operationalizing guideline- - asia ehealth information network meetings/2013 aehin gm... ·...

Operationalizing Guideline-

based Care

Derek Ritz


based Care Supporting HIV, TB, Malaria, MNCH, chronic disease management, episodic and emergency care by leveraging re-usable eHealth “building blocks”

The next 15 minutes…

• Why eHealth

– What is the health impact of eHealth?

• What eHealth

– Which functions do we operationalize?

– In what configurations?

• How eHealth…

– Shaun will introduce OpenHIE

What is the health impact of implementing eHealth?

Population Health

Health Interventions

Operationalizes

Yield

Person-centric transactional data

Population-level health metrics

eHealth Infrastructure

Generate

Inform

Population Health


Yield

Population Health


Operationalizes

Yield


Population Health


Operationalizes

Yield



Generate

Population Health


Operationalizes

Yield




Generate

Population Health


Operationalizes

Yield




Generate

Inform

The Role of eHealth

• eHealth infrastructure, at scale:

– Supports care continuity over time and across different sites

– Operationalizes guideline-based care

• Health “transactions”:

– Provide management metrics regarding care delivery

– May be aggregated to generate population indicators

Strategic Elements

Patient-Centric

Systems

M&E

Systems

Integrated Health

Information Systems

Pervasive eHealth

Infrastructure

Modify SOP

eHealth Transactional

Data Financial, Management &

Population Health Indicators

Standard Operating Procedures

SOP-based Interventions

Pervasive eHealth

Infrastructure

Modify SOP






Operationalize guideline-based care

Pervasive eHealth

Infrastructure

Modify SOP






Support care continuity

Pervasive eHealth

Infrastructure

Modify SOP






Provide management metrics

Pervasive eHealth

Infrastructure

Modify SOP






Provide population indicators

Pervasive eHealth

Infrastructure

Modify SOP






Support continuous improvement

Modify SOP






Support continuous improvement

Pervasive eHealth

Infrastructure

What is the health impact of implementing eHealth?

eHealth affords us a way to exert process control on the

health system to optimize “health production”.

What do I need the eHealth to do?

The Requirements…

• An analysis was made of WHO’s current published care guidelines for:

1. HIV

2. Malaria

3. TB

4. Antenatal care

5. Emergency care

6. Public health emergency response

• There are common tasks/processes which appear in multiple care workflows

Common Processes

25

Integrated Care Pathways

• The guideline-based workflow patterns arising from the analysis may be described using Integrated Care Pathway (ICP) diagrams

• ICPs describe high level, person-centric care workflows that may be long-running and cross institutional boundaries

• An ICP may be documented using rudimentary graphical primitives from the Business Process Modeling Notation (BPMN)

Start End Decision / Branch

Example: Negative HIV test

• A client arrives at a VCT clinic to be tested for HIV

• Pretest counselling is done; consent is obtained to conduct the tests

• HIV “quick tests” and other tests are performed as per the WHO’s 3ILPMS guidelines

• The results of the HIV quick tests are negative

• The client is not enrolled in the HIV care programme (ICP: start to end)

Care-seeking

Not an emergency

Not HIV positive

Not enrolled in HIV programme

HIV test; other tests

Example: Positive HIV test

• A client arrives at a VCT clinic to be tested for HIV

• Pretest counselling is done; consent is obtained to conduct the test

• HIV “quick tests” and other tests are performed as per the 3ILPMS protocol

• The results of the tests are positive; post-test counselling is provided

• As per guidelines, the client is immediately put on ART

• The client is enrolled in the HIV programme and will receive ongoing guideline-based care (ICP: start, loop)

Enrolled in HIV programme

Prescribe ART

Care-seeking

Not an emergency

HIV positive


Example: HIV Care

Management

• A client receives HIV care management reminders

• The client attends a regular follow-up visit

• Lab tests are performed as per guidelines

• Based on the test results, the medication regime (and, potentially, the care plan) is adjusted, as per guidelines

• The client’s ongoing care management, including reminders, reflects any changes to the care plan (ICP: loop)

Active in HIV programme

Adjust medications

Not an emergency

Adjust care plan, if necessary

CD4; viral load; other tests

Follow-up

Example: ART Refill

• A client receives HIV care management

reminders

• The client attends a regular follow-up visit

• Guideline-based care is delivered; clinical

observations are recorded

• ART medications are refilled

• The client’s ongoing care management,

including reminders, reflects the care plan

(ICP: loop)


Refill ART

Not an emergency

No lab test Follow-up

Example: Loss to Follow-up

• HIV care management reminders are sent

• The client does not attend follow-up visits

• Based on decision processes, the client is

determined as “lost to follow-up” and

removed from the HIV care programme

(ICP: end)

Loss to Follow-up

Example: Death from HIV/AIDS

• A very ill client presents at a facility

• Based on initial assessments, the client’s

care is escalated

• The client dies while in an acute care facility

and is discharged dead

• The client is removed from the active HIV

care management programme (ICP: start to

end)

Patient discharged from hospital dead

Care-seeking

Escalate care

Example: Directly-observed Therapy

• A client receives TB care management reminders

• The client attends a follow-up visit as per the care plan

• Guideline-based care is provided

• The client’s TB drugs are directly administered

• The client’s ongoing care management, including reminders, reflects progress in the therapy as per DOTS protocols (ICP: loop)

Active in TB programme

Not an emergency

Record clinical observations; administer directly-observed

therapy

Follow-up

Example: IMCI

• A mother brings a sick child into a clinic

• The initial (triage) assessment is made

• Clinical readings are taken and care is given based on the IMCI Chartbook, including immunizations and counselling of the mother regarding ongoing care at home

• ORS are given to the mother to be administered to the child at home

• A follow-up visit is scheduled as per the guidelines

Not an emergency

Record clinical observations; administer immunizations;

counsel mother Dispense ORS

Schedule follow-up visit

Example: MNCH

• A community health worker (CHW) receives client visit reminders on her mobile phone

• The CHW meets with a pregnant woman in her village

• Basic observations are recorded as per the maternal care guidelines; these update the pregnant woman’s ANC record

• NOTE: the CHW is compensated with “airtime” using a performance-based financing (PBF) scheme; the scheme leverages ANC records logged by the CHW

Woman is active in MNCH programme

Not an emergency

Record clinical observations

CHW follow-up reminder

PBF

Example: Injury (emergency)

• First responders arrive at a road accident

• The patient is transported to hospital

• The patient is discharged from hospital and

scheduled for follow-up care by a visiting

home nurse

Patient is scheduled for follow-up

Emergency care

First responders arrive on scene

Example: Injury (ambulatory)

• An injured person arrives at a clinic (e.g. rusty nail puncture through the foot; bleeding)

• Urgent care is provided as per guidelines (e.g. tetanus shot)

• A medicated cream is dispensed and the patient is instructed regarding application at home

• The patient is discharged; no follow-up is scheduled

No follow-up scheduled

Urgent care

Ambulatory injured patient arrives at clinic

Example: Public health emergency

• Based on trends noted from reported cases,

a public health emergency is declared (e.g.

drinking water contamination)

• Standing orders are issued to all clinics in a

region to check for warning signs; specific

instructions are given re: treatment

• Messages are sent to CHWs in the region to

look in on vulnerable patients (pregnant

women, elderly and child patients)

Check for warning signs

Look in on vulnerable clients

Treatment instructions

Example: Reportable Metrics

• Person-centric eHealth transactions are aggregated:

– By CHW, to support guideline adherence and PBF

– By facility, to support management, guideline adherence and local resource planning

– By district, to support resource planning and local population-level health indicators

– Nationally, to support resource planning, guideline efficacy and improvement, and population-level health indicators

Provider level metrics

Facility level metrics

District level metrics

National level metrics

Aggregate person-centric

eHealth data

“Building Blocks”

• The analysis across multiple programmes

yielded a set of common processes and an

“archetypal ” pattern

• This re-usable pattern may be employed as

the basis for each unique care guideline

• The “path” thru the ICP is different,

depending on the guideline (if-then

decision braches)

Common Processes

54

What do I need the eHealth to do?


based Care

• Every guideline-based care workflow may be described as a unique ICP route through the common processes

• To operationalize guideline-based care, eHealth infrastructure would need to:

– Support the common processes

– Support the unique decision logic for each guideline

• In this way, the archetypal ICP may be used to describe the base requirements for a national normative eHealth standards framework

Animating the Guideline-based

Workflows

Care-seeking

Not an emergency

Not HIV positive

Not enrolled in HIV programme


Enrolled in HIV programme

Prescribe ART

Care-seeking

Not an emergency

HIV positive



Adjust medications

Not an emergency

Adjust care plan, if necessary

CD4; viral load; other tests

Follow-up