A National EMR: Achieving PEPFAR's Goals for an AIDS-free Generation in Haiti
From tracking individual patients through the HIV Continuum of Care, improving quality and service provision at the facility level, to identifying national level trends for programmatic and policy decision-making, electronic medical records (EMRs) serve a critical role in efforts to achieve sustainable HIV epidemic control. iSanté has become the national EMR in Haiti and has a significant role to play in reaching PEPFAR goals in Haiti. iSanté is funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Centers for Disease Control (CDC), iSanté is jointly administered by the Ministry of Public Health and Population (known by its French acronym, MSPP) and the University of Washington’s International Training & Education Center for Health (I-TECH). The PEPFAR 3.0 phase of sustainably controlling the epidemic is organized around five action agendas. iSanté contributes to four of these: impact, efficiency, sustainability and partnership.
Impact and Efficiency Action Agendas
Accessibility of data plays an integral role in identifying and answering population and programmatic questions that are critical to increasing impact and improving efficiency. iSanté is currently used in 115 sites (roughly 90% of electrified HIV service points in Haiti), serves as the sole medical record for about 70% of all HIV patients, and houses over 700,000 patient records. This critical mass of data has been used at the national level to both identify, and target intervention to populations at greatest risk of attrition in HIV care and treatment:
- A study using iSanté facility data compared five different measures of risk for ART treatment failure based on adherence, and found that pharmacy data (proportion of days covered) did the best job at predicting treatment failure. This information is now being used to develop an alert in iSanté to help clinicians identify patients who are at risk of treatment failure and prompt interventions.
- Two recent studies measured retention and attrition on ART, again using iSanté facility data, found that retention was significantly lower and rates of attrition significantly higher among pregnant women in Haiti (Option B+)[2,3].
Sustainability Action Agenda
The goal is for iSanté to be fully owned, managed and maintained in-country and a transition plan is underway.
- PEPFAR funding for iSanté has served to build the capacity of local Haitians to manage, design, develop, and implement the EMR, as well as integrate it into clinical practice. Work is underway to ensure that the infrastructure and workforce capacity are in place to sustain iSanté’s momentum in combatting HIV into the future. The greatest achievement in this arena is the transition of all new iSanté development efforts to in-country Haitian developers.
- Currently PEPFAR is in the process of transitioning iSanté to an OpenMRS platform which is supported by a growing global community. The beginning of the phased national roll-out of the new version of the software (named “iSantéPlus”) is expected in 2017, but in FY16 the first big milestone was achieved with full mapping of iSanté concepts to a standardized, global dictionary. This is a dictionary of internationally standardized terminology that facilitates harmonization and information sharing between partners.
Partnership Action Agenda
The point-of-care EMR and accessibility of iSanté data is also promoting collaboration between I-TECH, the MSPP, and other PEPFAR funded partners to identify and apply differentiated models of care to diverse populations of patients on ART under the new Test and Start guidelines.
- Catholic Medical Mission Board (CMMB), a local organization committed to building locally sustainable healthcare solutions in Haiti, has recently begun to use iSanté to group patients at facilities into categories to target specific models with models of care that meet their diverse needs. I-TECH has not only trained the care providers of this organization but also ensures iSanté maintance in its sites.
- GHESKIO Centers (The Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections), another local organization dedicated to service, research, and training to combat HIV, is using iSanté to identify patients stable on ART who are at low risk for attrition for a “rapid pathway” model of differentiated care. These patients have separate clinical visits from ART refill only visits allowing them to move quickly through the facility to collect their ART at the ART refill only visits effectively decongesting clinics, saving patients’ time, and reducing the burden on HIV care providers.
- JHPIEGO: I-TECH trained JHPIEGO managers in the Healthqual methodology. I-TECH also trained providers of 21 sites (19 old and 2 new) in the use of iSanté and installed it in those sites.
- National Healthqual Committee: As a member of the national Healthqual committee, I-TECH has helped them develop and define new indicators and program them on iSanté.
- PNLS: I-TECH works with the National AIDS Control Programme to regularly update care and treatment protcols and training materials as well as conducts joint site visits with the agency.
- UGP: I-TECH works closely with the Program Management Unit of the MSPP to support operations and maintenance of iSanté servers and clinical implementations.
PEPFAR seeks to achieve epidemic control and an AIDS-free generation in Haiti through five impact agendas at the patient, facility, and level. iSanté is a widely deployed system that contains a critical mass of HIV data and can continue to be leveraged to support the achievement of an AIDS-free generation in Haiti.
1. The Office of the U.S. Global AIDS Coordinator. PEPFAR 3.0, Controlling the epidemic: Delivering on the promise of an AIDS-free generation. Washington, DC. December 2014.
2. Domercant JW, Puttkammer N, Young P, Yuhas K, et al. Attrition from antiretroviral treatment services among pregnant and non-pregnant patients following adoption of Option B+ in Haiti. Global Health Action, Submitted for Publication, January 2017.
3. Puttkammer N, Domercant JW, Adler M, Yuhas K. Comparative ART Attrition and Risk Factors among Option B+ Program Clients in Haiti. PLOS One, Submitted for Publication, December 2016.