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. Architectural Considerations for a National Health Information Infrastructures in Resource Poor Settings Bill Lober, MD MS Associate ProfessorUniversity of Washington (I-TECH)Center for Public Health Informatics (CDC COE) 2

3. Next… • Conceptual Framework • Scalability • Architecture • Data Collection • Technology • Performance

4. Next… • Conceptual Framework • Scalability • Architecture • Data Collection • Technology • Technical or Organizational Problem…

5. Necessary… • Environment • System • Usability • Local value/local support • National value/national support • It’s a Sociotechnical Problem…

6. Conceptual Framework for Computerized Health Systems • Classify Information and Communication Technologies (ICT) by function • Devices/Input • Mobile, Handheld • Web, Thick client (MS Access?!) • Electronic Medical Record (EMR) • Electronic Patient Monitoring (EPM) • Other population health applications

7. Conceptual Framework (Bill’s)Conceptual Framework Data quality management depends on depends on Useful data, delivered usefully! Clinical data quality Accuracy completeness User Interfaces User Interfaces Electronic Medical Record Electronic Medical Record PopulationHealth Applications Mobile, Web, PDA Clinical Input EPM, Research, QA

8. Scalability of Architecture • CDC National Center for Public Health Informatics (NCPHI) • Open Source, Open Data Standards • Non-proprietary, “unlocked” systems • Data interoperability (syntax/semantics) • Application interoperability (context) • Uses standardized/common services • Implements standard functions

9. Standards: • OpenMRS • HL7 • ICD10 • SnoMed • LOINC • GIS Standards • Others? Capacity Building Architectural Components HIV/AIDS Disease Surveillance Maternal Health TB Malaria Immunization Child Health Reproductive Health Nutrition Other Chronic Illness External Systems Vital Statistics Local Applications / Paper Systems Clinical/ Services Mgm’t Pharmacy Mgm’t LIMS Facility Mgm’t Inventory Mgm’t Finance APIs / Integration Surveillance Logistics/ Supplies Vital Events Insurance Finance Quality Assurance Insurance Functional Services Case Mgm’t Labs Training Tele- medicine Program Mgm’t Donor Reporting Supply Chain Management HR Registry Facility Registry Health Guidelines Patient Registry Geo & Baseline Data Repository Core Modules Health Data Dictionary Drug Formulary Organization Registry Indicator Registry Messaging GIS Mapping Data Analysis Data Import/Export Core Functionality Web Security Content Delivery Surveys Metadata Registry Data Mgm’t IVR SMS Core Application Platform J2ME Multi-Channel Interfaces PC Client Data Warehouse Excel Phone & Internet Connectivity Infrastructure PDA POS Smart Cards OGAC/Phones for Health (w/ permission)

10. CPHR ApplicationArchitecture HIV/AIDS Local Applications / Paper Systems Clinical/ Services Mgm’t APIs / Integration Surveillance Quality Assurance Functional Services Case Mgm’t Labs Training Program Mgm’t Donor Reporting Facility Registry Patient Registry Core Modules Health Data Dictionary Drug Formulary Indicator Registry Messaging Data Analysis Data Import/Export Core Functionality Web Security Data Mgm’t Core Application Platform Data Warehouse Internet Connectivity Infrastructure

11. Application Interoperability • What: Framework implementing… • Standard/common services • Implements standard functions • Why: Overall strategic vision expressed in architecture • Organizational responsibilities delineated in system boundaries • Business processes drive interfaces (PHII BPA) – try google for more information!

12. Haiti CPHRExample - Authentication • Service-Oriented Architecture (SOA) • Web Services standards and technologies • Common services (standards) • Authentication (LDAP) • Authorization (SaML, XACML) • Auditing (Apache Log4J & Syslog) • Authentication • Locally controlled business process • SOA (not WS) implementation

17. Application Interoperability - Methods • Common services - examples • (identity management) • Authentication • Authorization • Auditing • (security)

18. Scalability of Data Collection • Design for national scope • Integrate data across clinics • Integrate data across networks/organizations • Business rules around • Data sharing • Patient identification • Backups/fault tolerance/reliability

19. N a tional F ail o v er S a t elli t e Clinic Clinic with L ocal S e r v er S e r v er with R est r i c t ed A cc ess ( A d v an c ed IT I nf r astru c tu r e) (Limi t ed or No IT I nf r astru c tu r e) Ide n tified D a ta D a ta t r a v els via paper P aper f o r ms with off-si t e d a ta e n t r y On-si t e d a ta e n t r y of paper f o r ms C D , US B , e t c . P aper f o r ms with pe r iodic d a ta P ape r less d a ta e n t r y t o poi n t - of - ca r e e n t r y on-si t e ( r o ving lap t o p ) EMR Clinic r epo r ts gene r a t ed P a tie n t summa r ies and clinic r epo r ts off-si t e and sha r ed back gene r a t ed on-si t e D a ta t o the clinic N a tional r eplic a t es via P opul a tion i n t e r mit t e n t i n t e r net D a ta R eposi t o r y P r o g r am M&E D a ta W ith O ther A nal y sis t r a v els D e -ide n tified via D a ta r eliable Clinic with W eb A cc ess i n t e r net ( M ode r a t e IT I nf r astru c tu r e) M o n thly d a ta t r ans f er P aper f o r ms A pplic a tion S e r vi c e P r o vider On-si t e w e b -based d a ta e n t r y t o off-si t e d a tabase W e b -based d a tabase f or multiple si t es MESI P a tie n t summa r ies and P ublic A cc ess clinic r epo r ts gene r a t ed ww w .mesi. h t/mesi on-si t e Haiti CPHRScalable Data Collection

20. N a tional F ail o v er S a t elli t e Clinic Clinic with L ocal S e r v er S e r v er with R est r i c t ed A cc ess ( A d v an c ed IT I nf r astru c tu r e) (Limi t ed or No IT I nf r astru c tu r e) Ide n tified D a ta D a ta t r a v els via paper P aper f o r ms with off-si t e d a ta e n t r y On-si t e d a ta e n t r y of paper f o r ms C D , US B , e t c . P aper f o r ms with pe r iodic d a ta P ape r less d a ta e n t r y t o poi n t - of - ca r e e n t r y on-si t e ( r o ving lap t o p ) EMR Clinic r epo r ts gene r a t ed P a tie n t summa r ies and clinic r epo r ts off-si t e and sha r ed back gene r a t ed on-si t e D a ta t o the clinic N a tional r eplic a t es via P opul a tion i n t e r mit t e n t i n t e r net D a ta R eposi t o r y P r o g r am M&E D a ta W ith O ther A nal y sis t r a v els D e -ide n tified via D a ta r eliable Clinic with W eb A cc ess i n t e r net ( M ode r a t e IT I nf r astru c tu r e) M o n thly d a ta t r ans f er P aper f o r ms A pplic a tion S e r vi c e P r o vider On-si t e w e b -based d a ta e n t r y t o off-si t e d a tabase W e b -based d a tabase f or multiple si t es MESI P a tie n t summa r ies and P ublic A cc ess clinic r epo r ts gene r a t ed ww w .mesi. h t/mesi on-si t e Haiti CPHRImplemented Failover (UW) [N = 28] Clinic w/ Local Server [N = 11] National Population Data (UW) [N = 28] Clinic w/ Web Access [N = 17] ApplicationService Provider (housed at UW) (why?!) MESI (Haiti)

21. Scalability of technology • Scalable functionality w/in system • Variable data presentation • Variable data granularity • Variable site IT capacity • Scalable systems across levels of care • Requirements definition for national lab model • Implications for systems selection

22. Haiti CPHRScalable Technology • Range of users (presentation) • Data clerk entry • “Provider interface” • Historical / Distributed Care (granularity) • Registry model • Range of clinics (IT capacity) • Clinics w/ no ICT, to occasional ICT, to good ICT

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25. Intake as Data Clerk 1

30. Haiti CPHRScalable Technology • Range of users (presentation) • Data clerk entry • “Provider interface” • Historical / Distributed Care (granularity) • Registry model • Range of clinics (IT capacity) • Clinics w/ no ICT, to occasional ICT, to good ICT

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33. Haiti CPHRScalable Technology • Range of users (presentation) • Data clerk entry • “Provider interface” • Historical / Distributed Care (granularity) • Registry model • Range of clinics (IT capacity) • Clinics w/ no ICT, to occasional ICT, to good ICT

34. N a tional F ail o v er S a t elli t e Clinic Clinic with L ocal S e r v er S e r v er with R est r i c t ed A cc ess ( A d v an c ed IT I nf r astru c tu r e) (Limi t ed or No IT I nf r astru c tu r e) Ide n tified D a ta D a ta t r a v els via paper P aper f o r ms with off-si t e d a ta e n t r y On-si t e d a ta e n t r y of paper f o r ms C D , US B , e t c . P aper f o r ms with pe r iodic d a ta P ape r less d a ta e n t r y t o poi n t - of - ca r e e n t r y on-si t e ( r o ving lap t o p ) EMR Clinic r epo r ts gene r a t ed P a tie n t summa r ies and clinic r epo r ts off-si t e and sha r ed back gene r a t ed on-si t e D a ta t o the clinic N a tional r eplic a t es via P opul a tion i n t e r mit t e n t i n t e r net D a ta R eposi t o r y P r o g r am M&E D a ta W ith O ther A nal y sis t r a v els D e -ide n tified via D a ta r eliable Clinic with W eb A cc ess i n t e r net ( M ode r a t e IT I nf r astru c tu r e) M o n thly d a ta t r ans f er P aper f o r ms A pplic a tion S e r vi c e P r o vider On-si t e w e b -based d a ta e n t r y t o off-si t e d a tabase W e b -based d a tabase f or multiple si t es MESI P a tie n t summa r ies and P ublic A cc ess clinic r epo r ts gene r a t ed ww w .mesi. h t/mesi on-si t e Haiti CPHRLimited Technology Clinics