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A Real-time Electronic Medical R ecord to Drive the Quality I mprovement P rogram of Haiti

A Real-time Electronic Medical R ecord to Drive the Quality I mprovement P rogram of Haiti. On behalf of The Ministry of Public Health and Population (MSPP) & CDC- Haiti : The HIVQUAL- Haiti Team Bruce Agins, MD MPH; Director , HEALTHQUAL International Kuala Lumpur, July 2013.

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A Real-time Electronic Medical R ecord to Drive the Quality I mprovement P rogram of Haiti

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  1. A Real-time Electronic Medical Record to Drive the Quality Improvement Program of Haiti On behalf of The Ministry of Public Health and Population (MSPP) & CDC-Haiti: The HIVQUAL-Haiti Team Bruce Agins, MD MPH; Director, HEALTHQUAL International Kuala Lumpur, July 2013

  2. Overview of the presentation • Haiti and HIV • EMR genesis and implementation. • HIVQUAL Haiti • How you use national data to drive improvement at national level • How the EMR is used at the clinic to drive QI

  3. Situation of HIV epidemic in Haiti • HIV Prevalence in 20121 • Prevalence estimated in 2012 • Population =10,085,214 hab. (est 2010)2 • 142,000 HIV+ (~1.4% de la pop)3 • Around half of HIV+ (~ 60,000 - 71,000)4 are eligible for ART • Around 70% - 80% of eligible (~48,000)5 are on ART 1 EMMUS-V (2012) 2 ihsi.ht 3 NASTAD Haiti 4 ONUSIDA 5 mesi.ht

  4. Data collection and reporting processes separate Constraints for formatting data Difficulties for maintaining integrity of data Security and backup of data Difficulties for searching, analysis and sharing information Rationale for Implementing the EMR Paper based system:

  5. 2005 I-TECH began developing iSanté at the request of the Haiti MOH and the Centers for Disease Control and Prevention Global AIDS Program in Haiti (CDC GAP). • iSanté is an electronic medical record (EMR) that supports both individual and population health care of patients in Haiti. .

  6. iSantésupports health care workers and clinics to manage and utilize patient data, and facilitates timely and accurate reporting on national HIV, primary care and maternal health service delivery and surveillance. • There are more than 100 sites employing iSanté including government facilities, private hospitals, faith-based organizations, NGOs, and other networks, with a total of more than 160,000 patient records. Forty-nine iSantéclinics / hospitals have local servers, which eliminates reliance on slow Internet connections and allows automatic replication of patient data to a central patient data repository.

  7. Architecture of the EMR iSante is an open source system developed in an environment LAMP (Linux OS, Apache web server, MySQL database, and PHP scripting language)

  8. Timeline for the Development of an EMR ** Phase 3 (~10 months) Develop EMR for national pilot sites Phase 1 (~4 months) Refine paper-based HIV medical forms Identify sites for EMR expansion Develop, provide, review, and validate forms Finalize forms and guidelines on unique patient identifiers Provide support for form use Interface to support interactive EMR Protocols for use of EMR and reporting Deploy EMR and train personnel Training, implementation, and support Identify reports to be generated from the database Database matching paper-based forms Protocols for data cleaning, management, and reporting Phase 2 (~9 months) Develop data entry system for paper-based HIV medical record **PARTNERSHIP BETWEEN HAITI MSPP-CDC-ITECH-TULANE

  9. The Rollout • Development of system and preparation took approximately one year • Personnel capability required teamwork by an electrical engineer, Database specialist, Programmer Analyst and Network Specialist • 10 people are engaged in operation of the system • Customization can occur with appropriate skills and knowledge • Training of HCW requires 2 days • Piloting was conducted over a 3-month period

  10. Wide set of report for decision making Multiple retrospective or prospective reports that generate case lists for care reminders can be use at all levels Clinics Departments National

  11. Visit scheduled next 7 days

  12. USING THE EMR DATA AT THE NATIONAL LEVEL: A Systematic Approach to Quality Improvement

  13. HEALTHQUAL HAITI Timeline December 2007 • the MOH adopted the HIVQUAL methodology as a national program for monitoring and improving systems of care delivery for persons living with HIV. • Constitution by MOH of a National Advisory Committee of PEPFAR partners and stakeholders : (DG MSPP – LNSP – CDC – USAID – GHESKIO – PIH – AR - MSH – ITECH – FOSREF – FHI – POZ – GF – FEBS). • First training session on QI for HIVQUAL coaches by NYSDOH AI. • 19 HIV clinics were selected to begin HQ-HT, representing a mix of regions, clinic types and degree of support by partners • Ten performance indicators to measure the quality of HIV services covering adult and pediatric care and treatment, and PMTCT. August 2008 • Data collection was expedited by the incorporation of the indicators into the EMR : iSante March 2012 • Decision of the National Committee to move towards HEALTHQUAL in 71 health facilities • 19 indicators ( HIV - TB – MCH – Nutrition – Immunization - Mental health). March 2013 • As of March 2013 , 90 health facilities are implementing HEALTHQUAL with the backbone of an EMR Quality Management Program

  14. HealthQual-Haïti Organigram

  15. Semiannual meeting of National HEALTHQUAL Advisory Board • Evaluate performance improvement of clinics regarding the indicators from the EMR • Set benchmark for next review period. • Identify weakness and gaps of the health system • Provide feedback about implementing quality program in the clinics

  16. Cotrimoxazole Prophylaxis ( N: 10666 → 36685 pts ) Pourcentage de patients VIH+ qui ont reçu du Cotrimoxazole Hurricane Hanna Earthquake- Cholera • Interventions • Diffusion of National Guidelines to all clinics • Distribution of case list of taken from iSanté to the pharmacy unit • Systematic data entry of pharmacyform in iSanté National

  17. PMTCT ( N : 289 → 737 pts ) Pourcentage de femmes enceintes VIH+ ayant démarré la prise des ARV Cyclone Hanna Seisme - Cholera • Interventions • Revision and dissemination of PMTCT Guidelines • Introduction of female Case Managers in all clinics. • Agressive Tracking of HIV+ PW by field agents in the community. • Earlydispensing of ART HIV+ PW • Systematic data entry of OBGYN and pharmacyform in iSanté. National

  18. USE OF EMR AT CLINIC LEVEL TO IMPROVE QUALITY

  19. Idées pour surmonter les Barrières ANALYSES SYSTEMES Implémentation

  20. Improvement of ART enrollment through improvement of quality of serviceExperience of HopitalUniversitaire de la PaixDerivalRaymonde, MD; Bogart Mie Johanne, Nurse; Maisonneuve Yvette, Nurse; Isaac Daniel, SW; AristileWilliam,Data Clerk; Auguste Marie Carmen , Nurse; Jenny X; ClerrierNadege BACKGROUND -Rationale of the ART Enrollment project All medically eligible HIV positive patients should be enrolled on ART. ART enrollment will reduce the morbidity and mortality rate and improve the patients’ quality of life. From our Electronic Medical Record, data of HIVQUAL report from July to Dec 10 revealed that only 82 among 331 medically eligible patients (24.8%) had benefited from ART enrollment.

  21. A multidisciplinary team was created by the Quality Management Committee to assess the problem, led by 1 MD , with 3 nurses, 1 data cler, 1 field agent and 1 patient. AIM STATEMENT: To improve ART enrollment from 24.8% to 45% over six months. IMPROVEMENT CHANGES & INTERVENTIONS First Strategy-Patient Awareness: Psychologist & SW counsel patients about importance of visits; Clerk highlights new patients in register Second Strategy - Reduction in Pre-ART period: Weekly visits required for patients until ART Enrollment. Third strategy –Enrollment Acceleration: Increase number of new enrollees with new verifcation process by data clerk. Participation in post-test clubs.

  22. Reduction of pre-ART wait and increasing patient had the greatest impact LESSONS LEARNED: -Coordination between psychosocial and medical units was key to success of ART enrollment. -Need sufficient time for committee meetings to select patients for enrollment from pre-ART list. -Staffing levels require more than one psychologist to help patients accept treatment and address mental health problems.

  23. IMPLEMENTATION NEEDS AND CHALLENGES • Technology • power • IT (Servers, LAN, PC…) • Workforce: EMR and QI • Involvement of all MOH unit in the deployment of EMR and Healthqual program • Reinforcement of capacity of MOH departmental staff in data analysis, quality improvement • Resources • Financial and human

  24. Lessons learned • Utilization of iSante allowed standardization of care across the country • Leadership and commitment of highly qualified personnel are needed for development and rollout of the system with adequate financial reosurces • Reminders in the EMR can prevent harm and improve quality of care • A national quality improvement strategy (HEALTHQUAL Haiti) was required to spread implementation of data use for improvement throughout the country and required government ownership with support from donors to build technical capacity and management processes • Check it out….

  25. https://isante-demo.cirg.washington.edu/isante/  • username:  demo • password: demo Special thanks to NicaskyCelestinn and MargarethJasmin

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