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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.

Best Practices

To address the UNAIDS Sustainable Development Goals for elimination of HIV/AIDS, tuberculosis, malaria and other diseases by 2030, and the PEPFAR 3.0 goals, I-TECH leverages the technical expertise of its universities and partners, the broad experience of its funders, and best practices from 15 years of implementing programs.

 

Transition & Sustainability

The International Training and Education Center for Health (I-TECH) works in partnership with host country governments, universities, professional associations, non-governmental organizations, private sector groups and funding agencies to strengthen local capacity and build sustainable health systems.

I-TECH follows a partnership model that guides the provision of technical services and technical assistance toward local ownership and sustainability, creating projects and programs that can be readily transitioned into national systems.

Based at the University of Washington, I-TECH draws upon a strong global network of public health professionals. The approach described in this document is customized in each country to respond to local needs and priorities. In addition, each I-TECH country office team aligns the model with the unique Partnership Framework Implementation Plans of the partner host government.

1. IDENTIFY NEEDS in consultation with host country governments

I-TECH works with host country governments to assess existing health systems and identify specific areas where the delivery of health care could be improved. This early collaboration helps to ensure that technical assistance accurately reflects the country’s specific health strategies and priorities.

2. STRUCTURE PARTNERSHIPS that integrate projects into existing systems

In each partnership, I-TECH develops roles, responsibilities, and timelines based on a long-term vision of integrating projects into existing national systems. As part of this vision, I-TECH recognizes and leverages the strengths and resources of national systems, building on and maximizing these efficiencies. The partnerships that emerge are attuned to the needs, realities, and structure of host country systems. Thus, they build and maintain lasting capacity within host country systems, maximize cost-effectiveness, and produce projects that can be more readily scaled up to meet national goals.

3. SECURE TECHNICAL RESOURCES from affiliated universities, partners, and the I-TECH network

As a center based at the University of Washington, I-TECH has direct access to a wide variety of technical specialists. In addition, I-TECH draws upon a robust global network of locally based public health professionals. These specialists provide a wide range of technical expertise to meet project needs.

4. PROVIDE TECHNICAL ASSISTANCE AND SERVICES tailored to actual needs and resources

I-TECH is committed to technical services and technical assistance approaches that build upon and support the existing strengths of local health systems. In addition, I-TECH prioritizes the use of local and regional expertise, an approach that builds the capacity of local experts to meet locally determined needs.

5. MONITOR PERFORMANCE; evaluate achievement of objectives and measure outcomes

I-TECH implements projects within a quality improvement framework designed to track progress in institutional capacity building and guide successful implementation. Using the framework, implementers monitor the progress of each project against specific benchmarks of success; for example, the progressive transfer of skills and capacity to local institutions. This methodology ensures that objectives are met and provides data to adjust approaches as projects evolve.

6. TRANSITION PROJECT into national systems to ensure sustainability

The ultimate goal of I-TECH’s partnership model is to improve health outcomes by strengthening local capacity and building sustainable health systems. I-TECH’s technical services and technical assistance are tailored from the initial planning stage to produce projects that can be successfully absorbed into national systems within mutually determined and realistic timeframes. Recognizing that a successful transition takes time, I-TECH offers transition support in a variety of technical areas including quality improvement and grant management.

Leadership & Management

Training on leadership and management in health is a major focus of I-TECH’s health systems strengthening efforts. I-TECH works in close collaboration with the Department of Global Health’s E-Learning Program (eDGH) to ensure that training content on leadership and management can be offered at low cost in even remote areas by using e-learning approaches and technologies to expand the reach of its training programs.

Program Highlights

Improving Laboratory Quality in Cambodia
I-TECH’s laboratory program began in Cambodia in 2013 with the goal to improve operations and regional biosurveillance and biosecurity through improved laboratory quality assurance and management practices. In collaboration with the Cambodian Ministry of Health, the World Health Organization (WHO), and the U.S. Centers for Disease Control and Prevention (CDC), ...
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Laboratory Quality Stepwise Program in Cambodia
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Transitioning OpenELIS Training and Implementation to Local Professionals in Côte d’Ivoire
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Tuberculosis

To reduce the number of new cases of tuberculosis and improve diagnosis and treatment, I-TECH collaborates with governments and ministries of health to strengthen their health systems through facilitating trainings, advising on health policy and clinical guideline updates, supporting laboratory quality management, upgrading national health information systems, and implementing integrated TB/HIV care and treatment services.

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Malaria

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Voluntary Medical Male Circumcision

I-TECH has developed extensive capacity and expertise in voluntary medical male circumcision (VMMC) program implementation and management by providing comprehensive VMMC services and/or technical assistance across Southern and Eastern Africa in Botswana, Malawi, Mozambique, Namibia, Tanzania, and Zimbabwe. Technical focus areas include health policy and guideline development, including early-infant male circumcision and piloting and evaluating devices; external and internal quality assurance; demand creation and community mobilization; training; and direct service delivery – all built on a strong foundation of monitoring, evaluation, and learning. Since 2011, I-TECH has directly provided more than 660,000 VMMCs with an adverse event rate of less than 2%.

I-TECH promotes an integrated model, consistent with the Global Health Initiative (GHI) Principles, and supports data-driven program implementation and management. By working closely with the Ministries of Health, local partners, and communities, I-TECH ensures implementations are country-owned and foster strong health systems and sustainable programs.

Program Highlights

Achieving Targets through Performance-Based Financing in Zimbabwe
ZAZIC employs an innovative performance-based financing (PBF) system to speed progress towards ambitious voluntary medical male circumcision (VMMC) targets. The PBF schedule, which started at $25 USD and now varies from $6.50-$14 USD depending on the location and the circumcision team, is continually refined to set the program up for ...
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Ensuring High-Quality Service Provision in Zimbabwe
Describing Adverse Events within VMMC Programs at Scale I-TECH works diligently to review and revise procedures to identify, manage, and report adverse events (AEs). I-TECH’s previous publications on AEs reveal efforts to maintain high quality programming and emphasize patient safety alongside achievement of targets. An evaluation published in the Journal ...
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Innovative Training Models in Tanzania
I-TECH Tanzania has implemented many pre- and in-service training initiatives and materials, as well as adopted TrainSMART ...
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Case Finding and Retention in Care in Mozambique
I-TECH works with the Mozambique Ministry of Health (MISAU) to expand a pilot project to provide an assisted partner services intervention. The project is aimed at encouraging patients newly diagnosed with HIV infection to disclose their status to their partners, and bring them to the clinic for testing ...
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HIV Co-infection

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HIV and STI Prevention

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HIS Leadership and Governance in Kenya
As a key member of the Kenya electronic medical record (EMR) system technical working group, I-TECH works to implement and standardize the EMR systems used in the management of national HIV and AIDS care and treatment data. Similar efforts have focused on ensuring that different electronic systems can communicate with ...
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HIV Pre-Exposure Prophylaxis (PrEP) in Ukraine
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Human Resources for Health in Mozambique
I-TECH’s long engagement with clinician education in Mozambique includes support for improvements to the national undergraduate (“pre-service”) curriculum for laboratory technicians (Técnicos Medio de Laboratório) to make the content more current and reflect the health care priorities of the country, including advances in HIV diagnostics and treatment monitoring. The curriculum ...
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Pre-Exposure Prophylaxis for HIV Prevention in Namibia
I-TECH began supporting the implementation of pre-exposure prophylaxis (PrEP) as part of Namibia’s combination HIV prevention strategy in 2017 ...
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HIV Care and Treatment

I-TECH provides technical assistance on the clinical care and treatment of HIV and related opportunistic infections on a continuum that ranges from direct patient service delivery, to training and mentoring health care workers, to the development of national policies and health systems infrastructure. In particular, together with ministries of health and other key stakeholders, I-TECH has developed numerous curricula and clinical mentoring programs to train health care workers to safely and effectively treat patients who have HIV and TB or other opportunistic infections at a level of care commensurate with national and international standards.

I-TECH has also assisted ministries of health to create national prevention and care and treatment guidelines for infectious diseases, which has lead to standardized care and treatment for HIV, including antiretroviral therapy (ART) dosing for adults and children.

Program Highlights

Driving Collaboration with Local Implementation Partners in Zimbabwe
I-TECH builds local ownership and sustainability through collaborations throughout Zimbabwe. Under the CDC and PEPFAR awards, I-TECH has formed and leads two consortia – ZAZIC and ZimPAAC ...
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eLearning Programs for Health Care Workers in Trinidad and Tobago
I-TECH partners with the HIV/AIDS Coordinating Unit (HACU) of the Ministry of Health (MOH), the National AIDS Coordinating Committee (NACC) of the Office of the Prime Minister, and other local organizations to make accessible learning and capacity-building opportunities for all cadres of health care workers.

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Expanding HIV Care and Treatment in Zimbabwe
The ZimPAAC consortium collaborates with the Ministry of Health and Child Care (MoHCC) in Zimbabwe to meet the following primary HIV epidemic control objectives:

  • Diagnose 95% of all persons living with HIV through integrated testing
  • Ensure 95% of individuals diagnosed with HIV are initiated on antiretroviral therapy (ART), retained ...
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