HIV This Week

"Talkin' about a revolution": How electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings.

Braitstein P, Einterz RM, Sidle JE, Kimaiyo S, Tierney W. J Acquir Immune Defic Syndr. 2009 Nov;52(S1).

Health care for patients with HIV infection in developing countries has increased substantially in response to major international funding. Scaling up treatment programs requires timely data on the type, quantity, and quality of care being provided. Increasingly, such programs are turning to electronic health records to provide these data. The authors describe how a medical school in the United States and another in Kenya collaborated to develop and implement an electronic health records system in a large HIV care program in western Kenya. These data were used to manage patients, providers, and the program itself as it grew to encompass 18 sites serving more than 90,000 patients. Lessons learned have been applicable beyond HIV to include primary care, chronic disease management, and community-based health screening and disease prevention programs. Electronic health records will be key to providing the highest possible quality of care for the funds developing countries can commit to health care. Public, private, and academic partnerships can facilitate the development and implementation of electronic health records in resource-constrained settings.

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Editors’ note: Quality health care depends, among other things, on collecting, analysing, and using timely health information. Well managed health information management systems can help programme managers plan deployment of personnel, avoid drug stockouts, and maximise resource use. But, first and foremost, meeting clinicians’ requirements for complete and accurate data is key to ensuring high-quality care for patients. Electronic medical records using unique identifiers while protecting patient confidentiality and data security help coordinate care across multiple venues and specialities. Patients can be notified quickly of drug recalls or eligibility for novel treatments and can use their laminated personal card to access care throughout the health system. Investment in electronic health records for patients in antiretroviral treatment programmes is reaping benefits in low- and middle-income countries that are expanding data capture and management to support the scale up of efficient, effective clinical services for other conditions. We really are “talkin’ about a revolution”!

Nash D, Elul B, Rabkin M, Tun M, Saito S, Becker M, Nuwagaba-Biribonwoha H. J Acquir Immune Defic Syndr. 2009 Nov;52(S2).

Program monitoring and evaluation has the potential to be a cornerstone of health systems strengthening and of evidence-informed implementation and scale-up of HIV-related services in resource-limited settings. The authors discuss common challenges to monitoring and evaluation systems used in the rapid scale-up of HIV services as well as innovations that may have relevance to systems used to monitor, evaluate, and inform health systems strengthening. These include (1) Web-based applications with decentralized data entry and real-time access to summary reporting; (2) timely feedback of information to site and district staff; (3) site-level integration of traditionally siloed program area indicators; (4) longitudinal tracking of program and site characteristics; (5) geographic information systems; and (6) use of routinely collected aggregate data for epidemiologic analysis and operations research. Although conventionally used in the context of vertical programs, these approaches can form a foundation on which data relevant to other health services and systems can be layered, including prevention services, primary care, maternal-child health, and chronic disease management. Guiding principles for sustainable national monitoring and evaluation systems include country-led development and ownership, support for national programs and policies, interoperability, and employment of an open-source approach to software development.

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Editors’ note: This article starts with a diagnosis of the challenge of providing timely and useful feedback to key staff at individual health facilities when information is hand tallied from paper-based sources and reported up to district, regional, national, and international agencies on schedules that reflect the latter’s needs. When the objective is continuous improvement of quality, scale, equity, and impact of services, the benefits of web-based real-time systems using solar powered mobile phones for data entry (such as Rwanda is developing) are evident. Overcoming silos in HIV monitoring and evaluation systems, each one designed for its own programme (e.g. antiretroviral treatment, prevention of mother-to-child transmission, voluntary counselling and testing), is key to moving forward to systems that integrate disease- or programme-specific data within broader primary care.