Chris Seebregts, PhD Biomedical Informatics Research, Medical Research Council Department of Computer Science, University of KwaZulu-Natal Jembi SOUTH AFRICA OpenMRS and Open Architectures, Standards and Information Systems for Healthcare in Africa

THAT’SIT PROJECT That’sit is a methodology for improving access to HIV care for tuberculosis patients using a best-practices approach. The South African MRC is offering ART to qualifying TB patients as part of that’sit in several provinces in South Africa. The aim is to improve treatment outcomes for both TB and HIV by introducing and implementing integrated TB-HIV services wherever possible, including information systems.

That’sit is a methodology for improving access to HIV care for tuberculosis patients using a best-practices approach.

The South African MRC is offering ART to qualifying TB patients as part of that’sit in several provinces in South Africa.

The aim is to improve treatment outcomes for both TB and HIV by introducing and implementing integrated TB-HIV services wherever possible, including information systems.

Example of HIV / ART Structured Medical Record Forms (KwaZulu-Natal, South Africa)

Example of HIV / ART Structured Medical Record Forms (Free State, South Africa)

Tuberculosis Treatment Card Page 1

District Tuberculosis register

PEPFAR Indicators Core Indicator 1: Existence of national policies, strategies and guidelines for ART programmes Core Indicator 2: Percentage of districts or local health administration units with at least one health facility providing ART services in line with national standards Core Indicator 3: Percentage of ARV storage and delivery points experiencing stock-outs in the preceding six months Additional Indicator 3.1: Percentage of ARV storage and delivery points meeting the minimum quality criteria in addition to having no stock-outs Core Indicator 4: Number of health workers trained on ART delivery in accordance with national or international standards Core Indicator 5: Percentage of health facilities with systems and items for provision of antiretroviral therapy services Core Indicator 6: Percentage of health facilities with ART services which also provide comprehensive care, including prevention services, for HIV-positive clients Core Indicator 7: Percentage of people with advanced HIV infection receiving antiretroviral combination therapy Core Indicator 8: Continuation of first-line regimen at 6, 12 and 24 months after initiating treatment Core Indicator 9: Survival at 6, 12, 24, 36, etc. months after initiation of treatment

Core Indicator 1: Existence of national policies, strategies and guidelines for ART programmes

Core Indicator 2: Percentage of districts or local health administration units with at least one health facility providing ART services in line with national standards

Core Indicator 3: Percentage of ARV storage and delivery points experiencing stock-outs in the preceding six months

Additional Indicator 3.1: Percentage of ARV storage and delivery points meeting the minimum quality criteria in addition to having no stock-outs

Core Indicator 4: Number of health workers trained on ART delivery in accordance with national or international standards

Core Indicator 5: Percentage of health facilities with systems and items for provision of antiretroviral therapy services

Core Indicator 6: Percentage of health facilities with ART services which also provide comprehensive care, including prevention services, for HIV-positive clients

Core Indicator 7: Percentage of people with advanced HIV infection receiving antiretroviral combination therapy

Core Indicator 8: Continuation of first-line regimen at 6, 12 and 24 months after initiating treatment

Core Indicator 9: Survival at 6, 12, 24, 36, etc. months after initiation of treatment

South African National M&E Framework Indicators Number of accredited service points per district % of facilities experiencing stock out of basket of tracer drugs at any time in the last month Full time equivalent (FTE) per category as proportion of required personnel Male and female condom distribution rate % of eligible patients receiving supplement meal and nutritional supplements Proportion of adult patients on antiretroviral therapy with adherence lower than 70% Number of CD4 counts done per month Number of viral loads completed per month Proportion of registered patients on regimen 1a or 1b, 2 or child regimen % of patients with viral load <400 copies / ml % of patients with CD4 > 200/mm3 % of patients with weight gain > 10% compared to baseline % of child (6-14yrs) ART patients with CD4 <15% at staging Known-death rate among patients on antiretroviral therapy Proportion of patients assessed medically eligible for treatment % of assessed patients medically eligible for treatment that completed readiness training

Number of accredited service points per district

% of facilities experiencing stock out of basket of tracer drugs at any time in the last month

Full time equivalent (FTE) per category as proportion of required personnel

Male and female condom distribution rate

% of eligible patients receiving supplement meal and nutritional supplements

Proportion of adult patients on antiretroviral therapy with adherence lower than 70%

Number of CD4 counts done per month

Number of viral loads completed per month

Proportion of registered patients on regimen 1a or 1b, 2 or child regimen

% of patients with viral load <400 copies / ml

% of patients with CD4 > 200/mm3

% of patients with weight gain > 10% compared to baseline

% of child (6-14yrs) ART patients with CD4 <15% at staging

Known-death rate among patients on antiretroviral therapy

Proportion of patients assessed medically eligible for treatment

% of assessed patients medically eligible for treatment that completed readiness training

OpenMRS (Open Medical Record System) www.openmrs.org

REASONS FOR SELECTING OPENMRS Configurable forms based application that can provide a very close fit with systems created by the South African Ministry of Health. Readily configured for different forms used by different programs and provinces while maintaining the same basic concept dictionary (integration of data and same reports) Open source application, in line with the progressive decision by the South African Cabinet to promote the use of open source software within government departments. Scalable to accommodate hundreds of thousands or millions of patients on ART. Open standards and interfaces allowing interfacing with other applications, notably the electronic TB register and the DHIS. Powerful support for localization into other languages (African languages, Portuguese, French etc)

Configurable forms based application that can provide a very close fit with systems created by the South African Ministry of Health.

Readily configured for different forms used by different programs and provinces while maintaining the same basic concept dictionary (integration of data and same reports)

Open source application, in line with the progressive decision by the South African Cabinet to promote the use of open source software within government departments.

Scalable to accommodate hundreds of thousands or millions of patients on ART.

Open standards and interfaces allowing interfacing with other applications, notably the electronic TB register and the DHIS.

Powerful support for localization into other languages (African languages, Portuguese, French etc)

HIV/ART Information Management System in KwaZulu-Natal Paper Form Computerized Form

Encounter Forms (HIV / ART and TB)

Integration of OpenMRS with ETR.Net and DHIS

Integration of OpenMRS with ETR.Net

OPENMRS: IMPLEMENTATION SUPPORT

First OpenMRS Implementers Meeting – 130 Participants, 22 countries

OASIS Objectives OpenMRS Implementers Network Support and expand the OpenMRS implementers network; Strengthen existing implementations in South Africa, Mozambique and Zimbabwe; Investigate cooperative open source software development, implementation and maintenance in developing countries Capacity Development OpenMRS Internship Program; Regional Training and Implementers Meetings; Evaluating other health FOSS (free and open source software;) Evaluate data integration, open data access models and data sharing. Explore sustainable models for supporting OpenMRS and other open source health software applications in a commercial competitive market. Integrate and evaluate the lessons learned.

OpenMRS Implementers Network

Support and expand the OpenMRS implementers network;

Strengthen existing implementations in South Africa, Mozambique and Zimbabwe;

Investigate cooperative open source software development, implementation and maintenance in developing countries

Capacity Development

OpenMRS Internship Program;

Regional Training and Implementers Meetings;

Evaluating other health FOSS (free and open source software;)

Evaluate data integration, open data access models and data sharing.

Explore sustainable models for supporting OpenMRS and other open source health software applications in a commercial competitive market.

Integrate and evaluate the lessons learned.

LOCALIZATION (MOZAMBIQUE)

OpenMRS Training – Harare, Zimbabwe

Proposed Integrated PHC System

Standards-based Data Integration

Free and Open Source Software Interoperability Laboratory

Mobile Data Collection Linked to OpenMRS

JavaROSA Open Source Data Collection Application

Rural Workstation Integrated Teleconsultation Low cost diagnostics

Surveillance of Drug Resistance and Genetic Subtypes

The Zachman Framework

The Open Group Architecture Framework (TOGAF) Architecture Development Method (ADM) Enterprise Continuum

Architecture Development Method (ADM)

Enterprise Continuum

The Health Metrics Network Framework The HMN Framework (version 2) Roadmap for Implementing the HMN Framework

The HMN Framework (version 2)

Roadmap for Implementing the HMN Framework

Example: National TB Control Program

Example: National TB Control Program

WHO Guideline for TB Treatment

Archimate Notation and Modeling Language

HMN Framework

National TB Control Program (NTP)

Standards-based Data Integration

National TB Control Program

ETR.Net Function Point Analysis

ETR.Net Functions Patient Record Analysis Reports

Patient Record

Analysis Reports

Standard TB Class Diagram

TB Diagnosis Class Diagram

Standard TB Data Model

Semantic Table and Field Definition

Funders and Collaborators Centers for Disease Control – Bill Coggin, Subroto Banerji Dept of Health (KZN) – Chris Jack, Roger Pillay Dept of Health (National) – Carina Idema, Shaheen Khotu Foundation for Professional Development – Margot Uys Google Inc Health Information Systems Program – Calle Hedberg, Jorn Braa International Development Research Centre – Heloise Emdon, Steve Song Medical Research Council – Karin Weyer, Natasha Naidoo Harvard Medical School and Partners in Health – Hamish Fraser Regenstrief institute – Burke Mamlin, Paul Biondich, Bill Tierney University of KwaZulu-Natal – Yashik Singh, Carl Fourie University of the Western Cape – Harry Haussler WAM Technology cc – Paul Maree World Health Organisation – Christopher Bailey, Mark Spohr

Centers for Disease Control – Bill Coggin, Subroto Banerji

Dept of Health (KZN) – Chris Jack, Roger Pillay

Dept of Health (National) – Carina Idema, Shaheen Khotu

Foundation for Professional Development – Margot Uys

Google Inc

Health Information Systems Program – Calle Hedberg, Jorn Braa

International Development Research Centre – Heloise Emdon, Steve Song

Medical Research Council – Karin Weyer, Natasha Naidoo

Harvard Medical School and Partners in Health – Hamish Fraser

Regenstrief institute – Burke Mamlin, Paul Biondich, Bill Tierney

University of KwaZulu-Natal – Yashik Singh, Carl Fourie

University of the Western Cape – Harry Haussler

WAM Technology cc – Paul Maree

World Health Organisation – Christopher Bailey, Mark Spohr

DESIGN CRITERIA FOR THAT’SIT IS Support paper forms and computerized data systems Integrated TB and HIV information management; Support chronic care and clinical decision-making Integrated with other district, provincial and national health information systems; Balanced design between operational requirements and future needs; Effective by improving patient and treatment information management and easily providing for aggregate and indicator reporting functions; Configurable and adaptable to changing needs of the program, other clinics hospital, provinces and countries, other diseases; Affordable and available to a large number of sites; Scalable and able to robustly store a large number of records; Open standards for data storage and interchange and should use free and open source software (FOSS), wherever possible; Sustainable and maintainable; Powerful and easy to use; Flexible and extensible; Reuse existing application software and avoid `reinventing the wheel’.

Support paper forms and computerized data systems

Integrated TB and HIV information management;

Support chronic care and clinical decision-making

Integrated with other district, provincial and national health information systems;

Balanced design between operational requirements and future needs;

Effective by improving patient and treatment information management and easily providing for aggregate and indicator reporting functions;

Configurable and adaptable to changing needs of the program, other clinics hospital, provinces and countries, other diseases;

Affordable and available to a large number of sites;

Scalable and able to robustly store a large number of records;

Open standards for data storage and interchange and should use free and open source software (FOSS), wherever possible;

Sustainable and maintainable;

Powerful and easy to use;

Flexible and extensible;

Reuse existing application software and avoid `reinventing the wheel’.