RESUMEN
BACKGROUND: Lost, delayed or incorrect laboratory results are associated with delays in initiating treatment. Delays in treatment for Multi-Drug Resistant Tuberculosis (MDR-TB) can worsen patient outcomes and increase transmission. The objective of this study was to evaluate the impact of a laboratory information system in reducing delays and the time for MDR-TB patients to culture convert (stop transmitting). SETTING: 78 primary Health Centers (HCs) in Lima, Peru. Participants lived within the catchment area of participating HCs and had at least one MDR-TB risk factor. The study design was a cluster randomized controlled trial with baseline data. The intervention was the e-Chasqui web-based laboratory information system. Main outcome measures were: times to communicate a result; to start or change a patient's treatment; and for that patient to culture convert. RESULTS: 1671 patients were enrolled. Intervention HCs took significantly less time to receive drug susceptibility test (DST) (median 11 vs. 17 days, Hazard Ratio 0.67 [0.62-0.72]) and culture (5 vs. 8 days, 0.68 [0.65-0.72]) results. The time to treatment was not significantly different, but patients in intervention HCs took 16 days (20%) less time to culture convert (pâ=â0.047). CONCLUSIONS: The eChasqui system reduced the time to communicate results between laboratories and HCs and time to culture conversion. It is now used in over 259 HCs covering 4.1 million people. This is the first randomized controlled trial of a laboratory information system in a developing country for any disease and the only study worldwide to show clinical impact of such a system. TRIAL REGISTRATION: ClinicalTrials.gov NCT01201941.
Asunto(s)
Sistemas de Información en Laboratorio Clínico/organización & administración , Comunicación , Errores Médicos/prevención & control , Calidad de la Atención de Salud , Tuberculosis/diagnóstico , Tuberculosis/terapia , Adolescente , Adulto , Antituberculosos/uso terapéutico , Bases de Datos Factuales , Países en Desarrollo , Femenino , Humanos , Laboratorios/organización & administración , Masculino , Pruebas de Sensibilidad Microbiana/normas , Persona de Mediana Edad , Perú , Pobreza , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Mejoramiento de la Calidad , Proyectos de Investigación , Resultado del Tratamiento , Tuberculosis/tratamiento farmacológico , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Adulto JovenRESUMEN
INTRODUCTION: Multi-drug resistant TB (MDR-TB) is a complex infectious disease that is a growing threat to global health. It requires lengthy treatment with multiple drugs and specialized laboratory testing. To effectively scale up treatment to thousands of patients requires good information systems to support clinical care, reporting, drug forecasting, supply chain management and monitoring. METHODS: Over the last decade we have developed the PIH-EMR electronic medical record system, and subsequently OpenMRS-TB, to support the treatment of MDR-TB in Peru, Haiti, Pakistan, and other resource-poor environments. RESULTS: We describe here the experience with implementing these systems and evaluating many aspects of their performance, and review other systems for MDR-TB management. CONCLUSIONS: We recommend a new approach to information systems to address the barriers to scale up MDR-TB treatment, particularly access to the appropriate drugs and lab data. We propose moving away from fragmented, vertical systems to focus on common platforms, addressing all stages of TB care, support for open data standards and interoperability, care for a wide range of diseases including HIV, integration with mHealth applications, and ability to function in resource-poor environments.
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Países en Desarrollo , Registros Electrónicos de Salud/organización & administración , Tuberculosis Extensivamente Resistente a Drogas/diagnóstico , Tuberculosis Extensivamente Resistente a Drogas/terapia , Gestión de la Información en Salud/organización & administración , Sistemas de Medicación en Hospital/organización & administración , Consulta Remota/organización & administración , Prescripción Electrónica , Haití , Humanos , PakistánRESUMEN
BACKGROUND: In 2006, we were funded by the US National Institutes of Health to implement a study of tuberculosis epidemiology in Peru. The study required a secure information system to manage data from a target goal of 16,000 subjects who needed to be followed for at least one year. With previous experience in the development and deployment of web-based medical record systems for TB treatment in Peru, we chose to use the OpenMRS open source electronic medical record system platform to develop the study information system. Supported by a core technical and management team and a large and growing worldwide community, OpenMRS is now being used in more than 40 developing countries. We adapted the OpenMRS platform to better support foreign languages. We added a new module to support double data entry, linkage to an existing laboratory information system, automatic upload of GPS data from handheld devices, and better security and auditing of data changes. We added new reports for study managers, and developed data extraction tools for research staff and statisticians. Further adaptation to handle direct entry of laboratory data occurred after the study was launched. RESULTS: Data collection in the OpenMRS system began in September 2009. By August 2011 a total of 9,256 participants had been enrolled, 102,274 forms and 13,829 laboratory results had been entered, and there were 208 users. The system is now entirely supported by the Peruvian study staff and programmers. CONCLUSIONS: The information system served the study objectives well despite requiring some significant adaptations mid-stream. OpenMRS has more tools and capabilities than it did in 2008, and requires less adaptations for future projects. OpenMRS can be an effective research data system in resource poor environments, especially for organizations using or considering it for clinical care as well as research.
Asunto(s)
Registros Electrónicos de Salud , Internet , Tuberculosis Resistente a Múltiples Medicamentos/epidemiología , Lista de Verificación , Sistemas de Computación , Estudios Epidemiológicos , Sistemas de Información Geográfica , Humanos , Sistemas de Información , Perú/epidemiología , Desarrollo de Programa , Estudios ProspectivosRESUMEN
OBJECTIVE: To evaluate the time to communicate laboratory results to health centers (HCs) between the e-Chasqui web-based information system and the pre-existing paper-based system. METHODS: Cluster randomized controlled trial in 78 HCs in Peru. In the intervention group, 12 HCs had web access to results via e-Chasqui (point-of-care HCs) and forwarded results to 17 peripheral HCs. In the control group, 22 point-of-care HCs received paper results directly and forwarded them to 27 peripheral HCs. Baseline data were collected for 15 months. Post-randomization data were collected for at least 2 years. Comparisons were made between intervention and control groups, stratified by point-of-care versus peripheral HCs. RESULTS: For point-of-care HCs, the intervention group took less time to receive drug susceptibility tests (DSTs) (median 9 vs 16 days, p<0.001) and culture results (4 vs 8 days, p<0.001) and had a lower proportion of 'late' DSTs taking >60 days to arrive (p<0.001) than the control. For peripheral HCs, the intervention group had similar communication times for DST (median 22 vs 19 days, p=0.30) and culture (10 vs 9 days, p=0.10) results, as well as proportion of 'late' DSTs (p=0.57) compared with the control. CONCLUSIONS: Only point-of-care HCs with direct access to the e-Chasqui information system had reduced communication times and fewer results with delays of >2 months. Peripheral HCs had no benefits from the system. This suggests that health establishments should have point-of-care access to reap the benefits of electronic laboratory reporting.
Asunto(s)
Sistemas de Información en Laboratorio Clínico/organización & administración , Eficiencia Organizacional , Difusión de la Información , Sistemas Multiinstitucionales/organización & administración , Sistemas de Atención de Punto/organización & administración , Humanos , Análisis de Intención de Tratar , Internet , Programas Nacionales de Salud/organización & administración , Perú , Factores de Tiempo , Tuberculosis/diagnósticoRESUMEN
OBJECTIVES: To evaluate the effectiveness of a personal digital assistant (PDA)-based system for collecting tuberculosis test results and to compare this new system to the previous paper-based system. The PDA- and paper-based systems were evaluated based on processing times, frequency of errors, and number of work-hours expended by data collectors. METHODS: We conducted a cluster randomized controlled trial in 93 health establishments in Peru. Baseline data were collected for 19 months. Districts (n=4) were then randomly assigned to intervention (PDA) or control (paper) groups, and further data were collected for 6 months. Comparisons were made between intervention and control districts and within-districts before and after the introduction of the intervention. RESULTS: The PDA-based system had a significant effect on processing times (p<0.001) and errors (p=0.005). In the between-districts comparison, the median processing time for cultures was reduced from 23 to 8 days and for smears was reduced from 25 to 12 days. In that comparison, the proportion of cultures with delays >90 days was reduced from 9.2% to 0.1% and the number of errors was decreased by 57.1%. The intervention reduced the work-hours necessary to process results by 70% and was preferred by all users. CONCLUSIONS: A well-designed PDA-based system to collect data from institutions over a large, resource-poor area can significantly reduce delays, errors, and person-hours spent processing data.
Asunto(s)
Computadoras de Mano , Aplicaciones de la Informática Médica , Sistemas de Registros Médicos Computarizados/organización & administración , Tuberculosis Resistente a Múltiples Medicamentos/diagnóstico , Centros Comunitarios de Salud , Países en Desarrollo , Humanos , Estudios de Casos Organizacionales , Perú , Vigilancia de la Población , Administración en Salud PúblicaRESUMEN
13% of all drug susceptibility tests (DSTs) performed at a public laboratory in Peru were duplicate. To determine reasons for duplicate requests an online survey was implemented in the e-Chasqui laboratory information system. Results showed that 59.6% of tests were ordered because clinical staff was unaware of ordering guidelines or of a previous result. This shows a benefit of using a web-based system and the lack of laboratory information available to clinical staff in Peru.
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Sistemas de Información en Laboratorio Clínico/normas , Laboratorios/normas , Pruebas de Sensibilidad Microbiana/normas , Guías de Práctica Clínica como Asunto , Competencia Profesional/normas , Garantía de la Calidad de Atención de Salud/normas , Perú , Control de CalidadAsunto(s)
Terapia Antirretroviral Altamente Activa , Infecciones por VIH/diagnóstico , Infecciones por VIH/epidemiología , Cooperación del Paciente/estadística & datos numéricos , Servicios de Salud Rural/organización & administración , Población Rural/estadística & datos numéricos , Haití/epidemiología , Humanos , Vigilancia de la PoblaciónRESUMEN
BACKGROUND: Extensively drug-resistant tuberculosis has been reported in 45 countries, including countries with limited resources and a high burden of tuberculosis. We describe the management of extensively drug-resistant tuberculosis and treatment outcomes among patients who were referred for individualized outpatient therapy in Peru. METHODS: A total of 810 patients were referred for free individualized therapy, including drug treatment, resective surgery, adverse-event management, and nutritional and psychosocial support. We tested isolates from 651 patients for extensively drug-resistant tuberculosis and developed regimens that included five or more drugs to which the infecting isolate was not resistant. RESULTS: Of the 651 patients tested, 48 (7.4%) had extensively drug-resistant tuberculosis; the remaining 603 patients had multidrug-resistant tuberculosis. The patients with extensively drug-resistant tuberculosis had undergone more treatment than the other patients (mean [+/-SD] number of regimens, 4.2+/-1.9 vs. 3.2+/-1.6; P<0.001) and had isolates that were resistant to more drugs (number of drugs, 8.4+/-1.1 vs. 5.3+/-1.5; P<0.001). None of the patients with extensively drug-resistant tuberculosis were coinfected with the human immunodeficiency virus (HIV). Patients with extensively drug-resistant tuberculosis received daily, supervised therapy with an average of 5.3+/-1.3 drugs, including cycloserine, an injectable drug, and a fluoroquinolone. Twenty-nine of these patients (60.4%) completed treatment or were cured, as compared with 400 patients (66.3%) with multidrug-resistant tuberculosis (P=0.36). CONCLUSIONS: Extensively drug-resistant tuberculosis can be cured in HIV-negative patients through outpatient treatment, even in those who have received multiple prior courses of therapy for tuberculosis.
Asunto(s)
Antituberculosos/uso terapéutico , Terapia por Observación Directa , Tuberculosis Extensivamente Resistente a Drogas/tratamiento farmacológico , Adulto , Atención Ambulatoria , Terapia Combinada , Quimioterapia Combinada , Tuberculosis Extensivamente Resistente a Drogas/cirugía , Tuberculosis Extensivamente Resistente a Drogas/terapia , Femenino , Seronegatividad para VIH , Humanos , Masculino , Mycobacterium tuberculosis/aislamiento & purificación , Perú , Estudios Retrospectivos , Apoyo Social , Esputo/microbiología , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológicoRESUMEN
BACKGROUND: Multi-drug resistant tuberculosis patients in resource-poor settings experience large delays in starting appropriate treatment and may not be monitored appropriately due to an overburdened laboratory system, delays in communication of results, and missing or error-prone laboratory data. The objective of this paper is to describe an electronic laboratory information system implemented to alleviate these problems and its expanding use by the Peruvian public sector, as well as examine the broader issues of implementing such systems in resource-poor settings. METHODS: A web-based laboratory information system "e-Chasqui" has been designed and implemented in Peru to improve the timeliness and quality of laboratory data. It was deployed in the national TB laboratory, two regional laboratories and twelve pilot health centres. Using needs assessment and workflow analysis tools, e-Chasqui was designed to provide for improved patient care, increased quality control, and more efficient laboratory monitoring and reporting. RESULTS: Since its full implementation in March 2006, 29,944 smear microscopy, 31,797 culture and 7,675 drug susceptibility test results have been entered. Over 99% of these results have been viewed online by the health centres. High user satisfaction and heavy use have led to the expansion of e-Chasqui to additional institutions. In total, e-Chasqui will serve a network of institutions providing medical care for over 3.1 million people. The cost to maintain this system is approximately US$0.53 per sample or 1% of the National Peruvian TB program's 2006 budget. CONCLUSION: Electronic laboratory information systems have a large potential to improve patient care and public health monitoring in resource-poor settings. Some of the challenges faced in these settings, such as lack of trained personnel, limited transportation, and large coverage areas, are obstacles that a well-designed system can overcome. e-Chasqui has the potential to provide a national TB laboratory network in Peru. Furthermore, the core functionality of e-Chasqui as been implemented in the open source medical record system OpenMRS http://www.openmrs.org for other countries to use.
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Sistemas de Información en Laboratorio Clínico/organización & administración , Laboratorios/organización & administración , Desarrollo de Programa , Administración en Salud Pública/normas , Garantía de la Calidad de Atención de Salud/métodos , Tuberculosis Resistente a Múltiples Medicamentos/diagnóstico , Sistemas de Información en Laboratorio Clínico/estadística & datos numéricos , Implementación de Plan de Salud , Humanos , Laboratorios/normas , Área sin Atención Médica , Evaluación de Necesidades , Perú , Factores de Tiempo , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológicoRESUMEN
Managing the stock and supply of medication is essential for the provision of health care, especially in resource poor areas of the world. We have developed an innovative, web-based stock management system to support nine clinics in rural Haiti. Building on our experience with a web-based EMR system for our HIV patients, we developed a comprehensive stock tracking system that is modeled on the appearance of standardized WHO stock cards. The system allows pharmacy staff at all clinics to enter stock levels and also to request drugs and track shipments. Use of the system over the last 2 years has increased rapidly and we now track 450 products supporting care for 1.78 million patient visits annually. Over the last year drug stockouts have fallen from 2.6% to 1.1% and 97% of stock requests delivered were shipped within 1 day. We are now setting up this system in our clinics in rural Rwanda.
Asunto(s)
Internet , Preparaciones Farmacéuticas/provisión & distribución , Administración Farmacéutica/métodos , Equipos y Suministros , Infecciones por VIH/tratamiento farmacológico , Haití , Humanos , Sistemas de Registros Médicos Computarizados , Farmacias/organización & administración , Servicios de Salud Rural/organización & administración , Interfaz Usuario-ComputadorRESUMEN
Partners In Health (PIH) and its sister organization in Lima, Peru, Socios En Salud (SES), treat a majority of multidrug-resistant tuberculosis (MDR-TB) patients in Peru, in conjunction with the Peruvian National TB Program (NTP). Monthly bacteriology tests, which must be collected from health establishments located across this major city, are an integral part of this treatment. Currently, a SES employee visits each health establishment to collect this information by hand, process it and type it into an electronic medical record system (PIH-EMR). In this paper, we describe the development and implementation of a personal digital assistant (PDA)-based electronic system to collect, verify and upload monthly bacteriology data into the PIH-EMR. After an initial implementation period, we performed a pilot study to test the use of this system. We completed a baseline assessment in two health districts and then implemented the electronic system in one of the districts while the control site continued to use the paper-based system during the same period. The PDA-based system had a processing time of 6.2 days, significantly lower than measurements for both the baseline [54.8] and control sites [64.4] (both p<0.0001). It was also able to reduce the frequency of discrepancy from 10.1% to 2.8% (p<0.0001) and receive positive feedback from the users. Finally, the system's cost would be recuperated in three months from time savings due to increased work efficiency. This system will be the subject of a larger study to determine its impact on delays, errors and costs.
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Computadoras de Mano , Sistemas de Registros Médicos Computarizados , Mycobacterium tuberculosis/aislamiento & purificación , Tuberculosis Resistente a Múltiples Medicamentos/microbiología , Actitud hacia los Computadores , Análisis Costo-Beneficio , Humanos , Perú , Proyectos Piloto , Programas Informáticos , Telemedicina , Factores de TiempoRESUMEN
The PIH-EMR is a Web based electronic medical record that has been in operation for over four years in Peru supporting the treatment of drug resistant TB. We describe here the types of evaluations that have been performed on the EMR to assess its impact on patient care, reporting, logistics and observational research. Formal studies have been performed on components for drug order entry, drug requirements prediction tools and the use of PDAs to collect bacteriology data. In addition less formal data on the use of the EMR for reporting and research are reviewed. Experience and insights from porting the PIH-EMR to the Philippines, and modifying it to support HIV treatment in Haiti and Rwanda are discussed. We propose that additional data of this sort is valuable in assessing medical information systems especially in resource poor areas.
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Sistemas de Registros Médicos Computarizados , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Computadoras de Mano , Atención a la Salud/economía , Atención a la Salud/métodos , Humanos , Internet , Sistemas de Registros Médicos Computarizados/economía , Atención al Paciente/economía , Perú , Transferencia de Tecnología , Tuberculosis Resistente a Múltiples Medicamentos/microbiologíaRESUMEN
Large healthcare projects in developing countries need to track data for clinical care, patient outcomes, medication supplies, and research. These heterogeneous information needs are compounded by the wide range of skills and experience of staff. We describe analysis tools designed to bridge these requirements in a tuberculosis (TB) treatment project in Peru.
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Sistemas de Apoyo a Decisiones Clínicas , Sistemas de Registros Médicos Computarizados , Tuberculosis Resistente a Múltiples Medicamentos/terapia , Personal de Salud , Humanos , Gestión de la Información , PerúAsunto(s)
Fármacos Anti-VIH/provisión & distribución , Infecciones por VIH/terapia , Informática Médica/normas , Sistemas de Registros Médicos Computarizados/normas , Recolección de Datos/normas , Infecciones por VIH/epidemiología , Haití , Humanos , Internet , Salud Rural , Servicios de Salud Rural/organización & administración , Servicios de Salud Rural/normasRESUMEN
Socios En Salud uses directly observed therapy to treat a majority of the multidrug-resistant tuberculosis in Peru. The nurses play an important role in this community-based model as the patients' primary care givers. Since nurses, rather than physicians, are involved in patients' daily care, we developed a nurse-order entry system to test whether such a system would improve the accuracy and quality of medication data. We compared regimen information from patient electronic medical records, paper charts and pharmacy records. After a two-month training period on the new system, we conducted the trial for 52 days in two of Lima's six geographic treatment areas, and re-reviewed the three sources of medication data. We measured the error rates after the trial period and found there was no significant difference in the control group's (Lima Este), error rate (8.6% vs. 6.9%, P=0.66) after the trial. The intervention group (Lima Callao), however, showed a significant drop in the error rate (17.4% vs. 3.1%, P=0.0074) after the same time interval. Additionally, the nurse expressed satisfaction with the order entry system and its ease of use. The decrease in error rates and user satisfaction regarding the system are promising measures of our order entry system's success.
Asunto(s)
Antituberculosos/uso terapéutico , Sistemas de Registros Médicos Computarizados , Errores de Medicación/prevención & control , Sistemas de Medicación en Hospital , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Interfaz Usuario-Computador , Humanos , Enfermeras y Enfermeros , PerúRESUMEN
HIV-AIDS has become the world's leading infectious cause of adult deaths. Approximately 5% of Haiti's adult population is infected with HIV, making it the most affected nation in the western hemisphere[1]. The non-governmental organization Zanmi Lasante (ZL) launched an innovative program 5 years ago to treat HIV patients in the very impoverished central plateau with highly active anti-retroviral therapy (HAART)[1]. ZL currently follows more than 4000 HIV-positive patients, over 10% of whom are already on HAART, and was recently awarded funds from the Haitian grant from the Global Fund to fight AIDS, Tuberculosis and Malaria. Expanding treatment in a region with few doctors and virtually no roads, electricity, or electronic communication is a major challenge requiring careful coordination of clinical care, investigations and drug supplies. We describe a prototype Electronic Medical Record system to support treatment of HIV and tuberculosis in remote and impoverished areas.
Asunto(s)
Infecciones por VIH/terapia , Sistemas de Registros Médicos Computarizados , Haití , Humanos , Servicios de Salud Rural , Terapia Asistida por ComputadorRESUMEN
Multi-drug resistant tuberculosis (MDR-TB) is an important and growing problem in many developing countries. New strategies have been developed to combat the disease but require complex treatment regimens and close monitoring of patients' bacteriology results. We describe a web-based medical record system deployed in Peru to support the management of MDR-TB. Web-based analyses have been developed to track drug sensitivity test results, patterns of sputum smear and culture results and time to conversion from positive to negative cultures. Individual and aggregate drug requirements can also be monitored in real time. Multiple analyses can be linked together and data can be graphed or downloaded to spreadsheets. Over 1200 patients are currently in the system. We argue that such a web-based clinical and epidemiological management system is an important component for successful implementation of complex health interventions in resource poor areas.