1-Provider View PPT Revised July-2022.pptx

Sam & mam provider view

1. EMR-ART Providers View Training For Care Providers/Clinicians Debretabor, July 2022

2. 2 Outline Introduction to HIV/AIDS Data Management Paper vs Electronic Data Entry Rationale for Providers View EMR-ART Features and Functionalities Using EMR-ART for availability of complete HIV data Using EMR-ART Data for Clinical Decision

3. 3 Objective Clinicians/Care Providers will be able to: use EMR-ART for Individual level HIV Data Management & Clinical Service Quality Improvement Understand the r/ship b/n manual & electronic data mg’t Appreciate the effect of poor HIV data documentation in paper on the availability of better electronic data for clinical/program decision

4. Health System Building Blocks

5. Health information system (HIS) HIS refers to any system that captures, stores, manages or transmits information related to the health of individuals or the activities of organizations, which will improve health care management decisions at all levels of the health system In general, all functions of the health system rely on the availability of timely, accurate and dependable information for decision making.

6. Components of HIS Legislative, regulatory, & planning framework, personnel, financing, logistics support, ICT, coordinating mechanisms Measures, usually core set of indicators (determinants, inputs, outputs, outcomes & health status) Making readily accessible to decision makers, ensure information use Population-based sources (censuses, civil registration, surveys) Institution based data (individual, service & resource records) Others: Occasional surveys, research, & information, CBOs, Covers all aspects of data handling, collection, storage, quality-assurance, flow, processing, compilation & analysis, Data translated to information 6

7. Health information system in the context of HIV Program Ethiopia has endorsed the UNAIDS 95-95-95 HIV targets and is currently working towards meeting them. HIS are critical for monitoring the implementation of HIV/AIDS programs, tracking progress towards these targets, and conducting robust surveillance. The use of electronic data management systems for HIV programs reduces the resources needed for manual data entry and management, and improves data quality and data use.

8. HIV/AIDS and related Indicators Indicators based on National revised HMIS-HIV/VH Indicators and Based on President’s Emergency Plan for AIDS Relief’s (PEPFAR) – MER Indicators HMIS-HIV Indicators Federal Ministry of Health has adopted standardized HMIS in the past decade. According to the National FMOH HMIS indicator guide 2021. HIV/AIDS and Viral Hepatitis program is represented by 15 HIV indicators and 2 TB/HIV indicators

9. Trends of Indicator Revision 12/5/2022 9

10. Final Revised HMIS Indicators 2017_HMIS Total Indicator: 131 Continued: 103 Dropped: 25 Modified: 3 2021_HMIS Total indicators: 177 New:71

11. Revised HMIS Update S. No Type of Tools Maintained Modified New Total 1 Registers 13 26 1 8 57 2 Tally Sheets 5 9 7 21 3 Report forms There are changes in data elements (some modified and others added) and NTD, TB & Leprosy quarterly changed to monthly NB: Health Post level tools are not included Registers: for HCs/Hospital= 42 For Hospital only =13 For HC only= 1 Geographic Areas specific= 2 Special center=1

12. Number of Register and Tally by Program area Program area Number of Register Number of Tally Reproductive and Maternal health 7 6 Child and EPI 6 1 Nutrition 8 2 HIV/AIDS & Hepatitis 10 4 TB/Leprosy 6 Malaria 1 NCD & Mental health 3 1 NTD 2 Medical Service 11 7 HSS 3 Total 57 21

13. Revised Indicators (2021) Number of Indicators by category (2017 versus 2021) SN Indicator Category 2017 2021 1 Reproductive and Maternal health 14 15 2 PMTCT 7 6 3 EPI 13 12 4 Child health 8 10 5 Nutrition 8 8 6 Hygiene & environmental Health 2 10 7 Medical service 12 21 8 HIV/AIDS/Hepatitis viruses 10 15 9 Tuberculosis/TB/ & Leprosy 22 22 10 Malaria 5 8 SN Indicator Category 2017 2021 11 Neglected Tropical Diseases (NTD) 2 8 12 Non-communicable diseases (NCD) & mental Health 3 10 13 HEP and Primary Health care 3 4 14 Leadership and governance 4 4 15 Health Financing 3 4 16 Pharmaceutical supply and services 4 7 17 Evidence based decision making 3 6 18 Health Infrastructure 4 2 19 Human Resource Development & mgt 4 3 20 Regulatory system 1 2 Total 131 177

14. Revised HMIS HIV Registers and Tally Sheets Registers: HIV Testing Services (HTS) Register ART register PEP (post exposure prophylaxis) FU register DSD Register Pre-exposure prophylaxis Register HIV Self-testing (HIVST) Register Index Case Testing (ICT) Register HIV Positive Client Tracking register Hepatitis B Treatment Register Hepatitis C Treatment Register HIV tally sheets : HIV Testing Services (HTS) Tally ICT Tally sheet HIV Clinical care tally Currently on ART by regimen type and DSD tally sheets Black: Maintained Green: New Purple: Modified Cards Follow-up charts

15. 15 Individual Folder Intake A and B ART Follow Up Form Paper Based Recording Tools in HIV Unit Intake A & B Discuss Key Data Elements Captured in Intake A & B? What Data elements are commonly missed in these formats? Why are Data Elements Missed? Follow Up Form Discuss Key Data Elements Captured in Follow-Up Forms What Data elements are missed in this format Why Data Elements Missed & What is the Possible Solution?

16. HIV/AIDS and Hepatitis related Indicators… HIV HMIS (National) Indicators/ Green Color-New Included Indicators Percentage of people living with HIV who know their status Number of people living with HIV currently receiving ART Number of adults and children with HIV infection newly started on ART ART retention rate Number of ART Clients that interrupted Treatment Viral load Suppression Number of individuals receiving Pre-Exposure Prophylaxis Number of persons provided with Post-Exposure prophylaxis Proportion of clinically undernourished People Living with HIV (PLHIV) who received therapeutic or supplementary food Proportion of STI cases tested for HIV Percentage of non-pregnant women in the reproductive age living with HIV on ART using a modern family planning method Proportion of patients enrolled in HIV Care who were screened for TB Proportion of HIV positive women (15+) on ART screened for Cervical Ca Number of individuals tested for Hepatitis Proportion of diagnosed Hepatitis B and C patients who received treatment

17. HIV/AIDS and related Indicators… TB/HIV (National) Indicators Proportion of registered new and relapse TB patients with documented HIV status Proportion of HIV-positive new and relapse TB patients on ART during TB treatment

18. Facility-Based MER Indicators There are around 35 Standard MER indicators of which Ten are included in the 2 nd phase of EMR-ART System implementation a) TB_PREV Indicator(prevention)- Reported Semi-Annually Proportion of ART patients who completed a standard course of TB preventive therapy within the semiannual reporting period b) TX_NEW(Treatment)-Reported quarterly Number of adults and children newly enrolled on antiretroviral therapy (ART) TX_CURR(Treatment)- Reported quarterly Number of adults and children currently receiving antiretroviral therapy (ART) HTS_INDEX(Testing)-Reported Quarterly Number of individuals who were identified and tested using Index testing services and received their results e) PrEP_NEW:- Reported Quarterly:- Number of individuals who were newly enrolled on pre-exposure prophylaxis (PrEP) to prevent HIV infection in the reporting period f) PrEP_CT:-Reported Quarterly Number of individuals, excluding those newly enrolled, that return for a follow-up visit or re-initiation visit to receive pre-exposure prophylaxis (PrEP) to prevent HIV during the reporting period

19. Facility-Based MER Indicators… g) PMTCT_ART(Treatment)- Reported quarterly Percentage of HIV-positive pregnant women who received ART to reduce the risk of mother-to-child-transmission during pregnancy h) TX_TB(Treatment)- Reported Semi-Annually Proportion of ART patients screened for TB in the semiannual reporting period who start TB treatment. i ) TX_PVLS(Viral Suppression)- Reported quarterly Percentage of ART patients with a suppressed viral load (VL) result (<1000 copies/ml) documented in the medical or laboratory records/laboratory information systems (LIS) within the past 12 months j) TB_ART- Reported quarterly Proportion of HIV-positive new and relapsed TB cases on ART during TB treatment k) TX_ML- Reported quarterly Number of ART patients (who were on ART at the beginning of the quarterly reporting period) and then had no clinical contact since their last expected contact l) Tx_RTT --Reported quarterly Number of ART patients with no clinical contact (or ARV drug pick-up) for greater than 28 days since their last expected contact who restarted ARVs within the reporting period

20. Issues in Documentation of HIV Data

21. 21 Full Name (Grandfather Name missing) DOB not requested (rather age documented) Address data incompleteness (Physical address missing, Phone #) Clinical Data like TPT incomplete TPT completion date (DCs completed by guess) Clients coming as TI not asked TPT complete date Regimen of TPT (INH, 3HP or 3HR) Issues in Documentation of HIV Data Incomplete Data Elements Inappropriate doct’n of ARV dose Confusing ARV Dose & Dose Days Misunderstanding purpose of Follow-Up Forms, client history sheets and prescription forms Clinicians neglecting doct’n of ARV dose in the hand of a client in consecutive ARV refills; Not knowing the dose in the hands of clients ARV dose not matching with Next Visit Date

22. 22 Only giving due consideration for HVL Neglecting suppressed VL for archival or waiting a client to arrive for archival Not using viral load result for continuous client monitoring Issues in Documentation of HIV Data Not archiving VL result received

23. 23 No communication with clients receiving ARV in emergency setups in other facilities. The mother facility still declares as if the person is lost in this case. Clients having extra-dose in hand updated as LFU as no evidence & mechanism to document at facility level Restart clients documented by data clerks with no evidence Issues in Documentation of HIV Data No Standardized communication & data flow (in updating Final Follow-Up Status of clients missing appointment)

24. 24 Providing accurate, up-to-date, & complete patients data  at the point of care Quick access of Client Data across Continuum of Care Securely sharing electronic data with other clinicians for better clinical service Helping providers reduce medical errors. Improving patient and provider interaction and communication, as well as health care convenience Promotes legible and complete medical documentation Benefits of EMR

25. 25 TPT/TB Treatment, Cotrimoxazole, Fluconazole Therapy Viral Load Monitoring: High Viral Load Easily Identify eligible clients for VL (Decision Support) More Elaborated Content can be Stored like Indication for VL test Clients ARV Drug Information, Side Effects, Switch, Stop and Related Reasons for Switch, Substitution or Stop Dynamic Calculation of Client Age based on DOB Easily Monitor relevant variables like Weight, Nutritional & Pregnancy Status, Adherence to care and Medication… Benefits of EMR

26. 26 Scheduled & Clients Missing Appointments Monitor Functional Status and Clinical Stage (quality of life and Productivity) Generate HMIS and MER indicators(Reports) for Program Decision Analyze clients Follow-Up Status & Alerting of Not Updated/Lost to Follow-Up Clients Creates reliable Communication Platform at facility level Increases Data Demand & Provides data for Clinical Inquiry/Research Benefits of EMR

27. 27 Using EMR-ART for Clinical Decision Visibility of data by clinicians Improves completeness of programmatically important variables & uptake of some programs (like TPT and VL) Numerous Data Elements in the Paper are Incomplete, but Clinicians have not examined them, and there is no Communication Platform, Accessibility of Various Clinical/Non-Clinical Data Improves Clinical Service quality Temporary loss of client chart creating documentation break & clients mistreatment Clinicians unaware of facility performance on relevant indicators & less involved in the program performance improvement (TPT) Rationale for Providers View

28. 28 Features & Functionalities-EMR ART Dashboard Add Patient HIV Testing Service Chronic Care Registration Treatment and Follow-up Viral Load Report and Analytics Exposure prophylaxis Administration Data Quality Assurance Help

29. 29 Features & Functionalities-EMR ART Helps to visually track, analyze & display key performance indicators & metrics Dashboards

30. 30 Features & Functionalities-EMR ART Enables documentation of all clients centrally for all services Can be used to search clients before registering for any service Add Patient

31. 31 Features & Functionalities-EMR ART Enables Documentation of HIV Positives Tracking HIV Testing Service: Positive tracking

32. 32 Features & Functionalities-EMR ART Enables to document services related to Case Based Reporting HIV Testing Service: CBS

33. 33 Features & Functionalities-EMR ART Contacts Socio-Demographic Data Family Members Partner Data(Case Investigation Forms) Partner & FBICT

34. 34 Features & Functionalities-EMR ART Exposed person information Exposure detail Exposed person follow-up Post-Exposure Prophylaxis

35. 35 Features & Functionalities-EMR ART Follow-Up Documentation: General Nutrition, Pregnancy & FP TB Screening, OI & Pain Mg’t CTX Preventive Therapy & Lab Results ARV Drugs/TO Management HIV Prevention Pan DSD CxCa Follow-Up Form Print Functionality Delete Follow-Ups Treatment & Follow-Up

36. 36 Features & Functionalities-EMR ART To Document & Update Assessment Status, DSD category, Reason for categorization Category change date Enables patient tailor service delivery Improve service quality, results in cost savings or reduce health care costs, Improve health outcomes Treatment and Follow-Up: DSD

37. 37 Features & Functionalities-EMR ART Helps to track ART Clients Missing Appointment Shows Missed Appointment by Category: Missed(<30) 1st lost(30-59) 2nd lost(60-89) Dropped(90 & Above) Shows Additional Information for Decisions like Mobile Number Missed Days Last Treatment Current Date Treatment and Follow-Up: Tracing

38. 38 Features & Functionalities-EMR ART Enables documentation of Transfer Out Clients Enables Saving of Documented TO Form Print and Attach completed TO form Treatment and Follow-Up: Transfer Out Fill & Print TO Form for Transferred out clients Line List of Transferred out clients

39. 39 Features & Functionalities-EMR ART Automated version of viral load requisition and reporting form. Enables to automatically send test request and receive result using web API using an internet connection. Display VL eligibility list Display VL test request and result(HVL priority) Viral Load/ETORRS

40. 40 Features & Functionalities-EMR ART Enables the users to generate and export HMIS/DHIS2, DATIM, Line List, Summary, Cohort and Custom Reports Report & Analytics

41. 41 Features & Functionalities-EMR ART HMIS/DHIS2: Generate, Export, Save & Print HMIS/DHIS2 Report DATIM : Enables the users to generate and export DATIM report Report & Analytics: DHIS2 & DATIM

42. 42 Features & Functionalities-EMR ART Report & Analytics: TX_Curr Analysis Previous Month Tx_Current To Lost Drop Dead Not Updated Traced Back Restart TI Newly Initiated Current Month Tx_Current Tx_Current Net Increment Current Month Tx_Current Tx_Current Net Increment

43. 43 Features & Functionalities-EMR ART Report & Analytics: Lost/Drop Lost Status Dropped Status

44. 44 Features & Functionalities-EMR ART Report & Analytics Line List: Net Tx_New Newly Started

45. 45 Features & Functionalities-EMR ART Report & Analytics: Cohort Cohort Enables users to generate and export Cohort report

46. 46 Features & Functionalities-EMR ART Report & Analytics: Cohort Helps to :- To display clients’, follow up based on their ART Start Date To display patient info To display clients last follow up aggregate report grouped by follow-up status To display custom report based on filter criteria of “HIV Confirm Date”

47. 47 Data Quality Poor quality of data in the individual medical record due to Incompleteness, Duplication Loss of data Mistyping of Figures Knowledge or skill Gap in using Electronic System/EMR-ART Not Interested in using available system Possible Reasons for poor DQ vs EMR-ART Possible Reasons for poor DQ in HIV Data Validations Must be filed/required fields Auto-Calculating Data Fields Notification and Alerts Managing Duplicated Records Managing Incomplete Records Features in EMR-ART for DQ

48. 48 Data Quality Identifies charts with Various Data Quality Issues Duplication Completeness Consistency/Validation Deleted Duplication Possible Reasons for poor DQ vs EMR-ART

49. Data presentation/analysis for Provider view Summery of clinical patient Information Aggregate summery of completeness Line list of Clients with data completeness

50. 50 Features & Functionalities-EMR ART Report & Analytics: TX_Curr Analysis Previous Month Tx_Current To Lost Drop Dead Not Updated Traced Back Restart TI Newly Initiated Current Month Tx_Current Tx_Current Net Increment Current Month Tx_Current Tx_Current Net Increment

51. 51 Data Quality DQI & IU: Color Code Stickers Complete Address Data & Full Name Data At least one Variable Missing Complete Address Data & Full Name Data Full Name Region, Zone , Woreda, Kebele House Number Phone Number Address Viral Load TPT TPT Start Date & TPT Completed Date Months passed since TPT Start Date

52. 52 Data Quality DQI & IU: TPT Color Code Stickers TPT Start Date Documented TPT Completed Date Not Available <10 Months passed since TPT Start Date TPT Start Date & TPT Completed Date Either of the Dates not available >10 Months since Start Date & no competed date Start Data & Discontinued Date Documented >3 years since the client completed TB Treatment

53. TPT…Bronze Bronze: - includes a group of clients whose TPT status is not complete due to various reasons Bronze1 label is those clients whose TPT Start Date is recorded but TPT completed Date is Null plus Bronze2 label is those clients whose TPT Start and Completed Date is Null. Bronze3 label is those clients whose TPT Start and Discontinued Date is Entered Bronze4 label is those clients Eligible for TPT are selected as Yes in the follow-up data entry. Bronze5 label is those clients who have been on treatment but completed before 3 Years and no TPT start or completed date documented afterward. In general, all the above five bronze labels will collectively be displayed as Bronze in the aggregated report section.

54. 54 Data Quality DQI & IU: Viral Load Color Code Stickers Viral Load Not Applicable1: - Clients whose viral load Performed Date is Null and viral Load Eligibility Date is > Current Date for alive on ART and Restart clients only. Viral Load Not Applicable2: - Clients whose follow-up Status is different from Alive and Restart. Eligible for Viral Load 1: - Clients whose Viral Load Eligibility Date is less than the Current Date Eligible for Viral Load 2: - Clients whose Viral Load Eligibility Date > Current data and Status Alive and Restart, Current Date minus ART Start Data >= 12 months and viral load is null. the number of clients who are displayed under Viral Load Done: - Clients whose Viral Load Eligibility Date > Current date and Viral Load Performed Date is Different from Null. Not Started ART : - those do not start ART so far

55. 55 Data Quality DQI & IU: Cervical cancer Color Code Stickers Currently Eligible for Cervical Ca Screening (Yellow Star) = All women aged above 14 years and above: -Who were not screened previously and Eligible for Cervical Ca next visit date Not Applicable (Blue Star) All Males or Females aged <=14 Years of age with any follow-up status All clients with Final Follow-Up status TO and Dead Cervical Ca Screening Done (Green Star) = Cervical Ca screening documented, and Next Visit Date documented in the Cervical Ca screening page is greater/later than today. Not Started ART (Black Star) = ART Started Date no documented

56. 56 Data Quality DQI & IU: Cervical cancer Color Code Stickers Cervical Cancer Clients (Red Star) With Biopsy Test Result documented as Carcinoma In situ Invasive Cx Ca Other These clients will never be eligible for cervical cancer again and always appear in this category Clients being diagnosed with Cervical Cancer and not Eligible to be screened regularly, will be included here This will be final status of clients documented in EMR-ART

57. Partner &Family Based ICT ICT Not Eligible: - Clients started ART and their Follow Up Status is different from Alive and Restart. Screened1: - Clients Latest Follow Up Status is different from Restart or Screening Date is < = Latest Follow Update. Screened2: - Clients whose follow Up status is Restart and Screening Date = Latest Follow Up date . P&FBICT Eligible1: - Clients No Screening Information and Started ART. P&FBICT Eligible2: - Clients whose Latest Follow Up Status is Restart and Screening Date is < Latest Follow- Up date. P&FBICT Eligible3: - Clients whose Latest or most recent Viral Load Result is High, and Screening Date is < Latest HVL Received Date. Undetermined ICT Clients not fulfilling all the above-mentioned criteria will

58. DSD Models

59. Treatment and Follow-up: Different DSD Model No DSD Model Type Description 1 Appointment Spacing Model Stable clients will be appointed every six months for clinical visit and medication refill. 2 Three Months ARV Dispensing (3MMD) In the three months ARV dispensing model, clients who are eligible but not willing to be enrolled in 6 MMD (ASM) will be appointed every three months for both clinical visit and medication refill. 3 Fast Track ARV Drugs Refill Model Fast Track ARV drugs Refill (FTAR) is one of the facility based Differentiated Service Delivery Models of HIV care where patients categorized as stable make clinical visit once every six months but collect their medication every three months from pharmacy. 4 Health Extension Professional Managed Community ART refill group (HEP_CAG) Community ART refill groups (CAGs) are groups comprising of stable clients on ART living in the same community/locality that have a shared understanding. This model is managed by health extension professionals (HEPs) who already have roles in HIV testing and other HIV service provision as one of their packages.

60. Treatment and Follow-up: Different DSD Model No DSD Model Type Description 5 Peer lead community based ART distribution/Group (PCAD/G) The peer led Community based ART distribution (PCAD) groups are groups of PLHIV comprising of stable clients living in the same community/ locality. In PCAD, group members will take turns to pick up ARVs at the health facility and distribute among the other group members in the community. 6 Health care worker managed DSD Model for adolescent living with HIV (DSD for ALHIV) DSD for adolescents has three core elements which include ART refill, clinical consultation and psychosocial support. This model is coordinated by trained health care workers (HCWs), and regularly meet on weekends and share psychosocial supports. 7 DSD for key population (for FSWs) In Ethiopia there are efforts to make public and private facilities KP friendly by building the capacity of providers and arranging service delivery approach to match their needs. 8 MCH _DSD Mothers living with HIV and their infants are important target population for differentiated service model (DSD). 9 DSD for Adolescent DSD for adolescent is categorized under more intensive models assuming that most of the adolescents require close follow up and adherence support. 10 DSD-Others

61. 61 Using EMR-ART for Clinical Decision Clinical Patient Information See summary of Individual Patient Clinical Information from the already documented follow ups Address data Completeness Last Follow Up date Prescribed Regimen TPT Status Cervical Cancer Viral Load Status DSD Status and P&FBICT Status Helps to :

62. 62 Using EMR-ART for Clinical Decision Provider View: CLINICIAN VIEW LIST

63. 63 Using EMR-ART for Clinical Decision Provider View: Completeness Check Contains: Address Completeness Summary of all Registered Clients in EMR-ART TPT Information of Clients Viral Load Information of ART Started Clients ASM Status Summary of ART Started Clients P&FBICT Status Summary of ART Started Clients

64. 64 Summary Data can be used consistently to Improve Service Quality & service uptake Clinicians have Indispensable role to Improve HIV Data Quality and Facility level Data Use Movement Continuous Focused Data Completeness Check and Use of Creative Approaches like stickers and other locally developed methods/approaches Communication platform can be created by using EMR-ART data between data managers and clinicians for improvement of HIV service improvement

65. 65 Thank You!