Case Study: Using the HIV Package with PATH DRC

Project scope: The project aims to collaborate with PATH in the Democratic Republic of Congo (DRC) to develop an HIV module within the OpenMRS electronic medical record system be leveraging OpenMRS community HIV content package, OHRI. This module will enhance the existing system's capacity to manage HIV/TB/MNCH-related patient data efficiently. The project team consists of members from OpenMRS and PATH, with designated project managers overseeing the implementation. Development of this MVP is from April 2024 to September, 2024.

Stakeholders: CDC DRC, PATH DRC, ANICNS (The Digital Health Agency in DRC), DSNIS (Division of the National Health Information System) , PNLS (HIV program in DRC), PNLT (TB program in DRC), MNCH

EMR Requirements Gathering Process and Stakeholder Engagement

1. EMR Requirements Gathering Process

Initial HISEMR Site Assessment: PATH DRC began the EMR implementation process with a comprehensive site assessment. This involved evaluating existing health infrastructure, technological capabilities, and the specific needs of healthcare facilities across the country. The assessment provided crucial insights into the readiness and requirements for implementing an Electronic Medical Records (EMR) system tailored to local contexts.

Sampling Health Sites: Following the site assessment, PATH DRC strategically sampled three healthcare facilities to dive deeper into understanding user requirements for the EMR system. These sites were selected to represent a diverse range of healthcare settings, including rural and urban environments, ensuring a holistic view of regional healthcare challenges and opportunities.

2. Stakeholder Engagement

Engaging Healthcare Providers: PATH DRC prioritized stakeholder engagement throughout the requirements gathering process. Healthcare providers, including doctors, nurses, and administrative staff, were actively involved in discussions and workshops aimed at identifying their specific needs and challenges related to patient data management, clinical workflows, and reporting requirements. The site visits included program staff from PNLS, PNLT and MNCH respectively.

Collaboration with Local Authorities: Collaboration with local health authorities and government national agencies such as ANICNS played a pivotal role in ensuring alignment with national healthcare policies and standards. By engaging these stakeholders early in the process, PATH DRC ensured that the EMR system would support and enhance existing healthcare practices while adhering to regulatory requirements. To this end, a homologation letter was submitted to ANICNS in May, 2024 to support this initiative.

3. Outcome and Next Steps

Requirements Consolidation and Analysis

• Requirements consolidation and analysis: The data collected from the initial site assessment and sampled health sites were meticulously analyzed to identify common themes, challenges, and priorities for the O3 RefApp DRC module. This process involved synthesizing feedback from stakeholders to prioritize functionalities that would have the greatest impact on improving healthcare delivery and patient outcomes.

• Roadmap for Implementation: Armed with comprehensive user requirements and stakeholder feedback, PATH DRC developed a detailed roadmap for EMR implementation. This roadmap outlines key milestones, timelines, and resource allocations necessary to deploy the EMR system across healthcare facilities in DRC effectively. It reflects a tailored approach that addresses local needs while leveraging global best practices in health information technology.

• Alignment of EMR requirements with patient workflows: The DRC HIV prototype was developed with much consideration of the patient flow of health service delivery.

Ongoing Stakeholder Engagement

• Continued engagements with PATH DRC team ensuring that the EMR requirements in scope are translated effectively.

• Via PATH DRC, continued collaboration with the MOH program teams including PNLS, PNLT and MNCH to ensure EMR requirements are translated accordingly to meet the needs identified and that they are in scope for the period of implementation.
  
  The process: Harvesting OHRI HIV content package for DRC and concept mapping
  
  Lessons learned and challenges:
  In addition to the clarifications around concepts for the patient dossier form and the series of meetings with the DRC PATH team to gain clinical perspective and guidance, several other significant lessons and challenges arose during the development of the HIV prototype. These provide a deeper understanding of the complexities involved during the development process of the prototype.
  
  

• Standardization: One of the critical challenges encountered was ensuring that the data collected through the HIV prototype adhered to both national and international HIV guidelines. This involved aligning the prototype’s data fields, structure and flow with DRC's national health information policies/standards. In many instances, the local practices and workflows in DRC clinics had unique approaches to patient care and HIV treatment protocols that did not always match international guidelines. Balancing the need for global standardization while respecting and incorporating local practices required careful thought and multiple rounds of consultations. Lessons learned included the importance of early engagement with local health experts and PATH HIV experts to prevent misalignment of standards later in the project.

• Customization and localization: One of the critical successes of this project was the ability to customize the prototype to meet the specific needs of the DRC's healthcare environment. However, this was not without its challenges. Tailoring the system to account for local languages, cultural nuances, and specific healthcare practices required significant customization. For example, local terminologies used by healthcare providers in the DRC for describing HIV symptoms or treatment protocols needed to be integrated into the system. Moreover, adapting the workflow to reflect the on-the-ground realities of DRC clinics, such as different approaches to patient care, required flexibility in the form design. This iterative process of localization was essential to making the system both usable and effective, but it also revealed the challenge of balancing customization with scalability. Over-customization can make future adaptations for other regions or scalability across multiple sites more difficult, a valuable lesson for future projects.

• Training and adaptation: Introducing new digital tools in healthcare settings always presents the challenge of user adaptation, and this project was no different. The team in the DRC had limited experience with OpenMRS, which meant that the success of the prototype depended not only on the technology itself but also on how effectively users could learn and adapt to it. This required comprehensive training sessions that focused on both technical usage and the practical benefits of using the digital tool for patient care. Additionally, the usability of the form itself—its design, ease of navigation, and logical flow—had to be tested and refined based on user feedback. Lessons learned in this area included the need for an ongoing training program to address the continuous onboarding of program staff such as PNLS, PNLT and the critical role that user-centric design plays in the success of health information systems.

• Feedback integration: Throughout the development process, we consistently received feedback from stakeholders, including clinicians from PNLS, PNLT, data experts, and representatives from the PATH DRC team. While this feedback was invaluable for ensuring that the prototype met the real-world needs of the users, it also presented a challenge. Different stakeholders often had competing priorities or diverging views on how certain features or workflows should be implemented. For instance, clinical teams might prioritize detailed patient data entry, while data experts might focus on the need for efficient reporting and minimal data entry burdens. This required us to carefully manage expectations and prioritize features based on the overall goals of the project. The lesson learned here was the importance of structured feedback loops, where feedback could be categorized, assessed for feasibility, and then implemented in a way that balanced the needs of all users without overcomplicating the system.

• Long-term OpenMRS sustainability, adoption and ownership: Another important consideration during the development of the HIV prototype was discussing and planning for its long-term adoption, owner and sustainability by PATH DRC. This included ensuring that the system could be maintained and updated by local IT teams in the DRC or a selected vendor after the initial development phase. A challenge here was to design the system in a way that did not rely heavily on external support, but instead could be managed by the local teams with minimal external intervention. This will require extensive training and knowledge transfer sessions with the local teams or vendors that PATH will choose to work with post this fiscal project year. The lesson learned was the importance of building local capacity from the outset to ensure the system’s long-term success and sustainability.