Bobby Jefferson, Senior Health Informatics Advisor, Futures Group

• Principal Investigator CDC HMIS Grant Kenya

• CDC Strengthening HIV Strategic Information Activities In The Central Asia Republics Columbia University

• CDC Partners in AIDS Care and Treatment in Kenya, University of Maryland Institute of Human Virology

• CDC National Teaching and Referral Hospitals Centers of Excellence in Kenya, University of Maryland Institute of Human

Virology

Implementing eHealth EMR for Low Resource Hospitals in Developing Countries

Outline

Description Low Resource Environment

Approach Low cost, appropriate technology

Solutions

Sharing Lessons

We are working across 15 Countries, 1,033 Hospital Facilities + Satellites Clinics , Antenatal Care - PMTCT sites (535 in Tanzania)

Rural, remote, mission hospitals “serving poorest of poor” and Ministry of Health (MOH) facilities

• Intermittent power, • Lack IT staff, • Lack internet, • Sparse mobile coverage

Low Resource Environment

Results

• Internet

• Mobiles, SMS

Rural, Remote City

# of Facilities

• Sparse Mobile Coverage• No Internet

• Intermittent Power

Online Solutions

MobileSolutions

Offline, DisconnectedSolutions

• Smartphones

Nurses, Clinicians, Adherence Counselors, need health data, M&E program data in knowledge repository

• Lack of referrals, or linkage between HIV, PMTCT, TB, or to existing technology systems

• Cost effectiveness and sustainability -- no funds for proprietary licenses, or yearly maintenance fees

Low Resource Environment

Approach

Use of freely available, reusable, tools, “coded in country” Creative commons approach

Reusable software and technology across countries and programs

Offline Solutions, Disconnected model

Local programmers, all IT staff in country (Africa)

- Programmer training SQL, coding C#, Agile process

Low costs, Inexpensive $200-$350 Netbooks , Solar netbooks

Solar mobile phones, SMS instead of Smartphones

- Use of inverters to address power

Health IT Solutions

Collectively referred to as IQSolutions

1. Electronic medical records

1. IQCare - Technical Assessment by CDC Atlanta, WHO,

USAID, NASCOP and MOH

2. IQChart - French language Rwanda

2. Mobile Phone solution (IQSMS technology)

3. Visual Dashboards

4. Monitoring & Evaluation Electronic reporting

5. SQL Training, Programmer Training, Virus Remediation

Training

6. Data Demand and Information Use (DDIU) and reducing

operational costs

IQCare

*Paper-based records automated

*Clinicians able to review individual patient histories, prescribed drugs, ordered tests and results, and progress on care and

treatment during the exam

Clinicians able to review individual patient histories

*Clinicians review patient histories, prescribed drugs, ordered tests and results, and progress on care and treatment during the exam

Browser, SQL Express, .NET, openSSLArtifacts• Entity Relationship Diagram (ERD)• Data Dictionary• Use Case Document• Business Rules Document

EMR SystemIQCare

(Facility Level)

DonorsOGAC, CDC, HRSA, USAID

MOH National ReportsNext Gen Indicators (NGI)

Community Mobile health solutionsDimagi, mHealth Alliance,

Nethope

HL7 v2.4

SDMX-HD

mHealth

Pharmacy , Supply ChainManagement Sciences Health,

ARV dispensing tool (ADT)

Clinical/Medical PartnersSchool of Medicine, Faith Based Orgs

Mennonite Christian Charities

CHAK, IMA

Integrated HIV, TB, PMTCT

Intel World AheadNetbooks, low cost,

low power

Financial Mgmt PartnersPastel Software,

Tableau Dashboard

Laboratory PartnersOpenELISBika Labs

TherapyEdge

District Indicators, DHIS v2.0 software,

Other EMR

• Improved Data Quality• Improved Data Use at health facility• 200 Data Managers trained• Reducing Costs, Improved Patient Workflow

Kenya Results

• PMTCT forms• Integrated HIV, TB, PMTCT 3IPMS

MOH 711 , MOH 257 “blue card”

TotalTotal

Patients served Non ART ART Transactions UniqueVisits

Visit Type

ARTFollow UpVisits

Labvisits

pharmacyVisits

31 118,820 67,806 51,014 4,178,313 2,005,502 1,405,984 741,075 1,501,027

This is to sincerely thank you for having come to our users’ training that was held at Baraton from 1st – 5th August 2011. We had a successful meeting attended by 60 users from South Rift, Kisumu West and KDoD. From their feedback, they liked the IQCare because of its robustness, ease of use and especially the way it captures our forms. We shall be having more of this especially refresher courses in future after we have rolled out IQCare. As of now we are confident on the system and ready to implement the system.

demo

http://173.203.65.108/iqcare/frmLogin.aspx

Username: user1

Password: 1

Facility/Satellite: 001-01-01-Demo Site

PMTCT Currently consists of 4 types of monthly reports

1. PMTCT Antenatal Clinic (ANC) Monthly Summary Form

2. PMTCT Care Register Monthly Summary Form

3. PMTCT Maternity (L&D) Monthly Summary Form

4. PMTCT Mother - Child followup SummarForm

IQSMS PMTCT Reports

IQSMS – Mobile Phone Reporting by Health Workers

Monthly and Quarterly Reports

PMTCT Report

Must Pass All Data Quality Rules,District Office

Data Quality Checks

NUMBER OF CLIENT HAD HIV TEST AT ANC

• Nurses and community health worker receive per diem or transports costs for picking up or bringing their list and reports back and forth to health facilities, district offices, etc.,– they’re not interested in losing out in reimbursement;

• After early adopters, health care workers not keen sending message unless they have free airtime and toll free number available from their mobile telecom provider ; we increase use by 50% when toll free is available

• The older staff have more difficulty using mobile for messaging and reporting;

• Often other people have access to the phones (25% share phone vs. Own) and often those text message can be forwarded to others

• Staff in rural areas want their SMS messages in Swahili or local language; Detailed instructions in Swahili to how to do reporting and use phones for reporting

technology isn’t the barrier to scale up

Facility Name District

Distance from

Facility to

District (KM)

Time spent to

Deliver PMTCT

Report (Hrs)

Bus Fare (Tsh)

MWANZA Region

NYAMAGANA DISTRICT

Mwamashimba Health Centre Kwimba 50 1.30hrs 10000

Malya Health Centre Kwimba 25 1hr 5000

Kikubiji Dispensary Kwimba 102 4hrs 20000

Kiliwi Dispensary Kwimba 100 4hrs 20000

KWIMBA DISTRICTNyakalilo Health Center Sengerema 46 2 HRS 8000

Mwangika Health Centre Sengerema 98 4 HRS 10000

Sengerema Health Centre Sengerema 10 20MIN 3000

SENGEREMA DISTRICTKharumwa Health Centre Geita 115 3HRS 20000

Nzera Health Centre Geita 48 2HRS 8000

Katoro Health Centre Geita 50 45MIN 6000

Nkome Dispensary Geita 80 2HRS 6000

Nyang'hwale Health Center Geita 85 2HRS 7000

Kasamwa Health Centre Geita 25 30MIN 4000

Bukori Health Centre Geita 60 1:30HRS 6000

Tanzania

• Delays with data flow and information reporting from the District and Regional level to the National level

• Inaccuracy of reports being received thus requiring further on site data verification

• High cost of supervision and sending report to district in regards to travel costs to access the 535 health facilities

• Ever used the phone for SMS servicesNo 52.17%

Yes 47.83%

Total 100

– All staff own the telephone handset and share it in daily personal uses

Any problems with small buttons on the phone?

Response Freq %

No 30 85.71

Yes 5 14.29

Total 35 100

Instruction on Swahili critical to using IQSMS

Response Freq %

No 6 17.14

Yes 29 82.86

Total 35 100

• Reasons For Not Sending Monthly Report– Majority said they don’t understand English

language

– Need message understandable in Swahili language

IQSMS Instructions in Swahili

• Anything that can be improved on report submission to make report to be on time

• Response Freq %

• No 14 40.00

• Yes 21 60.00

• Total 35 100

Barriers to implementing mobile phone reporting for submitting all four reports each month Mobile Network Problem/failure

Server don’t respond on time

PCR report type is hard

It have been found that free Airtime is critical for scale up

*EMRS – Electronic Medical Records System

Health IT Solutions

*EMRS – Electronic Medical Records System

Health IT Solutions

Tanzania mobile phone coverage and mobile penetration Vpdacom Tanzania

•

Excel

PMTCT MONTHLY REPORT

PMTCT Antenatal Clinic (ANC) Monthly

Summary Form

ANC 01. New ANC clients this month

118

8ANC 02. Previously known to be HIV

positive 17

ANC 03. Total number tasted 574ANC 04. Number of new client had HIV test

at ANC 277

ANC 05. Tested HIV-Positive 37ANC 06. Post-test counseled for positive

and negative 574

ANC 07. Number of partners tested for HIV 16

ANC 08. Tested HIV-Positive 4

Orphans Vulnerable Children (OVC), Most At Risk Population (MARPS), Maternal Child Health (MNH)

Ms Access Database

PDA device

Web Internet Desktop

Excel Only

M&E Electronic Reporting SystemSolar Power Cell phones

Site Capacity Dashboard

demo

http://scademo.dyndns.org

Username: demo

Password: demo

Collaborators and Users

Rwanda

ICAP Columbia University 44 sitesIntra Health International 17 sitesElizabeth Glaser EGPAF 16 sitesFamily Health Inter FHI 45 sitesCatholic Relief Services 13 sites

Kenya

Catholic Relief Services - 32Pathfinder InternationalGertrude Children HospitalDOD Walter Reed - 28 Mount Kenya UniversityMOH Kenya Sites

AIDSReliefJohn Snow InternationalRakai Health Services Vaccine Research

Uganda

Intra Health International Southern Sudan

Mennonite Christian CharitiesAIDSRElief 35 sites

Nigeria

PMTCT , ANC sites 535 sitesElizabeth Glaser EGPAF

Tanzania

World Vision NETHOPE

Zambia

Ministry of HealthMinistry of Education

Guatemala

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.atsdr.cdc.gov

For more information http://www.iqstrategy.net/frmiqcare.shtml

Source Forge

Contact

Bjefferson at futuresgroup.com

Lburrows at futuresgroup.com