HIV Clinic Workflows to Support: Ampath, PIH Mexico, UgandaEMR

Goal

The goal is to create a packaged release to prove the feasibility of MFE from an implementation perspective, starting with a pilot in HIV Outpatient Clinic(s).

Live Requirements Spreadsheet

https://docs.google.com/spreadsheets/d/1PwivnnDUWHVSHQkEATzmTDlZSil9lymf9mzrUnoMmJg/edit#gid=0

HIV Clinic Workflow Requirements

Ampath

Step	User	Description	Why
Patient check-in	Registration clerk	Patient checks-in and issues clinic card at the registration desk. Patient is searched either by name or identifier indicated on the card.	Ensure that the patient is well identified and add relationships (in case they have any - e.g. a spouse). It is also at this point that the patient contacts are verified/updated.
Start Visit	Registration clerk	After patient search, today's visit is started by the registration clerk in the HIV Program that the patient is enrolled into e.g. HIV standard program. Patient is then sent to the triage nurse's desk.	By starting the visit, the patient is marked as checked-in
Triage	Nurse	Patient is triaged by capturing the vitals which are filled in a triage form within the visit that was started. Vitals captured are: BP, Pulse, RR, Temp, Weight, Height, Sp02, BMI (Auto calculated from weights vs height), MUAC. Patient is then sent to the Clinicians desk.	To find out if the patient is suffering from any other ailments e.g. high blood pressure.
View HIV summary	Clinician	Patient is reviewed by the clinician where they first get a review of the patient HIV summary and today's' vitals which are displayed below the patient header.	View historical medications that the patient is taking from the summary. Check patient adherence to medications.
View clinical notes	Clinician	Clinician reviews the clinical notes of the patient which is accessible on the side drawer menu within the HIV program.	View previous notes that a clinician/nurse had written about the patient that might need action.
View historical lab results	Clinician	Clinician reviews historical lab data results of the patient. This can go up to the date the patient was enrolled into HIV care. The most recent results will display on the first column.	Check if the patient is responding well to the medications administered by lowering their viral load and improving their immunity (CD4 count)
View lab orders	Clinician	Check to see if the patient has had any blood works ordered recently and if there is any pending lab orders whose results have not been received yet.	To determine whether to order a new test as required by the HIV guidelines.
Fill clinical encounter	Clinician	The clinician will then open a return clinical encounter which they would fill by asking the patient a number of specific questions that have been coded in the form. NB: Its also within the clinical encounter that medication orders, test orders and appointments are captured.	Patient is reviewed and clinical judgements made for the patient e.g. changing medications if they are not responding well to the current meds. By filling the clinical encounter, a number of concepts are captured in the form which are used for reporting purposes.
Order medications	Clinician	Medications are ordered on the form in the medication history page. There is a use value button (to use previous values) in case the current medication orders are not changing to a new one. We are currently capturing the orders through the form and the concepts are saved as observations	Capture the regimen of anti-retrovirals, PCP and TB medications that the patient is currently taking.
Indicate medication plan	Clinician	On the plan section, the clinician will indicate whether the regimen is a continuation, change, restart.....etc A prescription form is then written (hard copy) that is given to the patient to present at the pharmacy.	Capture any changes or continuation of the medications that the patient is taking.
Order for tests	Clinician	The test orders are made on the Plan page under Test Orders section. Upon saving the form, an order number will be generated that is used to track the test results from the AMPATH lab system. The results are synced into POC automatically. The patient is issued with a lab order form with the order number that will be presented to the phlebotomist.	Record any tests that the patient is supposed to undergo on their current visit. This helps in tracking the results from the lab system.
Give appointments	Clinician	The patient is given next visit appointment in the appointments section under the plan page. Since HIV clinics are quite busy at AMPATH a calendar is displayed after choosing the appointment date to display distribution of appointments through the week of the date selected. Patient is then sent to the pharmacy to pick drugs and/or the lab to get pricked if they have any blood work orders.	Capture appointments and help in tracing a patient in case they miss their appointment date. Appointments are displayed on the appointments schedule.
Draw test samples	Phlebotomist	The phlebotomist will receive the order number and key it into POC and indicate the date the sample was received after pricking the patient. They will also record the sample type extracted and post the order which shall be reflected in the AMPATH lab system as *received.*	Confirm the sample as received since not all patients that are sent to the phlebotomist actually go there. Some decide to go to the pharmacy and leave.
		See labs that were ordered
Dispense medications	Pharmacist	The patient will finally go to the pharmacy and present the prescription form which is recorded in the pharmacy system and patient issued with medications for the period indicated. First they will look up the patient in the pharmacy system (ADT) by searching their names	Find the correct patient in ADT
Dispense medications	Pharmacist	After finding the correct patient they would dispense the medications indicated on the prescription.	Ensure that they dispense the correct medications in ADT.

PIH Mexico: Tiny Clinic Workflow

These workflows relate to the rural clinics operated by PIH Mexico, which are staffed by one doctor, and sometimes a nurse.

Step	User	Description	Why
Patient check-in	Nurse or clinician	The clinician or nurse search for the patient by name. If the patient is found in the database, they proceed to enter vitals. If not, they register the patient.	Find out who the patient is and whether they're in the system.
Registration	Nurse or clinician	If the patient isn't found in the database, the user registers them.	Creates a patient record.
Vitals	Nurse or clinician	Record the chief complaint. Take the patient's weight, blood pressure, RR & HR. Take height if it's not unlikely to have changed since the last recorded value. Maybe take temp and SatO2. For known diabetic patients, take blood glucose and ask if the patient is fasting.	If there's a nurse, this saves time for the doctor.
Chart review	Clinician	Quickly look over the summary data of a patient's clinical history.	Helps jog the doctor's memory of this patient and their problems. For patients that haven't been in in a while, or that were seen by a previous doctor, provides important information about clinical history.
Start filling out consult form	Clinician	Start filling out a SOAP note, making reference to whatever other clinical data is available.	Record the details of the current interaction with the patient.
Condition-specific or program-specific chart review	Clinician	Refer back to more detailed information about the patient's clinical history. (This probably rarely happens in the current EMR because of the lack of support for entering and viewing data simultaneously).	Glean information that might be clinically important for the patient.
Program enrollment and program-specific data entry	Clinician	Mark the patient as needing continued care specific to one or more long-term conditions.	Provide high-quality and continuous care for high-risk patients.
Analysis, Plan	Clinician	Make a diagnoses (or several), make a plan for care	Finish SOAP
Medicate	Clinician	Go rifle around the pharmacy to find some medication to give the patient. Print a page that will tell the patient how to use the medication. Or write instructions on the box. Draw little diagrams if the patient is illiterate.	See Hippocrates, The Writings of Hippocrates and Galen
Print record	Clinician	Print the consult summary to stow in a big filing cabinet.	Mandate of the government.

And then, outside this workflow, there are two other important tasks, typically conducted in the evening.

Step	User	Description	Why	Part of PIH EMR needed	Part of MFE Proof of Concept MVP scope?
Retrospective entry	Clinician	The clinician fills in information that was abbreviated or skipped during the consults. Sometimes this is because of haste, sometimes because of technical issues, such as the power going out.	Add the information to the patient record before it's forgotten.
Fill out reports	Clinician	The clinician fills out weekly and monthly reports required by the government, generally by hand. Traditionally this is done by a combination of tallying and guesstimating, but it can be supported by reports produced by the EMR.	Ministry of Health requirement.

UgandaEMR : Functionality and UI to tie together

	Name	Layout/UI Category	What's included
General Info	Demographics
General Info	Height & Weight
Vitals	Vitals Summary	Summary Table - numeric
Vitals	Vitals Details
Meds	Active Medications	Complete List
Meds	Medications Details		Active, Past - Discontinued
Visit History	Past Visits Summary	Summary Table - non-numeric
Visit History	Past Visits Details
Conditions	Conditions Summary	Summary Table - non-numeric
Conditions	Conditions Details
	Recent Orders (past 7 days)
	Recent Lab Results (past 7 days?)
Clinican Information	Clinician Facing Dashboard