Nancy Puttkammer is an Acting Assistant Professor within the Department of Global Health at University of Washington and is the faculty co-lead of the Digital Initiatives Group at I-TECH (DIGI). Her interests are in strengthening health information systems and promoting data use and for quality improvement of health programs in resource-limited settings. She is trained as a health services researcher, specializing in using observational, routinely-collected data from electronic medical records (EMRs) to strengthen HIV care and treatment programs.
In her capacity as a Research and Evaluation Advisor at the International Training and Education Center for Health, Dr. Puttkammer works with informatics and training projects in Haiti, Kenya, and South Africa to improve large-scale implementation of EMRs, evaluate data quality and data use, support data analyses, and develop capacity for data use and implementation science research among colleagues and counterparts. Dr. Puttkammer has a PhD in Health Services from the University of Washington and an MPH in Community Health Education from the University of California, Berkeley.
It is critical that health care providers receive the necessary training to empower them to improve patient outcomes CHARESS supports both pre-service and in-service training efforts in Haiti. In particular, CHARESS is a key partner of MSPP in maintaining its national clinical guidelines. ... Read More
Scott Barnhart
Scott Barnhart, MD, MPH, has an extensivebackground as Professor of Global Health and former Director of Global Health Programs for I-TECH at the University of Washington. He has had responsibility for leading nine country offices, projects in 14 countries, and more than 500 staff. This experience and training has included extensive clinical work, research and program management in pulmonary and environmental and occupational medicine, and more than eight years as Medical Director of a safety net/Level 1 Trauma Center hospital.
Ensuring health systems can quickly detect and respond to emerging health threats is a critical challenge in both domestic and global health. Dr. Barnhart’s major implementation projects include scale-up of voluntary medical male circumcision (VMMC) in Zimbabwe and Malawi, OpenMRS, and laboratory information systems. Dr. Barnhart deploys his expertise in multiple African countries and Haiti to strengthen health systems and health care.
A goal of Dr. Barnhart’s work is to promote country-led, country owned sustainable development. Consistent with the principles of the Paris Declaration, the goal is to transition the bulk of development work and the associated leadership, ownership, technical direction and control of funding into the countries where development occurs. This approach ensures that the entire continuum of skills necessary for development (technical expertise, administration (human resources, operations, and management and accountability for funds) is transitioned to local partners. A key indicator is to have 75% or more of a grant’s funding expended in-country on local programs and local citizens and to support the local economies in these highly resourced constrained countries. Dr. Barnhart has worked closely to advance this model through projects in Haiti with a goal to shift the majority of a project to a local organization and in Zimbabwe where the VMMC program is largely run through local partners.
Electronic medical record (EMR) systems have the capacity to improve clinical decision making and quality of care at site level but can also be leveraged to make data-driven, population-level public health decisions. At the request of the MSPP Continue reading “Health Information Systems in Haiti”
In partnership with CDC, CHARESS helps the Haitian MSPP to implement the national care improvement program, HealthQual, by training providers on quality improvement concepts and using data from the EMR, iSanté, for clinical decision making and improved care. Continue reading “Continuous Quality Improvement in Haiti”
Guyana Ministry of Public Health’s Deputy Chief Medical Officer, Dr. Karen Boyle. Photo courtesy of Kaieteur News.
The International Training and Education Center for Health (I-TECH) recently partnered with the Ministry of Public Health in Guyana and the U.S. Centers for Disease Control and Prevention (CDC) to launch a new health information system (HIS) that will protect patients’ privacy, maintain confidentiality, and provide security for sensitive data.
In an article in Guyana’s Kaieteur News, Deputy Chief Medical Officer, Dr. Karen Boyle, described how health officials hope to reduce health service quality inequities between coastal regions and other parts of the country as part of the national 2020 plan, in part by reducing waiting time for medical services and improving patient health literacy. Dr. Boyle stated they expect to “improve access to health information” and allow for “shared responsibility” for health care decision-making by providers and patients.
The health information upgrade is also being supported by PAHO (the Pan-American Health Organization), UNAIDS, and local collaborating partners such as the University of Guyana, e-Government, the National Insurance Scheme, and the Government Technical Institute (GTI).
The International Training and Education Center for Health (I-TECH) is presenting three posters at the 7th Annual Consortium of Universities for Global Health (CUGH) conference in San Francisco on April 9-11. The theme of this year’s conference is “Bridging to a Sustainable Future in Global Health.”
A critical component in sustainability is the ability to collect accurate and meaningful data through electronic medical records (EMRs) – the subject of two abstracts from the I-TECH Kenya team.
In addition, online learning and electronic learning (e-learning) provides opportunities for health care workers in resource-limited settings to gain critical knowledge and skills while minimizing their need to leave the workplace.
In close partnership with the University of Washington Department of Global Health’s eLearning Initiative (eDGH), I-TECH piloted e-learning modules for KenyaEMR and transitioned the HIV management diploma program at the University of the West Indies into a blended learning program that incorporates online courses.
The transcript tab allows learners to read along with the narration.
Since 2012, the Kenyan Ministry of Health, PEPFAR, and partners have supported implementation of electronic medical record systems (EMRs) at more than 600 public-sector health facilities. The International Training and Education Center for Health (I-TECH) has supported scale-up at more than 300 of these sites.
However, implementation is just part of the story. Successful, sustained use of EMR data depends upon the knowledge and skills of front-line health care workers. To address this need, I-TECH and eDGH developed and piloted two interactive e-learning modules on EMR data quality and EMR data for decision-making.
I-TECH and eDGH found that facility staff were motivated to use EMR e-learning modules and apply what they had learned. Participants found the content relevant to their jobs and cited an interest in additional scenarios and modules. Self-paced e-learning modules were determined to be a viable solution for standardizing sustainable training on EMR systems.
To support progressive EMR data quality improvement, I-TECH developed a Routine Data Quality Assessment (RDQA) standard operating procedure and analysis tool. The RDQA procedure was defined in collaboration with the Kenyan Ministry of Health and integrated within existing policies and procedures.
From 2014 to 2015, 180 baseline and repeat assessments were conducted. I-TECH supported facility personnel to share results during county-level EMR review meetings; these presentations motivated other sites to plan for RDQAs and fostered a culture of ongoing data quality improvement. The RDQA procedure for EMR data has now been institutionalized as a method for progressively improving EMR data quality in Kenya.
In partnership with the University of the West Indies (UWI), eDGH and I-TECH transitioned a one-year diploma program in the Management of HIV Infection to a blended learning platform that combines online courses with either a clinical practicum or a research project.
The shift in pedagogy, methodologies, and technologies was achieved through a three-phased approach designed to not only train UWI faculty and staff, but also transfer online facilitation skills to them and sustain those skills.
In its second year as a blended learning online program, the diploma program has scaled up to include health care workers from Cayman Islands, Jamaica, and Suriname.
These projects are supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under U91HA0680, International AIDS Education and Training Center. The content and conclusions of this post are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the U.S. government.
Dr. Regine Juste (left) works on iSanté with Dr. Marinho Elisma, I-TECH Haiti’s Lead Clinical Mentor.
For a decade, the iSanté electronic medical record system and OpenELIS lab software, developed by the International Training and Education Center for Health (I-TECH), have allowed health care providers to document HIV patient care and patient care histories.
The evaluation also identifies strengths and challenges in POC use of the iSanté and OpenELIS systems in clinics and hospitals in Haiti, in order to guide improvements in the quality of I-TECH’s technical assistance.
The move to point of care
Until 2012, most sites used iSanté primarily to capture data that providers had recorded on paper forms. In 2012-13, with impetus from the Haitian Ministry of Health and funders, I-TECH supported some iSanté sites to move toward POC implementation.
This involves providers using iSanté during patient visits to enroll patients, review health history, capture clinical assessments and treatment plans, and record drug and laboratory orders.
Evaluation shows positive impact
Through in-depth interviews and focus group discussions with hospital personnel, I-TECH was able to grasp the positive impact of iSanté POC system use has on care and treatment.
Facility personnel at all levels were satisfied with the transition to POC system use. All five sites evaluated reported increases in provider confidence and improved human resource management, citing reduced provider workload and more effective use of provider time.
Personnel also perceived a number of positive effects of system use on productivity and quality of care including benefits to patient experience (reduced wait times) and service quality.
The theme of this year’s conference is “Mobilizing Research for Global Health,” and featured speakers include Olusoji Adeyi, Director, Health, Nutrition and Population, World Bank; Paul Farmer, Co-Founder, Partners in Health; and Stephen Morrison, Vice President, Center for Strategic and International Studies.
Staff members from the International Training and Education Center for Health (I-TECH) will attend to present research on several topics:
Malawi
Quality improvement practices decrease adverse event rates in a surgical male circumcision program in Malawi Kohler PK, Chilongozi DA, Namate D, Barr BA, Msungama W, Phiri O, Tenthani L, Chalulu K, Perdue T, Barnhart S, Krieger JN
Improving nursing and midwifery clinical education by developing local faculty mentoring capacity in Malawi Holman J, Muyaso M, Msiska G, Namate D, Wasili R
Haiti
An assessment of data quality in Haiti’s multi-site electronic medical record system Puttkammer N, Baseman JG, Devine EB, Hyppolite N, France G, Honoré JG, Matheson AI, Zeliadt S, Yuhas K, Sherr K, Cadet JR, G. Zamor, Barnhart S
Kenya
Evolution of the KenyaEMR training program: Towards efficiency and quality in scale-up Atelu C, Antilla J, Muthee V, Puttkammer N
About CUGH
Founded by leading North American university global health programs, CUGH aims to:
Define the field and discipline of global health;
Standardize required curricula and competencies for global health;
Define criteria and conditions for student and faculty field placements in host institutions;
Provide coordination of projects and initiatives among and between resource-rich universities and less-developed nations and their institutions.
CUGH is dedicated to creating balance in resources and in the exchange of students and faculty between institutions in rich and poor countries, recognizing the importance of equal partnership between the academic institutions in developing nations and their resource-rich counterparts in the planning, implementation, management and impact evaluation of joint projects.
From L to R: Igor Kuzin, Head of the National M&E Center at UCDC; Dr. Natalia Nizova, Director of UCDC; Matt Heffron, I-TECH Informatics Implementation Specialist; Anna Shapoval, I-TECH Ukraine Country Director; and Mykhailo Rabinchuk, PR and Event Manager at UCDC.
This landmark event consolidated cooperation between the International Education and Training Center for Health (I-TECH) — a DGH center — and UCDC. This partnership started in 2013 with the launch of the I-TECH-developed Clinical Assessment for Systems Strengthening (ClASS) tool within a project to build clinical and managerial capacity of HIV/AIDS services in Ukraine.
All parties expressed confidence that this MOU would help foster relationships and the development of possible collaborative projects in capacity building, monitoring and evaluation, and research aimed at quality improvement of health care services in Ukraine.
“I-TECH is very excited about this new development in our collaboration with UCDC,” said Anna Shapoval, Country Director of I-TECH Ukraine. “The MOU will help to formalize, fortify, and, hopefully, expand our partnership with the UCDC in the coming year and beyond — in particular in the area of health systems strengthening through development of human resources for health and supporting strategic information systems.”
For nearly a decade, iSanté has allowed providers to share information among care team members and health professionals.
Over the past several years, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has invested heavily in health systems and clinical data analyses in low-income countries around the world, in its efforts to support the care and treatment of those affected by HIV and AIDS.
With the support of PEPFAR, through the Health Resources and Services Administration (HRSA), in 2005, the International Training and Education Center for Health (I-TECH), together with Haiti’s Ministère de la Santé Publique et de la Population (MSPP) and the U.S. Centers for Disease Control and Prevention (CDC), developed and implemented iSanté — an electronic medical record system to capture and report information on patients living with HIV and AIDS.
For nearly a decade, this system has allowed providers to document HIV patient care, look up patient care histories, and share information between care team members and health professionals.
The MSPP has been particularly concerned with patient adherence to antiretroviral therapy (ART) and treatment failure due to a number of factors, including the 2010 Haiti earthquake. While iSanté has gotten kudos in Haiti for storing and linking patient data, three recent papers, lead-authored by I-TECH Research and Evaluation Advisor Nancy Puttkammer, have illustrated the potential of using this data source to identify and help solve the challenges of adherence and patient attrition.
“Before and After the Earthquake: A Case Study of Attrition from the HIV Antiretroviral Therapy Program in Haiti,” published in Global Health Action in August 2014, compared attrition from the national HIV ART program at two large public-sector hospitals where I-TECH works. One site was less than 30 km from the epicenter of the devastating earthquake of January 2010, while the other site was outside of the area strongly affected by the earthquake. Surprisingly, the paper showed that attrition improved after the earthquake in the site closest to the epicenter. This finding underscores the resilience of patients and providers, and contributes evidence that it is possible to maintain continuity of HIV services even in the context of a complex humanitarian emergency.
“Development of an Electronic Medical Record Based Alert for Risk of HIV Treatment Failure in a Low-Resource Setting,” published in PLOSOne in November 2014, shows that ART-dispensing data and other data contained in iSanté can be used to estimate patients’ adherence to their medications and predict the patients most likely to experience ART treatment failure in the future. Having an alert to signal patients with high risk of future treatment failure could help providers better target counseling and other adherence support.
“Patient Attrition from the HIV Antiretroviral Therapy Program at Two Hospitals in Haiti,” currently in press at the Pan American Journal of Public Health, examines ART attrition at the same two hospitals, during the period 2005-2011. The study found higher risk of attrition among patients who lived farther away from the hospital, who started on non-standard ART regimens, who did not receive ART adherence counseling before initiating ART, and who rapidly started ART following their enrollment in HIV care and treatment. The findings suggest opportunities for several quality improvement interventions at the two hospitals.
“This research has provided a valuable contribution in documenting health outcomes and encouraging improvement in the ART program in Haiti,” says Dr. Scott Barnhart, Professor of General Internal Medicine and Global Health at the University of Washington. “We are at the dawn of translating large investments in EMRs into useful data for improving the care of patients, as well as supporting important pub
