Using Data from the iSanté National Electronic Medical Record System to Strengthen Haiti's HIV Antiretroviral Therapy Program

Thesis (Ph.D.)--University of Washington, 2014The scale-up of electronic medical records (EMR) in low resource settings offers opportunities to improve patient care and health outcomes through improved information to guide decision-making at individual patient, facility, and national levels. In this dissertation, we explored use of data relevant for quality improvement in Haiti's national HIV care and treatment program, at each of these three levels of decision-making. Our first analysis was relevant to improved clinical decision making for individual patients. We developed a simple prediction model for risk of therapeutic failure among patients on HIV antiretroviral therapy (ART), using pharmacy-based adherence data and other patient characteristics. This model strongly differentiated patients at high, medium and low risk and could be help providers identify which patients to target with intensive adherence support services. We concluded that targeting patients according to their predicted risk could help providers to reach the greatest number of patients with high need in the context of constrained resources. Our second analysis examined attrition from the ART program in two large departmental hospitals in Haiti and identified patient demographic, clinical, temporal, and health service-related factors associated with ART attrition. This analysis was relevant to improved management of services at the facility level. We found that at 12 months after ART initiation 26.6% of ART patients were no longer retained in care (95% CI: 24.6-28.7%). Location of patient residence in communes distant from the health care facility was strongly associated with attrition, as was briefer duration of enrollment within HIV care and treatment prior to ART initiation, having a non-standard ART regimen, and having no counseling sessions prior to ART initiation. We concluded that quality improvement interventions which address these risk factors merit further testing within the two facilities. Our third analysis examined the performance of 95 facilities using the iSanté EMR system with respect to a series of 14 priority data quality indicators. In this analysis, we examined consistency of performance across the indicators, as well as site and system use characteristics associated with strong vs. weak data quality. This analysis offers insight on where and how efforts to strengthen data quality should focus, and on which system "ingredients" may be necessary to produce strong data quality. Together our analyses demonstrate the value of using data from the iSanté EMR system to identify improvements in individual patient follow-up, organization of services, quality of information, and allocation of system-wide resources. There are tremendous on-going pressures to expand access to HIV care and treatment, to assure quality of services, and to optimize efficiency in Haiti and other low-resource settings. Our analyses of iSanté EMR data represent three examples of data use which address these pressures. Building upon the momentum of the present analyses by translating the findings into on-ground program improvements, and by exploring other data uses which answer timely health services research questions is of great importanc