1.             to determine whether the quality and availability of information in the District Health Information System (DHIS) is improved through the use of an interactive and integrated electronic primary care information system;

2.             to evaluate the use of fingerprints as a unique individual identifier for use in primary care information systems;

3.             to use these unique individual identifiers to develop electronic registers to record service utilisation and track continuity of patient care in selected primary health care programs with a view to improving compliance and outcome;

4.             to use this primary care information system to link the records of individuals under demographic surveillance, with their utilisation of health services in the demographic surveillance area; and

5.             to identify the feasibility of implementing an electronic medical record into primary health care clinics.

Fit with Africa Centre research strategy

This project forms part of the implementation and evaluation of HIV treatment and prevention programmes, contributing by assessing the suitability of routine health service information systems such as the DHIS to serve as data sources for the evaluation of local health systems; evaluating patient identification technologies to enable more effective patient identification for follow-up in clinical studies; evaluating the performance and acceptability of biometric identification techniques, such as finger-printing, to link health service data on patients to the individual population base of the demographic surveillance, supporting the use of the population base as denominators for health system investigations; and exploring and evaluating information system technologies, such as electronic medical records, cellular phone communication, and pen-based data input, for their suitability in health and research information systems.

Data Sources

The PCIS collected primary data of DHIS use in 10 rural clinics in the Hlabisa sub-district; qualitative data collected through structured interviews with PCIS users in four pilot clinics; electronic medical records for approximately 25 000 patients and 85 000 encounters in 6 pilot clinics; electronic fingerprint templates for approximately 22 000 individuals; electronic fingerprint templates for a sample of approximately 1 000 individuals under demographic surveillance; a database of hospital admissions and discharges at the Hlabisa hospital from March 2008 and still ongoing.

Methodology

We evaluated the implementation of the DHIS in 10 primary health care clinics in rural northern KwaZulu-Natal within a health sub-district which had 15 fixed clinics and several mobile service points. The clinics included were convenience sampled and included 6 that were intended intervention clinics for the larger study, and 4 chosen randomly. The evaluation was designed around the information cycle framework and was structured to assess how well each step within this cycle was working. Interviews were conducted with key informants in each clinic, clinic supervisors, district information officers and other primary health care and district management staff. Interviewees were also shown graphs of data collected by their facilities and asked to explain and interpret them to assess understanding of the data collected and indicators calculated from them. Additional information and feedback based on their own indicators were provided to the interviewees as a training exercise. Raw data extracted from the DHIS software for each clinic for a 12-month period were analysed, looking at data correctness, completeness, and consistency to assess the quality of the data collected. This was done separately from the interview to provide a more objective measure of data quality.

An electronic medical record system (PCIS) based on the OpenMRS standard medical record database was developed and implemented in the six clinics within the Africa Centre demographic surveillance area. The system used pen-based input on tablet computers to allow nurse clinicians and other clinic staff to enter and retrieve patient information interactively. The system covered all primary health services and mimicked the current paper-based data collection forms as closely as possible. Fingerprint recognition was used as a means for patient identification and to limit the creation of duplicate records for the same patient. Clinical data entry was done by clinic staff themselves, but patient registration was done by a clinic administrative assistant employed by the project at each clinic. Each clinic had a small database server linked to the system laptops (4 to 8 per clinic) via a wireless network system. No electronic linkage existed between the clinics or with a central server, a project to evaluate the use cellular radio communication to do this is ongoing.

Data is collected from a sample of household members within the catchment areas of two of the pilot clinics (Gunjaneni and Mpukunyoni) recording consent for fingerprint data collection and consent to use this information to link participant’s demographic surveillance information with the data collected about them in the primary care information system (PCIS) in the clinic. Participants are revisited in six months time and a second fingerprint template is collected.

A modified version of the PCIS system has been implemented in the Halbisa hospital and a data collection clerk makes daily rounds at each ward to record all patient admissions and discharges. Admission and discharge diagnoses are recorded and will be used in the assessment of hospital utilization and mortality. Information of patients who resides within the demographic surveillance area will be used in support of the verbal autopsy system.

Findings

In the DHIS evaluation a high perceived work burden associated with data collection and collation was found. Some data collation tools were not used as intended. There was good understanding of the data collection and collation process but little analysis, interpretation or utilisation of data. Feedback to clinics occurred rarely. In the 10 clinics, 2.5% of data values were missing, and 25% of data were outside expected ranges without an explanation provided. These results have been published in the South African Medical Journal.

Preliminary investigation of the electronic medical record system shows acceptable use of the system to identify and record service utilization in the participating clinics, but poor acceptability of the system for electronic clinical record keeping with only about half of patient encounters with electronic notes. The qualitative research indicated that the need to for a duplicate system of paper record keeping in addition to the electronic system and the associated increase in workload as a possible reason for the lack of electronic data entry. The system essentially functions as an island of computerization within a sea of paper. The electronic medical record evaluation phase of the system was concluded in December 2009 and the data will be further anlaysed and published.

Current analysis of the data is focusing on the experience of using fingerprint biometrics to identify individuals. Following a workshop at the Africa Centre organised in early 2009 and attended by 12 INDEPTH sites a publication has been submitted to the Global Health Action journal outlining a framework for the use of fingerprint biometrics to link demographic surveillance data to health records. The publication highlighted the experience of three sites (Africa Centre, Agincourt and Kisumu) with fingerprint collection. Adult (18--65 years old) fingerprint enrolment rates varied between 94.1% (95% CI  93.6--94.5) for facility-based fingerprint data collection at the Africa Centre site to 96.7% (95% CI 95.9--97.6) for population-based fingerprint data collection at the Agincourt site. Fingerprint enrolment rates in young children were much lower, reaching 55.1% (95% CI 52.7--57.4) in children less than one year old. By age 5 years child fingerprint enrolment rates were comparable to those of adults.

Further Work

Remaining work will focus on the development and evaluation of an inter-clinic communication system to exchange patient information between clinics and with referral institutions and the conclusion of the evaluation of the population to health service linkage of individual records.

Implications