STRATEGIES FOR BUILDING NATIONAL-SCALE LONGITUDINAL ELECTRONIC PATIENT MONITORING SYSTEMS FOR HIV TREATMENT AND CARE IN PEPFAR COUNTRIES
October 2–5, 2007 Lusaka, Zambia
Zambia Case Study
SmartCare Implementation
Dr. Mark Shields , CDC, Zambia
Derrick J. Muneene, CDC, Zambia
2
Population: 10.3M (2000 Census, CSO) Over 1600 Health Facilities, some offer ART some offer PMTCT Has 4 level health administrative structure
Population: 10.3M (2000 Census, CSO) Over 1600 Health Facilities, some offer ART some offer PMTCT Has 4 level health administrative structure
Presentation Outline
• The Preamble, Problem, Solution and Background
• The Assessment (SWOT) of Health Information Systems in Zambia
• The Design Methodology and Choice of Technology
• The Development Organization and Process
• The Implementation : Process, challenge and successes
• The Current Next Steps
SmartCare Scope : More than just ART care – OPD longitudinal EHR systemEHR Developed based on Existing Zambia MoH Forms
SmartCare Scope : More than just ART care – OPD longitudinal EHR systemEHR Developed based on Existing Zambia MoH Forms
The Preamble, Problem, Solution and Background
Current SmartCare Modules
1. ART – Adult2. ART – Paeds (NEW)3. ANC-PMTCT4. VCT/CT5. Labour and Delivery6. Postnatal (NEW)7. Labs8. Pharmacy 9. Various Reports
The Problem and Background
General service delivery and information challenges
• Client confidentiality (especially with regards to HIV positive clients)
• Unavailability of related health information (ART, TB etc) for continuity of care, to help improve patient care
• Lack of system to facilitate patient follow-up for both mother and baby, and patients on ART
• Data aggregation and reporting challenges
• Etc
The Assessment (SWOT) of Health Information Systems in Zambia
Zambia H.I.S. SWOT Analysis Assessment Item
Strengths Weaknesses Opportunities Threats
Community Card carrying practice : National, business and medical
Eagerness for Tech
Electronic devices not used in health settings
Absence of Standard Practices
Strong linkages between communities and local facilities
Potential for stigmatization for a card carrying system
Non compliance
Potential for distrust
Health facility Medically Trained health workers
Good understanding of existing health paper system
Even coverage of population
No I.S./IT Training in educational institutions
No adequate I.S./I.T infrastructure
Availability of user friendly technologies to support non I.T. staff
Presence of initial donor support
Equipment misuse
Equipment theft
Lack of on going maintenance
Governance structure Local Leadership support and good will
Presence of ICT qualified staff
Inadequate software development staff at top level
Inadequate ICT infrastructure
No Confidentiality protocols for health
Local Capacity building (for sustainability)
Staff migration
Zambia H.I.S. SWOT Analysis Assessment Item
Strengths Weaknesses Opportunities Threats
Community Card carrying practice : National, business and medical
Eagerness for Tech
Electronic devices not used in health settings
Absence of Standard Practices
Strong linkages between communities and local facilities
Potential for stigmatization for a card carrying system
Non compliance
Potential for distrust
Health facility Medically Trained health workers
Good understanding of existing health paper system
Even coverage of population
No I.S./IT Training in educational institutions
No adequate I.S./I.T infrastructure
Availability of user friendly technologies to support non I.T. staff
Presence of initial donor support
Equipment misuse
Equipment theft
Lack of on going maintenance
Governance structure Local Leadership support and good will
Presence of ICT qualified staff
Inadequate software development staff at top level
Inadequate ICT infrastructure
No Confidentiality protocols for health
Local Capacity building (for sustainability)
Staff migration
Zambia H.I.S. SWOT Analysis Assessment Item
Strengths Weaknesses Opportunities Threats
Community Card carrying practice : National, business and medical
Eagerness for Tech
Electronic devices not used in health settings
Absence of Standard Practices
Strong linkages between communities and local facilities
Potential for stigmatization for a card carrying system
Non compliance
Potential for distrust
Health facility Medically Trained health workers
Good understanding of existing health paper system
Even coverage of population
No I.S./IT Training in educational institutions
No adequate I.S./I.T infrastructure
Availability of user friendly technologies to support non I.T. staff
Presence of initial donor support
Equipment misuse
Equipment theft
Lack of on going maintenance
Governance structure Local Leadership support and good will
Presence of ICT qualified staff
Inadequate software development staff at top level
Inadequate ICT infrastructure
No Confidentiality protocols for health
Local Capacity building (for sustainability)
Staff migration
Zambia H.I.S. SWOT Analysis Assessment Item
Strengths Weaknesses Opportunities Threats
Community Card carrying practice : National, business and medical
Eagerness for Tech
Electronic devices not used in health settings
Absence of Standard Practices
Strong linkages between communities and local facilities
Potential for stigmatization for a card carrying system
Non compliance
Potential for distrust
Health facility Medically Trained health workers
Good understanding of existing health paper system
Even coverage of population
No I.S./IT Training in educational institutions
No adequate I.S./I.T infrastructure
Availability of user friendly technologies to support non I.T. staff
Presence of initial donor support
Equipment misuse
Equipment theft
Lack of on going maintenance
Governance structure Local Leadership support and good will
Presence of ICT qualified staff
Inadequate software development staff at top level
Inadequate ICT infrastructure
No Confidentiality protocols for health
Local Capacity building (for sustainability)
Staff migration
The Design Methodology and Choice of Technology
The Development Team
But List is more than this …
• M&E Staff : CDC, MoH
• Training Staff : MoH, NG
• Deployment support staff
• etc
The Choice of Solutions
Data Transport
Data Entry
Data Storage
Date Synchronization
The Choice of Solutions
Data Transport
Data Entry
Data Storage
Date Synchronization
Continuity of Care : Existing Paper Methods
Continuity of Care : Computerized (SmartCare) Patient held tools
Data Transport
• Enforces patient confidentiality and data security, especially for HIV positive mothers
•Entire EMR is stored on card
•ART, TB, PMTCT, VCT, etc
•Entire EMR is stored on card
•ART, TB, PMTCT, VCT, etc
Data Transport
• Enforces patient confidentiality and data security, especially for HIV positive mothers
• System is password driven, with a role based security model (RBS)
•Card data is compressed and encrypted •Card can not be read by a non CCPTS system – requires specialized card driver and code logic to read the data from the smart card
•Card data is compressed and encrypted •Card can not be read by a non CCPTS system – requires specialized card driver and code logic to read the data from the smart card
Data Transport
• Based on a distributed database model
• The distributed databases are linked via a virtual network for data communication / synchronization, driven by the patient
‘the client serves AS the network’
‘the client serves AS the network’
A mother receiving s smart card for the first time
Data Transport
• Based on a distributed database model
• The distributed databases are linked via a virtual network for data communication / synchronization, driven by the patient
Facility in District
Facility in District
Patient with smartcard
Data Transport
• Based on a distributed database model
• The distributed databases are linked via a virtual network for data communication / synchronization, driven by the patient
Facility in District
Facility in District
Data Transport
• Based on a distributed database model
• The distributed databases are linked via a virtual network for data communication / synchronization, driven by the patient
Facility in District
Facility in District
Facility by Facility synchronization
The Choice of Solutions
Data Transport
Data Entry
Data Storage
Date Synchronization
A Nurse using a touch screen for data entry
• Uses touch screens for ease of data capture
This reduces the computer literacy learning curve
This reduces the computer literacy learning curve
UI Objects, such as this soft keyboard, popup
appropriately
3. System Implementation… Cont iii. System Features
• Uses touch screens for ease of data capture
This reduces the computer literacy learning curve
This reduces the computer literacy learning curve
3. System Implementation… Cont iii. System Features
• Uses touch screens for ease of data capture
This reduces the computer literacy learning curve
This reduces the computer literacy learning curve
Type ahead feature for text data, to
speed data entry
Type ahead feature for text data, to
speed data entry
The Choice of Solutions
Data Transport
Data Entry
Data Storage
Date Synchronization
SQL Server
DB(Free
Express Edition)
SQL Server
DB(Free
Express Edition)
•C# Front end•Middle tier uses xml for enumerations and Data validations
•C# Front end•Middle tier uses xml for enumerations and Data validations
•Keyboard and mouse are optional
•Keyboard and mouse are optional
A Form of offsite backupA Form of offsite backup
4. The Choice of Solutions
Data Transport
Data Entry
Data Storage
Date Synchronization, use and reporting
District in Prov
Facility in
DistrictFacility by Facility synchronization
Facility in
District
District in ProvDistrict by District synchronization
Prov in Country
Prov in Country
Country
Province by Province synchronization
Facility DBAsymmetric MergeRecord Linkage/De-dup
Facility DBAsymmetric MergeRecord Linkage/De-dup
District DBDe-duplication and De-identification algorithm
District DBDe-duplication and De-identification algorithm
Provincial DBDe-duplication and De-identification algorithm
Provincial DBDe-duplication and De-identification algorithm
National DBDe-duplication and De-identification algorithm
National DBDe-duplication and De-identification algorithm
The Development Organization and Process
The Development Process
• System Design and implementation Process
Consensus building and concept formation,
Dec2003
Concept formation
Government and NGO
consensus Formation of development
teams
Identification of and collaboration with, existing systems:
ZEPRS, PTS, ARTIS, ARTServe, LABIS, HMIS
The Zambia SmartCare Development, M&E, and Central Deployment Team
2. System Design and Implementation Process
• System Design and implementation Process
Consensus building and concept formation, 2002
Piloted in April, 2005
2. System Design and Implementation Process
• System Design and implementation Process
Consensus building and concept formation, 2002
Piloted in April, 2005
Baseline survey, facility level data Analysis, use, flow of care and record keeping
2. System Design and Implementation Process
• System Design and implementation Process
Consensus building and concept formation, 2002
Piloted in April, 2005
System reviewed and fine tuned
System expanded to include ART
(CCPTS)
14 more Smart card facilities added in
2006
To date, there are more than 50 sites running the ART module of SmartCare capital with about 120,000 patients in the database
To date, there are more than 50 sites running the ART module of SmartCare capital with about 120,000 patients in the database
To date, there are 14 sites running the Delivery,ANC-PMTCT-VCT modules of SmartCare based in the initial pilot district, Kafue, with about 7,000 clients carrying smartcards, and stored in the database
To date, there are 14 sites running the Delivery,ANC-PMTCT-VCT modules of SmartCare based in the initial pilot district, Kafue, with about 7,000 clients carrying smartcards, and stored in the database
April, 2006, MoH approves CCPTS to be the national
system for ART care
April, 2006, pilot district plans for district wide expansion,
after which other district would follow
1 Day District Management Training session 3 Day Frontline Health worker staff training
3 Day Frontline Health worker staff Training 2 day Frontline Health worker staff Training
2. System Design and Implementation Process
• System Design and implementation Process
Consensus building and concept formation, 2002
Piloted in April, 2005
System reviewed and fine tuned
System expanded to include ART
(PTS TO CCPTS)
12 more Smart card based facilities added
in 2006
To date, there are over 40 sites running the ART module of the SmartCare system nationwide, with about 90,000 patients in the database
To date, there are over 40 sites running the ART module of the SmartCare system nationwide, with about 90,000 patients in the database
To date, there are 12 sites running the ANC-PMTCT-VCT modules of SmartCare based in the pilot district, Kafue, with about 5,000 patients carrying smartcards, and stored in the database
To date, there are 12 sites running the ANC-PMTCT-VCT modules of SmartCare based in the pilot district, Kafue, with about 5,000 patients carrying smartcards, and stored in the database
April, 2006, MoH approves CCPTS to be the national
system for ART care
April, 2006, pilot district plans for district wide expansion,
after which other district would follow
Addition of more modules and expansion of system …
2007 Modules include integration with other systems and addition of new module: TB, OPD and under five
2007 Modules include integration with other systems and addition of new module: TB, OPD and under five
SmartCare Careware
2007 Work Effort includes: SmartCare and Careware integration
The Implementation
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Monze MHChikankata
Sesheke DH
Senanga DH
Petauke DH
Lewanika GH
Choma General Hospital
Chipata GH
Mazabuka GH
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UTH
KaraUNZA
George
Estate
Kanyama
Kamwala
Chipata
Chawama
Chilenje, Our Lady's Hospice
Kafue DH
Chelstone
Nangongwe
Matero Reference
Railway
Kabwata
Kalilangalinga, Mtendere, Mother Theresa's Hospice
Bauleni
Facilities in Lusaka and Kafue districts
N 0 4 8 Kilometers
0 40 80 KilometersN
2006 SmartCare Coverage
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Monze MHChikankata
Sesheke DH
Senanga DH
Petauke DH
Lewanika GH
Choma General Hospital
Chipata GH
Mazabuka GH
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UTH
KaraUNZA
George
Estate
Kanyama
Kamwala
Chipata
Chawama
Chilenje, Our Lady's Hospice
Kafue DH
Chelstone
Nangongwe
Matero Reference
Railway
Kabwata
Kalilangalinga, Mtendere, Mother Theresa's Hospice
Bauleni
Facilities in Lusaka and Kafue districts
N 0 4 8 Kilometers
0 40 80 KilometersN
2006 SmartCare Coverage
6. Lessons Learned
Lessons learned
• Smart card adherence has been estimated to be about 98%. This shows that patients will remember to bring smart cards when seeking health care
card loss rate is estimated at < 0.4% / person-year
• Good community awareness led to patient acceptance
• Inclusion of smart card lessons during group education increases patient confidence and smart card adherence
Lessoned learned
• Using touch screens instead of keyboards and mouse reduces computer training time. Health workers were able to work alone with minimum supervision.
• Interactive software development increases user ownership
• Presence of local development team increases software processes
Some Challenges
• Harmonization with legacy system (paper based)
• Adherence to international standards
• Printing capacity in low power locations
• Availing decision support to services that function out doors, like the TB corner
• Ongoing hardware maintenance By facility staff
Current SmartCare Activities
• Training Provincial ToT performed on existing models Provincial/District Scale up underway
• SmartCare and other systems integration (e.g. Careware) Addition of modules
• Light weight OPD• TB module
• SmartCare use in research activities: Migrant Health workers study
• E-Learning centre at MoH for continuous education
• Mapping functionality
Example interface for querying the data to generate a map report
Example map report interface showing: District map type, color shading, manual classification (user enters break values).
Example of: District map type, queried to southern province, color shading, manual classification (user enters break points), and labeling enabled.
Example of: Health facility catchment map type, drawing a background layer (health facility points), gray shading, and equal interval classification.
Data in this mapping example are fictional.
5. Next steps
• Rollout
• Integration with other systems
Conclusion
CCPTS Smartcard
based System
System has capacity to guide health
worker in service delivery and protocol adherence by using
decision support tools
System has capacity to guide health
worker in service delivery and protocol adherence by using
decision support tools
Produces flexible HMIS data, based on raw data
Produces flexible HMIS data, based on raw data
Enables patient information to be available to other services, there by introducing continuity of care, and a continuous medical record
Enables patient information to be available to other services, there by introducing continuity of care, and a continuous medical record
CCPTS Smartcard
based System
System has capacity to guide health
worker in service delivery and protocol adherence by using
decision support tools
System has capacity to guide health
worker in service delivery and protocol adherence by using
decision support tools
Produces flexible HMIS data, based on raw data
Produces flexible HMIS data, based on raw data
Enables patient information to be available to other services, there by introducing continuity of care, and a continuous medical record
Enables patient information to be available to other services, there by introducing continuity of care, and a continuous medical record
Thank You!!!Thank You!!!