Informatics Team April 23, 2012

 Project goals & key objectives  Project Plan  Engagement of site staff and clinical leaders  Data collection  Process analysis  Recommendations for change  Future state documentation for implementation

 Transition the health records at Mosoriot and Turbo sites (Pilot sites) to establish a model for the CDM, PHC Episodic Care and MCH clinics that will be used across the AMPATH catchment area  To establish a model for an electronic reporting solution that will be applicable for all AMPATH PHC sites. ◦ The model must meet the MOH and AMPATH Monitoring and Evaluation reporting requirements and the managers’ administrative requirements.  To develop a strategy for the expansion of provision and use of the Universal ID for all AMPATH patients/clients across the AMPATH catchment area.

 The pilot sites will have new processes / workflows for Episodic Care, Maternal Child Health and Chronic Disease Management clinics  Encounter forms for Chronic Disease Care, Episodic Care, and Maternal Child Health care will be updated  Meet the clinical and reporting requirements of the clinicians and administrators  Prepare for direct clinician use of the AMRS  The AMRS will be updated based upon the changes in the updated encounter forms and reporting requirements  The pilot sites will have new policies regarding Health Records taking into consideration the move to electronic records  The pilot sites will have a support model to follow  includes access to site health records / process experts and IT support staff

 Identified through Stakeholder Identification and Analysis process at beginning of project ◦ AMPATH CDM and PHC Clinical Leader Representatives ◦ AMPATH and MOH PHC Leadership ◦ AMPATH Monitoring & Evaluation ◦ Mosoriot and Turbo Site Leadership: PHC and HIV Clinics ◦ Site Staff at Turbo and Mosoriot – All Departments ◦ AMPATH Information Technology Leadership and Staff ◦ AMPATH Clinical Decision Support Leadership  Each group is involved at a different level ◦ Active input, validation, decision making, configuration, information only

 Collected information on current processes, policies, documentation, clinical protocols, and identifiers for all PHC and HIV clinic departments at both pilot sites ◦ Processes through interviews & observation ◦ Documentation - site specific, MOH, AMPATH, CDC project encounter forms  Collected information on requirements ◦ *Clinical ◦ *Reporting for PHC – MOH, USAID, AMPATH Internal ◦ Administrative

 Swim lane diagram draft #1  Narrative description draft #1  Review and validation with health practitioner  Modification of diagram and narrative ◦ Draft #2  Second review and validation with health practitioner if required  Final current state process ◦ Turbo Site Example  26 diagrams HIV Clinic with narrative for each  18 diagrams PHC Clinic with narrative for each

Current State Workflow

ANC 1The patient arrives at ANC clinic from either Filter or the CO’s office with their AMRS Peri- Natal Encounter Form which they received at Registration. If they are a return patient they also have their Mother and Child Health Booklet with them. ANC 2 The ANC Nurse determines if the patient is a new patient or not. 2a. If it is a return visit, the ANC Nurse finds the patients record in the MOH ANC Register 405. She finds this by checking the Mother and Child Health Booklet for the last visit, and then going to the entries on that specific date. If the ANC Nurse does not find the patient record in the MOH ANC Register, the ANC Nurse starts a new patient record entry (note that the data entered will not be continuous in this case). ANC 3If the patient is a new ANC patient the ANC Nurse first completes pMTCT testing with the patient. ANC 4The ANC Nurse then immediately documents the pMTCT test results in the in the pMTCT Register, ANC Register, Perinatal Encounter Form, and Mom and Child Health Book ANC 5If the patient is HIV positive and the HIV clinic is still open, the ANC Nurse takes the patient directly to the HIV clinic to see the CO responsible for pMTCT. Note: the patient is able to go to the front of the queue because they have already waited in the ANC queue. ANC 6 If the patient is not HIV positive, then the ANC Nurse takes the patient’s AMRS Perinatal Encounter Form and circles the lab tests that need to be completed (Hgb, urinalysis, VDRL, pregnancy test, blood grouping, RH status and malaria, if symptoms). The ANC Nurse sends the patient to the laboratory with the Encounter Form to have the tests completed Workflow Narrative Example

Process #IssueOpportunity ANC #4 Documentation of ANC information in the MOH ANC Register does not provide for the ability to report electronically and is a repeat of the information that is currently in the Perinatal Encounter Form. Nursing time is used for duplicate documentation instead of patient care. Recommendation: d/c documentation in the MOH ANC Register. Replace with documentation in new ANC Encounter Forms. Benefit i)ANC Nurse will document in one health centre record which will limit the amount of time documenting on a daily basis. This will translate into more patient care time. ii)Information available for electronic reporting

Process #IssueOpportunity PHC R2 to R9 Only one registration clerk has a computer therefore only they can check the AMRS to determine if there is a patient record. This is a bottleneck making the queue very long at registration, especially in the morning. Recommendation: Two registration clerks each with a computer and sharing the printer & laminator. Each clerk handles all of the registration functions. Benefit – To shorten the queue at Registration and get patients flowing to the clinics more quickly in the morning as the clinical officers and nurses are waiting in the clinics with idle time.

 Discuss recommendations with clinical and administrative leadership ◦ Pilot site leadership teams  Turbo and Mosoriot PHC Leadership  Turbo and Mosoriot HIV / CDM Leadership ◦ AMPATH clincial leadership  PHC  CDM ◦ MOH leadership  For PHC component  Final approval required by leadership groups

DeptClinical Documentation Retaining Clinical Documentation Discontinuing New Documentation Records All PHC clinical depts  MOH Referral Form  PHC Orals Prescription Form  Free Net Pack Record Card  Monthly Tally Sheets  Paper monthly reports  Clinical Summaries  Requisition form for laboratory and x-ray tests  Internal referral form  PHC Injectables Prescription Form

DeptClinical Documentation Retaining Clinical Documentation Discontinuing New Documentation Records MCH Antenatal Clinic  Mom and Child Health Booklet  AMRS Perinatal Encounter Form  MOH ANC Register #405  AMRS Antenatal Care Initial Encounter Form  AMRS Antenatal Care Return Visit Encounter Form

 Filter / Triage ◦ CWC clients to go directly to CWC from Registration and not through Filter (if mom does not need to access MCH services)  Will decrease bottleneck at Filter  Filter staff is only taking temperature of baby  With decreased documentation in CWC, anticipated that staff will have time to temperature  Lab ◦ Laboratory and X-ray staff to document results on the lab & x-ray requisition form which is sent back to CO with patient ◦ Labs from Eldoret AMPATH lab – received directly into AMRS  Lab tech to check AMRS daily for results ◦ Labs from National Reference Lab  Paper lab results to CO in-charge (determine course of action), to lab tech (validate with original requisition), to data assistant (to enter into AMRS and then print clinical summary with result), to cough monitor or back to CO

 Clinical – MCH ◦ Integrate Cervical Screening with MCH Adult  Postnatal Family Planning Cervical Screening  CO MCH Cervical Screening  Registration MCH Cervical Screening ◦ CWC  Patients will see the nutritionist first and then the nurse  Assessed and treated for malnutrition before immunizations and supplements provided  Reporting ◦ Reports will be pulled electronically from the AMRS by site personnel by the third day of the month and  Reviewed and entered by site personnel into the DHIS by the 3 rd day of the month  Once an AMRS/DHIS interface is built the transfer of reporting information from AMRS to DHIS will be automatic  Anticipated within next one year

 Based upon approved recommendations  Swim lane workflow diagram  Narrative description

Future State Workflow

 Project Repository ◦  Contacts ◦ Wilson ◦ Jeff ◦ Lori