Data Use Community, March 2023
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The Data Use Community (DUC) is an open global community passionate about improving health by leveraging data sharing and use. It is a forum of virtual meetings and an online discussion board for sharing and learning from peers and country experiences. On March 29, 2023, Christina White, Technical Program Manager and Piotr Mankowski, Interoperability Engineer with The Digital Initiatives Group at I-TECH (DIGI) - University of Washington (UW) shared the Haitian experience with preparing to pilot a patient identity management system using biometrics and demographic data. Below is a summary written by the DUC Secretariat of what was understood at the time of sharing.
Background
The use of electronic medical records (EMRs) can increase the efficiency of capturing, finding, and storing patient information. EMRs can be linked across facilities with patient information governed by a patient identity management system (PIMS). While the benefits of deploying PIMS include increases in process efficiency, implementation challenges may be encountered when dealing with established systems and outdated technologies.
In 2008, Haiti implemented a national EMR system known as iSante, and in recent years, when Haiti was looking to address key clinical challenges, the following findings were noted: 1) the EMR was using aging technologies that were not sustainable, difficult to upgrade, and not scalable; 2) the system was often bundling functions and were being used for multiple purposes - rather than a “fit for purpose” use – making the EMR less efficient; and 3) gaps in the IT workforce for maintenance and upkeep.
The Digital Initiatives Group at I-TECH (DIGI) - University of Washington (UW) is working to pilot a PIMS that leverages existing infrastructure consisting of collecting demographic information and fingerprint biometrics. In doing so, challenges related to the continuity of care for HIV (including patient loss to follow-up, and across sites and facilities – sharing lab results, patient transfers, and HIV regimens) will be addressed. The goal for this use case is to improve the ability to provide high quality care to patients who move between different health services, facilities, and networks across the country. This started with the work towards updating iSante to iSantePlus (OpenMRS Ref App) in 2020.
Technical Approach
During patient registration at a facility, a patient provides demographic information, such as first name, last name, date of birth (DOB), and fingerprint biometrics to initiate a search of the national patient registry and national fingerprint database. If patient records are found, then the facility can import the records locally. If the patient needs to be registered, the demographic information and fingerprints collected at the facility will be used and sent to the national databases which will prevent duplication of records at facilities. OpenHIM facilitates data exchange between the facility level and national level. If a facility experiences connectivity issues, a local search and local storage of the information at the facility will occur until the connection is restored. The diagram below outlines the workflow of Haiti’s National Health Informatics System (HIS) Architecture (Diagram 1).
Diagram 1: Haiti National Health Informatics System (HIS) Architecture*
The following features were factored in to serve as support features for PIMS:
Patient Search: The ability for patients to be searched in the national databases given internet access.
Patient Registration: The process of checking the national databases for matching demographics or fingerprints upon a patient’s presentation at the facility and the ability to import those records locally.
Continuum of Care Workflows (Shared Health Record): The ability to enter information at one facility and pull that information at other facilities for cross reference.
Recorded demonstrations illustrating the impact of these support features in iSantePlus are available below:
The technical components and processes used for PIMS are shown below (Table 1).
Table 1: Technical Components
Impact & Challenges
Efforts towards implementing PIMS have yielded the following outcomes thus far:
Updating the EMR from iSante to iSantePlus;
Ministry approval of a standard operation procedure (SOP) on patient identification created with input from a technical working group; and
Conducting a pre-pilot of PIMS implementation at two different sites which included the support features of patient searching, patient registration, and continuum of care workflows.
Preparing for full implementation of a new PIMS, however, is not without its challenges. The following challenges were identified:
Lack of patient matching criteria definitions for implementation;
Limited ability to seamlessly integrate components with the existing infrastructure due to inefficient and outdated technology, software, and workflows;
Making decisions on whether there would be a bulk import of existing patient records at one time or starting with a patient’s next visit;
Potential for duplication of records if a facility is offline and who has the authority to remove duplications; and
Encountering patients who may have had fingerprints registered previously and/or unable to have their fingerprints captured.
Lessons Learned
During the planning for the implementation of Haiti’s PIMS, the following lessons were learned:
Reviewing existing infrastructures, current workflows, and available data before making changes can help with identifying where updates and system connections are needed for implementation to occur. This can also help with developing new workflows which will serve as a guide during implementation.
Discussing integration and importation of records from one system to the next before making changes can help to facilitate conversations. These conversation topics can include expectations, potential problems, and steps to take if these problems are encountered.
Discussing steps to take when upgrades become available after implementation in the planning stage can help to establish procedures to use for when this occurs.
Discussing roles and responsibilities at different levels in HIS architecture, so that all parties are aware of the tasks needed to be completed, before, during, and after implementation.
Planning for connectivity challenges, which can help stimulate conversations on troubleshooting techniques before implementation occurs.
Engaging various stakeholders throughout planning and implementation processes, such as in a technical working group setting, can lead to the discovery of additional topics to be discussed, an understanding of terminology, and creation of documents such as a SOP.
Looking Ahead
A pilot is currently underway at six sites to better understand the effectiveness and efficiency of the system and workflows. Following successful implementation and assessment of the pilot program, the next step includes scaling PIMS nationwide. At the same time, the following activities are occurring to advance the next phase of implementation:
Working on data availability and connectivity with lab partners and national reporting partners;
Working with sites in Haiti that use other EMRs to align terminology;
Discussing data ownership and accountability and next steps if issues arise;
Discussing roles and responsibilities on who has the authority to delete duplicate records, as currently the duplicate records are just linked. Preliminary conversations suggest that this authority will be at the national level; and
Planning for the incorporation of other systems and use cases.
For more information on the experiences in Haiti, please visit the DUC presentation here.
References
DUC Meeting March 29, 2023: Presentation by Christina White, Technical Program Manager and Piotr Mankowski, Interoperability Engineer, DIGI-UW
iSantePlus MPI Workflow Demo, September 23, 2020: UW FHIR
iSantePlus Continuity of Care Demo, September 24, 2020: UW FHIR
Reaching Health Standards and Creating a Client Registry in Haiti - OpenHIE (ohie.org), OpenHIE
