Health Records Transition Project

Informatics Team April 23, 2012

Project goals & key objectives Project Plan Engagement of site staff and clinical leaders Data collection Process analysis Recommendations for change Future state documentation for

implementation

Agenda

Transition the health records at Mosoriot and Turbo sites (Pilot sites) to establish a model for the CDM, PHC Episodic Care and MCH clinics that will be used across the AMPATH catchment area

To establish a model for an electronic reporting solution that will be applicable for all AMPATH PHC sites. ◦ The model must meet the MOH and AMPATH Monitoring and Evaluation reporting

requirements and the managers’ administrative requirements.

To develop a strategy for the expansion of provision and use of the Universal ID for all AMPATH patients/clients across the AMPATH catchment area.

Project Goals

The pilot sites will have new processes / workflows for Episodic Care, Maternal Child Health and Chronic Disease Management clinics

Encounter forms for Chronic Disease Care, Episodic Care, and Maternal Child Health care will be updated Meet the clinical and reporting requirements of the clinicians and administrators Prepare for direct clinician use of the AMRS

The AMRS will be updated based upon the changes in the updated encounter forms and reporting requirements

The pilot sites will have new policies regarding Health Records taking into consideration the move to electronic records

The pilot sites will have a support model to follow includes access to site health records / process experts and IT support staff

Key Objectives

Project Plan

Identified through Stakeholder Identification and Analysis process at beginning of project◦ AMPATH CDM and PHC Clinical Leader Representatives◦ AMPATH and MOH PHC Leadership◦ AMPATH Monitoring & Evaluation ◦ Mosoriot and Turbo Site Leadership: PHC and HIV Clinics◦ Site Staff at Turbo and Mosoriot – All Departments◦ AMPATH Information Technology Leadership and Staff◦ AMPATH Clinical Decision Support Leadership

Each group is involved at a different level◦ Active input, validation, decision making, configuration,

information only

Engagement

Collected information on current processes, policies, documentation, clinical protocols, and identifiers for all PHC and HIV clinic departments at both pilot sites◦ Processes through interviews & observation◦ Documentation - site specific, MOH, AMPATH, CDC project

encounter forms Collected information on requirements

◦ *Clinical ◦ *Reporting for PHC – MOH, USAID, AMPATH Internal◦ Administrative

Data Collection

Swim lane diagram draft #1 Narrative description draft #1 Review and validation with health practitioner Modification of diagram and narrative

◦ Draft #2 Second review and validation with health

practitioner if required Final current state process

◦ Turbo Site Example 26 diagrams HIV Clinic with narrative for each 18 diagrams PHC Clinic with narrative for each

Analysis – Current State Process

Current State Workflow

ANC 1 The patient arrives at ANC clinic from either Filter or the CO’s office with their AMRS Peri-Natal Encounter Form which they received at Registration. If they are a return patient they also have their Mother and Child Health Booklet with them.

ANC 2 The ANC Nurse determines if the patient is a new patient or not.

2a. If it is a return visit, the ANC Nurse finds the patients record in the MOH ANC Register 405. She finds this by checking the Mother and Child Health Booklet for the last visit, and then going to the entries on that specific date. If the ANC Nurse does not find the patient record in the MOH ANC Register, the ANC Nurse starts a new patient record entry (note that the data entered will not be continuous in this case).

ANC 3 If the patient is a new ANC patient the ANC Nurse first completes pMTCT testing with the patient.

ANC 4 The ANC Nurse then immediately documents the pMTCT test results in the in the pMTCT Register, ANC Register, Perinatal Encounter Form, and Mom and Child Health Book

ANC 5 If the patient is HIV positive and the HIV clinic is still open, the ANC Nurse takes the patient directly to the HIV clinic to see the CO responsible for pMTCT. Note: the patient is able to go to the front of the queue because they have already waited in the ANC queue.

ANC 6 If the patient is not HIV positive, then the ANC Nurse takes the patient’s AMRS Perinatal Encounter Form and circles the lab tests that need to be completed (Hgb, urinalysis, VDRL, pregnancy test, blood grouping, RH status and malaria, if symptoms). The ANC Nurse sends the patient to the laboratory with the Encounter Form to have the tests completed

Workflow Narrative Example

Issues and Opportunities

Process #

Issue Opportunity

ANC #4 Documentation of ANC information in the MOH ANC Register does not provide for the ability to report electronically and is a repeat of the information that is currently in the Perinatal Encounter Form. Nursing time is used for duplicate documentation instead of patient care.

Recommendation: d/c documentation in the MOH ANC Register. Replace with documentation in new ANC Encounter Forms.

Benefit i) ANC Nurse will document in one

health centre record which will limit the amount of time documenting on a daily basis. This will translate into more patient care time.

ii) Information available for electronic reporting

Issues and Opportunities

Process #

Issue Opportunity

PHC R2 to R9

Only one registration clerk has a computer therefore only they can check the AMRS to determine if there is a patient record. This is a bottleneck making the queue very long at registration, especially in the morning.

Recommendation:

Two registration clerks each with a computer and sharing the printer & laminator. Each clerk handles all of the registration functions.

Benefit – To shorten the queue at Registration and get patients flowing to the clinics more quickly in the morning as the clinical officers and nurses are waiting in the clinics with idle time.

Discuss recommendations with clinical and administrative leadership◦ Pilot site leadership teams

Turbo and Mosoriot PHC Leadership Turbo and Mosoriot HIV / CDM Leadership

◦ AMPATH clincial leadership PHC CDM

◦ MOH leadership For PHC component

Final approval required by leadership groups

Recommendations to Leadership

Dept Clinical Documentation Retaining

Clinical Documentation Discontinuing

New Documentation Records

All PHC clinical depts

MOH Referral Form

PHC Orals Prescription Form

Free Net Pack Record Card

Monthly Tally Sheets

Paper monthly reports

Clinical Summaries

Requisition form for laboratory and x-ray tests

Internal referral form

PHC Injectables Prescription Form

Recommended Documentation Changes for PHC Level 3 Health Centres

Dept Clinical Documentation Retaining

Clinical Documentation Discontinuing

New Documentation Records

MCH Antenatal Clinic

Mom and Child Health Booklet

AMRS Perinatal Encounter Form

MOH ANC Register #405

AMRS Antenatal Care Initial Encounter Form

AMRS Antenatal Care Return Visit Encounter Form

Recommended Documentation Changes for PHC Level 3 Health Centres

Filter / Triage◦ CWC clients to go directly to CWC from Registration and not through Filter

(if mom does not need to access MCH services) Will decrease bottleneck at Filter Filter staff is only taking temperature of baby With decreased documentation in CWC, anticipated that staff will have

time to temperature Lab

◦ Laboratory and X-ray staff to document results on the lab & x-ray requisition form which is sent back to CO with patient

◦ Labs from Eldoret AMPATH lab – received directly into AMRS Lab tech to check AMRS daily for results

◦ Labs from National Reference Lab Paper lab results to CO in-charge (determine course of action), to lab

tech (validate with original requisition), to data assistant (to enter into AMRS and then print clinical summary with result), to cough monitor or back to CO

Recommended Workflow Changes

Clinical – MCH◦ Integrate Cervical Screening with MCH Adult

Postnatal Family Planning Cervical Screening CO MCH Cervical Screening Registration MCH Cervical Screening

◦ CWC Patients will see the nutritionist first and then the nurse Assessed and treated for malnutrition before immunizations and supplements

provided

Reporting ◦ Reports will be pulled electronically from the AMRS by site personnel by the

third day of the month and Reviewed and entered by site personnel into the DHIS by the 3rd day of the month Once an AMRS/DHIS interface is built the transfer of reporting information from

AMRS to DHIS will be automatic Anticipated within next one year

Recommended Workflow Changes

Based upon approved recommendations Swim lane workflow diagram Narrative description

Future State Workflow Processes

Future State Workflow

Project Repository ◦ http://

wiki.ampath.or.ke/display/ampath/Health+Records+Project

Contacts◦ Wilson Too wkipkoech@yahoo.com◦ Jeff Adina ajadinajo@gmail.com◦ Lori Siddall lorisiddall@gmail.com

Documents and Contacts