Operationalizing Guidelinebased. Derek Ritz

Operationalizing Guidelinebased Care Derek Ritz

Operationalizing Guidelinebased 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?

Inform Operationalizes Health Interventions ehealth Infrastructure Person-centric transactional data Population-level health metrics Population Health Generate Yield

Health Interventions Population Health Yield

Operationalizes Health Interventions ehealth Infrastructure Population Health Yield

Operationalizes Health Interventions ehealth Infrastructure Person-centric transactional data Population Health Generate Yield

Operationalizes Health Interventions ehealth Infrastructure Person-centric transactional data Population-level health metrics Population Health Generate Yield

Inform Operationalizes Health Interventions ehealth Infrastructure Person-centric transactional data Population-level health metrics Population Health Generate Yield

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

Standard Operating Procedures SOP-based Interventions Pervasive ehealth Infrastructure Modify SOP ehealth Transactional Data Financial, Management & Population Health Indicators

Operationalize guideline-based care SOP-based Interventions Standard Operating Procedures Pervasive ehealth Infrastructure Modify SOP ehealth Transactional Data Financial, Management & Population Health Indicators

Standard Operating Procedures SOP-based Interventions Pervasive ehealth Infrastructure Modify SOP Support care continuity ehealth Transactional Data Financial, Management & Population Health Indicators

Standard Operating Procedures SOP-based Interventions Pervasive ehealth Infrastructure Modify SOP ehealth Transactional Data Provide management metrics Financial, Management & Population Health Indicators

Standard Operating Procedures SOP-based Interventions Pervasive ehealth Infrastructure Modify SOP ehealth Transactional Data Financial, Management & Population Health Indicators Provide population indicators

Standard Operating Procedures SOP-based Interventions Pervasive ehealth Infrastructure Modify SOP ehealth Transactional Data Support continuous improvement Financial, Management & Population Health Indicators

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 HIV test; other tests Not HIV positive Not enrolled in HIV programme

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)

Care-seeking Not an emergency HIV test; other tests Prescribe ART HIV positive Enrolled in HIV programme

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)

Not an emergency Follow-up CD4; viral load; other tests Adjust medications Adjust care plan, if necessary Active in HIV programme

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)

Not an emergency Follow-up No lab test Refill ART Active in HIV programme

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)

Care-seeking Escalate care Patient discharged from hospital dead

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)

Not an emergency Follow-up Record clinical observations; administer directly-observed therapy Active in TB programme

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

Not an emergency CHW follow-up reminder Record clinical observations Woman is active in MNCH programme 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

First responders arrive on scene Emergency care Patient is scheduled for follow-up

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

Ambulatory injured patient arrives at clinic Urgent care No follow-up scheduled

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 Treatment instructions Look in on vulnerable clients

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

National level metrics District level metrics Aggregate person-centric ehealth data Facility level metrics Provider level metrics

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?

Operationalizing Guidelinebased 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