Health Information Technology for Continuous Quality Improvement of HIV Treatment Programs

As HIV treatment programs are scaled-up, monitoring the quality of care that patients receive and their clinical outcomes is increasingly important. This compendium of health information technology (HIT) seeks to inform the implementation of HIT to facilitate continuous quality improvement (CQI) of antiretroviral therapy (ART) programs and improved patient outcomes in low and middle income countries. HIT includes a broad array of tools that provide a means to effectively manage and share healthcare systems data and patient health information. CQI is a team effort that involves repetitive cycles of performance measurement, quality improvement activities, and re-measurement to determine if the activities resulted in a change.

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Overview

Health worker using a mobile phone in a remote location.

In the context of scaled-up HIV programs, health information technology (HIT) offers a set of tools to facilitate continuous quality improvement (CQI) of health care delivery and clinical outcomes. Given that the field has not advanced to the point of fully integrating the use of HIT into routine CQI practice, two crosswalk tables are presented:

  • The Partners and Agencies Crosswalk synthesizes selected CQI and HIT resources from implementing partners and agencies as a means to contribute to the integration of the two areas.
  • The HIT Research Crosswalk synthesizes research conducted by developers, researchers, and early adopters to provide experiential information on the use of HIT to monitor the quality of antiretroviral treatment (ART) service delivery on a country-by-country basis.

Finally, the compendium synthesizes these resources to extract lessons learned, including advantages and disadvantages to each type of technology and special considerations for implementation. Taken together, the compendium intends to contribute to the assimilation of CQI and HIT to narrow the gap between HIT research and routine use.

Background

The rapid scale-up of HIV treatment programs in low and middle income countries has significantly reduced HIV-related morbidity and mortality. To sustain these gains and to move closer to universal access to HIV care and treatment, ministries of health (MOH) and HIV programs have begun to develop and implement CQI plans to routinely track the quality of HIV care and services in order to identify areas that require improvement and to support responsiveness to potential needs. In this context, robust CQI of ART outcomes at the programmatic-, clinic-, and patient-levels is critical to move toward high-quality care and to inform the planning of expanded ART coverage.

HIT can be defined as a broad array of tools that provide a means to effectively manage and share healthcare systems data and patient health information. As such, HIT has the potential to support patient care and facilitate and expand MOH strategies for CQI of ART programs using tools such as:

  • Geographic Information Systems (GIS)
  • Health Information Management Systems (HIMS)
  • Electronic Health Records (EMR)
  • Cellular Phones
  • Electronic Adherence Devices

From an MOH perspective, successful CQI of ART programs with HIT may allow for improved efficiency and patient outcomes to sustain best practices. Based on lessons learned from HIT and CQI in action as well as HIT research, the compendium may provide guidance on which HIT strategies have been effective in the settings of HIV treatment and care programs by assessing factors influencing feasibility, development, implementation, and evaluation of HIT approaches in low and middle income settings. Careful synthesis and subsequent broad dissemination of findings to healthcare professionals is an important and necessary step to inform HIV programs at all levels on the use of HIT to promote sustained high-quality care.

Approach

Staff members examine a map of community health worker locations at St. Gabriel's Hospital in Namitete, Malawi.<br> © 2008 Josh Nesbit, Courtesy of Photoshare

AIDSTAR-One conducted a comprehensive and systematic literature review of scholarly journals using PubMed, Google Scholar, the Association for Computing Machinery’s Digital Library, the Institute of Electrical and Electronics Engineers’ Xplore, as well as partners’ websites. Resources from partners were included if they described either CQI and/or HIT programs for HIV care and treatment. Resources from agencies such as the World Health Organization (WHO), United Nations agencies, and national health ministries were considered if they created programs and/or policies regarding HIT or CQI. Resources were included in the HIT Research Crosswalk table if they addressed the feasibility, development, implementation, or evaluation of innovative HIT that directly supported or facilitated CQI of ART programs to improve patient outcomes in low and middle income countries.

Partners' and Agencies' Crosswalk Resources

Each component of this crosswalk was categorized by level of application, country of activity, goal of the resource, and type of resource. The Partners' and Agencies' Crosswalk also provides a brief summary of the resource along with hyperlinks to the resources.

Levels of Application: HIV care and treatment resources pertaining to CQI and/or HIT.

HIT Research Crosswalk

Each reference included in the HIT Research Crosswalk is categorized by type of technology, level of application, care population, country of use, and issues addressed. The HIT Research Crosswalk table also provides a brief summary of the project which highlights the objectives, successes and challenges, and outcomes from the research. Finally, it provides hyperlinks to the technology source(s) and the reference, and provides contact information for the author of the paper.

Type of Technology: Innovative technologies that facilitate CQI of ART programs and improve patient outcomes. The following technologies are described and evaluated in the compendium:

  • Geographic information systems (GIS) are computer-based tools for mapping and linking topographic, demographic, and facility data. GIS also integrate database queries and statistical analysis with data that is geographically referenced.
  • Health information management systems (HIMS) are systems used by a country or healthcare program to facilitate the collection, management, and integration of health information from multiple sources to support reporting and other programmatic functions.
  • Electronic medical records (EMR) are computer-accessible resources of medical and administrative information collected by and accessible to providers involved in patient care.
  • Cellular phones are pocket-sized, wireless electronic devices, typically comprised of a small visual display screen and a miniature keyboard or touch screen for user input.
  • Electronic adherence monitors are pocket-sized electronic devices that record and save the date and time that the user accesses their medication. The device may directly hold the medication or it may be attached to a pill bottle.

Level of Application: Technologies were assessed for their potential to facilitate HIV programs and improve clinical care at three levels. The levels of care are described as follows:

  • At the programmatic-level, HIT approaches focus on strategies to facilitate CQI via the aggregation of system-wide data to support supervision across already scaled up ART sites. Such strategies include GIS, HIMS, and EMR.
  • For HIT strategies at the clinic level, the compendium includes EMR and cellular phones, which may support patient management and safety to improve clinical outcomes.
  • At the patient-level, technologies such as cellular phones and electronic adherence monitors are included for their potential to improve adherence, support program retention, and facilitate communication with healthcare workers.


The Partners and Agencies Crosswalk frames CQI and HIT resources to inform strategies so as to incorporate HIT into CQI of HIV programs.

Refine by Level of Application:Refine by Goal:
Level of Application Country Goal Type of Resource Summary
CQI

For global dissemination; includes country experiences from Thailand, Kenya, Uganda, and South Africa

Knowledge and Creation

Standards for quality HIV care

HIT

Global

Synthesis and Dissemination

Report

CQI

Botswana
Guyana
Haiti
Kenya
Mozambique
Namibia
Nigeria
Rwanda
Swaziland
Thailand
Uganda

Implementation and Use

Website with toolkit available

HIT

Global

Implementation and Use

Guidelines for HIV care including data collection utilizing an electronic system

HIT

Global

Synthesis and Dissemination

Report

HIT

Unspecified

Knowledge and Creation

Website with virtual Health Unbound (HUB) to discuss mHealth strategies

HIT

Kenya
Rwanda
Tanzania

Implementation and Use

Project website

HIT

Botswana
Kenya
Lesotho
Namibia
Rwanda
Southern
Sudan
Swaziland
Tanzania
Uganda

Implementation and Use

Organization website

HIT

India
Tanzania

Implementation and Use

Organization website

HIT

Global

Knowledge and Creation

Website with a literature review on all HIT strategies

HIT

Global

Knowledge and Creation

Website with links to an mHealth literature review as well as an mHealth database

HIT

Global

Synthesis and Dissemination

Report

HIT

Mozambique
Uganda

Implementation and Use

Program website

HIT

Haiti
Lesotho
Malawi
Peru
Russia
Rwanda

Implementation and Use

Organization website

CQI

Ghana
Malawi
South Africa

Implementation and Use
Knowledge and Creation
Synthesis and Dissemination

Organization website

CQI

Global

Implementation and Use

Organization website with access to any number of resources including training materials, toolkits, reports, and literature

CQI

Côte d’Ivoire
Mozambique
South Africa
Tanzania

Implementation and Use

Organization website

CQI

Global

Synthesis and Dissemination

Field guide

CQI

Botswana
Ethiopia
Jamaica
Mozambique
Swaziland
Tanzania

Implementation and Use

Project website

CQI
HIT

Not specified

Synthesis and Dissemination

Program website

CQI
HIT

Southern hemisphere

Implementation and Use
Knowledge and Creation
Synthesis and Dissemination

Program website

HIT

Vietnam

Implementation and Use

Case Study

HIT

South Africa

Synthesis and Dissemination

Program plan

CQI
HIT

Asia (unspecified)
Chile
Guatemala
Peru

 

Implementation and Use

Program website

CQI
HIT

Global

Implementation and Use

Program website

HIT

Rwanda

Implementation and Use

Program website

HIT

Mexico

Implementation and Use

Health affairs report

The HIT Research Crosswalk table summarizes findings in the academic literature published by HIT developers, researchers, and early adopters to describe their experiences with the feasibility, development, implementation, and evaluation of HIT.

Refine by Level of Application: Refine by Technology: Refine by Purpose:
Level of Application Technology Country Care Population Purpose Summary
Patient Cellular Phone

Kenya

Adults
Alerts/Reminders
ART Initiation and Adherence
Patient Cellular Phone

Cameroon

Adults
Access and Retention in Care
Alerts/Reminders
ART Initiation and Adherence
Patient
Clinic/clinician
Cellular Phone

South Africa

Pediatrics
Access and Retention in Care
Alerts/Reminders
Data Quality and Management
Health Education
PMTCT
Patient Cellular Phone

Kenya

Adults
Access and Retention in Care
Alerts/Reminders
ART Initiation and Adherence
Patient Cellular Phone

South Africa

Adults
Access and Retention in Care
Alerts/Reminders
ART Initiation and Adherence
Program GIS

South Africa

Adults
Access and Retention in Care
Program Management
Clinic/clinician
Program
HIMS

Mozambique

General population
Access and Retention in Care
Data Quality and Management
Program Management
Clinic/clinician EMR

Rwanda

General population
Access and Retention in Care
Alerts/Reminders
Data Quality and Management
Program Management
Quality of Care
Program EMR

Multi-continent

Unspecified
Data Quality and Management
Program Management
Program GIS

Brazil

Adults Program Management
Clinic/clinician Cellular Phone

Peru

Unspecified Health Education
Program EMR

Malawi

General population
Access and Retention in Care
ART Initiation and Adherence
Program Management
Quality of Care
Patient
Clinic/clinician
Cellular Phone

South Africa

General population
Alerts/Reminders
ART Initiation and Adherence
Patient Cellular Phone

Uganda

Pediatrics
Alerts/Reminders
ART Initiation and Adherence
Data Quality and Management
Clinic/clinician EMR

Kenya

Unspecified
Alerts/Reminders
Data Quality and Management
Program Management
Clinic/clinician EMR

Uganda

Adults
ART Initiation and Adherence
Data Quality and Management
Program Management
Quality of Care
Clinic/clinician
Program
HIMS

Peru

Adults
Access and Retention in Care
Program Management
Quality of Care
Program GIS

Brazil

Pediatrics
PMTCT
Program Management
Patient Cellular Phone

Kenya

Adults
Access and Retention in Care
Alerts/Reminders
ART Initiation and Adherence
Program EMR

Angola
Cameroon
Democratic Republic of the Congo
Guinea Bissau
Kenya
Malawi
Mozambique
Nigeria
Republic of Guinea
Tanzania

Unspecified
Access and Retention in Care
Data Quality and Management
Program Management
Quality of Care
Program GIS

India

Unspecified Program Management
Clinic/clinician
Program
EMR

Haiti

General population
Data Quality and Management
Program Management
Quality of Care
Program GIS

South Africa

Unspecified
Data Quality and Management
Program Management
Program EMR

Philippines

Unspecified
ART Initiation and Adherence
Program Management
Quality of Care
Program GIS

Uganda

Women
Access and Retention in Care
ART Initiation and Adherence
PMTCT
Program EMR

Rwanda

General population
ART Initiation and Adherence
Data Quality and Management
Program Management
Quality of Care
Program EMR

Kenya

Unspecified
Access and Retention in Care
Alerts/Reminders
Data Quality and Management
Program Management
Patient Cellular Phone

Peru

Adults
ART Initiation and Adherence
Health Education
Clinic/clinician
Program
EMR

Botswana

Unspecified
Access and Retention in Care
ART Initiation and Adherence
Data Quality and Management
Program Management
Clinic/clinician
Program
EMR

Haiti

Unspecified
Alerts/Reminders
Data Quality and Management
Program Management
Quality of Care
Program GIS

Thailand

Adults
Access and Retention in Care
Program Management
Patient Electronic Adherence Monitor

Uganda

Adults
Access and Retention in Care
Alerts/Reminders
ART Initiation and Adherence
Patient Electronic Adherence Monitor

Tanzania

Adults
ART Initiation and Adherence
Data Quality and Management
Patient Electronic Adherence Monitor

South Africa

Pediatrics
ART Initiation and Adherence
Data Quality and Management
Patient Electronic Adherence Monitor

Botswana

Unspecified ART Initiation and Adherence
Patient Cellular Phone

India

Adults
Alerts/Reminders
ART Initiation and Adherence
Clinic/clinician
Program
EMR

Kenya
Tanzania
Uganda

Unspecified
Data Quality and Management
Program Management
Quality of Care
Patient
Clinic/clinician
Cellular Phone

Kenya

Adults
Access and Retention in Care
Alerts/Reminders
ART Initiation and Adherence
Data Quality and Management
Patient Electronic Adherence Monitor

India
Malawi

Adults ART Initiation and Adherence
Program GIS

South Africa

Unspecified
Access and Retention in Care
Data Quality and Management
Program Management
Quality of Care
Clinic/clinician Cellular Phone

Ghana
India
Malawi
Uganda

Unspecified Data Quality and Management
Patient Cellular Phone

Uganda

Adults
Access and Retention in Care
Alerts/Reminders
ART Initiation and Adherence
Patient Cellular Phone

India

Adults
Alerts/Reminders
ART Initiation and Adherence
Clinic/clinician
Program
EMR

Kenya

Unspecified
Access and Retention in Care
Alerts/Reminders
ART Initiation and Adherence
Data Quality and Management
Program Management
Quality of Care
Patient Electronic Adherence Monitor

South Africa

Pediatrics ART Initiation and Adherence
Patient Cellular Phone

Malawi

Unspecified ART Initiation and Adherence
Clinic/clinician Cellular Phone

South Africa

Unspecified
Access and Retention in Care
ART Initiation and Adherence
Data Quality and Management
Patient
Clinic/clinician
Cellular Phone

South Africa

Unspecified Quality of Care
Patient Cellular Phone

South Africa

General population
Alerts/Reminders
Data Quality and Management
Program HIMS

China

Pediatrics
Access and Retention in Care
ART Initiation and Adherence
Data Quality and Management
Program Management
Program HIMS

South Africa

Unspecified
Access and Retention in Care
ART Initiation and Adherence
Data Quality and Management
Program Management
Program HIMS

Myanmar

Unspecified
Data Quality and Management
Program Management
Program HIMS

South Africa

Women
Data Quality and Management
PMTCT
Program Management
Clinic/clinician EMR

Kenya

Adults
Alerts/Reminders
Quality of Care
Clinic/clinician Cellular Phone

Unspecified

Unspecified
Data Quality and Management
Quality of Care
Patient Cellular Phone

India

Adults
Alerts/Reminders
ART Initiation and Adherence
Clinic/clinician EMR

Uganda

Unspecified
Access and Retention in Care
Quality of Care

Advantages and Disadvantages to HIT

Technology
Advantages
Disadvantage

Geographic Information System

  • Routine assessment to monitor infrastructure and services over time
  • Spatial data to compare healthcare facilities with disease prevalence to inform program planning
  • Integration of demographic data to identify inequitable distribution of services across populations
  • Open source software is available
  • Detailed data required for analyses may not be available in some settings
  • Proprietary software may be costly
  • Technical expertise required to use the software

Health Information Management System

  • Assessment of unique parts of the healthcare system for health system strengthening
  • Filtering functions group data to compare sites
  • Support for CQI and program-level reporting
  • Allows for operations research to evaluate implementation of quality improvement measures
  • Requires a reliable power supply
  • Requires technical knowledge of computers and databases
  • Concerns with security of patient health information
  • Proprietary software may be costly

 

Electronic Medical Record

  • Facilitates patient care with easy access to longitudinal, comprehensive patient health information
  • Point-of-care systems combine data collection with clinical care
  • Data management can reduce errors
  • Clinical decision support can facilitate adoption of clinical guidelines
  • Clinical summaries can save physician time
  • Queries of clinical databases can support CQI and reporting
  • Open source software is available
  • Requires a reliable power supply
  • Requires technical knowledge of computers and databases
  • Concerns with security of patient health information
  • Proprietary software may be costly

 

Cellular Phone

  • Reliable with good reception in many settings
  • Solar-powered chargers are available
  • Text message reminders can improve adherence to ART and retention-in-care
  • Facilitates communication between patients and healthcare workers
  • Provides for remote data collection, clinical decision support, and health worker education
  • Concerns for security of patient health information
  • Risk of theft
  • May be shared by multiple people or turned off
  • Question regarding provision of funds for use

Electronic Adherence Monitor

  • Less prone to bias than other adherence measures
  • Collection of ongoing data is informative to clinicians
  • Real-time monitoring allows clinicians to intervene prior to the development of resistance or opportunistic infections
  • Some require a reliable power supply
  • More expensive than other adherence measures
  • May require data management strategies

Implementation Considerations

Image of health workers using health infromation technology.

HIT offers great potential to facilitate CQI of ART programs and thereby improve patient care and outcomes. New technologies, however, should be approached with caution and comprehensive planning at all phases of implementation. In particular, it is critical to clearly define the problem and establish whether the technology has the ability to solve the problem. Additionally, the technology must be adapted to meet the needs of all end users, integrated into pre-existing frameworks and workflow, and maintained beyond implementation via staff trainings and modification as required. When implemented with due planning, HIT may provide a mechanism to evaluate comprehensive data, inform program planning, and support clinical care.

 

Implementation Phase
Considerations

Pre-Implementation

  • Identify the objective of the technology, with special consideration as to whether the technology has the capability of meeting the objective
  • Consider the local context, including physical and information technology infrastructure, the availability of support personnel, and the resources available to implement and sustain the technology
  • Consider whether the constraints of the local context permit the future need to scale-up to more users or sites
  • Conduct focus groups with all types of end users to determine needs, perceived usefulness, and ease of use
  • Conduct a pilot study to assess acceptability, feasibility, and usability to inform implementation

Implementation

  • Collaboration and regular communication between implementers and a representative group of end users
  • Include opportunities for structured feedback from end users throughout design, development, and implementation
  • Conduct trainings of all end users
  • Integrate the new technology with already existing patterns of workflow to minimize time disruptions and to improve efficiencies

Post-Implementation

  • Implement an ongoing communication mechanism, such that end users can report system errors and programmers can respond to feedback
  • Ensure ongoing technical support
  • Train and update end users on system changes or modifications and provide refresher sessions
  • Develop and implement a protocol to monitor data quality and correct inaccuracies
  • Conduct regular evaluations of the system
A health workers uses a computer in a rural setting.<br> © 2008 Josh Nesbit, Courtesy of Photoshare

Conclusions

As HIV care and treatment programs are scaled-up, CQI of these programs is gaining increased focus. HIT holds much promise to fulfill a myriad of important tasks:

  • At the programmatic level, technologies such as GIS and HIMS, hold the potential to carry out surveillance activities and aggregate patient medical information to support reporting and program planning.
  • At the clinic level, technologies such as EMR and cellular phones hold the potential to improve clinical outcomes, provide tools for patient management, support clinical decision-making, and facilitate remote data collection.
  • At the patient level, cellular phones and electronic adherence monitors hold the potential to improve ART adherence and retention in care as well as provide an improved means for communication between providers and patients.

Future adopters of these technologies may utilize this compendium to identify methods that are most appropriate for a program, learn how to utilize the technology in a manner that results in improved patient care, and measure the quality of patient care. It is expected that as these technologies become more widely employed, utilization of HIT for CQI strategies will become increasingly commonplace and ultimately will result in improved outcomes for patients enrolled in HIV care and treatment programs.

Acknowledgments

The authors would like to thank the many colleagues who contributed to the development of the Compendium of Health Information Technology for Continuous Quality Improvement. The vision and input of Thomas Minor and Robert Ferris, members of the Technical Working Group, provided ongoing guidance to support this effort include. The authors are also grateful to the technical experts at John Snow, Inc. who generously gave their time and expertise to contribute to the Compendium, including: Lauren Alexanderson, Daniel Cothran, Mike Frost, Margot Harrington, Lisa Hirschhorn, Anna Lisi, John Nicholson, and Jill Posner.

Recommended Citation

Johnson, Kristin L., Malia H. Duffy, John M. Carper, Bisola O. Ojikutu. 2012. Health Information Technology for Continuous Quality Improvement of Antiretroviral Treatment–Related Outcomes in Low and Middle Income Countries. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources. AIDSTAR-One, Task Order 1.

Corresponding Author: kjohnson@jsi.com