1. The Evolution of an electronic Patient Information System at the Tygerberg Hospital Infectious Diseases Clinic M la Grange 10 December 2009 University of Stellenbosch

2. Some goals are important

3. South African ARV Rollout Programme Operational Plan For Comprehensive HIV & AIDS Care, Management And Treatment For South Africa (19 November 2003). Aims: –To provide care and treatment for people living with HIV and AIDS –To facilitate the strengthening of the National Health System Objective of this operational plan: –By 2009: All individuals requiring treatment for AIDS able to access comprehensive care and treatment –Actuarial Society of South Africa estimated that by 2009, about 1.4 million people would require ART ARV Rollout Programme started in 2004

4. Implications for Clinics Vast increase in patient numbers Monthly statistical reporting, including: –Patients started on ART –Patients on ART at month end –Patients who stopped ART, became LTFU, died or were TFO –Adverse events –Pregnant patients In addition to clinical notes, doctors to provide data for reports

5. Birth of an Electronic Database The Infectious Diseases Clinic developed an Electronic Patient Information System to address these challenges. First phase of Patient Information System: –MS Access database developed and maintained by doctor –Patient Visit Form allows doctors to complete both clinical notes and data for reports on one form –The Patient Visit Form presents clinical information for the specific patient during follow-up –Filing clerk used for data capturing –Basic patient information captured –Interactivity between doctors and the system

6. Flow of Information

7. Strengthening the System Problem: Poor data accuracy leading to poor doctor compliance PEPFAR funding was obtained in 2006. In 2007, the following staff were employed –Data Manager –Full-time data capturer for the Adult PEPFAR project –2 full-time data capturers for the Paediatric PEPFAR project Next phase of Patient Information System: –Access database centralized and migrated to MS SQL Server –Detailed patient data captured accurately per patient –Visit forms re-introduced to clinic

8. Note: Personal patient information used in this presentation has been altered.

9. Patient Visit Form

10. Patient Visit Form - continued

12. Data quality is the difference between a data warehouse and a data garbage dump. - Jarret Rosenberg Data Quality

13. The Next Level: e-Filing Problem: Thousands of physical patient folders A secure web-based, e-filing system for storage of digital images of patient records is being implemented Barcodes on documents are used to store scanned documents to patient folders Data from existing ID Clinic database is used to automatically index data (by file number, first name, surname, DOB, ID) Part-time scanning clerk appointed, 1.5 days per week

14. System Context Diagram

15. Benefits of the System Improved Clinical Care –The customized Patient Visit Form presents accurate, up-to-date clinical information during follow-up at a glance –The system minimizes unnecessary and repetitive note-taking –Doctors have more time for patient interaction due to time gains –The Patient Visit Form prompts doctors to address habitually neglected health care issues, e.g. last PAP smear and condom use Secure internet access to e-filing system –Doctors are able to securely access scanned patient records via the internet, e.g. for after-hours telephonic consultations –Down-referred patients followed up efficiently at primary clinics –User password required and https protocol

16. Benefits of the System - continued Statistics can be retrieved for Rollout and PEPFAR reports The clinical team evaluates morbidity and mortality data every month Data used for research Data supports the clinic operationally, e.g. to identify patients living in a specific area for making transport arrangements

17. Success Factors Doctors, patients and administrators benefit from captured data due to the design of the Patient Visit Form. The Patient Visit Form promotes cooperation of doctors, which increases data accuracy. The development of the system has been initiated by the clinic doctors. Therefore, the original database design was relevant to the clinics needs. A dedicated data team is responsible for data capturing, monitoring and reporting. Data is stored in a centralized database, ensuring that up to date data is available to all system users. Laboratory results are imported into the database, ensuring data accuracy.

18. Acknowledgements Dr. Hans Prozesky did the initial development of the system and continues to play a crucial role in maintenance thereof Dr. Michele Zeier secured funding for, and established a dedicated data team for the clinic This project forms part of a program of the Perinatal HIV Research Unit (PHRU) and funding is provided through PEPFAR