Building Sustainable Strategic Information Systems in Low-Resource CountriesBobby JeffersonSenior HMIS AdvisorAIDSRelief projectFutures Group International LLCPresenting on behalf of Lanette Burrows, Pat Bass, Ian Wanyeki

AIDSRelief OverviewPEPFAR Track 1.0 InitiativeCatholic Relief Services – Prime (CRS)University of Maryland Institute of Human Virology (IHV)Futures GroupCatholic Medical Mission Board (CMMB)Interchurch Medical Association (IMA)5-year project focused on increasing access to high quality HIV care and treatment

AIDSRelief OverviewImplemented in 9 countries: Guyana, Haiti, Kenya, Nigeria, Rwanda, South Africa, Uganda, Tanzania, Zambia, Ethiopia (April 2009)Focus on building capacity for quality HIV care and treatmentlab, pharmacy, clinical services, M&EMore than 212 local partner treatment facilities (LPTF)Small Rural Health CentersRural Health Clinics District HospitalsMission HospitalsUrban High Volume hospitals

Where we work729212 ART Treatment Facilities (Clinics) + 122 satellite Sites + 288 PMTCT sites1825107831824

Futures Group OverviewFutures Group provides strategic information (SI) capacity building and focuses on:Improved data demand and information use (DDIU)Enhancing/implementing patient monitoring and management (PMM) systems that meet local requirementsEnhancing Data quality for better services and clinical outcomesUsing local experts to build capacity at partner sites

Futures Group provides strategic information (SI) capacity building and focuses on:

Improved data demand and information use (DDIU)

Enhancing/implementing patient monitoring and management (PMM) systems that meet local requirements

Enhancing Data quality for better services and clinical outcomes

Using local experts to build capacity at partner sites

The teamFutures Group AIDSRelief is a comprehensive team of:M&E specialists HIV/AIDS expertsCliniciansHMIS expertsProgrammersProject Managers

Futures Group AIDSRelief is a comprehensive team of:

M&E specialists

HIV/AIDS experts

Clinicians

HMIS experts

Programmers

Project Managers

Regional Software development teamsin Kenya, Rwanda, South Africa, India

Strategic InformationCommitted to collecting only information essential for clinical management and quality improvementCapacity building (local ownership)Committed to feeding back information to the local partner treatment facility (Clinic) to address gaps in program and services

Committed to collecting only information essential for clinical management and quality improvement

Capacity building (local ownership)

Committed to feeding back information to the local partner treatment facility (Clinic) to address gaps in program and services

To offer a library of tools and solutions built around adaptive management, high quality data, and sustainability Freely available software, no licensing fees User , Admin Training, and In-country Programmer or Database Training availableTo develop requirements through practical field experience and lessons learnedTo take a collaborative approach using local experts throughout the development process

International Quality SolutionsSound products based on experience in the field– IQCare – IQChart – IQTools – IQGeo – IQReporting – IQShare – IQTrack – IQTraining– Training and Mentoring – Local Experts – DQ & QI – Ownership + Data useSkills transferIncreased CapacityAdaptive ManagementImproved servicesSustainabilityBest PracticesPositive outcomes

Patient Management and MonitoringTypical Hospital Records Center

Finding patient information in the past

KeyFeaturesStability and ease of use A browser-based, easy-to-use software tool with robust underlying SQL databaseNo Internet access required to use systemFacility and Patient DashboardsReal Time data entry and reportingCustom reports

Data Quality check

Data Quality Check

Data validationData Quality Check during data entryRequired FieldsEnforcement of required fieldsAlerts for data required for reporting or clinical trackingField level data validation present on every clinical formDate validationBoundary validation for numeric dataLaboratory result validationAlerts for data outside of normal range

Other FeaturesAutomated back upExport to Excel or access databaseCustom FieldsSites can add data fields for additional indicators specific to their needsDocumentationTraining manuals, Browser based help, IQShare portal

Monitoring our programs through IQSolutionsDemonstrate outputs and outcomesClinics ability to hit set targetsTrend analysisCD4 count changesMortality & Lost-to-follow-up ratesCase studies demonstrating outcomesUsing data collected on a routine basis for:Life table analysisDefaulter trackingQuality of life analysis

Clinics ability to hit set targets

Trend analysis

CD4 count changes

Mortality & Lost-to-follow-up rates

Life table analysis

Defaulter tracking

Quality of life analysis

“After successful assessment, the IQ Care system developed and supported by the Constella Futures Group and Catholic Relief Services came up top in terms of overall features (technical and non technical) and also in terms of largest number of installations ““From the above data, IQ Care comes out strongly ….recommended for medium to large ART centres.”WHO and CDC sponsored EMR Assessment Report , Kenya May 2009

What does it provide us with? ARV Pickup Report

Whatdoes it provide us with?Close monitoring of the ART pick up habits over time at LPTFs has helped ensure that fewer patients miss collecting their ARTs on time

ReportingARV Pickup ReportCDC Track 1.0 Quarterly ReportMonthly TRAC MOH reportsCustom user and Data quality reportsCohort mortality reportDisplay on screen or export to Excel

Three sites showing the sub-districts they service

# Defaulters per village – Green <5, Yellow 5-10, Red >10

Capacity Building and decision makingIdentify defaulters per village or sub-districtDeploy adherence counselors to follow-upIdentify trendsLink defaulter data to average distance travelled or average time taken reach the siteProvide supplemental services (transport)Open field service centers

Select a village to see the defaulter list and HCW assigned

Other DevelopmentsElectronic first (E-First) data entryPaperless ClinicsPilot in KenyaPilot in Nigeria ClinicWireless at ClinicsSecurity, Use of HTTPS, OpenSSL

# Defaulters (red) vs avg distance travelled to reach site (blue)Thank you

Useful Practices

Useful Low Tech ApproachesTraining local university students as data entry clerksInviting local internet service provider (ISP), and IT staff of other implementing partners to trainingsTraining of local programmersUse of daily skype conferencecalls or chat to communicate with in-country teamsUse of SMS text

Useful PracticesUse local experts to gather system requirements, pilot systems, and perform field acceptance testingUse of interactive Storyboards Follow up training 1-2 weeks after implementation ensures users have time to acclimatize to the new application and ask more meaningful questionsComplete documentation of system Integrate backup feature into the system and train staff on a standard operating procedure for backup

Useful PracticesEncourage data ownership at ClinicsTraining includes entire HIV case management team and focus on data quality and data use; other training areas include computer basics, data entry, data analysis and interpretation, system administration and custom report buildingMonthly and quarterly feedback to Clinics in addition to on site TA enhances information use and creates strong SI networks among Clinics

Build Data cultureData is key for informed clinical and programmatic decision makingBuild a data culture use by empowering clinics to make use of the data they collect (Local Ownership)Collect data that will be used Routine feedback to stakeholders helps improve accuracy of data collected and reports generated Use appropriate tools that facilitate data use

Routine feedback to stakeholders

Use appropriate tools that

Choosing the right SystemWith Local Partners: PMMSComprehensive system based on longitudinal medical recordsHigher capacity site with greater data demandHigh volume site with multiple data entrantsIT supported environment preferredScalable, single desktop to large hospital networkBasic but flexible system based on WHO register dataLower capacity site with lower data demandMinimal IT support requiredMulti-language capability

Comprehensive system based on longitudinal medical records

Higher capacity site with greater data demand

High volume site with multiple data entrants

IT supported environment preferred

Scalable, single desktop to large hospital network

Basic but flexible system based on WHO register data

Lower capacity site with lower data demand

Minimal IT support required

Multi-language capability

Tools for data verification, cleaning and reportingClinical reports for adaptive managementData migration toolIn use at 100-150 sites in 5 countries within AIDSReliefLocal capacity buildingAllows local sites to develop their own reports

Overview of GISHighly technical and specialized fieldSkills scarceConsulting fees highTraditional GIS Software expensiveRecurring billing‘Per seat’ billingModular or ‘per feature’ billingApplications are complex and inflexibleDesigned for use by GIS experts

Custom GIS ApplicationsUsing free Google earth to create custom applications, one can:Target specific audiencesCreate simplified and familiar interfacesEasier and logical for staffReduced learning curve

Google MapsGoogle maps export file format well establishedEasy to interact and share data with other systemsEasy to share visual data with colleagues via emailExport to .kmlColleagues view results in free Google Earth

Futures Group GIS experienceGoogle earth integrated with data from Local PMMSInternational aggregate databasesImprove treatment outcomesFacilitate adaptive managementFacility level Program level

Additional Technical BenefitsBuild our own library of data layers and presentation tools for use and view in familiar Google Earth environmentEasily store additional information using standard Google Earth markers and toolsDirections to hospital sites GPS coordinatesOffice contact information, Address, location informationLocal photos, street level viewsFacility start date (the date the facility started receiving funding)Number of clinical and data managers Number of satellites clinics and locationsServices at site HIV, VCT, PMTCT, TB, NutritionPhoto or picture of hospital facilityPhoto or picture of satellite facilityDescription of hospitalCan integrate large quantities of information about the environment and provide a powerful set of analytical tools to explore the data

Google Maps -technical considerationsApplication and data hosted locally or on an intranet but...Internet connection requiredBasic map data comes from GoogleUser data and application stored locallyEnterprise version can be used offline butAnnual license fees

Custom GIS ApplicationsVarious data sources can be usedExcel, Access, SQL, XMLDevelopers can create multiple interfaces for different audiences:Facility management tool for local managementCountry or multinational program managementNational MOH level interface

Current Uses at AIDSReliefAIDSRelief was assigned to districts and is providing services throughout the district at all health facilitiesCurrently providing services sites and scaling up in the near futureGIS application:Will break down provinces to districts to sectors and cells Map current AIDSRelief sites and their current catchment areas and to planned service expansion areasIdentify areas where coverage may be lackingMap prevalence rates by sector or cell and compare to where AIDSRelief is providing services

Capacity Building and decision makingCatchment areas per site identifiedUnder serviced areas highlightedCompare prevalence rates and population statistics to services providedInformed decisions made:Open satellite sitesDeploy additional staffTransfer patients from under performing sites to other nearby sites and redeploy funds elsewhere for greater impact.