October 2–5, 2007  Lusaka, Zambia

1. STRATEGIES FOR BUILDING NATIONAL-SCALE LONGITUDINAL ELECTRONIC PATIENT MONITORING SYSTEMS FOR HIV TREATMENT AND CARE IN PEPFAR COUNTRIES October 2–5, 2007 Lusaka, Zambia

2. Overview of the Development, Piloting and Evaluation of a National Electronic Data System for ART M&E in Malawi 2 October 2007

3. Overview Background EDS Task Force System Features Accomplishments and Challenges Current Status Lessons Learned/Best Practices

4. Background ART continues to rapidly scale up 114,375 patients on ART as of June 2007 109 public sector sites 37 private sector sites Target of 250,000 patients on ART by end of 2010 M&E Cornerstone of National ART Program Paper-based ARV Patient Mastercard and ARV Patient Register Quarterly supervision to all ART sites for quarterly and cumulative cohort analysis

5. Number of People Receiving ARV Treatment in Countries Supported by PEPFAR (as of March 31, 2007) Source: U.S. Department of State, Office of the Global AIDS Coordinator, U.S. President's Emergency Plan for AIDS Relief, available at: http://www.pepfar.gov/press/85520.htm.  

6. Why an EDS is Needed Paper system will not cope as ART system continues to scale-up Extensive time to conduct supervision More difficult to compile accurate information as volume increases Accurate, Complete, and Timely Data on ART Scale-Up Needed Site Monitoring Drug Forecasting Guiding National Policies

7. ART M&E EDS Task Force Electronic Data System Task Force Strengthen the National ART M&E System Pilot the usefulness and feasibility of the EDS for expanded (national) use Formal evaluation EDS Task Force has met every one to two months since September 2005

8. EDS Task Force Composition MOH HIV/AIDS Unit HMIU ART Service Providers Mzuzu CH Lighthouse MSF/Thyolo Dignitas/ZCH Health Information Systems Specialists Taiwan Medical Mission Baobab Health Partnership Development and Technical Partners CDC (chair) WHO

9. EDS Task Force Accomplishments System Functional and Technical Specifications (approved by MOH) Identification and Funding of Partners for Implementation North: Taiwanese Medical Mission Central: Baobab Health Partnership Development of Data Transfer Standards (HL7) with support from WHO and CDC Development of Evaluation Protocol for Pilot (Baseline Data Collection Complete)

10. How does the System Work? Touchscreen interface Captures data at Point-of-Care Guides health care providers through protocol Workstation in each room/point of service Photo: Nkhata Bay Clinic (TMM)

11. System Features Touchscreen web browser interface 30+ hours of battery backup Barcode scanner Label printers Developed by Malawian programmers (Baobab) Photos: Martin Preuss Center (Baobab)

12. Screenshots from Taiwan Medical Mission’s and Baobab’s System Photo: TMM System Photo: Baobab System

13. Demonstration of Patient Registration

14. System Features Standards Based Approach HL7 standards have been adopted by Malawi to allow interoperability of data across sites and across systems Strong collaborative effort in development of HL7 messaging ART M&E EDS can serve as a platform upon which other electronic health information systems can be built (e.g. TB, PMTCT, etc.)

15. Benefits of the System Clinical Rewards Protocol guidance BMI and dosage calculations Ordering and labeling (labs, pharmacy) Warnings and prompts Data Rewards Promotes complete and accurate data Facilitates timely and accurate reporting Data validation

16. Beta / Acceptance Testing May & July of 2007 Baobab and TMM review each other’s system

17. Successes to Date Malawi first country to develop and implement against national specifications for EDS Malawi first country to develop national data transfer standards (HL7) to ensure interoperability of data Collaboration and sharing of innovations between implementers Wide stakeholder buy-in (MOH, ART providers, development partners) Roll-out of two unique systems to four pilot sites

18. Challenges Time Nothing is as simple as it appears Flexibility Difficult to design a system that ‘fits’ the work environment Ease of Use Intuitive and useful Monitor Remote Sites System support

19. Current Status Piloting in Four District Hospitals Northern Region - Nkhata Bay and Rhumpi Central Region - Salima and Dedza Reconvening EDS Task Force Conducting EDS Formal Evaluation Assess the impact of EDS on ART provision Refresher training for evaluators

20. Evaluation Instruments User Surveys What is the impact of the system from the perspective of health care workers/clinic management? Observational Study Does use of EDS positively affect the patient-provider interaction? Time Flow Study Does the use of EDS affect the time required by ART patients to receive care? Log of System Errors Is the system maintainable? How frequently does the system break down? Analysis of Data Quality Does an electronic data system result in more complete and accurate information?

21. Next Steps: Scale-Up Planning Determine rate of roll-out Technical support capacity Human resources Financial resources Supervision – what does it look like? Confidentiality and security of transmitted data Governanceissues

22. Best Practices / Lessons Learned Clear success criteria National specification Formal evaluation Script for acceptance testing Continual communication with end-users in order to improve the system Strong leadership (EDS Task Force)

23. For Additional Information Please Contact: Amy Gottlieb, MPH, PhD Candidate Monitoring and Evaluation Officer Centers for Disease Control & Prevention Global AIDS Program, Malawi Tel: 265-(0)1-775-188 ext. 208 Fax: 265-(0)1-775-848 Email: agottlieb@mw.cdc.gov