A Real-time Electronic Medical Record to Drive the Quality

Improvement Program of HaitiOn behalf of The Ministry of Public Health and Population (MSPP) & CDC-Haiti:

The HIVQUAL-Haiti TeamBruce Agins, MD MPH; Director, HEALTHQUAL International

Kuala Lumpur, July 2013

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

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

Adult15-49 2.2% (1.9-2.6)

Women 2.2% Men 2.0%

Urban 2.4% Rural 2.0%

1 EMMUS-V (2012) 2 ihsi.ht 3 NASTAD Haiti 4 ONUSIDA 5 mesi.ht

Rationale for Implementing the EMR

• 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

Paper based system:

• 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. .

• iSanté supports 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 iSanté clinics / hospitals have local servers, which eliminates reliance on slow Internet connections and allows automatic replication of patient data to a central patient data repository.

Architecture of the EMR

iSante is an open source system developed in an environmentLAMP (Linux OS, Apache web server, MySQL database, and PHP scripting language)

Timeline for the Development of an EMR **

Phase 1 (~4 months)Refine paper-based HIV medical forms

Phase 2 (~9 months)Develop data entry system for paper-based HIV medical record

Phase 3 (~10 months)Develop EMR for national pilot sites

Develop, provide,

review, and validate forms

Provide support for

form use

Finalize forms and

guidelines on unique patient

identifiers

Identify reports to be generated from

the database

Protocols for data cleaning, management,

and reporting

Training, implementation,

and support

Database matching paper-based forms

Identify sites for EMR

expansion

Interface to support

interactive EMR

Protocols for use of EMR

and reporting

Deploy EMR and train personnel

**PARTNERSHIP BETWEEN HAITI MSPP-CDC-ITECH-TULANE

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

Multiple retrospective or prospective reports that generate case lists for care reminders can be use at all levels Clinics Departments National

Wide set of report for decision making

Visit scheduled next 7 days

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

HEALTHQUAL HAITI TimelineDecember 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

National Quality Advisory BoardResponsible: DG MOH

Core TeamResp: MOH, CDC

Departmental Quality CommitteeResp : DD

Clinic Quality CommitteeResp : Medical Dir,

Coordinnator or Site Manager

Departmental Quality Committee Resp : DD

Clinic Quality Committee Resp : Medical Dir,

Coordinnator or Site Manager

Departmental Quality Committee

Clinical Quality Committee

HEALTHQUAL InternationalResp: NYSDOH AI

Coaching TeamResp: CDC

SecretariatResp: MOH

HealthQual-Haïti Organigram

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

Cotrimoxazole Prophylaxis ( N: 10666 → 36685 pts )

0

10

20

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60

70

80

90

100

Jan-Juin Juil-Dec Jan-Juin Juil-Dec Jan-Juin Juil-Dec Jan-Juin Juil-Dec Oct-Mars Avr-Sept

2008 2009 2010 2011 FY 2012

Scor

e m

oyen

des

clin

ique

s en

(%

)

Hurricane Hanna

Earthquake- Cholera

National

Pourcentage de patients VIH+ qui ont reçu du CotrimoxazoleInterventions

• Diffusion of National Guidelines to all clinics

• Distribution of case list of taken from iSanté to the pharmacy unit

• Systematic data entry of pharmacy form in iSanté

PMTCT ( N : 289 → 737 pts )

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Jan-Juin Juil-Dec Jan-Juin Juil-Dec Jan-Juin Juil-Dec Jan-Juin Juil-Dec Oct-Mars Avr-Sept

2008 2009 2010 2011 FY 2012

Scor

e m

oyen

des

clin

ique

s en

(%

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Cyclone Hanna

Seisme - Cholera

National

Pourcentage de femmes enceintes VIH+ ayant démarré la prise des ARV

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.

• Early dispensing of ART HIV+ PW

• Systematic data entry of OBGYN and pharmacy form in iSanté.

USE OF EMR AT CLINIC LEVEL TO IMPROVE QUALITY

Idées pour surmonter les

Barrières

ANALYSES SYSTEMES

Implémentation

Improvement of ART enrollment through improvement of quality of serviceExperience of Hopital Universitaire de la PaixDerival Raymonde, MD; Bogart Mie Johanne, Nurse; Maisonneuve Yvette, Nurse; Isaac Daniel, SW; Aristile William,Data Clerk; Auguste Marie Carmen , Nurse; Jenny X; Clerrier Nadege

BACKGROUND -Rationale of the ART Enrollment projectAll 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.

Continuity ARV

Monit CD4

ARV Enrol

Px TMS

Adherence

TB Screnning

Nutrition as

sess

Family

Planning

PMTCT

Immunisa

tion0

20

40

60

80

100 HIVQUAL report jul-dec 10

%

A multidisciplinary team was created by theQuality 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 registerSecond Strategy - Reduction in Pre-ART period:Weekly visits required for patients until ARTEnrollment. Third strategy –Enrollment Acceleration:Increase number of new enrollees with newverifcation process by data clerk. Participation in post-test clubs.

Reduction of pre-ART waitand 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 toselect patients for enrollment from pre-ART list.-Staffing levels require more than one psychologist to help patients accept treatment andaddress mental health problems.

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

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….

• https://isante-demo.cirg.washington.edu/isante/

• username: demo• password: demo

Special thanks to Nicasky Celestinn and Margareth Jasmin