RESUMO
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.
Assuntos
Sistemas de Informação em Laboratório Clínico/organização & administração , Comunicação , Erros Médicos/prevenção & controle , Qualidade da Assistência à Saúde , Tuberculose/diagnóstico , Tuberculose/terapia , Adolescente , Adulto , Antituberculosos/uso terapêutico , Bases de Dados Factuais , Países em Desenvolvimento , Feminino , Humanos , Laboratórios/organização & administração , Masculino , Testes de Sensibilidade Microbiana/normas , Pessoa de Meia-Idade , Peru , Pobreza , Modelos de Riscos Proporcionais , Estudos Prospectivos , Melhoria de Qualidade , Projetos de Pesquisa , Resultado do Tratamento , Tuberculose/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Adulto JovemRESUMO
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.
Assuntos
Países em Desenvolvimento , Registros Eletrônicos de Saúde/organização & administração , Tuberculose Extensivamente Resistente a Medicamentos/diagnóstico , Tuberculose Extensivamente Resistente a Medicamentos/terapia , Gestão da Informação em Saúde/organização & administração , Sistemas de Medicação no Hospital/organização & administração , Consulta Remota/organização & administração , Prescrição Eletrônica , Haiti , Humanos , PaquistãoRESUMO
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.
Assuntos
Sistemas de Informação em Laboratório Clínico/organização & administração , Eficiência Organizacional , Disseminação de Informação , Sistemas Multi-Institucionais/organização & administração , Sistemas Automatizados de Assistência Junto ao Leito/organização & administração , Humanos , Análise de Intenção de Tratamento , Internet , Programas Nacionais de Saúde/organização & administração , Peru , Fatores de Tempo , Tuberculose/diagnósticoRESUMO
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.
Assuntos
Computadores de Mão , Aplicações da Informática Médica , Sistemas Computadorizados de Registros Médicos/organização & administração , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Centros Comunitários de Saúde , Países em Desenvolvimento , Humanos , Estudos de Casos Organizacionais , Peru , Vigilância da População , Administração em Saúde PúblicaRESUMO
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.
Assuntos
Sistemas de Informação em Laboratório Clínico/normas , Laboratórios/normas , Testes de Sensibilidade Microbiana/normas , Guias de Prática Clínica como Assunto , Competência Profissional/normas , Garantia da Qualidade dos Cuidados de Saúde/normas , Peru , Controle de QualidadeRESUMO
Over the past 10 years, the Peruvian National Tuberculosis (TB) Program, the National Reference Laboratory (NRL), Socios en Salud, and US partners have worked to strengthen the national TB laboratory network to support treatment of multidrug-resistant TB. We review key lessons of this experience. The preparation phase involved establishing criteria for drug susceptibility testing (DST), selecting appropriate DST methods, projecting the quantity of DST and culture to ensure adequate supplies, creating biosafe laboratory facilities for DST, training laboratory personnel on methods, and validating DST methods at the NRL. Implementation involved training providers on DST indications, validating conventional and rapid first-line DST methods at district laboratories, and eliminating additional delays in specimen transport and result reporting. Monitoring included ongoing quality control and quality assurance procedures. Hurdles included logistics, coordinating with policy, competing interests, changing personnel, communications, and evaluation. Operational research guided laboratory scale-up and identified barriers to effective capacity building.
Assuntos
Laboratórios , Avaliação de Programas e Projetos de Saúde , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Antituberculosos/farmacologia , Antituberculosos/uso terapêutico , Meios de Cultura , Humanos , Laboratórios/organização & administração , Laboratórios/normas , Laboratórios/provisão & distribuição , Testes de Sensibilidade Microbiana/métodos , Testes de Sensibilidade Microbiana/estatística & dados numéricos , Técnicas Microbiológicas/métodos , Mycobacterium tuberculosis/efeitos dos fármacos , Mycobacterium tuberculosis/isolamento & purificação , Peru , Desenvolvimento de Programas , Garantia da Qualidade dos Cuidados de Saúde , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/microbiologiaRESUMO
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.
Assuntos
Sistemas de Informação em Laboratório Clínico/organização & administração , Laboratórios/organização & administração , Desenvolvimento de Programas , Administração em Saúde Pública/normas , Garantia da Qualidade dos Cuidados de Saúde/métodos , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Sistemas de Informação em Laboratório Clínico/estatística & dados numéricos , Implementação de Plano de Saúde , Humanos , Laboratórios/normas , Área Carente de Assistência Médica , Avaliação das Necessidades , Peru , Fatores de Tempo , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológicoRESUMO
We created a web-based laboratory information system, e-Chasqui to connect public laboratories to health centers to improve communication and analysis. After one year, we performed a pre and post assessment of communication delays and found that e-Chasqui maintained the average delay but eliminated delays of over 60 days. Adding digital verification maintained the average delay, but should increase accuracy. We are currently performing a randomized evaluation of the impacts of e-Chasqui.
Assuntos
Sistemas de Informação em Laboratório Clínico , Tuberculose Resistente a Múltiplos Medicamentos , Instituições de Assistência Ambulatorial/organização & administração , Bacteriologia , Humanos , Internet , Laboratórios/organização & administração , Peru , Controle de QualidadeRESUMO
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.
Assuntos
Computadores de Mão , Sistemas Computadorizados de Registros Médicos , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Resistente a Múltiplos Medicamentos/microbiologia , Atitude Frente aos Computadores , Análise Custo-Benefício , Humanos , Peru , Projetos Piloto , Software , Telemedicina , Fatores de TempoRESUMO
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.