data collected, stored and analyzed in
information management systems are evaluated according to criteria such as
certainty, up-to-datedness, reliability, and being unnecessary. As much as possible
in the planning of information systems in public administration, the requirements
of vertical and horizontal hierarchical levels in the public organizations should be
estimated. Information management systems in the public sector are used to
monitor the environment and to take into account the interaction of external
factors with each other and with public authorities (Bozeman and Bretschneider,
1986: 481-483). The Hospital Information Management System is a system that
hospitals collect and process all necessary information is processed and collected
through computers about health care services and management. This information
can be transferred between the units via the automation system in the electronic
environment. It plays integrating role different information that emerges in terms
of medical, financial and management functions of the hospital (Akkoç, 2009: 33).
The hospital information management system is an institutional resource planning
system that has been privatized and increased in quality according to the needs of
the health sector (Özoğul, Karsak, Tolga, 2009: 2093).
Hospital information management systems keep a lot of data because hospitals
have so many functions. In this type of system, there is a wide variety of
information available from the workforce used by the patient to what the staff can
make or do in order to follow the functioning of the hospital and facilitate
administrative tasks (Saka, 2003: 64-67). The system provides feedbacks on
patient care processes for hospitals. It reminds us of the necessary tasks to
perform and allows us to develop a diagnosis and treatment protocol that can be
applied to a special patient (Yılmaz and Aloğlu, 2002: 335).
First-generation hospital information management systems were first developed
in the 1960s and ended in the 1970s. In 1972, the first hospital information
management system was used the El Camino Hospital in California. This system
only provided request inputs and result reporting services. It did not provide
emergency and outpatient services. In this process, computers have changed from
single-tasking hosts to multi- tasking, user-friendly computers. Besides, along with
other factors such as economic developments and increased data manipulation
have led to the development of hospital information management systems.
Information management systems developed during this period include some
patient care topics and basically the automation of patient medical records. The
second generation hospital management information systems emerged in the mid-
1970s and ended in the late 1970s. In this period, hospitals are focused on the use
of financial systems and financial problems. The main purpose of the system is to
transfer information from the end user to financial systems. During this period,
interest in patient care has increased. By bringing together information from
different clinics, integrated patient care information files have been transferred to
computers (Ball, 2003: 89; Dağlı, 2011: 9-10).
Third generation hospital information management systems began in the late
1970s. This phase was under the influence of the introduced database technology
at the beginning of the 1980's and focused on problems such as patient care
planning, laboratory, and pharmacy issues. Fourth generation practices began at

Journal of Current Researches on Health Sector, 2017, 7 (1), 37-50. 39

the beginning of the 1980s. An important feature of this period is that it integrates
with third party systems, including financial and other departmental systems.
Providing all the needs of a single firm is the basic feature of this phase. Hospitals
have adopted the best practice or a software procurement strategy available in the
market for private clinics. In 1990, investments in hospital information
management systems projects increased, along with the cheapness of computers.
Information systems have been used more extensively as the proportion of
computer ownership of health care providers has increased. In 1991, the Institute
of Medicine published the report "Computer-Based Patient Records: Essential
Technologies in Health Care". This report concerns the problems caused by paper-
based records and encouraged the use of electronic patient records. In addition,
the report pointed out the importance of the doctors in the system and stated that
the focal point of the system should be patient (Dağlı, 2011: 9-10; Ball, 2003: 83-
89). After the 2000s, patient safety, reduction of medical errors and an increase in
health care quality became the priority in the system. Broadband internet access,
smaller and more portable devices, wireless technologies and radio-frequency
identification tools have been used as important technological tools in the
healthcare industry (Dağlı, 2011: 10). Today, electronic health record systems are
among the most basic applications of the health sector.
A patient index is registered at the base of the hospital management information
system. All transactions are done using this index. The patient index consists of the
patient's name and surname, date of birth, gender, address, second name, marital
status, mother and father's name, allergic reaction information and name and
phone information for emergency situations (Murphy, 1996: 586). Once the
patient enters the system with patient acceptance, he is transferred to the relevant
compartment and comes out of the system as a discharge after the treatment
period. These systems process different patient information in hospital
management. It conducts out-of-hospital communication on issues such as
procurement and finance. It functions as medical departments and services in
patient care (Reichertz, 2006: 286-289).
Hospital information management systems can be classified as integrated and
modular systems. All information system functions are carried out together with
the integrated information systems. Integrated information systems are divided
into hospital general information system, clinical information systems,
management information system, and a database management system. The
hospital general information system sets up on- line information systems for the
entire hospital. The clinical information systems allow medical interpretation and
processing of medical data in the context of diagnosis and treatment. The
management information system is the processing and storage of the data needed
to help management units on decision making, planning, and auditing functions.
The database management system carries out storage of a large number of related
data in a general format. The modular systems, on the other hand, involve different
operating and application forms within and among other units. This type of
structure reduces the initial investment cost by piecemeal institution's procedures
(Davis, 1994).

40 Demirel, D. (2017). Hospital Management Information Systems in Health Sector and

Development in Turkey
Hospital management information systems are seen to include resource usage and
programming, financial management, material and facility management and
personnel management systems in some reference sources. Effective resource
allocation is achieved through resource usage and programming system and the
system offers convenience to the patients. This system is very useful when hospital
admission and operation day are determined. Thanks to the system, more
economical use of staff and services, patient transfer between services and staff
support are provided (Harwood, 2003: 24).
The objectives of a financial management program are listed as follows (Dieter,
1987: 71-72):
 To carry out daily accounting transactions
 To provide the necessary numerical data in order to minimize the expenses
in the investment decisions
 Developing efficient and functional financial sub-systems
 To provide management information for evaluation and control of
transactions
In the material and management system, computers are one of the main means of
providing information to management, helping hospitals to manage facilities and
materials more efficiently. For example; this includes the procurement, inventory
control, food management, food list preparation, facility maintenance, energy
management, programming and supervision of projects (Austin and Boxerman,
2013: 12). In addition, there is a need for a good personnel management
information system in hospitals in order to benefit from labor force planning and
productivity analysis. The functions of the hospital personnel management
information system can be summarized as follows (Austin and Boxerman, 2013:
198; Degoulet and Freschi, 1997: 91, Haux et al., 2004: 30-33):
 Keeping and recording the files of hospital staff constantly
 Getting information and correction of information processes from files
when necessary, provision of task control
 To draw out the study analysis reports of each cost center of the hospital, to
produce reports to analyze personnel problems
 To produce information on cost distribution of labor costs, quality control,
and personnel productivity
 Providing enhanced information support on the effects of diseases, drugs,
diagnostics and treatments
 Knowing the special talents and document situations of the staff
 Getting information about patient treatment quality, performance, and costs
 Using Purposes and Benefits of Patient Management Information Systems
The purposes of use of hospital management information systems are (Akbolat,
2013: 115; Winter, 2001: 99-109):

Journal of Current Researches on Health Sector, 2017, 7 (1), 37-50. 41

  All information about the patient's CV and the illness is recorded instantly
on the computer and can be accessed when requested.
 Loss of time is avoided for the establishment of a modern archiving system.
The diagnosis of the disease is fast and reliable.
 All hospital management information is followed by the computer system
and this information is easily accessible.
 Increase in incomes through billing and official document preparation
processes are performed in a reliable manner
 All trading and material distribution operations in hospitals are carried out
through computers.
 Medical research is supported and high-quality communication is provided
by exchanging information between different hospitals.
 Protective and curative health services can be managed.
 Establish an effective financial transaction sub-system.
 Time is saved. The output of labor and medical devices is at the highest
level.
The main benefits of hospital information management systems are as follows
(Özyurt, 2009, www.saglikbilisimdernegi.org; Hatcher, 1998: 124-127; Özoğul,
Karsak, Tolga, 2009: 2093):
 Reducing the red tape by arranging all forms used in the hospital through
the system.
 Statistical results can be obtained according to different criteria.
 Unnecessary usage and leakage are prevented by input, output, control and
follow-up of all kinds of materials in the hospital.
 During operation, the relevant images are saved and the reporting system is
recorded in the digital environment.
 All information is stored in an electronic environment via digital archiving.
 The personnel's performances are constantly followed by recording the
movements of hospital staff.
 The acceleration of the health services presentation ensures continuity of
patient treatment and patient satisfaction.
 Support is provided for personnel management, logistics operations, and
case costs. Better strategic decisions are made by increasing the efficiency
of the supply chain of the health care organization.

42 Demirel, D. (2017). Hospital Management Information Systems in Health Sector and

Development in Turkey
3. Use of Hospital Management Information Systems in Turkey
Initiatives to establish hospital management information systems in Turkey began
in 1990 with the passing of the Ministry of Health and the World Bank's Health
Information Systems Project. The development of the health information system is
in the main objectives of the 1st Health Project launched in 1991, the development
of the management information systems and the primary health care information
systems are the main objectives of the 2nd Health Project covering the years 1995-
2001 (Özsarı, 1998: 15). In this way, the Health Information Systems Project
started in 1992 with the planning phase. At this stage, problems related to the
quality and information validity of the hospitals were evaluated. Since 1995,
hospitals' interest in hospital management information systems has increased and
hospitals have begun to take advantage of information systems more. In 1996, the
data processing department of the under-secretariat of the Ministry of Health was
established. In the same year, Hospital Information Systems Technical
Specification Evaluation Commission was established under the data processing
department. However, no standardization has been achieved in practice. For this
purpose, the Ministry of Health prepared a report entitled "Purchasing Principles
of Hospital Information Systems" and distributed it to all hospitals. In 1999, the
Ministry of Health tried to create application software within the data processing
department and selected Ankara Education and Research Hospital as a pilot
hospital. However, at the end of 2003, this project was stopped. It has been
decided that the hospitals should obtain their information management system
needs from private sector companies with their own sources of revolving funds. In
the same year, "Turkey Health Information System Action Plan" was created by
Turkey Health Information System Action Plan Working Group. In 2004, the
ministry completed work on basic care services in the field of health care. In 2005,
SSK, BAĞ-KUR and the pension fund and the contracted hospitals were merged
under the roof of the Social Security Institution and this institution checked the
payment process of the patients registered via Medula (General Health Insurance)
system. In addition, the Social Security Institution requires that each hospital
information system is integrated with Medula over the Internet.
In 2005, the rate of having hospitals' information systems reached 90%, and 100%
in 2006 (T.C. Sağlık Bakanlığı, www.sagliknet.saglik.gov.tr/giris.htm, 02.05.2017).
In 2007, the Ministry updated the Principles on the Purchase of Hospital
Information Systems and put the Health-Net project into effect. The data obtained
from the hospital information systems are shared with the Health-Net platform
over the internet. The health information about the patients is also stored in
Health-Net (Dağlı, 2011: 9-14). In addition, the Ministry of Health established
health data warehouses starting from 2014 and planned to use the information
applications on the Health Special Network (SB.Net). In 2015, the ministry has
passed web-based architecture in hospital information management systems and
family medical information systems.
The basic components of Hospital Management Information Systems used in
Turkey are (Reyhanoğlu, 1998: 416-419):

Journal of Current Researches on Health Sector, 2017, 7 (1), 37-50. 43

  Patient Registration-Acceptance: The personal information about the
patient applying to the hospital is recorded in the related polyclinic. The
patient's provision is taken.
 Patient Inpatient-Discharge Procedures: Patient admission procedures
are followed by expendable supplies of patients in the hospital and drug
use. After the diagnosis and treatment of the patient, discharge operations
are carried out.
 Patient Follow-up: It keeps records of procedures performed on the
patient's examination, given medications, applied examination, and
treatment.
 Referral of the Patient: If the patient cannot be treated in the hospital
where the patient is referred to, the patient is transferred to another
hospital.
 Central Hospitalization: It gives a hospital admission appointment to the
patients to be admitted to the hospital.
 Emergency Service: It makes a patient record to the hospital emergency
department. It forms the consultation records of the patient. It records the
treatment applied to the patient.
 Human Resources: It is the systems where the information about the
personnel can be followed and made accrual processing. It consists of four
modules in the form of record, leaves, staff movements, and promotions-
accrual. In the system, permissions for users on the screen and transaction
basis are defined. Thus, users can only perform the operations they are
authorized to do with the system.
 Voluntary Work: It keeps records of examinations and surgeries done by
doctors, working days of staff, gross wages earned.
 Health Board: It keeps a record of the permission and medication reports
given to the patient and transfers this information to the e-health system.
 General accounting: It maintains general accounting and fixed asset
system records in accordance with the SSK curriculum.
 Purchasing/Material: It defines the necessary materials for the hospital
and codes them. It provides storage of materials in warehouses and shelves.
It keeps track of the entrance and exit movements by following the hospital
stock status of the material.
 Appointment System via Phone: It enables the appointment process to be
carried out 365 days/24 hours without an operator. It reports, patient flow
information such as the daily number of patients calling, the number of
appointments, and the number of patients examined each day.
 Laboratory: It manages the auto-analyzer devices used in hospital
laboratories. It coordinates the desired tests to be performed for the
patients in the appropriate hospital and auto-analysis device. After

44 Demirel, D. (2017). Hospital Management Information Systems in Health Sector and

Development in Turkey
 receiving the results from the system and confirming to the laboratory
supervisor, the report is presented to the patient.
 Pharmacy: It keeps stocks of drugs and expendable supplies and provides
the necessary statistics. It performs the material orders, invoices, and
discharge of hospitalized patients. It follows the prescribed process of the
outpatient clinic.
A study conducted by the Ministry of Health has identified some standards related
to hospital management information systems used by health institutions in Turkey.
These are listed as follows (T.C. Sağlık Bakanlığı, 2005: 13):
 Unique Descriptive Standards: These relate to the patient, the health care
facility and the equipment and other materials used in the health
institutions. It includes patients or healthy persons, all types of health care
providers, related organizations, used devices and inventory, consumables,
drugs, blood and blood products.
 Model, Content and Building Standards for Electronic Patient Records:
They are the standards that deal with the modelling, contents, and structure
of public hospitals. It is necessary to follow a regular chain of rules so that
hospital information systems can continue to operate in a coordinated and
successful manner. These standards are one of the most important rings of
the regular rules chain.
 Message/Data Communication Standards: It includes storing and
reliable storage of data between the administrative and financial units
(diagnosis and treatment data, blood transfusion, e- prescribing, electronic
provision and billing, laboratory, imaging data) and communication with
those who request data.
 Standards related to the Display of Clinical Data: It includes disease
diagnosis, health care services, dentistry, and grouping of patients
according to their diagnosis, all surgical procedures, medical wastes,
pharmacology, medical consumables, and medicines.
 Privacy/Personality and Safety Standards: It covers standards related to
patient confidentiality and patient safety. Personal data belonging to all
patients who apply to the hospital are recorded and stored according to the
privacy principle. This personal data is made ready for use when necessary.
 Standards related to Health Information Management and Quality
Indicators: It covers all communication tools in health services as well as
quality standards and indicators of statistical data in laboratories.
Reporting of these data and getting ready for use are included in a certain
program. These standards are appropriately presented for the use of health
institutions and organizations.
4. Conclusion
Information systems are one of the structural changes that public institutions have
adopted in recent times. One of the basic requirements of the information society
is transparent and fast public administration. It is thought that such an

Journal of Current Researches on Health Sector, 2017, 7 (1), 37-50. 45

administrative structure will be effective in service provision. Healthcare is one of
the areas where the public sector allocates the most resources. First of all the
states must ensure the health of the family and society in general, taking into
account the public interest. For this, it is important to harmonize preventive and
therapeutic health practices to current developments in information and
communication technologies in order to ensure the productivity of the healthcare
industry.
Hospital information management systems are systems that collect data from
different sources, taking on functions of gathering information in hospitals and
transmitting information to administrative units. Such a system consists of
software, hardware, and the necessary communication infrastructure and is
established both on paper and computer. It permits the efficient exchange of data
with doctors and other hospital personnel with colleagues in and out of their own
institutions. Hospital information management systems have made progress since
the 1960s. These systems, which focused on reducing costs in the 1970s, aimed at
bringing together various elements in a holistic way in the 1980s. According to
this; all detailed information about patients is kept in a system. In this way,
physicians can make accurate diagnoses by reaching the information about the
patients instantly. This situation offers an advantage in terms of cost and time by
avoiding unnecessary medical tests to be applied to the patient. The use of
electronic patient records became widespread in the 1990s. After the 2000s, it was
aimed to increase the quality of patient care in the health sector through
technological applications.
Hospital Management Information Systems are classified as integrated and
modular. Another classification incorporates staff management systems into
hospital information systems with resource utilization and programming, financial
management, materials and facility management.
Hospital management information systems have greatly reduced red tape practices
in public hospitals today. It avoided unnecessary use of resources. The storage of
all information in the electronic archive environment has improved the quality of
the health care service and increased patient satisfaction. Hospital management
information systems in Turkey have developed since the 1990s. In 1996, with the
establishment of the Data Processing Department affiliated to the under-
secretariat of the Ministry of Health, the studies in this area gained momentum. In
1999, the Ministry of Health began work on creating application software.
However, at the end of 2003, this project was ceased and applications based on
free competition and market orientation became widespread in the health sector.
It has been decided that the hospitals should purchase information systems from
private sector firms with own budget possibilities. In 2005, the Social Security
Institution began to monitor patient records electronically via the Medula (General
Health Insurance) system. In 2007, the Health-Net Project of the Ministry of Health
was improved and the data obtained from various hospital information systems
were shared with the Health-Net platform. Today, hospital management
information systems are used in institutional processes such as patient
registration, patient follow-up, hospitalization, patient referral and discharge
operations, health board reports, human resources, voluntary work, buying and

46 Demirel, D. (2017). Hospital Management Information Systems in Health Sector and

Development in Turkey
material procurement, general accounting records. Laboratory analysis results can
be entered into information systems. Thanks to these systems, citizens can receive
hospital appointments by phone or over the internet.
Hospital management information systems have a history of about 30 years in
Turkey. The Ministry of Health establishes standards for the use of hospital
management information systems in accordance with the developments in the
world and it has become compulsory for health institutions to participate
effectively in the system.
Suggestions for a successful hospital management information system are:
Hospital information management systems should be able to meet the needs of
patients, healthcare staff, managers and system designers. Stakeholders involved
in the health care system should be able to access 24 hours a day, regardless of
occupational and geographical boundaries. The system administrators should
clearly define administrative objectives. The records of primary and secondary
health care services should be standardized. Processes related to the supply and
use of information technology should be simplified. The requirements for
information systems should be determined at the institutional level. Hospital
management information systems should be coordinated and controlled by the
Ministry of Health at the national level. Political interventions should be avoided in
the process of institutional decision making. Health care users should be
encouraged to participate and contribute to the information management system.
The health personnel should also assume an active role in the planning process
and inform to the hospital management of any deficiencies that may arise as a
result of the system being used.

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