Summary of the Problem

WHO expert groups want to get best-practice guidelines out into the real world, fast, and update those guidelines as medical knowledge changes. This currently takes years.
2 Central Hypotheses:
- 1) The OpenMRS 3 framework allows content like that in the ANC DAK to be quickly created into a new sample "ANC package"; and,
- 2) Understanding In-Country Content Decision Makers' needs and workflows is mission-critical for successful DAK & O3 package adoption even beyond ANC.
OpenMRS, AMPATH, Mekom, and PIH are being supported by Digital Square's Notice F Award to coordinate design of a DAK-Based OpenMRS 3.x ANC Package that:
- meets ANC DAK core dictionary, functional, and non-functional requirements
- has the decision support component of the ANC DAK
- has program indicators
- Design: Design related deliverables include published results from user research/assessment and designs for whatever we prioritise.

Links to Know

Key Contacts: suruchi dhungana (Product Manager) & Paul Adams (UX Designer)
Communication: Slack channel #anc (most discussion and updates are happening in slack)
Issue Tracker: Jira Board here (all issues with label "ANCDAK")
Designs: Pending
Timeline: June 2022-June 2023

In this page:

The ANC DAK contains the content needed to execute WHO-recommended ANC care guidelines, such as: workflows, medical codes, decision support rules, metrics, and functional requirements.

Our 3-Prong Approach

Image source file here.

Open Questions

How do we expect the ANC DAK content to be used in the real world?
How does content decision making happen in countries: In Ministries? In Implementations? (i.e. how people decide what content/care pathways should be applied at their sites)

Detailed Roadmap

2023 Roadmap
Jan-Feb	Mar-Apr	Apr-May	Jun-July	Aug
Identify & Prep Users for Interviews: ANC Staff/Care providers Target countries to engage for user interviews: Sierra Leone, Zimbabwe, Ethiopia...) Status: DONE PIH MEKOM AMPATH OHRI Start Interviews: ANC Staff Status: IN PROGRESS SONDER FELLOW Data Optimization Pt 1: Need engine to optimize data extraction to just the 1 patient of interest Status: IN PROGRESS OMRS FELLOW Data Optimization Pt 2: Need engine to optimize data extraction to just the 1 careplan / relevant data of interest Status: IN PROGRESS OMRS FELLOW Blocker: Careplan Output Bug: Patients who don't qualify are being assigned risk flags by engine Status: IN PROGRESS OMRS FELLOW	Milestone: COMMUNITY DEMO OF PROTOTYPE 1st week March Trigger Logic Definition Status: IN PROGRESS OMRS MEKOM/SONDER UX Results: Publish results from UX assessments of ANC Staff and Content Decision Makers Status: IN PROGRESS SONDER FELLOW Publish Designs for ANC UX Status: NOT STARTED SONDER Patient Flag Module Gaps Fixes Status: TO DO	Usability testing Status: NOT STARTED SONDER	____ Status: X WHO DOES IT?	END

Detail ANC UX Design Activities timeline

Research synthesis and OOUX work will be completed by March 10th
Between March 6th and 24th, hoping to be working on mock-ups
By March 31st, we’ll have research summary document, and a design prototype to test
Probably have a bit of down time over Easter weekend then which is 6-12 of April
But before and after that test the prototype with users remotely
Usability testing will be happening at the latest, the week of April 17th
Iterate and apply learnings to the prototype / mock-ups to have something to be finished with in early May

2022 Roadmap Archive

2022 Roadmap Archive
August	Sept	Oct	Nov	Dec	2023...
FHIR IG Deep Dive w/ Bryn Rhodes & FHIR Squad Explored existing L3 resources and whether automating intake of a FHIR IG might be valuable approach. (Notes) Outcome: Decided not* to have a FHIR IG-heavy approach.* Status: DONE Joined WHO SMART Implementers' call group Raise awareness among the WHO working group of our work on this project, and address early questions about materials available and what user research had already been done. (Notes) Status: DONE Gap Analysis of Functional & Non-Functional Requirements Gap Analysis here Status: DONE	Identify & Prep Users for Interviews: ANC Staff/Care providers Target countries to engage for user interviews: Sierra Leone, Zimbabwe, Ethiopia...) Status: IN PROGRESS PIH MEKOM AMPATH OHRI Identify & Prep Users for Interviews: Content Decision Makers Status: IN PROGRESS PIH MEKOM AMPATH OHRI Sample Code Set in OCL + Qnr in O3 Need to pick a Qnr. Start by picking a preferred DS rule/care plan. OCL Code Set Status: DONE FELLOW Review of Key Functional Gaps with Team Gap Analysis here Status: DONE FELLOW 1st set of Feedback Initial feedback to share with WHO DAK team. (Doc here) Status: DONE FELLOW	Start Interviews: Content Decision Makers Status: NOT STARTED SONDER FELLOW Test Automation plan Likely less about FE E2E tests rather than scaleably useful ones, eg (1) OCL-related tests / concept conflict notifications +/- logs, and (2) O3 test framework/test pipeline improvements. Status: NOT STARTED FELLOWS Present 1st set of Feedback Initial feedback shared with WHO DAK team. (Doc here) Status: NOT STARTED FELLOW	UX Results: Publish results from UX assessments of ANC Staff and Content Decision Makers Status: NOT STARTED SONDER FELLOW Prototype Pkg O3 ANC MVP Package released (scope: limited concepts, forms, widgets, & clinical view) Status: NOT STARTED TBD	Start Interviews: ANC Staff Status: NOT STARTED SONDER FELLOW Publish Designs for ANC UX Status: NOT STARTED SONDER Publish Designs for Content Management Flows Status: SCOPE? SONDER UAT & Findings Documentation Status: NOT STARTED SONDER Plan for Reports Add to ANC O3 Package Status: NOT STARTED TBD	Decision Support Plan eg leverage opensource Decision Support Engine (depending on business viability indicators of that asset by Jan 2023; will also need confirmation / work to cover any gaps in OMRS FHIR representation of the medical record) Status: NOT STARTED TBD Reports Add Indicator Reports to ANC O3 Package Status: NOT STARTED TBD Data Viz Demo indicators visualized w/ Superset Status: NOT STARTED TBD MEKOM?

User Contact Champions

These contact points are the ones our UX+PM team can reach out to in order to organize user research/interviews etc with ideal users.

Sierra Leone: PIH (Maternal Centre of Excellence) - Ellen Ball

TBD - Haiti or Cambodia: (Hospital/NGO with ++deliveries) - Dimitri R

Ethiopia: Jen to f/u w/ UCSF/ICAP contacts

Actions & Decisions Log

Date	Action or Decision or Request for Information	Notes (Links, Comments, etc)
2022.07.27	2 key findings so far: (1) content not meeting minimum expectations (PIH) eg clear fetal outcome; (2) FHIR IG confusing w/ ++ broken links. Considering focusing on creating tools that would ingest L3 (FHIR IG) content automatically into OMRS. UX Proposal submitted by Sonder here, proposing OOUX approach to research. Reviewed types of Decision Support content: different information types & urgency types. Id'd gaps in existing UI Patterns in O3 to support ANC CarePlan outputs - these red gaps will be a focii for UX research, so output will be a complete toolkit.	Meeting: ANC DAK Product Vision & Roadmap Whiteboarding - All Whiteboard: https://metroretro.io/board/LBUYIYVOLJML Recording
2022.08.18	After a ++helpful deep dive w/ Bryn Rhodes on the ANC FHIR IG: Decided we will not pursue a FHIR IG-based approach at this time. 2 main findings: Decision Support Engine: Learned that Bryn’s team has created an opensource Decision Support Engine, now maintaining this, Google Android SDK group is their user at the moment. We could leverage this engine for our Decision Support needs (and OMRS could then bypass need for bespoke data model update for careplan support, b/c you don't actually need careplan support to make use of the engine). Gap in Content Decision Maker Persona/Research: Seems that ANC DAK has missed a key persona: country-level content decision makers. Eg the massive lift for them to consider all this content and reconcile it with their regional requirements, funder requirements, and current data collected. Decision: this will be a critical user for us to involve in user research.	FHIR IG review with Bryn Rhodes - All Explored existing L3 resources and whether automating intake of a FHIR IG might be valuable approach. (Notes)
2022.08.19	Identified 9 names who informed the ANC DAK who could be starters for interviews re. "real world use" of guideline content, developing understanding of market demand/market pain points. Need follow up plan for Sept.	List here - 9 of 70 listed as informants for ANC DAK are from implementer groups
2022.08.29	Knowledge base amidst WHO SMART working group on content management processes at Ministry or Implementer is unclear - still a grey-area. We should proceed with plan to understand this as it has huge implications for ANC Guidelines + any other future SMART guidelines.	Joined WHO SMART Implementers' call group - Suruchi, Grace Raise awareness among the WHO working group of our work on this project, and address early questions about materials available and what user research had already been done. (Notes)
2022.09.29	Ellen & Wamz pick 1-2 ANC care plans from DAK as our first ones to prototype in O3 with codes, forms, and widgets (Ideal: both valuable for end users to see in testing, and relatively low effort) Current top candidates: Danger signs (1), Pre-eclampsia and HTN (17), HIV testing (8)	Need: would be helpful for our ANC grant group to do a small prototype to see the lift required to implement one of these ANC DAK Qnrs + Codes. Could also be a helpful asset for Suruchi & Paul Adams during user interviews. https://openmrs.slack.com/archives/C03GWFC9ZKQ/p1662577762775669
TODO	Contacted WHO - Nat to confirm no updated spreadsheet w/ more CIEL code mappings	Currently ~40 needed medical codes have mappings to CIEL in "ANC.End"; all others have no reference to CIEL in the spreadsheet resource (Web annex A: Core data dictionary). Andrew Kanter has a version with CIEL maps (not 100% complete)
TODO	Assign champion per country to i.d. people to interview/test
TODO	Review together the OHRI MCH Mindmap (to understand OHRI MCH goals & needs)
2022.09.13	Request to Ellen & Dimitri: Gather list of contacts now Jen to f/u re contracting
2022.09.23	Grace met in person w/ Jembi, Regenstrief, and CDC-HQ officers in S. Africa - discussed SMART Guidelines ++. Much interest in and alignment with our 3-prong strategy (staff research, content research, engine prototype). Intellisoft Botswana interested in supporting w/ Content Decision Makers for user research → followed up.	There is growing interest by PEPFAR in wanting to fund HIV SMART L2 implementation - all very interested in this OMRS grant's work. All folks talked with agreed big need to understand in-country content reconciliation workflows, concern that alert UI to end users needs to not overwhelm esp. when ANC+HIV+NCD etc get combined, and all are +++ interested in technical findings re using the CQL engine.
2022.09.23	Suruchi has begun work to implement the O3 Qnrs and Codes in OCL for the Preeclampsia Care Plan.
2022.09.27	Shared update on 3-fold plan (staff research, content decision maker research, and CQL engine prototype plan) with the Implementing Smart Guidelines working group with multiple WHO and DPG representatives present.	Learned: Ona seems to be implementing now as well. Google Android SDK increasingly leveraging too. A member Kashya has possibly found a way to bypass needing to "save" a FHIR Qnr - notes and screenshots here.
2022.09.27	Emailed Jose & Bryn about contact for support re. trialing the CQL engine.
2022.09.27	Design Roadmap discussion - Jen Grace Ciaran Paul.
2022.09.28	Team meeting. Picked a Decision Support set for prototyping: High risk & educational: Pre-ecclampsia Could re-use some parts from the PLIR project that were sending data from OMRS to other server (packaging to send fhir resource from OMRS to a different FHIR server); also triggered a measure written in CQL on that FHIR server.	Followed up on support from Mozzy re recent OMRS cmty work on something involving CQL: Later versions of the Hapi FHIR JPA Server (5.3.0 +) come with an embedded CQL engine . https://talk.openmrs.org/t/anc-dak-setting-up-a-prototype-with-the-cql-decision-support-engine/37630/4
2022.09.30	Intro interview w/ Dr. Astrid	Bio, Interview Plan, Questions, and Notes
2022.10.07	Discussion w/ Derek Ritz
2022.10.11		Design Plan, Process, & Timeline reviewed and agreed on by squad Analysis of Categories of Decision Support rules by urgency & expected UI-types: findings shared w/ squad (key takeaway: majority of careplans require tasks for providers) Screenshots of Actions & Timelines/Schedules discovery: each output has an action + notes, and often >1 action; DAK also includes timelines (schedules) and not yet clear how we plan to leverage these --> PM to spend time reviewing these in more detail
2022.10.12	Digital Square Check-in
2022.10.14	Interview w/ Dr Astrid	Bio, Interview Plan, Questions, and Notes
2022.10.26	ANC DAK SMART call	Recording
2022.11.08	ANC Squad call with WHO Reps	How are adaptations documented internally in an organization? WHO Team working on way to capture adaptations → Would help in reflection. WHO supporting some country implementations with adapting guidelines nationally. eg some countries have strong PMTCT-based guidelines. Two-way learning. Unclear how indicators are being changed at the country level. "Want to learn how people are using the resources we put out" → any draft report = of interest. Tool for helping policy makers adapt the ANC guidelines so they can update their policies.
2022.11._	Meeting with Alex Goel (company & CDS builder tools using Encender)
2022.11.10	Meeting with Google Health - FHIR SDK team	Recording
2022.11.__	Debrief w/ Derrick Ritz
2022.11.10	Technical onboarding & training for engineering setup of CQL Evaluator w/ Bryn Rhodes / Alphora	Recording Engineer Daniel now equipped to implement CQL module in OMRS
	Milestone: Team reckoning over whether CQL/opensource engine setup is the right approach for this grant. Decided it IS.	CDS "To Engine or Not to Engine": Approach Options for ANC Grant
2022.11.17	Check in between Suruchi and Daniel on idea of prototype for OpenMRS-CQL Engine-OpenMRS workflow ANC CQL engine: Next steps	Discussed full detail about the requirement and decided to try OpenMRS module for OpenMRS-CQL workflow
2022.11.23	Squad Call: Update on Tech work thus far Concept set established in OCL (for preeclampsia prototype) Simpel Questionnaire built in O3 (for preeclampsia prototype) CQL Module has been set up!	Recording Link to ANC 17 (Preeclampsia) concepts set up in OCL: https://app.openconceptlab.org/#/orgs/openmrs/collections/ANCDAK/ Daniel shared progress on creating OMOD where the CQL Evaluator (and Engine) have been set up. Requires Java11. Success so far in provided test case; now finishing setting up the Preeclampsia careplan. Details: Cloned evaluator. Provides service of translating CQL→ ELM, and embeds Java-based CQL engine. When Cloned: Resulting OMOD was 100MBs in size. After round trip works well, he’ll look at what to remove from Module. How: Runs plan def $apply and end up with a careplan. Text that takes JSON that represents plandefinition, and then outputs JSON (ELM) which is the careplan. ELM is what the engine actually executes. Client then decides what to do based on the careplan sent to it. Current ongoing prototype work: Loaded ANCDAK17 (preeclampsia) plan definition from WHO site → Run → # of errors. Discovered it has expectations for terminologies. Next: Set those up. Together we drafted a diagram of round-trip-journey: Diagram
2022.11.29	Session re. medAL-creator Algorithm Builder & Authoring Tool Demo. Goal: Understand possibility of integrating with their Alg. Authoring tool.	Notes & Recording
2022.11.30	Digital Square Check-in	Slides and visuals
2022.11.30	Discussion between Suruchi, Daniel and Joshua on ANC DAK CQL Engine: UI requirement and discussion	Decided to use patient flag module in O3 to display flags returned from CQL engine
2022.12.15	Suruchi interviewed Sanjaya and Diwash from Nepal for Decision Makers Research	Notes
2022.12.16	ANC DAK SMART call: WHO SMART team and University of Gondar	Recording
2022.12.20	Discussion with Andy regarding issues of unavailable data element id in OpenMRS concepts ANC: CQL-API module and concept codes (Discussion)	Daniel ran into issue of not being able to get codes in OpenMRS that would exactly match with CQL codes so reached out to Andy and he helped with the idea of adding WHO data element id in CIEL next release.
2023.01.03	Joshua Nsereko raised a PR in O3 for patient flag: Add support for Patient Flags to RefApp 3.x	Link to PR. Significance: Shows existing Patient Flags Module can be leveraged in O3.
2023.01.03	Suruchi created Product Requirement Document(PRD) for OpenMRS-CQL Engine Prototype
2023.01.11	Discussion between Suruchi and Daniel regarding data element id update in OpenMRS concepts mapping and next steps	Recording
2023.01.18	SMART Squad call. Updated JIRA board w/ current ongoing technical work: COnfig CQL Module to use optimized approach for data retrival; API for patient flags module to query; Table to save results per-patient; Hook on form submission.	Recording
2023.01.23	SMART Authoring call: Presented progress & asked questions: Status of OpenMRS L2 & L3 work with ANC - finding interesting mapping duplication e.g. question/concern around ANC.B5.DE62 vs ANC.B5.D42. → WHO content team will look into this. We are looking to talk to Engineering folks who have used the CQL Evaluator and/or CQL in production. → Patrick of SwissTPH reached out. Turns out he has also already built a first-iteration of a tool to automate mapping content to the DAK codes; code here Quick Question: Can CQL & the CQL Evaluator be leveraged for Schedules? (e.g. related to ANCDAK sections ANC-S-1 to 5) → Bryn: Yes, example here; this has to be manually created (all other planDefinitions were created by DAK Processor)	Presentation
2023.01.23	CDC TAP Stakeholders: Presented progress, new tooling, challenges and risks to CDC HQ TAP leadership, and UCSF and PATH TAP leadership, for ideas on how this work can tie-into and be useful for PEPFAR projects & OHRI. CDC HQ leadership emphasized this approach, experimentation and i.d. of challenges, is exactly what they're looking for in the HIV content realm.	Presentation
2023.01.25	Digital Square Check-in
2023.02.03	Meeting with Android SDK team Jing	Notes
2023.01.16+	Calls being planned for late Jan / early Feb: (also include OHRI Tech Lead) ONA/OpenSRP (their Architect Peter) - experience w/ CQL Emcare - SwissTPH - Patrick Delcroix - experience w/ CQL Engine project & new alpha mappings-automation-tool UW Engineers - experience w/ CQL in domestic program Thrive Health - FHIR careplan & qnrs & cds rules authoring InterSystems - FHIR careplan authoring	TBC
2023.02.07	Daniel filed an issue with a PR at cqframework github	PR: https://github.com/cqframework/clinical-reasoning/pull/243
2023.02.09	Meeting with Peter and Benjamin from ONA	Notes: https://docs.google.com/document/d/1Tm_X19WaFfVCUFHBsZbeQ6xcXeT5JXES8bAW7aIO8lo/edit
2023.02.06-16	Public Communication Activities	Presented video recording of progress thus far to folks from: WHO Implementers and Authoring calls, Twitter, OMRS Community Forum, shared directly with CDC, PATH, Jembi, UCSF, and more Squad representatives joined SwissTPH CDSS Symposium day
2023.02.16	SMART & CDS Squad call	Recording
2023.02.06-16	User Interviews +++	Research in numbers Josh (Global Strategies / NoviGuide, USA / Uganda) Dickson (PMTCT clinical officer, AMPATH, Kenya) Irene (PNC nurse, AMPATH, Kenya) Isata (ANC nurse, PIH, Sierra Leone) Billy (ANC nurse, PIH, Sierra Leone) Dr. Muhindo (ANC & PNC, Uganda, no EMR, uses NoviGuide) Janet (ANC Clinician, MTRH, Kenya) Meredith (Nurse / Midwife supervisor, Haiti) Dr. Millien (Supervising doctor, Haiti) 9 people from 4 different contexts, some with experience using an EMR and decision support tools like NoviGuide, some without experience of either.
2023.02.28	ANC DAK meeting - Demo by Frank from Intersystems	Recording
2023.03.15	ANC DAK meeting	Recording
2023.03.28	ANC DAK meeting cancelled and merged to WHO call, Ciaran and Paul presented UX design update
2023.04.12	Short ANC DAK call due to low attendance	Recording
2023.04.25	ANC DAK meeting	Recording
2023.05.08	Ciaran shared Maze link in ANC channel for prototype usability testing	Maze
2023.05.10	ANC DAK meeting	Recording
2023.05.16	Meeting with Hadijah and Daniel to discuss frontend UI design and relevant development	Recording and Notes
2023.05.24	ANC DAK meeting	Recording
2023.05.30	Technical Discussion	Recording
2023.06.07	ANC DAK meeting	Recording
2023.06.21	ANC DAK meeting	Recording

Reference Resources

Workplan with Timelines & Deliverables
Full ANC DAK Guideline: "Digital Adaptation Kit for Antenatal Care: Operational requirements for implementing WHO recommendations in digital systems"
Annex A: Core data dictionary (our copy): Codes/concepts for all rules & indicators. Andy's version where he added CIEL mappings and comments is here.
Annex B: Decision support logic (our copy): CDS rules in IF/THEN spreadsheet format.
Annex C: Indicators (our copy): Reporting metrics the WHO hopes will be generated as a result of this structured ANC data collection.
Annex D: Functional & non-functional requirements (our copy): Product features/requirements.
FHIR IG:
- GitHub for ANC FHIR IG
- FHIR IG Documentation: Helpful!! Has all the workflows, personas, scenarios etc. This guide is to be considered in our work.
- Careplans (PlanDefinitions): e.g. Preecclampsia, Syphillis, HIV, HepC screening, etc...
- - All Questionnaires needed: ANCA Qnr: Registration ANCB4: Confirm pregnancy ANCB5: Quick check (q's to always ask) ANCB6: Profile & History ANCB7: Symptoms & F/U ANCB8: Physical Exam ANCB9: Labs & Imaging ANCC Qnr: Emergency referral ANCEnd Qnr: Delivery info
FHIR Clinical Decision Support Committee
OHRI MCH Mindmap draft
How Digi Sqr defines "Shelf Ready"
All ANC WHO SMART Resources: Includes everything from literature review results that formed these guidelines, to links like to FHIR IG.
WHO SMART Guidelines Vision
HIV DAK
DAK Processor Tool
Sample ANC L4 App by WHO
CDC-TAP SMART Guidelines Work Shared Folder

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