2009 Implementers Group Meeting Program Point of Care vs Retrospective Data Entry
Note: As promised during the session, Isaac Holeman set up a Point of Care page where we can focus our efforts to adapt OpenMRS for use at the point of care.
Definitions
Point of care: Data entry during clinical visit/encounter.
Retrospective: Data entry after encounter, usually from paper form.
Expectations for Point-of-care systems:
Clinics already overburdened - reduce how many times data is written down. No data entry team available. Enter data only once.
Neal Lesh: 95% of OpenMRS data is retrospective.
Why is the retrospective data entry happening? What are the barriers?
Speed is so important - so many patients - typical systems cannot keep up
OpenMRS not designed for Point-of-care environment - need system designed to flow through the patient encounters
Problem w/ retroactive entry - data not available throughout the clinic - paper in the wrong place
Point-of-care system opportunity to improve quality of care - patients do not have to wait so long for their appointments, reduce time to wait from a day to an hour or two
At the moment aggregate data is pushing downwards - external factors are collecting - data is not used or available by clinicians.
What are circumstances that cause us to use Retrospective rather than Point-of-care?
Connectivity and uptime/consequence of downtime
Legal requirements - must have paper copy for legal reasons
Perceived extra hardware complexity - using mobile phones not as big a barrier as pc's - more accepted by indigenous community
Dr. Aamir Khan, Indus Hospital Research Center, Karachi, Pakistan - They made a move towards thin clients to reduce maintenance issues. It is important to note that as you move to Point-of-care systems, you need more sophisticated tech support.
Security: Look out for security issues:
Western cape system w/ 2.5 million patients - some clinics completely cleaned out by thieves. They are considering the use of VMware type systems and thin clients - When thieves steal equipment, it is worthless to them.
Power - Challenges of thin clients - do not have batteries
Pakistan - at clinics - use cellphones rather than pc's, since the clinic is less secure than the hospital - but important to close the feedback loop - return data to the clinic
Daniel's Andriod OpenMRS for mobiles - cellphone app example
Important design points for a Point-of-case system
Runs on a browser and can run in a thin client model - do not need a ton of servers - especially at the point of care.
Process are important part of Point-of-care. How to change business processes at the clinics? Does OpenMRS support modeling business processes?
More than interface: need to be able to track delivery of service
Baobab very successful at doing this - can see where patients are waiting
Baobab - some clinics have different roles - flexible roles where anyone can do anything. This is very useful in resource-poor environments where nurses double as pharmacists.
XForms include skip logic capability - can this (i.e., use of XForms' skip logic) be a useful tool for Point-of-care?
MOH Uganda: How to develop system that can easily configure workflow to support the local processes?
Time issue: System must be inherent to the processes so user does not notice it. Do not ask too much of the user, unnecessary fields.
Performance is very important - cannot wait for a long screen refresh
Types of Point-of-care
Centralized system
Distributed - sync issues -
Which type does OpenMRS support?
Sync
OpenMRS has a sync feature built-in
Use of guid to identify records that go up all the way - human resources system example in uganda
Boabab: If server can connect to other clinics, it can grab data from other peers
Importance of unique patient identifiers
Baobab - have unique identifiers for patients. Not using uuid's for baobab - just nat'l unique id.
Access to patient information
Is having instant access to patient record more of a requirement of a Point-of-care system or is this typical of all systems including Point-of-care
Very important for Point-of-care in order to track patient
Northern Nigeria - silos of data of maternal health data - now to get this data in front of clinicians? paper system doesn't work - no one knows the utility of some of these fields.
Opportunity is instant access to data vs. not having historical data avaialble
Patient Health Card - smart card w/ last 10 visits on it.
Separate Point of care data from administrative data - sometimes the data sytems collect too much admin data that is not particularly useful to clinicians.
What does OpenMRS need in order to implement a Point-of-care system?
Broad issues:
Where
When and
What
Is it a ui framework or more modularized?
Example of mdr-tb module - Model the Point-of-care process and enable programmers to create appropriate modules
Needs to accommodate different types of clients - pc's, phones, etc.
Hardware:
Promise for mobile phones and thin clients
Need analysis for the different contexts - 'device strategy' - rural health centres have different needs from urban hospitals
In a rural setting they may need a bed rather than a pc, but they need a communication device to send the data to the people who can provision the bed.
Need wiki pages on equipment recommendations, stories on what works
Working groups
Device strategy
Software design/data model
Case Studies
Pakistan: one Point-of-care system was being scaled up to over 40 sites, but OpenMRS did not yet have the features to do this.
Who has deployed Point-of-care systems? - page on wiki to publish success cases
Look at these stories to filter out some best practices, not just OpenMRS deployments. Don't expect our community to supply all of the solutions.
Patient registration system in Rwanda is a Point-of-care system currently in development.
Paper review of HMIS systems
System development
While developing system, the clinicians worked 3-4 hours a day w/ the programmers in developing each module - therefore they had a strong sense of involvement - they owned it.
Build flexibility in system - enable clinicians to add extra fields themselves - they may work on a special form of TB and collect extra data.
How to adapt OpenMRS for primary care?
Don't always know what type if data will be needed when someone comes into the clinic.
Should the team concentrate on primary care system, or on a subset like HIV?
Think of the issue on a more general level, on health outcome.
Need for reference implementations. AMPATH has stimulated alot of OpenMRS developments.
Next Steps
Sign up to the workgroups - Issac will help organise this activity.
Please add any useful reference material to Point of Care System Examples.
Idea of funding study of 5-6 Point-of-care sites and gather info for the team.