The use of technology to enable better health care is the wave of the future globally, and IDI is intent on ensuring that Africa is involved in this wave. Technology is used very little in health care in Africa, which means that even small interventions can lead to great benefits. Technology can facilitate better care to individuals through increasing the knowledge with which health workers make medical decisions, and providing patients with information that can help inform their own decision-making; and can help facilitate the collation of information on cohorts of individuals experiencing similar health-related complications. IDI aims to be at the forefront of this movement.
IDI uses technology to provide better quality health care for its patients, and also develops approaches and models that can be replicated in other resource limited settings. In addition, efforts are increasingly being made to create exportable products that facilitate the IDI mission, and that might be used by others for similar work. In the future these are likely to include e-learning platforms that enable creative methods of teaching and learning; and regional data management services, that enable data to be processed within the region, rather than being sent back to the US or Europe for processing (thus reducing the cost of doing research in the region, and increasing capacity within the region for engaging in all parts of the research process).
Integrated Clinic Enterprise Application (ICEA), to support clinicians in providing better care based on more accurate, ready-to-use data: This year ICEA was launched in support of IDI clinic and research activities. This system, although easy to use, contains a number of features that help to automate the care process, and provide accurate and up-to-date information to clinicians and researchers working in the IDI clinic.
Patient Registry: allows for management of all information related to patients including the services for which they visit the clinic and the research studies in which they are involved. It also allows for capture of patient demographics and visit registration.
Patient Management: allows for an overview of a patient’s complete medical record. It also allows for capture of vital signs, computerized provider entry of prescriptions and ordering of lab tests.
Data Management: allows for the data capture of all forms used in the clinic at IDI; additions or modifications of forms, to serve individual research projects, are also possible. This application provides extensive data quality checks and allows for double data entry where required. It also provides data in a form that is suitable for research.
Clinic Management: allows for monitoring and evaluating work flow in the clinic, monitoring the flow of patients through the clinic (currently on a request basis but will eventually be included as part of the management dashboard—covered in the “Challenges and Opportunities” section), and monitoring indicators related to some prevention activities. It also provides for management reporting.
Planned improvements over the next year include increasing the fields that medical providers can enter directly into the system. In addition, counselors will be able to enter data from the counseling form directly into ICEA. This is important for several reasons. First, all IDI clinic visits begin with a meeting with a counselor. If a doctor or a nurse has access to counseling data, this will ensure that s/he has relevant non-medical information on a patient’s situation, which may help rule out medical reasons for certain conditions. For example, if a patient appears to be responding negatively to his/her drugs, a doctor might assume that the regimen is inappropriate for that person. However if the doctor knows that the patient drinks alcohol in excess, this might lead him/her to ask more questions about why the drugs are not working. The second reason why counseling data is useful is that it will enable research that includes counseling data, which has not been possible up to now.
ICEA has been designed in such a way that users need only minimal experience with computers to use the system effectively; and it can be easily scaled up or adjusted, as IDI’s clinical and research needs evolve. The ultimate benefit of this system is that it improves the quality of care delivered to IDI’s Friends, as a result of data being more accurate, more complete, and more easily accessible by Friends’ care providers. From a management perspective, it helps to facilitate continuous and impartial monitoring of the clinic work flow, improves security and tracking in the drug distribution process, and is easy to use in monitoring clinical activities as a whole, as well as the care provided for each individual patient.
Centrally accessible databases, to ensure access to clinical and research data: IDI maintains electronic databases with information on every patient that has ever registered at the IDI clinic. This ensures that key information is always available online (paper files can get lost, torn, etc.; which is avoided when files are kept electronically). It also facilitates research using aggregate data from groups of patients. Data is available to all clinicians and researchers who need access to this confidential information, in order to do their work. Some of the information that is collected includes name; demographic information; date of first visit; whether or not the patient is on ARVs and if so the ARV start date; past medications received; results of lab tests; etc. The reports interface is similar to a web page, so it is easy to use; however there is a database of information behind every field, and queries can be run on either individual data or aggregate data.
Data management systems for partner clinics: A key aspect of IDI’s outreach activities is strengthening the ability of partner facilities to collect and maintain patient data. At the moment systems for supported KCC clinics are fully operational (there was no electronic record keeping previously); planning is still in progress for strengthening data management within Kibaale and Kiboga. When patients are transferred from IDI to KCC clinics for follow up, their data is transferred to electronic patient information databases that have been established for partner KCC clinics. The databases are hosted at IDI, so IDI and project data management personnel and clinicians/researchers retain access to that information, which enables them to monitor the quality of care being provided to patients who have been transferred, and to use the data in support of research activities. Clinicians at KCC clinics record information on paper charts while they are seeing a patient; then data entrants in-put it to the electronic system. This process enables several checks to ensure that clinicians are keeping complete records on visits.
Challenges and Opportunities
There are a number of areas that would strengthen IDI’s ability to use technology to support better health care in Uganda and Africa:
- Mobile devices: IDI hopes to pilot the use of personal digital assistants (PDAs) or other mobile devices to support health workers. Very quickly, mobile devices could be piloted in two ways. The first is to support home health visitors to provide routine care in the home environment, particularly for patients who are very ill and cannot come to a facility for care, or for patients who live in villages far from a health centre. PDAs would provide home visitors with the patient background information they need to make clinical decisions based on the patient’s clinical history, and would also provide general information about drugs that might be prescribed, anomalies that might be observed, etc. Another potential use for mobile devices is for clinicians who are working in facilities where they are monitoring multiple patients at one time. So, for example, if a nurse were moving around a ward, s/he could quickly pull up information on the condition of a patient whose bed s/he was attending to during a round. It would increase this nurse’s efficiency, and would ensure that s/he had his/her patients’ clinical data quickly available, in case of emergency situations that had to be dealt with quickly. These devices could also enable health workers to gather and transmit patient information for inclusion in electronic record keeping systems, reducing the risks associated with paper files. The benefits of this technology would most likely be tested through IDI’s outreach activities, where it could lead to quick and visible results.
- Biometric identifiers: Biometric identifiers are biological means of establishing a person’s identity (for example through thumb prints). In health care, they can be used to identify either caregivers or patients. In the case of caregivers, biometric identifiers can be used to ensure and track that it is only qualified caregivers who prescribe lab tests or drugs; or to accurately identify who has provided care to patients at various points in their care process. In the case of patient identification, use of biometric identifiers can ensure that patients actually are who they say they are; and if databases are shared among facilities using biometric identifiers to identify patients, it can be ensured that each patient is only receiving care at one facility.
- Electronic decision support systems: These are “rule based alerts” that will be integrated into the existing ICEA system, and will use data available on a patient’s background to alert care providers of potential medical errors. For example, if a patient is allergic to something and it has been entered into the electronic systems, and a clinician prescribes a drug that includes that component, the electronic system will flag the fact that the patient should not be given that drug. This can be helpful, as it makes a clinician’s decision-making less reliant on his/her individual judgment, through providing a check to ensure that decisions made are in line with historical data on the patient.
- Business Intelligence Application (BIA): A BIA allows a clinic’s management to generate customized information on clinical activities from aggregate clinical data, on request. An example of the kind of information that might be calculable would be productivity of individual doctors, derived from looking at the ratio of each doctor to number of patients seen over a period of time. This information is currently available at IDI, but can only be generated through the information services department. In the longer run it would be preferable to have this accessible “on-the-fly” by a wider range of management staff.
Using the BIA, clinic’s management would also be able to choose several indicators and customize them. Milestones on customized data can then be flagged, providing automatic decision-making information to managers. For example, a dashboard might be set up to monitor and flag certain situations, such as if 50% of patients registered in a day had not been seen by lunchtime—thus allowing clinic management to consider options such as putting additional staff into clinical activities after lunch. Essentially this allows key management decisions to be made more quickly, based on information that is automatically generated and interpreted.