strategies for building national-scale longitudinal electronic patient monitoring systems for hiv...

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

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

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



Facility in District


Patient with smartcard

Data Transport





Data Transport





Facility by Facility synchronization


Data Transport

Data Entry

Data Storage


A Nurse using a touch screen for data entry

• Uses touch screens for ease of data capture

This reduces the computer literacy learning curve


UI Objects, such as this soft keyboard, popup

appropriately

3. System Implementation… Cont iii. System Features




3. System Implementation… Cont iii. System Features




Type ahead feature for text data, to

speed data entry

Type ahead feature for text data, to

speed data entry


Data Transport

Data Entry

Data Storage


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


Consensus building and concept formation, 2002

Piloted in April, 2005





Baseline survey, facility level data Analysis, use, flow of care and record keeping





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





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

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




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


CCPTS Smartcard

based System











Thank You!!!Thank You!!!

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