DHIS2 Tracker

INTRODUCTION

Maternal and child health forms an important part of the healthcare system in Palestine. There are approximately 60,000 live births in the West Bank annually, and 99 percent are reported to be delivered in hospitals. Therefore, the public health system plays a major role in screening for pregnancy complications: gestational anemia, hypertensive disorders of pregnancy, gestational diabetes mellitus, and fetal growth restriction are identified as priority conditions for prevention. However, approximately 43 percent of pregnant women attend public antenatal care (ANC) services, and just 13 percent according to the recommended national schedule, which results in inadequate coverage of clinical interventions. 

In 2016, the Maternal and Child Health (MCH) e-Registry, a custom application built on the DHIS2 Tracker platform, was introduced to Palestine’s public ANC system to improve the delivery of quality healthcare during pregnancy. Through the e-Registry, care providers capture essential patient data at the point of care and respond to real-time clinical decision support notifications. Complimentary digital health interventions have since been layered on top of this client management system. For example, targeted client communication is sent via SMS before each scheduled ANC visit, and critical quality improvement indicators are monitored by clinician-facing dashboards. In addition to this specific project, DHIS2 Tracker is used in RMNCAH and related programs (such as HIV prevention) in many countries. However, this case study provides detail on only one implementation country. More information on other DHIS2 projects and use cases can be found at dhis2.org.

ABOUT DHIS2 TRACKER

In 2014, the Palestinian National Institute of Public Health (PNIPH) assessed the MCH register in Palestine. As a result of this assessment, and based on an agreement with the Ministry of Health (MoH), PNIPH partnered with the Norwegian Institute of Public Health (NIPH) and University of Oslo (UiO) to introduce the MCH e-Registry in Palestine. The main goal of the e-Registry is to automate client-level data collection, relieving care providers of reporting burden while transferring data to the national level to support evidence-based decision-making.

The e-Registry is an electronic health record for ANC built on the DHIS2 Tracker data model and localized with Palestine’s reproductive health facilities, services, and care guidelines. Algorithms for screening and treatment based on gestational age were embedded within the client record through pop-up alerts, skip logics, and suggested referrals to lab tests or high-risk clinics. Before each appointment is scheduled through the e-Registry, a client receives automated SMS to nudge healthy behaviors based on her record (for example, improving diet if hypertensive). Clinicians review their adherence to guidelines for screening and treatment of hypertension, anemia, and diabetes through a custom quality improvement dashboard.

The MCH e-Registry was planned and implemented through a consensus-driven process with MCH stakeholders across Palestine. As part of the e-Registry design process, national antenatal and postnatal care guidelines were updated. Additionally, a governance structure was developed to provide privacy and confidentiality, alongside an appropriate message library for SMS to clients.

During a phased roll-out, 1,500 health care providers were trained on using the e-Registry in the West Bank and Gaza Strip. As of the end of 2020, 360 of 427 governmental clinics are using the system.

EVALUATION AND RESULTS

The first of two cluster-randomized controlled trials of the e-Registry, the eRegQual study (2018), assessed the comparative effectiveness of e-Registry’s interactive checklists with clinical decision support and the existing paper-based recording routines. The trial evaluated 60 facility clusters using e-Registry and 60 clusters using paper records, enrolling 6,367 pregnancies in total. Results showed that screening dramatically improved for diabetes and anemia. Proper management of hypertensive disorders also improved (49 percent vs 19 percent).

The trial included a sub-study called “eRegTime”, observing the effect of the e-Registry on time spent by the care providers on client care, documentation, and reporting at 24 clinics. Compared to paper records, care providers using the e-Registry took 33 percent less time on health information management (9.9 minutes per client with paper compared to 6.6), and marginally more time spent on client care (4.9 minutes vs. 5 minutes). The second trial,eRegCom, began in autumn 2019.

The eRegCom study is a 2×2 RCT design with arms comparing layers of two e-Registry interventions during the phased introduction, including targeted client communication via SMS, quality improvement dashboard, both interventions, or decision support only. Preliminary results show that clients in the arm with both SMS and dashboards were more likely to attend four timely ANC visits than women in clinics with just one. Another sub-study, a survey of SMS recipients, showed that the targeted SMS did not increase pregnancy-related worries among recipients and there was no difference in women’s satisfaction with the ANC services between intervention and control arms.

LESSONS LEARNED

• A rule-based workflow that was modifiable to match national treatment guidelines helped immensely to streamline MCH data collection and improve the quality of care.
• Implementing the system required achieving consensus on national standard treatment guidelines and developing proper governance.
• As a point-of-care electronic health record with complex decision support algorithms, the e-Registry demanded frequent monitoring, minimal downtime, and rigorous testing before updates were pushed to the production system. The lack of realistic testing environments or automated metadata synchronization across separate DHIS2 instances was a critical technical limitation for responsive troubleshooting.
• PNIPH has invested heavily in establishing a Palestinian Country Team, which includes PNIPH and the MoH members, and has built local capacity in DHIS2 configuration to sustain implementations without external support. These skills proved essential after the outbreak of COVID-19 in Palestine when MCH system adaptations and a new COVID-19 surveillance tracker were implemented within weeks.

CONCLUSION

The success of this e-Registry has led the Ministry of Health to adopt DHIS2 for routine reporting and disease surveillance in other areas, including COVID-19 surveillance in 2020. After the trials, PNIPH and Palestine’s MOH have built on and maintained the MCH e-Registry across public ANC clinics. Plans include linking a number of other DHIS2 Tracker programs across primary care with the MCH e-Registry, which would support better monitoring and continuity of care. Meanwhile, results from the trials, as well as experiences with the point-of-care use case in Palestine, have informed the development of the next generation of DHIS2 Tracker features, including referral management, analytics, and clinical decision support thereby enabling similar use cases in other contexts.

REFERENCES

• Awwad, T., Venkateswaran, M., Lindberg, M., Abu Khader, K., Hijaz, T., Ghanem, B., Mørkrid, K., Ramlawi, A., Salman, R. and Frøen, J, (2021). Use of the national electronic maternal and child health registry (MCH eRegistry) in primary care clinics in occupied Palestinian territory: a pilot time-motion study. [online] Available at: <https://www.sciencedirect.com/science/article/abs/pii/S014067361930604X> [Last accessed September 15th, 2021].
• Bogale, B., Mørkrid, K., Abbas, E., Abu Ward, I., Anaya, F., Ghanem, B., Hijaz, T., Isbeih, M., Issawi, S., A. S. Nazzal, Z., E. Qaddomi, S. and Frøen, J. (2021). The effect of a digital targeted client communication intervention on pregnant women’s worries and satisfaction with antenatal care in Palestine–A cluster randomized controlled trial.
• Mørkrid, K., Bogale, B., Abbas, E., Abu Khader, K., Abu Ward, I., Attalh, A., Awwad, T., Baniode, M., Frost, K., Frost, M., Ghanem, B., Hijaz, T., Isbeih, M., Issawi, S., Nazzal, Z., O’Donnell, B., Qaddomi, S., Rabah, Y., 4. Venkateswaran, M. and Frøen, J. (2021) eRegCom—Quality Improvement Dashboard for healthcare providers and Targeted Client Communication to pregnant women using data from an electronic health registry to improve attendance and quality of antenatal care: study protocol for a multi-arm cluster randomized trial. [online] Available at: <https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-020-04980-1#citeas> [Last accessed September 15th, 2021].
• Venkateswaran, M., Mørkrid, K., Ghanem, B., Abbas, E., Abuward, I., Baniode, M., Norheim, O. and Frøen, J., (2021). eRegQual—an electronic health registry with interactive checklists and clinical decision support for improving quality of antenatal care: study protocol for a cluster-randomized trial. [online] Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778657/> [Last accessed September 15th, 2021].