FamilyConnect EMTCT Web Application

The use of electronic health management information systems (eHMIS) has gained traction in Uganda with both the private and public health sectors using various versions both open source and proprietary tools. The Ministry of Health (Uganda) has rolled out OpenMRS as the eHMIS in public health facilities. OpenMRS is an open-source tool that can work both offline and online and would require less bandwidth for operation.

In Uganda, OpenMRS has been used to support a number of health areas including HIV/AIDs, maternal newborn and child health, and Nutrition among others. However, as most developmental partner funding is around HIV/AIDs cascade, the OpenMRS has substantially been expanded in HIV/AIDS care and treatment including the elimination of mother-to-child transmission of HIV. 

The OpenMRS platform houses longitudinal data as virtual cohorts tracking the number of outcome indicators including antenatal attendance, health facility deliveries, antiretroviral clinic appointment adherence, early infant diagnosis, and nevirapine syrup uptake among sero-exposed infants for the EMTCT module. With known challenges in the completion of the EMTCT cascade, a text messaging platform known as rapid-pro has been deployed to support this. 

The current deployment of the rapid-pro module requires that data clerks (health facility records officers) have editor access rights to RapidPro, Redash, and UgandaEMR (OpenMRS). These enable the data clerks to:

1. Download EMTCT target beneficiaries from OpenMRS in a specified excel/CSV format containing the beneficiaries’ details and their next appointment dates.

2. Upload the UgandaEMR excel/CSV file into RapidPro. This has to be done periodically in Rapidpro for timely scheduling and sending out appointment reminders.

3. Download the OpenMRS report from Redash that would be added to the local deployment of UgandaEMR at the health facility to update the patient follow-up register developed by the health facility or implementing partner.

This technical approach has challenges as the OpenMRS does not ‘talk’ to the Rapid-pro platform (not integrated) and also, since Rapid-pro and Redash are often institution owned, there are limited access rights offered to the health facility data clerks. This means there will be no way to execute (II) and (III) above critical to scheduling appointment reminders and updating patient records in UgandaEMR.

Our pilot FamilyConnect EMTCT Web Application is a workaround solution designed to enable data clerks to execute their roles without having login access to RapidPro and Redash. A web application developed for use by data clerks to execute their roles. This web application handles periodic data exchanges and updates with RapidPro and Redash in the backend.

Our solution, the FamilyConnect EMTCT Web Application is customized and configured for the Family Connect (FC)-EMTCT messaging component in the RapidPro system, the FC-EMTCT Analytics component in Redash, and the integration component with OpenMRS patient data import and export templates in excel/CSV. The web application successfully executes the:

1. Registration of FC-EMTCT target beneficiaries via a USSD menu.

2. Sending of SMS stage-based messages to FC-EMTCT target beneficiaries in their preferred language.

3. Uploading of patient-level data such as the next scheduled appointment date from UgandaEMR (OpenMRS) in excel/CSV into FC RapidPro.

4. Automatic scheduling and sending SMS appointment reminders to the target beneficiaries.

5. Downloading the UgandaEMR Report in excel/CSV from Redash to update the patient-level data in the UgandaEMR follow-up module.

6. Display of project-level performance indicators, results, data analytics, and visualizations.

Our solution targets different stakeholder levels including;

1. Health facility data clerks– These are responsible for uploading and updating the OpenMRS platform and making sure that reminders are sent to the EMTCT beneficiaries (mother-baby pairs and caretakers). Currently, they have limited access rights/user roles and also will need continuous downloading and uploading of contact from two separate platforms that are not talking to each other i.e. OpenMRS and Family Connect Rapid-pro. 

2. District health teams– These require up-to-date data on their monitoring dashboards on all health outcome indicators related to the EMTCT cascade at the health facility level. Often this data is not available and were available, not to date due to delays in updates.  

3. Implementing partners– Developmental agencies require accurate and real-time data for decision making and also to be able to track the performance of supported health projects. Often they lack this visibility and this affects resource allocation and utilization

Our team piloted this intervention along with the Ministry of Health and an implementing partner in the Southwestern district of Kabale in Uganda, this past performance experience with the government positions our team at a favorable spot with stakeholder engagement. In addition, our experience in designing and integrating platforms for existing and widely deployed open source eHMIS like OpenMRS and Rapidpro will ensure ease of adaptation in case of challenges during solution deployment. 

The FamilyConnect EMTCT Web Application was piloted in Southwestern Uganda, Kabale district along with the Ministry of Health and the Southwest regional implementing partner Elizabeth Glazer Pediatric AIDs Foundation (EGPAF) team with positive results and high satisfaction with end-users. 

However, financial limitations have affected the roll-out and wider integration of the FamilyConnect EMTCT Web Application across the Southwestern region of Uganda. We are applying for this challenge to access funds to support the scaling of the application across all health center IV and district hospitals. 

National Health Information management systems are siloed and do not communicate with each other. This means that governments will end up investing in a number of systems to meet different requirements. This is costly and unsustainable with additional Information technology added required costs in maintenance, and software costs among others. In addition, given the current application of eHMIS in Uganda with OpenMRS being the adopted national system, there is no cost-effective and data-secure way for information systems exchange between OpenMRS and messaging systems like FamilyConnect. These messaging platforms are used to send reminders on different health facility events for mother-baby pairs within the OpenMRS database including antenatal reminders, ARV medicine refills, and early infant diagnosis (EID) schedules among others. These reminders act as nudges to the realization of EMTCT health indicators and performance. In addition, the data input into the OpenMRS is downloadable into CSV files which can be manipulated for data visualization as required. Our solution is a web-based module built to integrate OpenMRS, FamilyConnect Rapid pro system, and redash. This allows for seeming less exchange of data between these 3 systems without any fears of a data breach as there is no downloading or uploading of files involved. In addition, the responsible persons for executing this task will have individual login credentials which further increases data security and allows for an audit trail.  

1. Scale up the FamilyConnect web-application integration across the South Western region health facility offering HIV/AIDs care and treatment by 2022. We shall achieve this through partnerships with the Ministry of Health and implementing partners supporting the region and sourcing for funding to facilitate the activity.

2. Scale up the FamilyConnect web-application integration nationwide by 2024. We shall achieve this through partnerships with the Ministry of Health and implementing partners supporting the region and sourcing for funding to facilitate the activity.

1. Number of new health facilities integrating OpenMRS with FamilyConnect tool for EMTCT program.

2. Proportion of mother-baby pairs completing the eMTCT cascade at supported health facilities.

3. Number of data clerks and healthcare professionals trained on the FamilyConnect-EMTCT web application.

Our theory of change is the diffusion of Innovation Theory where technology adoption in the healthcare system will gain momentum and diffuse/spread through the healthcare system and gets to be adopted and utilized. The key to this theory is that the target audience should perceive the solution/technology as new and innovative. In this theory of change, the end user will go through a series of stages prior to adopting the new innovation, and these include; awareness of the need for the innovation, decision to adopt (or reject) the innovation, initial use of the innovation to test it, and continued use of the innovation. 

FC-EMTCT Web Application will be built using django framework which follows the MVC architecture. Below is the architectural layout that will be used to build the application. 

The diagram below shows the decomposition of the FC-EMTCT Web Application. 

Django was the preferred framework that was selected to build the FC-EMTCT Web Application since FamilyConnect messaging application, RapidPro is built using django and provides a python client to easily use the RapidPro Rest API. Django follows the MVC pattern closely, however it does use its own logic in the implementation. Because the “C” is handled by the framework itself and most of the excitement in Django happens in models, templates, and views, Django is often referred to as an MTV framework.

Data clerks or health assistants at the health facilities. These collect data from the paper-based HMIS records and transcribe it onto the OpenMRS platform. This is often done on a schedule that could be daily or weekly depending on the clinic traffic and human resources available. These tasks are part of the data clerk and health assistant’s job description, however in some instances, implementing partners may support this data collection process through availing internet, training, and other capacity-building incentives.

Our intervention works with a simple feature phone that will not require an internet connection to access the scheduled health messages and nudges via Rapid-pro. In addition, the training and learning curve to operate the web application is short as it leverages already existing platforms like OpenMRS. Our team is young and diverse and has a 50% female composition.