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Innovations in data collection and use for monitoring, surveillance and population tracing

Presenter: Johanzi Mvula

Dates: 11th – 22nd September, 2017

Zambia’s Use of SmartCare (EHR) on Mobile

Devices in Communities

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Layout of the Presentation

• Introduction

• Background

• Objective of Community use of SmartCare

• What is the SmartCare EHR?

• Why did we start community use of SmartCare ?

• Where did we start community use of SmartCare?

• How is data collected in the community?

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Background

The Driving Policy

• June 2011 the government of Zambia endorsed the goal of

eMTCT, defined as;

a 90% reduction in new HIV infections among children by 2015

Reduction of MTCT of HIV to less than 5% by the end of breastfeeding

• This endorsement called for innovative strategies to promote

Option B+

• A drive to ensure wider access to skilled maternity and neonatal

services in the country hence the thought to initiate Community

based HTC Program – for community HIV Epidemic Control

• Zambia’s national EHR, which

supports clinical care and continuity

of care by providing confidential

portable health records of clients on a

Smart Card that can be used at any

facility where SmartCare is

operational

• Reports on and aggregates data from

a large patient population

• Operational in a third of all health

facilities in Zambia serving over

One Million People across the

country

• Smarting for 90-90-90: The system

is able to support the Test and Treat

policy and ACT Strategy

What is SMARTCARE ?

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“Why did we Start it?”

Community SmartCare

As a remediation strategy to improve the management of community data at Health

Facilities (HFs) due to:

• High volume of patients

• Struggle to increase numbers

• Difficulty tracking patients who miss appointments (typically difficult to manage using

paper based records)

To bridge gaps in the management of patient records currently in paper-based systems,

by:

• Ensuring that data generated from the community to the HF is complete, accurate and not

duplicated

• Improving the quality of health care by providing support to deliver “Continuity of Care”

where existing paper systems are failing to provide a longitudinal data view.

• Providing effective support to the co-ordination, monitoring & evaluation of Community

health care services.

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When did we start it?

Community SmartCare

First piloted in Southern Province in 2015, in one District

(Mazabuka) with two HFs and so far, it has been extended

to 20 facilities in four Districts namely;

– Mazabuka

– Livingstone

– Choma

– Chikankata

– Sinazongwe

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Objectives Of Community SmartCare

To achieve 90-90-90 in the

Community through:

Community HIV counseling and

testing

Index testing

Prompt linkage to ART care and

preventive services

Improving adherence

Improving retention in care

Reducing community HIV

transmission

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COMMUNITY• Defined

geographic area or

priority population

• Leaders & CBOs

engaged

• Sensitizations

carried out

CHW• Selected from

community

• Trained by MoH/CDC

• Running Community

SmartCare on tablet

• Linked to

Facility/DHO/MoH

• Paid a stipend

• Receives bonus

incentives

FACILITY• Each CHW linked

to facility

• Supervised by

Health Centre-in-

Charge

• Data entry by

CHWs

• Merges

Community

SmartCare with

HF SmartCare

How data is collected at Community level?

Community SmartCare (EHR)

• Zambia developed the Community module of SmartCare which is currently being used for tracking patient interactions and linking patient data between the community and the facility

• It enables the user to search for clients, register clients, capture data in the community, harmonize and update data collected in the community with facility data for each client

• The CHWs use the tablets for data collection in the community. The system has strict security controls with all users requiring login credentials to access both versions of SmartCare

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Use of SmartCare to Track Index Cases

SmartCare v4506 This version is able to support the “lite” mode

Wireless LAN Local Area Network (LAN) Enables syncing or merging of records from the facility computer to a mobile device

Card ReaderUsed to read information on the care card, as well as save information to the card

Mobile Device (Tablet)Used to capture care provided in the community

Care CardThis holds each patient’s health record

Requirements for SmartCare Use

Getting Started with SmartCare Use

Logging Into SmartCare SmartCare Home Screen

Registration

Steps:Search for the client

and Select the client from the tabletorRegister the client

SmartCare Community Module

Steps:Select the type of visit you want – Load HIV testing and counselling

Press “next page”

Services in SmartCare Community Module

Steps:Select the if couples test or for one clientPress “next page”

HTC Services

Steps:Select the HIV counselling detailsPress “next page”

Steps:Enter Health History

detailsSelect next page

Note: The following page after this one collects physical exam details. If you have a female client, your next page will collect LMP details then the page after that will be physical exam.

Client Care – Stable Clients

Steps:Enter Adherence

Counselling detailsPress next page

Steps:Enter Adherence ScorePress next page

Stable Clients - Adherence

Stable Clients - Drug Dispensation

Steps:Select the dateSelect the drug you

wish to dispenseEnter Dispensation

detailsSelect AddSelect Next Page

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• Smart Care has several reports including patient-level and

aggregate reports, for decision making. They include, the

HIA1 & 2 Reports, MER (PEPFAR) Reports and Facility ACT

Reports.

• The system provides for timely and accurate reports that will

inculcate into planning and provision of technical support

supervision to the lower levels

• Program Managers are able to access data in real-time via the

click of a button

• The system is able to monitor performance as part of a

Facility’s QA/QI plan

Integration of Data Use into Programs

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• Utilizes CHWs recruited from their own communities to

effectively deliver eMTCT/Test and Treat

• Expands HIV testing to communities

• Improves patient tracing and data management

• Reduces burden on facility-based ART care

• Decongests facilities by transferring stable patients from care

in facilities, to community care

• Improves retention in care

• Removes patient costs for accessing services at facilities

• The tablets have also served as a source of motivation for

CHWs (as a kind of status symbol)

Advantages

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• Quarterly mentorship is optimal to maintain standards of

practice

• Monthly data verification is very important to ensure that high

quality data is being reported

• Using this model, ART defaulters have been tracked back into

care

• Improved HTC data collection at community level

• The clinical and software teams are very key for the model to

be successful

• Facility staff should be fully engaged in the project for them to

have full ownership

• Joint technical support visits have been helpful, as all key

stakeholders are available to resolve issues

Lessons Learnt

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• No customized community reports - making its difficult for

CHWs to understand their specific contributions

• Low literacy levels of some CHWs pose a challenge in

operating the tablets

• Some CHWs are unable to get to the facility to synchronize

data at facility level, due to inadequate support, as most of

them are doing voluntary work

• Lack of transport to enable CHWs reach far-flung areas

• Lack of electricity, particularly in rural areas

• Tablet screen breakages/cracks

Challenges

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• Customized reports and community dashboard, to be

developed

• National roll-out using a phased approach

• Inter-operability between SmartCare and DHIS-2

• Additional training for CHWs on use of tablets

Way Forward

Zikomo

Twalumba