Chris Seebregts, PhDBiomedical Informatics Research, Medical Research CouncilDepartment of Computer Science, University of KwaZulu-Natal

JembiSOUTH AFRICA

OpenMRS and Open Architectures, Standards and Information Systems for Healthcare in Africa

THAT’SIT PROJECTTHAT’SIT PROJECTo That’sit is a methodology for

improving access to HIV care for tuberculosis patients using a best-practices approach.

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

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

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

Tuberculosis Treatment Card Page 1Tuberculosis Treatment Card Page 1

District Tuberculosis registerDistrict Tuberculosis register

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

o 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

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

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

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

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

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

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

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

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

South African National M&E Framework IndicatorsSouth African National M&E Framework Indicators

1. Number of accredited service points per district

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

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

4. Male and female condom distribution rate

5. % of eligible patients receiving supplement meal and nutritional supplements

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

7. Number of CD4 counts done per month

8. Number of viral loads completed per month

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

10. % of patients with viral load <400 copies / ml

11. % of patients with CD4 > 200/mm3

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

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

14. Known-death rate among patients on antiretroviral therapy

15. Proportion of patients assessed medically eligible for treatment

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

OpenMRS (Open Medical Record System)OpenMRS (Open Medical Record System)

www.openmrs.org

REASONS FOR SELECTING OPENMRSREASONS FOR SELECTING OPENMRSo Configurable forms based application that can provide a very

close fit with systems created by the South African Ministry of Health.

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

o 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.

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

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

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

HIV/ART Information Management System in KwaZulu-NatalHIV/ART Information Management System in KwaZulu-Natal

Paper Form Computerized Form

Encounter Forms (HIV / ART and TB)Encounter Forms (HIV / ART and TB)

Integration of OpenMRS with ETR.Net and DHISIntegration of OpenMRS with ETR.Net and DHIS

Integration of OpenMRS with ETR.NetIntegration of OpenMRS with ETR.Net

OPENMRS: IMPLEMENTATION SUPPORTOPENMRS: IMPLEMENTATION SUPPORT

First OpenMRS Implementers Meeting – 130 Participants, 22 countriesFirst OpenMRS Implementers Meeting – 130 Participants, 22 countries

OASIS ObjectivesOASIS Objectives1. OpenMRS Implementers Network

1. Support and expand the OpenMRS implementers network;

2. Strengthen existing implementations in South Africa, Mozambique and Zimbabwe;

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

2. Capacity Development1. OpenMRS Internship Program;

2. Regional Training and Implementers Meetings;

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

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

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

6. Integrate and evaluate the lessons learned.

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LOCALIZATION (MOZAMBIQUE)LOCALIZATION (MOZAMBIQUE)

OpenMRS Training – Harare, ZimbabweOpenMRS Training – Harare, Zimbabwe

Proposed Integrated PHC SystemProposed Integrated PHC System

Facility

HIV/ART DataOpenMRS(Vanderbilt)

PHC Data (TB)OpenMRS(OASIS)

HL7

Modulo BasicoMS-AccessVanderbilt

DHISMS-Access

(OASIS)

IXF

IXF

ObitoMS-Access

(OASIS)HL7

ObitoReports

District

DHISMS-Access

(OASIS)

DH

IS

National

DHISMS-Access

(OASIS)

Province

DHISMS-Access

(OASIS)

DH

ISD

HIS

CRIS IXF

ETR.Net(CDC)

PHC Data (TB)OpenMRS(OASIS)

HL7

IXF

IXF

Modulo BasicoMS-AccessVanderbilt

Modulo BasicoMS-AccessVanderbilt

IXF

IXF

Modulo BasicoMS-AccessVanderbilt

IXF

IXF

Standards-based Data IntegrationStandards-based Data Integration

Free and Open Source Software Interoperability LaboratoryFree and Open Source Software Interoperability Laboratory

Mobile Data Collection Linked to OpenMRSMobile Data Collection Linked to OpenMRS

JavaROSA Open Source Data Collection Application

Rural WorkstationRural Workstation

Integrated Teleconsultation

Low cost diagnostics

Surveillance of Drug Resistance and Genetic SubtypesSurveillance of Drug Resistance and Genetic Subtypes

The Zachman FrameworkThe Zachman Framework

The Open Group Architecture Framework The Open Group Architecture Framework (TOGAF)(TOGAF)

Architecture Development Method (ADM)

Enterprise Continuum

The Health Metrics Network FrameworkThe Health Metrics Network Framework

The HMN Framework (version 2)Roadmap for Implementing the HMN Framework

Example: National TB Control Program

WHO Guideline for TB TreatmentWHO Guideline for TB Treatment

Archimate Notation and Modeling LanguageArchimate Notation and Modeling Language

HMN FrameworkHMN Framework

National TB Control Program (NTP)National TB Control Program (NTP)

Standards-based Data IntegrationStandards-based Data Integration

National TB Control ProgramNational TB Control Program

ETR.Net Function Point AnalysisETR.Net Function Point Analysis

ETR.Net FunctionsETR.Net Functions

Patient Record Analysis Reports

Standard TB Class DiagramStandard TB Class Diagram

TB Diagnosis Class DiagramTB Diagnosis Class Diagram

Standard TB Data ModelStandard TB Data Model

Semantic Table and Field DefinitionSemantic Table and Field Definition

Funders and CollaboratorsFunders and Collaboratorso Centers for Disease Control – Bill Coggin, Subroto Banerjio Dept of Health (KZN) – Chris Jack, Roger Pillayo Dept of Health (National) – Carina Idema, Shaheen Khotuo Foundation for Professional Development – Margot Uyso Google Inco Health Information Systems Program – Calle Hedberg, Jorn Braao International Development Research Centre – Heloise Emdon, Steve Songo Medical Research Council – Karin Weyer, Natasha Naidooo Harvard Medical School and Partners in Health – Hamish Frasero Regenstrief institute – Burke Mamlin, Paul Biondich, Bill Tierneyo University of KwaZulu-Natal – Yashik Singh, Carl Fourieo University of the Western Cape – Harry Hausslero WAM Technology cc – Paul Mareeo World Health Organisation – Christopher Bailey, Mark Spohr

DESIGN CRITERIA FOR THAT’SIT ISDESIGN CRITERIA FOR THAT’SIT ISo Support paper forms and computerized data systemso Integrated TB and HIV information management;o Support chronic care and clinical decision-makingo Integrated with other district, provincial and national health information

systems;o Balanced design between operational requirements and future needs;o Effective by improving patient and treatment information management and

easily providing for aggregate and indicator reporting functions;o Configurable and adaptable to changing needs of the program, other clinics

hospital, provinces and countries, other diseases;o Affordable and available to a large number of sites;o Scalable and able to robustly store a large number of records;o Open standards for data storage and interchange and should use free and

open source software (FOSS), wherever possible;o Sustainable and maintainable;o Powerful and easy to use;o Flexible and extensible;o Reuse existing application software and avoid `reinventing the wheel’.