Data Use Community, June 2023
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The Data Use Community (DUC) is an open global community passionate about improving health and healthcare 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 June 28, 2023, Loic Ntwali, Business Analyst and Frank Kitema, Chief Digital Officer with QT Global Software shared the Rwandan experience with implementing a client registry to strengthen the identity management system. Below is a summary written by the DUC Secretariat of what was understood at the time of sharing.
Background  
Inefficient processes for Patient Identity Management (PIM), including patient identification (ID) and verification, can impact treatment and continuity of care for patients. When seeking health care services, a patient’s identity is validated upon presenting a form of ID. In this process, the ID can serve as an identifier that pulls existing patient data from local and/or national data systems. The number and forms of IDs and system linkages may vary across health facilities. A collection of these processes and systems creates a health informatics exchange (HIE) ecosystem.
QT Global Software is working with Rwanda’s Ministry of Health (MoH) on digital health initiatives for the HIE ecosystem. Wanting to improve PIM, Rwanda investigated building a HIE ecosystem that integrates a client registry (CR), which collects demographic information and can utilize multiple forms of IDs presented at a point-of- service.
Rwanda’s PIM goals include:
Uniquely identify individuals seeking care from any health facility across the country;
Maintain a set of identifiers in the CR associated with an individual; and
Avoid duplication of patient records within the CR and in local electronic medical record (EMR) systems.
Technical Approach 
In the Rwanda Health Informatics Exchange (RHIE), there are three components: the point-of-service applications, the interoperability layer, and the centralized resources. The diagram below illustrates the RHIE Architecture (Diagram 1).
Diagram 1: Rwanda Health Informatics Exchange Architecture
At the point-of-service, a person can present their National ID or other forms of ID. The diagram below shows examples of the forms of IDs that can and cannot be used for identification purposes (Diagram 2).
Diagram 2: Citizen Identity
These IDs are all integrated into the CR, which uses the FHIR standard and connects to the EMR. When an individual visits a health facility, his/her information is entered into the system. This begins the searching process for where records can be pulled from beyond the EMR, allowing the registration and identification process to begin by auto-populating the fields. As the health system in Rwanda is decentralized, different systems are used across health facilities. An API is used to support integration with the different EMRs found within public and private health facilities. The interactions described can be found in the diagram below (Diagram 3).
Diagram 3: Client Registry
A unique patient identification (UPID) is created if the person does not already have a UPID tied to their records. The diagram below shows the Registration Page in the National EMR (Diagram 4).
Diagram 4: Registration Page in National EMR
In Rwanda, the National ID is the most common form of ID presented at the point-of-service, as the community-based health insurance is linked to this ID. However, the National ID is only assigned once a person is older than 16 years of age. For those 16 years old and less, there is a National Application Number (NIN), which is given upon birth when parents register their children with the local government, that can be used. The parents can receive this via SMS. If a person is a foreigner or not registered, a UPID can still be created, and new information will need to be imputed at the point-of-service.
When a patient arrives at registration at a point-of-service, he/she will provide his/her National ID. If a new patient is being registered, the health worker will key in the National ID to see if a UPID already exists. If a UPID does not exist, the CR will take information from the National ID to generate a UPID. This information will then be sent back to the EMR.
If an existing patient presents at a point-of-service, then he/she will provide his/her National ID. The National ID will be put into the system, the health worker will verify the patient information, and any updates to the patient’s information will be sent to the CR.
The technical components and processes used are highlighted in the table below (Table 1).
Table 1: Technology Components 
Impact & Challenges
There are about 50 health facilities leveraging the RHIE and CR when registering patients. Notable impacts thus far include:
Improved efficiency with the identification process;
Having a mechanism in place for central management and integration of patient demographic information and identification; and
Having a National Identification Agency (NIDA) has helped with not needing to match patient’s information from multiple sources.
The challenges faced include:
Working with existing patient records
Errors can occur when looking up information or when making updates to patient records. This can lead to not finding the records and needing to go through additional verification steps to find the records;
Delays in updates to patient record if a facility is offline; and
Potential duplication of patient records if a patient does not have one of the forms of IDs that work with the system - for example a foreigner.
Technical and performance challenges including:
Designing the technological infrastructure and interactions with services;
Scaling the technological infrastructure to meet needs; and
Accommodating technological components.
Lessons Learned
The following are lessons to consider when working with a CR to strengthen PIM in a HIE ecosystem environment:
Consider the design, scale, and capacity to accommodate various technical components when planning for implementation;
Consider the incorporation of offline capabilities when planning for implementation in case any connectivity issues arise;
Prepare troubleshooting tips for known errors that may occur (e.g. not finding an existing patient record) when planning for implementation;
Continuously monitor throughout implementation to address any unexpected findings that might arise; and
Review existing processes and discuss the use of having a central location for identification during planning.
Looking Ahead 
As work continues to strengthen the PIM system, there are a few activities worth noting:
While patients can present different forms of ID at point-of-services, there is work that still needs to be done for those who might not have one of these IDs, for example foreigners;
Research and conversations about tools that can be utilized for cleaning and validating patient records are taking place; and
At the national level, there is work being done to look at having a Single Digital ID to address some of the challenges faced with duplication and to streamline processes further.
For more information on the experiences in Rwanda, please visit the DUC presentation here.
References
DUC Meeting June 28, 2023: Presentation by Loic Ntwali, Business Analyst and Frank Kitema, Chief Digital Officer, QT Global Software
