SMART Guideline Implementation: ANC DAK
- Grace Potma
- suruchi dhungana
- Jennifer Antilla
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)
Detail ANC UX Design Activities timeline
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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 |
| 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 |
| |
| 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 | |
| 2022.10.07 | Discussion w/ Derek Ritz | |
| 2022.10.11 |
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| 2022.10.12 | Digital Square Check-in | |
| 2022.10.14 | Interview w/ Dr Astrid | |
| 2022.10.26 | ANC DAK SMART call | |
| 2022.11.08 | ANC Squad call with WHO Reps |
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| 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 | 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
| 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 | |
| 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:
| 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 | |
| 2023.01.16+ | Calls being planned for late Jan / early Feb: (also include OHRI Tech Lead)
| 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 |
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| 2023.02.16 | SMART & CDS Squad call | Recording |
| 2023.02.06-16 | User Interviews +++ | Research in numbers |
| 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