PEPFAR Malawi Baobab Health Trust EMRS Leveraging Patient-level Systems for Surveillance & Monitoring September 13, 2017 Johannesburg, South Africa
What is the Baobab EMRS System? Modular Point of care approach Computer touchscreen Label printer Bar code scanner HIV Related Modules ART HIV Testing Services (pilot) Pharmacy (supply management & Rx Fast Track software) Lab Management Software Open source User Support/ Monitoring Dashboard for active monitoring of equipment over network Telephone help desk for users 2
Patient Monitoring/ Reporting Decision Support Viral load clinical reminder RxFast track software indicating eligible patients Weight monitoring for nutrition counseling/ support BP/ hypertension monitoring (pilot) Medication adherence Reporting Defaulter list (patient info & contact details) Cohort report for DHA quarterly data collection Missed appointments 3
EMRS Coverage Where Deployed ART: 99 high volume sites nationally Coverage of nearly 50% of patients on ART HIV Testing: 4 pilot sites RxFast Track Software: 4 pilot sites Lab Information Management System: 5 DNA PCR Labs Antenatal Care: 24 sites Accelerated Rollout 120 facilities have all hardware & software (Oct 2017) 188 have activated ART modules (Sep 2018) 270 facilities fully equipped (March 2019) 4
Data Collection for Program Monitoring/ PEPFAR Systems integration 48 sites currently linked to network backbone for electronic data transfer to BHT Plans to link all sites by March 2018 BHT staff travel to site and manually download data from most facilities quarterly Data collection/ transfer Data collected during quarterly MoH collection/ supervision exercise EMRS printed report provided at facility and keypunched into DHAMIS Currently no electronic data transfer to MoH 5
Highlighting Effectiveness & Challenges of Current Baobab EMRS Effectiveness ART module Produces high quality, consistent, facility and individual level data Many disags possible Good for site level analyses/ comparisons Limited Results in improved clinical management due to decision support Intuitive and user friendly software facilitates clinician use Hardware functions well in low-resource environment Challenges Going to scale Connectivity: Malawi not well connected, so many work-arounds Electricity: has 12 hour backup system Currently creating new ART register for use only when system is down Currently using patient register and patient cards used in parallel, but system produces printed stickers to attach to patient card to improve efficiency Lack of technical support at facility level when system has functional issues 6
HIV Case-based Surveillance Continuum of HIV captured by case-base surveillance 1 st positive HIV test Linkage to care 1 st and f/u CD4 count ART eligible ART initiation Advanced HIV - OI Viral Load/ viral suppression Death DATE
WHO consolidated SI guidelines for HIV in the health sector: global indicators CBS provides numerators for key global indicators
Malawi Case Surveillance System Objectives: Monitoring of patients across the HIV care cascade: HCT to VL suppression Measuring burden of disease Monitor impact of disease Project implementation I-TECH and Baobab Health Trust Process: Integrate existing electronic systems to generate a national individual level/longitudinal data for program management Central repository of merged & de-identified patient-level data Selected data elements to be pushed from EMRs at facilities to a central database using encrypted transmission Source modules to include: HTS, ART, ANC and LIMS; Death Registration system is planned for integration in future National Health IDs and a duplicate matching algorithm to be used to deduplicate records from same patient seen at multiple facilities Data to be de-identified and stored in a separate surveillance database
Malawi Case-Based Surveillance System ART ANC OPD HTC TB Central Data Base (linked, de-duplicated, de-identified) CRVS Data Surveillance Data Cohort
Routinely Generated Program Data VCT Facility - Demographics - Behavioral risk factors - Date of diagnosis PMTCT Facility - Demographics - Date of diagnosis (mother) - Date of exposure (baby) - PCR value (baby) - ART (mother & baby) Laboratory - Demographics (if available) - Date of diagnosis - Lab tests (CD4, VL, PCR) Longitudinal Database Vital Statistics - Case Identifier - Demographics (if available) - Date of death TB Clinic - Demographics - TB diagnosis, TB treatment, ART initiation, etc. - Date of event ART Facility - Demographics - ART eligibility, ART initiation, comorbidities, etc. - Date of event
Data Stored at Centralized or Decentralized Repository(s) Data can be centralized at a national or sub-national level, provided capacity exists for: Routine data cleaning and quality assurance Routine monitoring of the system (completeness, timeliness, accuracy, etc.) Feedback/support to providers not appropriately transmitting data Matching/de-duplication of HIV clinical surveillance data Routine analysis and dissemination Promote data use by strategic information and program staff to direct program planning and improvement
Why HIV Case-based Surveillance? Increased demands by national and international stakeholders to use program data for planning and measuring impact National HIV program planning PEPFAR COP process (e.g., SDS) and APR/SAPR reporting WHO consolidated strategic information indicators Disease modeling (e.g., SPECTRUM) Measuring progress to UNAIDS 90-90-90 and PEPFAR epidemic control Current systems may not fully meet all these demands in most PEPFAR supported countries