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  • 2009 Implementers Group Meeting Program Point of Care vs Retrospective Data Entry
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Note: As promised during the session, Isaac Holeman set up a Point of Care page where we can focus our efforts to adapt OpenMRS for use at the point of care.

Definitions

  • Point of care: Data entry during clinical visit/encounter.
  • Retrospective: Data entry after encounter, usually from paper form.

Expectations for Point-of-care systems:

  • Clinics already overburdened - reduce how many times data is written down. No data entry team available. Enter data only once.
  • Neal Lesh: 95% of OpenMRS data is retrospective.
  • Why is the retrospective data entry happening? What are the barriers?
    • Speed is so important - so many patients - typical systems cannot keep up
    • OpenMRS not designed for Point-of-care environment - need system designed to flow through the patient encounters
    • Problem w/ retroactive entry - data not available throughout the clinic - paper in the wrong place
    • Point-of-care system opportunity to improve quality of care - patients do not have to wait so long for their appointments, reduce time to wait from a day to an hour or two

At the moment aggregate data is pushing downwards - external factors are collecting - data is not used or available by clinicians.

What are circumstances that cause us to use Retrospective rather than Point-of-care?

  • Connectivity and uptime/consequence of downtime
  • Legal requirements - must have paper copy for legal reasons
  • Perceived extra hardware complexity - using mobile phones not as big a barrier as pc's - more accepted by indigenous community
    • Dr. Aamir Khan, Indus Hospital Research Center, Karachi, Pakistan - They made a move towards thin clients to reduce maintenance issues. It is important to note that as you move to Point-of-care systems, you need more sophisticated tech support.
  • Security: Look out for security issues:
    • Western cape system w/ 2.5 million patients - some clinics completely cleaned out by thieves. They are considering the use of VMware type systems and thin clients - When thieves steal equipment, it is worthless to them.
  • Power - Challenges of thin clients - do not have batteries
    • Pakistan - at clinics - use cellphones rather than pc's, since the clinic is less secure than the hospital - but important to close the feedback loop - return data to the clinic
    • Daniel's Andriod OpenMRS for mobiles - cellphone app example

Important design points for a Point-of-case system

  • Runs on a browser and can run in a thin client model - do not need a ton of servers - especially at the point of care.
  • Process are important part of Point-of-care. How to change business processes at the clinics? Does OpenMRS support modeling business processes?
  • More than interface: need to be able to track delivery of service
    • Baobab very successful at doing this - can see where patients are waiting
    • Baobab - some clinics have different roles - flexible roles where anyone can do anything. This is very useful in resource-poor environments where nurses double as pharmacists.
    • XForms include skip logic capability - can this (i.e., use of XForms' skip logic) be a useful tool for Point-of-care?
    • MOH Uganda: How to develop system that can easily configure workflow to support the local processes?
  • Time issue: System must be inherent to the processes so user does not notice it. Do not ask too much of the user, unnecessary fields.
  • Performance is very important - cannot wait for a long screen refresh

Types of Point-of-care

  • Centralized system
  • Distributed - sync issues -

Which type does OpenMRS support?

Sync

OpenMRS has a sync feature built-in

  • Use of guid to identify records that go up all the way - human resources system example in uganda
  • Boabab: If server can connect to other clinics, it can grab data from other peers
  • Importance of unique patient identifiers
    • Baobab - have unique identifiers for patients. Not using uuid's for baobab - just nat'l unique id.

Access to patient information

Is having instant access to patient record more of a requirement of a Point-of-care system or is this typical of all systems including Point-of-care

  • Very important for Point-of-care in order to track patient
  • Northern Nigeria - silos of data of maternal health data - now to get this data in front of clinicians? paper system doesn't work - no one knows the utility of some of these fields.
  • Opportunity is instant access to data vs. not having historical data avaialble

Patient Health Card - smart card w/ last 10 visits on it.

Separate Point of care data from administrative data - sometimes the data sytems collect too much admin data that is not particularly useful to clinicians.

What does OpenMRS need in order to implement a Point-of-care system?

Broad issues:

  • Where
  • When and
  • What

Is it a ui framework or more modularized?

  • Example of mdr-tb module - Model the Point-of-care process and enable programmers to create appropriate modules
  • Needs to accommodate different types of clients - pc's, phones, etc.

Hardware:

  • Promise for mobile phones and thin clients
  • Need analysis for the different contexts - 'device strategy' - rural health centres have different needs from urban hospitals
    • In a rural setting they may need a bed rather than a pc, but they need a communication device to send the data to the people who can provision the bed.
    • Need wiki pages on equipment recommendations, stories on what works

Working groups

  • Device strategy
  • Software design/data model

Case Studies

  • Pakistan: one Point-of-care system was being scaled up to over 40 sites, but OpenMRS did not yet have the features to do this.
  • Who has deployed Point-of-care systems? - page on wiki to publish success cases
  • Look at these stories to filter out some best practices, not just OpenMRS deployments. Don't expect our community to supply all of the solutions.
  • Patient registration system in Rwanda is a Point-of-care system currently in development.

Point of Care System Examples

Paper review of HMIS systems

System development

  • While developing system, the clinicians worked 3-4 hours a day w/ the programmers in developing each module - therefore they had a strong sense of involvement - they owned it.
  • Build flexibility in system - enable clinicians to add extra fields themselves - they may work on a special form of TB and collect extra data.

How to adapt OpenMRS for primary care?

  • Don't always know what type if data will be needed when someone comes into the clinic.
  • Should the team concentrate on primary care system, or on a subset like HIV?
  • Think of the issue on a more general level, on health outcome.

Need for reference implementations. AMPATH has stimulated alot of OpenMRS developments.

Next Steps

  • Sign up to the workgroups - Issac will help organise this activity.
  • Please add any useful reference material to Point of Care System Examples.
  • Idea of funding study of 5-6 Point-of-care sites and gather info for the team.
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