Author: Anne Fox

Case Study of iSanté proposes sustainability as key success factor for health information systems in LMIC

I-TECH Haiti’s Dr. Marinho Elisma works with clinician Belhamie Ketleen on the iSanté electronic medical record system.

To mark the 10th year of the iSanté electronic medical record (EMR) system, the International Training and Education for Health (I-TECH) team in Haiti embarked on an analysis of the EMR’s implementation, the results of which were published as a case study last month in Health Policy and Planning.

The study focuses on factors of success, contributing to the industry’s understanding of what it takes to sustain and transition an EMR system in a low- and middle-income country (LMIC) like Haiti. The team found that while functionality and technical factors continue to be relevant as EMR implementations mature, other factors also become significant over time, including governance and leadership, ongoing user capacity, data quality, integration within a larger eHealth framework and financing.

The team assessed factors for success in eight categories: functionality, technical, organizational, training, political, ethical, financial, and sustainability. Seven of these were determined by the work of Fritz et al. in a review of factors contributing to EMR system success in low-resource settings.[1] However, one of the main findings was the eighth category the Haiti team added to the list of factors: sustainability.

Why sustainability is critical

When a system like iSanté is implemented at scale for so many years, the definition of success shifts from design, planning, and rollout to financing, governance, maintenance, and long-term ownership of the system by Haitian stakeholders. Transition planning, including long-term financial sustainability of the system, needs to begin at the start of any implementation.

“iSanté is a part of the legacy of the HIV information system, a model that will be used from generation to generation especially in terms of sustainable HIV/AIDS interventions,” said Nirva Duval, M&E Lead at the National AIDS Control Programme of the Ministry of Public Health and Population (MSPP) in Haiti, a case study author who has been involved in the iSanté implementation since its beginning in 2005. She went on to add, “Use of iSanté data is a major asset and an opportunity to better understand issues and contribute to decision-making at all levels.”

Ultimately, the goal is for iSanté to be fully owned, managed, and maintained in Haiti and wholly integrate into clinical practice. In 2016, I-TECH, the U.S. Centers for Disease Control and Prevention (CDC), and the MSPP undertook an overhaul of iSanté, including moving all servers and the majority of software development to Haiti.

Lessons learned pave the way for integration

The rebuild, known as iSantéPlus, uses an OpenMRS platform, which is supported by a growing global community. The phased national rollout of iSantéPlus is under way and will continue during 2018. I-TECH is also supporting the creation of a new national health information exchange known as “SEDISH” (Système d’Echange d’Information de Santé d’Haïti in French).

SEDISH will ensure a seamless flow of data between the community level to sites to the national level and back, improve clinicians’ ability to see patient history from other sites, and maintain a continuity of care document for patients who move between care sites. SEDISH uses international data standards and a Master Person Index to facilitate harmonization and information sharing between the EMR and other health data systems like lab and supply chain systems, transitioning the Haiti HIS landscape from multiple disparate systems to an interconnected network. Both iSantéPlus and SEDISH will promote collaboration between MSPP and CDC- and USAID-funded partners to improve how health care providers serve individual patients and populations across these systems.

Many of the lessons learned during the implementation of iSanté were applied in the design and execution of iSantéPlus and SEDISH. “iSanté has kept Haiti on the leading edge of HIS implementation in resource-constrained countries,” said Dr. Scott Barnhart, Principal Investigator and Professor in the University of Washington’s Departments  of  Medicine and Global Health. “The changes under way will have broad global applicability — integrating across direct patient care, lab, pharmacy, as well as supply chain. We have an exciting opportunity to come together and build on our success to respond to the challenges of local ownership, financing, cost-effectiveness, and governance so that these important tools are sustainable.”

Once the team completes and assesses the results of the iSantéPlus and SEDISH pilot, the new systems will be deployed throughout Haiti. It will be critical that the MSPP, CDC, and I-TECH’s partners in Haiti come together to assess the sustainability of iSantéPlus and SEDISH and their impact on the HIS landscape in Haiti.

[1] Fritz F, Tilahun B, Dugas M. 2015. Success criteria for electronic medical record implementations in low-resource settings: a systematic review. Journal of the American Medical Informatics Association 22: 479–88.

Leadership and Management in Health Online Course Reaches Thousands Worldwide

Treats served at an end-of-course celebration in Kenya, 2016

Training on leadership and management is a critical component of the University of Washington (UW) International Training and Education Center for Health’s (I-TECH’s) health systems strengthening efforts. To that end, I-TECH has worked closely with the UW Department of Global Health E-Learning Program (eDGH) since 2012 to offer a heavily subscribed online course on leadership and management to health care workers in low- and middle-income countries.

Designed and taught by I-TECH Executive Director and UW Professor of Global Health Ann Downer, Leadership and Management in Health (LMIH) is a 12-week course focusing on the practical leadership and management skills required for working in complex global health environments. Weekly modules include content on team building, accountability, supervision and delegation, conflict management, financial management, use of data for decision-making, and effective communication.

“I want to express my gratitude for giving me the opportunity to do the UW course on Leadership Management in Health. …I find myself going back to these documents again and again to understand and imbibe what is given. I feel that the simple narrative of the course material has made all the difference.”

–2016 course participant from India

Participants from Tunisia, 2015

The course consists of recorded lectures, required readings, a weekly online discussion forum, quizzes, self-reflection assignments, and a final verbal presentation. It is targeted to practicing health care professionals and public health specialists who already have some experience managing people. In most cases, LMIH participants gather in weekly site-specific, in-person discussion groups led by a volunteer facilitator to discuss the material and apply it to their particular linguistic, cultural, social, and political environment.

“We just finished our site discussion this afternoon and the level of contribution and application to our various office settings was wonderful. …I have told my Chief Executive … about the course and he is thinking of asking all Management Staff to do it compulsorily in the next episode.”

–2017 course site facilitator

Due to high enrollment, the course is now offered twice a year, with a completion averaging 84%. Approximately 4,500 individuals are enrolled in the latest offering of the course, representing a nine-fold increase in five years. More than 10,000 health workers in 65 countries have graduated from LMIH since 2012.

Participants from Myanmar, 2017

According to a survey conducted by eDGH, more than half of graduates from the spring 2016 cohort now mentor colleagues on leadership and management-related job tasks. In addition, 67% said they were given new responsibilities or projects as a result of course completion, and 74% reported that they had maintained contact with other students from their sites.

“We consistently hear that how empowering the course is,” said Anya Nartker, E-Learning Project Manager with eDGH. “The course uses a blended model, where participants are required to meet with their local site each week to apply what they are learning in the course, and share problems that they support each other in solving.”

 

I like the idea of all students teaming together and working together despite their backgrounds and level of education. There were many who were highly educated and some who were moderately [educated], and we all understood and accommodated each other.

–2016 course participant from Kenya

Course graduates have requested a deeper exploration of certain topics introduced in LMIH. As a result, a certificate series of three online courses is being developed that will include LMIH; a new course titled Global Project Management; and a third online course, Fundamentals of Implementation Science.

The Global Project Management online course will be offered as a stand-alone course from July-September 2018, co-taught by Dr. Downer; I-TECH Deputy Director, Chichi Butler; and I-TECH Senior Program Manager, Harnik Gulati. The certificate will be offered in 2018.

Ukrainian Partners Visit UW for eLearning Training

E-learning training participants from Ukraine and trainers from eDGH.

In late October, the University of Washington’s Department of Global Health E-Learning (eDGH) facilitated a five-day course on e-learning best practices for a six-member delegation from Ukraine.

The goal of the training was to improve competencies in the development and implementation of online and blended teaching courses in health care. Throughout the five days, experts from eDGH covered the nuts and bolts of e-learning content design, development, rollout, management, assessment, and continuous improvement.

The training participants, led by the International Training and Education Center for Health (I-TECH) Ukraine Program Director Iryna Yuryeva, and Training Developer Tetiana Bairachna, included delegates from the Public Health Center of the Ministry of Health of Ukraine (PHC), Ukrainian Family Medicine Training Center of Bogomolets National Medical University (UCFM), Nursing College of Ternopil State Medical University (TSMU), and Nursing College of Poltava Ukrainian Dental Academy (PUDA).

The host organizations are either currently implementing online learning programs or planning to launch them in the near future: PHC recently introduced a series of distance learning products on HIV care and treatment and UCFM adapted the University of Washington’s Leadership and Management in Health course to the Ukrainian context.

Thanks to the training, “we finally discovered formulas to calculate continuing medical education credits awarded for a distance course completion,” said Volodymyr Vysotskyi of UCFM.

The Nursing College of TSMU offers online degrees such as a Bachelor and Master of Science in Nursing, and will benefit particularly from the course’s focus on evaluation. “Information on e-learning evaluation strategies was of special interest as we are planning to develop new online continuous medical education courses for nurses,” says Svitlana Yastremska of TSMU.

The team of trainers – Alex McGee, eDGH Managing Director; Anya Nartker, eDGH Manager of Online Education; and Elizabeth Scott and Leslie Wall, eDGH Senior eLearning Developers – shared their expertise in planning, development, and implementation of e-learning courses.

In addition, eDGH presented best practices and challenges and advised participants on technicalities of current e-learning courses under development in their organizations. “The approaches to sustainably institutionalize e-learning into the medical education system, both pre- and in-service programs, were the most important part of this training for me,” noted Mykhailo Riabinchuk of PHC.

To ensure continuity of the training, I-TECH and eDGH plan to start a series of follow-up webinars to support training participants as they promote and scale up e-learning in health care in Ukraine. I-TECH Ukraine views developing local capacity in e-learning as a strategic component of programmatic efforts as it extends access and improves efficiency.

“Leveraging the knowledge gained on distance learning, we will be able to take the postgraduate education at our institution to the next level of quality,” said Vadym Bodnar of PUDA.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under U91HA06801, the International Aids Education and Training Center (IAETC). The content of this post is the author’s and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. government.

HIV Positive Teens in Namibia Gather for Weekend of Fun and Support

HIV-positive teens gathered at B2Gold’s Otijikoto Mine Nature Reserve for a weekend of team-building exercises, support, and discussions about the importance of adherence to treatment.

All teens need consistent opportunities to build self-worth, explore their gifts, and feel the support of peers and adults. For teens who are HIV positive, the everyday pressures and fears of adolescence (rejection, bullying, gossip) can be amplified, making these opportunities especially important. In Namibia, adolescents and young people, especially girls and young women, continue to be disproportionately affected by HIV.

In response to these realities, in late August, a three-day Teen Club Retreat was organized by the Katutura Hospital Paediatrics Communicable Disease Clinic (PCDC) team, in collaboration with B2Gold, Champions for Life, and the International Training and Education Center for Health (I-TECH).

Fully funded by B2Gold and hosted at its Otjikoto Mine Nature Reserve, the retreat included 49 teens from the clinic (31 girls and 18 boys), who were joined by clinic doctors, nurses, and counselors as well as facilitators from Champions for Life, a psychosocial-spiritual program for children, adolescents, and young adults with the challenges of being infected or affected by HIV.

Through team exercises, game drives, inspiring films such as “Hacksaw Ridge” and “The Soul Surfer,” lectures, and small group sessions, the retreat aimed to:

  • strengthen bonds and networks;
  • create enthusiasm about the future;
  • develop self-respect;
  • instill the values of a healthy environment, teamwork, and responsibility; and
  • keep teens engaged in care.

“I enjoyed the movies, as they motivated me. I realized that I am not the only one facing challenges. When I courageously tackle my challenges, I remain strong even if I may not win them all.” – Teen Club member

I-TECH Namibia’s Sharon Mambo, an HIV Pediatric Expert Nurse, served as a chaperone and as one of the key organizers of the retreat. Mambo led a discussion on the importance of treatment adherence and viral load suppression. In addition, she tasked one of the teens with facilitating a discussion on “transitioning,” the process during which adolescents move from paediatric HIV care to more independent adult care. At Katutura hospital, this means accessing health services at an adult ART clinic.

Addressing the teens’ fears of waiting too long for services and meeting unfamiliar faces, Mambo assured the group that a specific health worker has been assigned to work with them and they would be “fast tracked.”

“It’s a matter of changing consultation rooms when you transition to the adult clinic,” said Mambo. “You will still meet the happy, friendly staff on the other side, so lay your worries aside.”

Teen Club members enjoyed a tour of the B2Gold facility, as well as nature and wildlife walks.

Highlights of the retreat also included a tour of the B2Gold mine and a game drive, where the kids were thrilled to see reserve animals including giraffes, springboks, wildebeests, and zebras at close range. “I got to see some of these animals for the first time,” said one teen. “I never knew that some animals could be as clever as human beings.”

The team from Champions for Life also held a full-day seminar titled “NICHE,” focused on self-image, identifying gifts and abilities, and creating one’s vision for the future. This was done through music, dance drama, group presentations, and poetry.

 “I enjoyed the team-building activities because we got to work as a group and had the opportunity to come up with ideas together as a team.” – Teen Club member

“A major success of this trip was the close bond, mutual respect, and trust that developed between the staff and adolescents during the three days,” says Mambo. “The shared experience and willingness of the staff to participate fully in all sessions of the program really lowered some of the barriers and discomfort that normally exist between teens and adults.”

Mambo has also been working with teen leaders from the group to support other facilities in Windhoek to establish their own Teen Clubs.

Caribbean Partnerships

I-TECH works with a wide variety of partners in the Caribbean and the United States. Partners include:

Regional Organizations partnering with I-TECH include:

Health Information Systems in Botswana

I-TECH has worked with the Ministry of Health and Wellness (MOHW), Centers for Disease Control and Prevention (CDC), and other implementing partners to develop and implement robust national health information systems (HIS) that enable greater efficiency and accountability and strategic use of information. These HIS include: Continue reading »

National-Level Quality Improvement in Botswana

I-TECH Botswana provides technical assistance at the national-level to improve HIV care and treatment, TB/HIV, and HIV testing and counselling programs through continuous quality improvement activities. Continue reading »

Laboratory CQI in Botswana

I-TECH Botswana works to strengthen external quality assurances (EQA) for HIV-related testing by conducting regular on-site proficiency testing support visits, conducting competency assessments and carrying out CQI activities at 22 I-TECH supported labs (45% of the labs in the country). I-TECH Botswana also provides technical assistance and support to the Botswana National Quality Assurance Lab (BNQAL).

HIV Testing Services in Botswana

I-TECH Botswana conducts facility-based HIV testing at selected PEPFAR supported scale-up sites in seven PEPFAR districts. Testing is carried out by Health Care Assistants and includes expanded provider initiated testing, counseling, and partner notification. In addition, I-TECH Botswana conducts regular continuous quality improvement (CQI) visits at I-TECH-supported facilities and provides support for linkage to care. Continue reading »