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Project Spotlight: Local Community Building for National EMR in Mozambique Oct. 31-Nov. 4

By Joaquin Blaya, PhD Moderator | 26 Oct, 2016

Hi everyone,
We’re continuing with our Project Spotlights, where we highlight a specific project. Next week, we’re lucky to have the team members from eSaude (http://www.esaude.org/) in Mozambique that will be talking to us about how they built a local community to support a national Electronic Medical Record (EMR) implementation in Mozambique.

We wanted to introduce our 3 presenters
Valério João, Msc, is currently Health Information Systems: HIV C&T Lead at UC Global Programs Mozambique. His work focus on developing EMR system and point of care components in HIV care and treatment for the Ministry of Health, to support reporting data for USG, to lead the HIS development team in country and to collaborate with the eSaude community to identify, develop and implement common HIS solutions.

Etelvina Mbalane, Msc, has much experience in the use of HIS for Monitoring and Evaluation, program management, eHealth and data quality programs in PEPFAR HIV C&T programs. She has pioneered the implementation and design of retrospective patient tracking systems in country, as well as development of procedures and policies for implementation. Currently she is Director for HIS in UCSF Global Programs in Mozambique, coordinating the development the National POC EMR among MOH HIV clinical partners acting both as stakeholder coordinator and liaison person with the MOH.

Stélio Moiane is a Health Information System Developer and lead of the Maternal and Child Health (MCH) and eSaude Pharmacy projects at Friends In Global Health. His work consists of developing new software components/solutions expanding on what exists in OpenMRS and also collaborating with the eSaude community to architecture and design HIS needs. He is also Java and JavaScript enthusiast always trying to get people lives better using software

We’re attaching a case study that was written about this effort. The URL for the case study is http://openmrs.org/2016/08/mozambique-case-study/.

We will start our discussions on this coming Monday, October 31.

Attached resources:

Replies

 

Pierrette Cazeau Replied at 7:45 AM, 28 Oct 2016

Thanks for the invite I will be glad to participate

Nino Dal Dayanghirang Replied at 7:59 AM, 28 Oct 2016

Thank you very much for the invitation. Happy to participate.

Saa Fillie Replied at 8:36 PM, 28 Oct 2016

Thanks in advancve for inviting me. I will paticipate.

Saad Hashmi Replied at 4:59 AM, 29 Oct 2016

Nice to see this invitation.I am looking forward to participating in this event.

Etelvina Mbalane Replied at 12:38 PM, 31 Oct 2016

"What were the biggest challenges in creating the eSaúde Community?"

Competition: In Mozambique several PEPFAR parners need to "healthy" compete for donor funding for the implementation of HIV programs. Innovation drives the game and who ever leads it is in the best position for more funding. This was also the case for HIS. Partners were reluctant to come together as a community and would avoid sharing information on HIS. Competition and luck of trust is even higher with NON PEPFAR partners.

Lack of Knowledge on what a eSaude community is: How does it function, what are the benefits? How do i operate within the community? How do i contribute? these questions were often there and would hinder active participation in the community.

Lack of resources: Most partners didn't have resources, especially staff resources who could contribute actively for the community.

Joaquin Blaya, PhD Moderator Replied at 3:27 PM, 31 Oct 2016

Thanks Etelvina. On the case study (
http://openmrs.org/2016/08/mozambique-case-study/) I read the following
part "The eSaúde distribution of OpenMRS is now deployed in over 200
facilities across seven provinces in Mozambique, impacting hundreds of
thousands of lives."

and I wanted to see what you thought the impact of having the same
distribution has been. Is the data able to be centralized in some fashion,
have reports been easier to gather, or something else?

Also, how many different organizations have been involved in doing all of
those implementations?

Naomi Muinga Moderator Replied at 2:16 AM, 1 Nov 2016

Thanks Etelvina. I must commend the eSaúde for the work that has been done so far.

I have a question regarding the developers, how easy/hard was it to convince the developers to contribute? How long did it take to set up a community that you would say actually works?

A/Prof. Terry HANNAN Moderator Replied at 3:25 AM, 1 Nov 2016

Naomi, I like this question as it has relevance to what happened to us in Kenya with the MMRS that preceded OpenMRS. After 2 years of use of the "user facilitated design of the clinical data capture interface" they were able to produce a report -essentially at the touch of a button- that generated an health care information management report that showed the users, the managers and the Kenyan government of how and what they were managing in day-to-day care. In summary with a known 14% prevelance of HIV (government testing of the community) the clinic reported a 0% incidence of HIV abd TB. THEY demonstrated that they were not even measuring the disease. The information managment model altered the whole approach to care-in particular HIV- in Kenya then sub-Saharan Africa. The government's response to the report. "This system had to be in every clinic in Kenya". The rest is history.

Etelvina Mbalane Replied at 3:49 AM, 1 Nov 2016

Hi Naomi,

it did not take long to convince developers to come together. PEPFAR had already started encouraging developers to work together to refine queries for reporting. they wanted to make sure that they were not comparing apples to oranges when analyzing and comparing performance of individual partners. It was mainly their individual organization´s willingness to have them participate, share time, knowledge and contribute that represented the main obstacle.

it took a year of joint and individual meetings to introduce the concept, share the vision and goal, to have partners come together as a community. it took discussions on even agreeing in allocating human resources to contribute to the community: once common goals ad projects were identified each partner slowly started to take an active role in development and sharing within the community.

Stelio Moiane Replied at 3:51 AM, 1 Nov 2016

Hi thanks to be part of this discussion,

I make part of eSaude community Developers and I guess I have a part of an answer for your question Naomi.
In general convincing developers to make part of or contribute for a community it's not an easy task to do. They always have questions like:
- Why do I have to contribute ?
- What are the benefits ?
- How is it going to improve my skills as a HIS developer ?
- And so on and so forth.

What we try to do is make them understand that it's much easier for us to get accepted as a group rather than a single person in such a way that systems/solutions can be developed very fast with the quality expected.
People have opportunity to test or improve their skills with things that help or change their life.

Thanks.

Valério João Replied at 4:21 AM, 1 Nov 2016

Hi Naomi, about your first question. The biggest part of eSaude contributors is composed by developers hired by USG implementing organizations in Mozambique working in HIV. Those partners share the same needs when it comes to reporting to PEPFAR and MoH, improve the quality of services, etc. This creates a common need to standardize/uniform software tools and the underlying technologies and development process. What mainly motivate developers, is to give something to the community and have something in return.

The eSaude is actively participating in GSoC (Google Summer of Code) over the years, with specific eSaude projects for Moz context where some of the objectives are to find talents from universities inside and outside the country, and to spread the community in order to have more contributor. Besides the motivation of being participating in an international Google project, the Students can use the eSaude opportunity in their academic curriculum, for instance to do their final course project, internship and/or dissertation. And this practice is proving to be giving positive results as we get more and more contributors.

Etelvina Mbalane Replied at 4:29 AM, 1 Nov 2016

Hi Joaquin

The driving force behind the expansion of OpenMRS still is the need of data for MOH and PEPFAR reporting. Cohort monitoring and retention indicators are hard to track on paper based system in facilities that have thousands of patients on ART. In recent years, we have observed a change in the use of OpenMRS for data use monitoring the quality of services provided, use data for defaulter tracing, use data act on suspected treatment failure, starting ARV in priority patients (children and Pregnant women) are just a few examples we can share.

Individual implementing partners (IP) are responsible for its implementation in the supported regions/provinces. Currently there is a total of 6 PEPFAR IPs but the community is composed of Non-PEPFAR partners too.

Implementation is often agreed with provincial health authorities of the supported regions. Data for that particular region/province is usually kept with the provincial health authorities and individual IPs. Data would only be accessible to other IPs through appropriate formal requests. Until very recently, MOH had not taken an active role in regulating the implementation of the systems. For a long time implementing partners were responsible for data storage in their individual servers.

Recently, PEPFAR and MOH came to an agreement and created the MOZART (standing for Mozambique ART data). PEPFAR would start the process of storing the data at a central server and provide technical assistance to MOH to leadership on it. MOH has recently created a technical working group that among other things will also wonk o policies, procedures for electronic medical records.

Reports are easier to generate as there is previous participatory preparation among community members. there is also division of, tasks: Some will develop the reports, other will verify the queries and others will run tests. Then, reports made available for import by individual partners

PEPFAR takes advantage of the data stored at the central server to work with the HIV program to generate national specific reports or modelling the impacts of a specific intervention.

Lilian Chumba Replied at 3:10 PM, 1 Nov 2016

I am very impressed with the amazing work done by esaude. This says a lot about the magnitude of work that can be done when people work together. From what I am reading and getting from the discussion, the electronic medical records deal only with HIV patients. Please enlighten me further on this and any plans to scale it up to include other diseases or have this system be used in hospitals across the country.

Saleem Haider Replied at 4:13 PM, 1 Nov 2016

Hi Guys. Firstly congratulations on the work you are doing. Really impressive achievements. Can you share some details on

the time lines and key milestones on the implementation of OpenMRS

what have been the main challenges

How did the hcp and local teams adapt on the use of the platform. Were there any complications on usability and adoption on using the technology

And finally about the process and procedures... Who provided the governance to ensure the process was being followed and where there any issues there.

Thanks for your feedback

Saleem

A/Prof. Terry HANNAN Moderator Replied at 4:27 PM, 1 Nov 2016

Saleem and others, many of these questions can be answered at https://talk.openmrs.org/
Free to join OpenMRS talk
Also these may help.
The History of OpenMRS 2012: http://youtu.be/1krGBK39G-M
B. Mamlin OpenMRS in 3 MINS: http://www.youtube.com/watch?v=CkGyNBYMTxM&feature=related
MDRTB Pakistan: http://www.youtube.com/watch?v=1N8236ReWnM
Andy Kanter MVP (short) http://www.youtube.com/watch?v=SgvqskZZ5-Y
AMPATH SUMMARY 2014 (2): http://www.youtube.com/watch?v=vD2auECFLvY

Joaquin Blaya, PhD Moderator Replied at 5:22 PM, 1 Nov 2016

Lilian,
I completely agree of the advantages of having people work together. I have
never heard of organizations dividing the work of creating reports, Idon't
know if others have.

Also, the ability to have a centralized server with all of the data from
different hospitals without having to implement something like a shared
health record (https://ohie.org/shared-health-record/) is wonderful. Do you
see the potential for this to be replicated in other countries either
because other countries are interested or because the funders have learned
how to help create this?


Joaquín

Naomi Muinga Moderator Replied at 2:11 AM, 2 Nov 2016

Thanks for the resposnses...very useful! Its true that the developers has to benefit in some way even as the community also benefits from their input. Is there an official arrangement with the universities for students?

Who else is a member of the community? ie apart from developers.

It would also be nice to have the whole process documented clearly so that if another country wants to replicate what you have the requirements would be available as Joaquin has pointed out

Valério João Replied at 6:05 AM, 2 Nov 2016

When the first implementation of the EMR started, it was for HIV patients only, and we did it in a extendable way to allow other types of patients in the future. For instance we have now included MCH module that allows non HIV mothers, a pharmacy module that also dispenses non ARV drugs for non HIV patients, the same approach for TB solution in the future. Notice that there is somehow an interception of all these groups of patients with HIV, but we believe that this is possible to grow from there into a national hospital system.

When there is a major event where the community is involved, such as GSoC, we approach the local University to either recall the previous arrangement or to establish a new one. After that we follow with several interactive sessions with students, so that they know the community, the project, and what are the opportunities. We also receive students from universities outside the country, but in this case the initiative of the first contact comes from student and university.

Our community is open for everyone to be part of without any kind of restrictions, and we have people with different background other than developers, just to name some, we have: M&E officers, data managers, clinicians, HIS advisors and system implementors.

There are many challenges that can be found when implementing an EMR system and creating a community, we can later provide a document describing those that we encounter, and many of them are not different with what other similar communities all over the word have experienced. What I can tell is that there was a lot of perseverance from the community members, and we were lucky to have a lot of support from existing and similar communities, in all the different aspects. For e.g. in 2015 we had the OpenMRS implementing meeting in Mozambique in a very crucial moment where the process of migrating to an EMR was going on, and the community had to stay together more than ever before. We leverage at maximum we can in what other communities are doing and have done, and we also do our best to contribute back.

A/Prof. Terry HANNAN Moderator Replied at 6:10 AM, 2 Nov 2016

This discussion is evolving as one of the best on GDDonline that I have seen over the years. I feel it should almost be collated into a reference document for implementation guidance.

Ayun Cassell Replied at 6:12 AM, 2 Nov 2016

The EMR project is great. It is the fundamental of any sustainable health system especially for data management and forecast.

Joaquin Blaya, PhD Moderator Replied at 5:50 PM, 2 Nov 2016

Another part of the case study mentions

"A compelling example of the benefits of the system is with maternal and
child health. On paper, without a national person identifier, tracking
patients between services was unreliable, if not impossible. Once the baby
is born there is no way to track if the baby is tested, enrolled, and
receiving treatment, which as we know now is incredibly crucial to ensure a
productive life for the child. With the new eSaúde OpenMRS implementation,
clinicians and program directors are able to see the transition from pre-
to post-natal care and monitor the child through the Child-At-Risk program."

In the community we've talked many times before about the lack of
identifiers, so I wanted to see if you could tell me a little more about
how this is done and if it means that data is transferred between
institutions.

Valério João Replied at 12:42 PM, 3 Nov 2016

The lack of a unique identifier to rely on still exists despite all the effort that authorities are putting in to make sure that each person is properly and uniquely identified, this is a process that need its time, but from the system perspective we're gradually making sure that there is a Master Patient Index at health facility level. Patients should only be registered in OpenMRS registration despite of their referral service, this way we can give as many identifiers as we need for the patient and those are permanently bounded to the patient. Clearly this doesn't solve all the problem specially when we scale up to a central level. We have been exploring biometrics, but haven't implemented that yet.

Saleem Haider Replied at 1:14 PM, 3 Nov 2016

Thanks for all the responses. They are great insights. What is on the road map for the next 12 months which map to the strategic objectives of the healthcare agenda.

Thanks

Saleem

Joaquin Blaya, PhD Moderator Replied at 10:33 AM, 4 Nov 2016

To build on Saleem's question I think it would also be great to hear how if
there are other organizations that were interested in following the eSaude
example, what they could do to learn more about it.


Joaquín

Ali Sajjad Replied at 2:13 PM, 5 Nov 2016

An important topic to be identified, unfortunately very well neglected in our setting

Joaquin Blaya, PhD Moderator Replied at 8:10 AM, 7 Nov 2016

We wanted to officially end this Project Spotlight, which has been
extremely interesting.

We wanted to thank the members who took part in the discussion, and
especially our 3 guests, Valerio, Etelvina, and Stelio, they have done an
amazing job of keeping up with a lot of questions and comments. We
appreciate your time.

Warm regards,


Joaquín

Valério João Replied at 8:44 AM, 7 Nov 2016

On behalf of eSaude community I would like to thanks to everyone for this great opportunity to share broadly our eSaude, and apologize for any non answered questions. Please visit our website at http://www.esaude.org for more info, and feel free to contact us directly. We are looking forward to participate in future events like this.

Thanks a lot

John Mark Esplana Replied at 9:47 AM, 8 Nov 2016

Hi eSaude team. Congratulations on the success!

I have a couple of questions regarding metadata management and patient ID's:

1. How is the metadata managed in all facilities? Are independent partners managing their own metadata for their facilities or is this controlled centrally? Is this done manually or are you using a metadata sync module?

2. In terms of Patient ID - are the patient ID's generated centrally from MOZART? Can a patient record be sent to another facility in case of patient relocation?

Thanks!

John

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