 Okay, I think we'll go ahead and get started and people can trickle in while I'm doing a bit of an intro just to say welcome and thanks for joining the session. I'm Mike Frost. I'm the product manager for DHS to tracker. Just a bit of a misnomer because actually we do all of the individual level data so we also have the capture app, which is where events are being collected at this point as well as all of the longitudinal data from tracker capture, which now is being put into the capture app and there's there's a lot going on there but essentially that's kind of what we want to talk about today which is individual data and why are we collecting it and why are we trying to get down to the point of service. A little bit about the challenges and the impact, mostly I won't be the one doing the talking we have some great country experiences to share, but I wanted to give just a very brief introduction here if my slide advances. Let's see it advanced on my side, there it is. Okay. I think if you're here it's because you have some interest in this and maybe could already make these points yourself, but there is a kind of global push for data health for getting the data from the health care center from the lowest levels, from having the kind of longitudinal data that you can use to do many different things then we're able to achieve from the aggregate reporting and monthly style of reporting. Some of the things people talk about are that we could reduce the data burden, which the first point public health is a data monster it wants all of the data doesn't care about any other part of health except for its particular part of health and it thinks everybody should be the reporter for that. So what we've done is turn of course the entire world of clinical people into reporters for public health. And it's become quite a monstrosity actually at the point of service any of you that work at or have worked out or know the care providers, they're spending way too much time just filling out these reports for us. There's a million pictures like this just yet another one this was from two months ago in and allows essentially all of the data is there at that site. That's where all of the health interactions are happening either there or from a community health worker whoever's actually seeing the client is the one that has all of the information that the national program wants that the WHO wants that the global donor agencies want. There's a million different ways they've devised to make these poor people report. Supposedly we can reduce that if we're able to actually just capture the clinical interactions if you're able to collect some of the minimal data points that are needed to calculate all of your indicators. Hopefully that also gives us better data quality. When you're not having the human entry process of going from the register and then tallying them up into your weekly summary and tallying those up to put in a monthly report, which you're then sending to another person who's going to enter into the computer and maybe there's doing some additions. So so many possibilities for human error in that process that we have an assumption that we can get better quality if we capture it one time when the interaction happens and would be able to reuse it and we're talking of course we're talking a lot about health here but this is true across every industry. We've all heard about big data and all of the interest and Facebook selling your life to advertisers is the same movement actually you need the individual discreet information in order to do better analysis and be able to do their predictions and be able to understand complex behaviors so you want that granular data. So yes supposedly giving us better data quality supposedly giving us better data analysis. So why wouldn't you do point of service. Well, probably the exact same reasons. Does it actually reduce data burden. Not usually not the way that it gets designed everybody wants or we're going to be down there in the clinic we can get every piece of information that they possibly have and you go through the design process and you end up with some monstrosity of a data collection form. So it doesn't reduce the burden, you didn't even take the paper away. Now they do extra data entry because they enter it all into their individual point of care. The data quality. Probably not very good if they don't have the time to actually do all of the things that they're being asked to do we have seen many countries over and over we have health care workers that are now taking weekends and extra time to try to digitize all of this data on paper in the week, and that they used to just be able to send as a paper report but now they're being asked to also enter it into another system data quality, probably going down, not as much reporting, probably causing problems. The data analysis all the sophisticated analytics that we're doing with tracker data, hardly existent there's not a lot of new sophisticated ways to actually triangulate the data and have better answers to public health problems. Obviously are generating the same global indicators that we've always had. We're just doing it from the individual data now, and when we query the individual data directly it actually slows down all of the analytics and so maybe now you're having a harder time getting your reports. So again, many different reasons why maybe not to do it. I, as the tracker manager believe of course it can be done and it can be done well and it can have the impact that we think it should. This is an area that's in its infancy across sectors as well about how to get at this data if you try looking at the best research about what the impact is of collecting in this way. We're shifting a lot all the time. There's also of course, undecided norms around data privacy. There's questions about at what level to save and store data for how long so there's a lot going on in this field so my, my hope is that all of us that are here are here because we're interested in the potential of it. We're all learning together we think that there are ways to do it correctly. And we have a couple of experts here to share with us today, a couple of my colleagues that didn't know we were going to organize this session and went ahead and submitted something relevant for it anyway so Shristi Rijal is going to speak to us first monitoring and evaluation specialist from hang on I'm going to skip a couple of these from FHI 360 will be reporting to us a bit about the experience in Nepal. I had a second presenter from FHI 360 who I don't think has been able to make it. So we will probably miss that which maybe gives us a bit more time to discuss. And then we will have Mohammed Bonilla from the Palestinian National Institute of Public Health that will present with us. So I will stop talking and I'll turn it over to Shristi if you want to share your screen. Yeah, thank you so much Mike. Let me share my screen. Are you able to see my screen. Yes, we do. Okay, a very warm good morning, good afternoon and good evening to everyone present physically and virtually in the DHS to annual conference 2023. My colleague vendor stressor are going to present on strengthening community action to achieve ending HIV 2030 in Nepal. This is our experience of using DHS to in HIV prevention testing treatment here and support program in Nepal. Nepal has concentrated epidemic of HIV monkey population, such as female sex workers, people who injects drugs, men having sex with men and transgender people. In 1993, FHI 360 and currently pick Nepal project with the support of the far us it in a coordination with the National Center of AIDS and as to the control is working in six out of seven provinces of Nepal, covering 37 districts out of 77 districts and comprising of 387 municipalities. In addition, the project has been providing technical support to 56 ARD sites. The services are delivered to key population led 26 city clinics and 25 dispensing sites for continuum of HIV care. The community led approaches for the HIV prevention activities is crucial for averting new transmission for HIV infection, early diagnosis of HIV cases in the community, and their early enrollment into the treatment. Their roles in treatment retention, monitoring the treatment progress is also equally important to end HIV epidemic in the country. For the successful and effective community mobilization, there is an immense importance of accurate, timely captured and complete person centric data, followed by the analysis and its interpretation. This robust person centric data is fundamental for the differentiated service delivery of HIV. The overall data use will eventually support in preparing action plans on daily, weekly and monthly basis to improve the quality of HIV services. It also guides to meet the targets focusing in the high risk area and population. In 2016, Nepal had been using management information system based on Microsoft Access. You can see the screen over there. Though all the implementing partners used to update the client's record in daily basis, the data could not be extracted instantly to track the progress analyze it and interpret to take the programmatic decision. The database had measured limitations, such as delay in receiving complete data at the head office level delay in identification of programmatic gaps and constraints in person centric data linked with the continuum of services. The project face, face problems for a day to day progress monitoring and planning at the implementing partners level. Realizing the need of person centric data at real time FHI 360 Nepal through USA for support did an assessment at its implementing partners for the readiness of using DHS to as new recording and reporting system in 2018. The recommendation from the assessment steered to the adoption of the system. Then the customization of DHS to was carried out, which led to the development of Meru data, meaning my data to capture person centric HIV prevention specific data. The implementation of the system started with the capacity building of the end users and admin level users. We also supported the implementing partners for required system and capacity of adaptation of the highest to and provided technical backstop to guide them. This was the first time DHS to do DHS to was customized in the country for HIV prevention program. There are 60 users from implementing partners, city clinics and ARB dispensing sites across the countries using the system to epic Nepal project. Okay, hello everyone. This is Resta and working as a senior monitoring and evaluation specialist in the epic Nepal FHI 360. Okay, after the customization of DHS to for HIV prevention program. Meru data has been an asset to capture granular client level information service level details and geographical mapping of each client. This has supported in monitoring HIV program throughout the continuum of care, the person centric data supports in segmentation of clients based on their risk behavior service use or dinner. These categorization enables community based supporters and navigators to advocate for HIV screen to all the clients who are at high risk of HIV, leaving or working in high prevalence areas. Okay, this cycle shows the process of community mobilization using DHS to in each implementing partners monitoring and evaluation officer carry out daily monitoring on the program to progress including the reach of people with HIV prevention messages. There are a number of clients diagnosed clients linked to HIV care services and those who started ART. The community based supporter and peer navigators are mobilized at the field based on the gaps among certain key populations or in certain geographical areas determine their partner's level staff carry out weekly as well as monthly program analysis, which is discussed among the field staff so that they can intervene. Followed by it, the execution of the plan is done and reflected for long term implementation. These are the glimpses of visualization of key indicators and their cascades. They are analyzed and discussed with the staffs of implementing partners on the basis for the mobilization of community based supporters, prepare program covers map documenting their community force in daily locks it and service record found occurring. Similarly, these are some more examples of how inbuilt application in metadata is helpful for community strengthening to deliver quality service to the client. This is the dashboard prepared by the implementing partners, which provides periodic achievement at different organization unit level against the set targets. This helps to monitor and review the performances based on this dashboard the implementing partners and staff from FSI 360 conducts periodic meeting for improving the plans for community mobilization and replanning the strategy. You can see the visualization, the visualization helps community based supporters and peer navigators to monitor the progress of HIV prevention care and support services at their individual level. It makes it easier them to understand the program to gap at the reaching pockets. Okay, the line list of the client has been helpful community mobilizer for identification and prioritizing the client for the services. Follow-ups on the higher risk population has been efficient with this event support. This has been effective to advocate services like pre-exposure profile access services among highest of HIV populations. Similarly, regular follow-up for the pill HIV in the denial of ART and those who are with unsuppressed viral load result has been possible. Okay, the scheduling feature. The scheduling feature has definitely provided the benefit to the case managers, those who are stationed at city clinics in each implementing partners to conduct regular follow-up for the services. The data has been vital for not only data recording and reporting, but for the use of the data in evidence-based planning and education to the community-based workers. They contribute for capturing granular client-level information, service-level details and geographical mapping of each client for real-time data that leads to action. This has supported monitoring HIV program throughout the continuum of care and facilitating to provide differentiated service delivery based on the status of clients and their risk behavior through community-led approaches. So in nutshell, this person-centric data management system has strengthened the implementation of evidence-based community action to support ending HIV by 2030 in Nepal. Following this success, the model has been adapted by the national system as well to build and strengthen one national HIV information system in Nepal. Thank you, everyone. Do you have any questions? Sorry, we were just... All right, I'm trying this again. Is that better? Yeah. Sorry about that. I have a lot of computers in front of me. Thank you so much. That was excellent. And I know that we have a bit of extra time. So I was going to see if anybody wanted to ask questions either from the audience or online. I've got the chat pulled up as well. Does anybody have any questions for the project before we move on and talk a little bit about Palestine? We can also come back to questions at the end, but yes, please. I'll bring you the microphone. We'll see if they can hear us. Yeah. Thanks so much. Obviously, the intervention in HIV obviously means that you probably have a lot of clients and patients that are very concerned with anonymity and, you know, in key populations. So how are we able to solve that challenge? I guess, you know, from one hand, gathering granular level data and from the other hand, you know, trying to keep the privacy and anonymity of the individuals secured. We have been practicing the use of UIC, a unique identifier code so that they can track all the data using the unique identifier codes. Is that clear? Yes. And maybe a follow up on that. So you showed the line listing, for example, as a key possibility for community level follow up. Can you talk a little bit about at what level those line lists are made available and who might have access to them just as one of those areas of considering anonymity? Actually, the line list is available for those who are like community supporters and those who are care providers, you know, and beyond that level, the line list is not available or they can only see the client codes. And for those who really providing services at the field level, they can only access the details of client so that they can easily like recognize the client and all to get all the details of clients. Great. Thank you. More questions in the audience? Did I miss any online just checking? So maybe I would ask one more and others from the audience can and then we'll move on. But I was wondering if you could maybe say some of the biggest challenges that you had in carrying out this project. It looks like it was a lot of work very well thought out. What maybe was surprising or challenging that you would recommend people prepare for or plan for? Like the challenges like in the community level, everyone will not get the internet access. So what we did was we tried to manage internet access in all the implementing partners and like we were trying to expand it at the field level as well but because they are also implementing partners were working at the border level and there are issues of internet so it was kind of difficult for us to run everyone to run the DHIS too. Similarly also there are some because it's a key population-led organization. It was difficult for us to capacitate everyone so we have been doing a lot of wide range of capacity building, capacity strengthening trainings and there is a lot of turnover as well. So it is difficult to spend a lot of resources for capacitating them. These are the major challenges that we have faced while implementing it. The name is Farshad Farzad Far. I am a scientist in the NCD department, WHO at quarter. Thank you so much for the presentation. I really liked it. Just a question, what are the measures that you are going to take to make sure that the data quality remains as reliable and valid data? At the field level, what we do is we do the verification using the locksets that we had mentioned in the presentation, followed by it we have been carrying out data quality assessment based on the need. Like if the data quality is very poor then we do it three times in a year or if it's good based on the scale we do annually and rather than that we also have been using Power BI to see like about further visualization and to check the quality of the data. Okay, besides that, we also do record service in hard copy forms as well. So as a source form of this system, e-formed. So on the basis of those field of hard copies we regularly and periodically conduct data quality assessment data verification so that we can ensure the quality of data. Thank you very much. My name is Zamanis Yam. I'm the regional advisor for Sierra region from WHO. Sorry, I'm asking you maybe a kind of archaic question but just if you can reflect on your experience, please about the ethical part of it. The sort of the, let's say patient or client consent for you recording and registering personal data if you can give us some insight into that because the common understanding point is we have from facilities like inpatient facilities that this comes naturally with the registration sometimes and it's a kind of an embedded sort of practice but when you are doing outreach and community based sort of work how are you getting the client consent that you would register their data and process it. Thank you. Thank you for your question. Yeah, the confidentiality of privacy has been like maintained in capturing the electronic in electronic form. So we basically we we obtain clients consent during our registration. So at the time of registration we like explained our various wide ranges of services they can utilize from our organization and at that time if client is like client convinced and give the consent for the service utilization. We basically we explain all the procedures and take consent during the service enrollment period. And we also like we also like inform inform them about their privacy and confidentiality and about the we also keep their records in locked cabinet so we basically we ensure the confidentiality and privacy of the clients. And adding to that we have different users for in every implementing partners who have their own password code code and we tell them that if any of the staff leave the leave the organization they have to change the past password so that the information is not leaked anywhere. And, and also, also all the people based are having insured that they are kept safely and and and we ensure they are maintained with a perfect confidentiality and privacy. Great. Thank you so much. Thank you, Kendra and Shrestha for for sharing with us it was very interesting. We'll, we'll move on now but maybe first round of applause I don't know if you'll be able to hear but thank you so much. Thank you so much. Thank you. I think we'd be happy to turn now to to you I think yes we can see your screen. Thank you. Thank you Mike and colleagues for having me to share our experience in Palestine. Can you hear me well. Yes, we hear you fine. Yeah, yeah, that's great and you can see the screen as well. So, just, I'm, I'm, I'm, I'm from Palestine, working in the World Health Organization as a system officer and leading several public health informatics initiative in the primary healthcare sitting in Palestine. So today we will, we will share our experience in Palestine for using the details to a large scale implementation. And really, this is the, the unique experience of utilizing the details to a large scale implementation, not only on the Chinese routine statistics, but also on the tracker as a patient record. And really, we started in 2016 by utilizing the details to as a factor patient base for the mother and child care. Then we decide to add more services, including the family health and other health services inside the primary healthcare. And it's a presentation will go quickly for the main modules that related to the HR because we, we, we proposed like a new, like a term to be used inside the Ministry of Health to consider it, not like a tracker, but also it's like an HR. When we utilizing the family health record. So we are utilizing all health services inside that record so it's an HR. So that's why we will repeat this term. Then we will, we will focus on the issues that could be replicated from Pakistani experience to other countries. Now, just quickly to say, we were seeing your slides in the slide mode, but if you wanted to put them in present mode, just just wanted to. Sorry. No. Yes, well, now we're seeing the preview mode actually. Okay, it was, it was working okay the other way as well. So if, if it's something about dual screens then it's fine you can just go back but right now we're seeing them in the preview or like your own presenter view. Okay, so let me present it. Again, now this work. No, that's back to the presenter mode I think it's maybe best if you just go back to your original setting that's okay. No, okay. This works also. Yeah. Okay, okay, that's okay. Sorry about that. No, don't worry. So now in this slide, you can see the level of implementation. This is the key fact on the implementation in Palestine now we have 380 clinics are using as a tracker, 50 clinics are using the tracker on the family health record including the child adult and CDGP specialist visit laboratory radiology, the drugs immunization. We have 14 district are using it to my s as a witness to the sex 14 district are using case based surveillance system for the communicable disease 14 district are using mammography registry as a tracker 14 district are using dental registry as a tracker 14 district to use it for that based violence and really, this is a unique model where we have ministry of women, ministry of and pure ministry of health ministry of education. We have more than four core stakeholder are using the same tracker for reporting on the base violence. We have also the art here. This is also unique model because we are utilizing the road traffic accident not only registry of health, but also for the private hospital and Geo is hospital and governmental host hospital are reporting on the same tracker details to. Before that it was everyone they send their data to the to the ammo accident they compile it and do the data entry again into one system for utilization. Currently, all of them are using the same system for reporting. And also we have 14 district using the health education platform as an event. So we have event program tracker program and aggregate program. In fact, we were driven with the national information system strategy, which is published on 2013. And part of that is to improve the information product and improve the surveillance as well. So that's why we focused on all means and surveillance. And this is an important and really a successful recipe. In the implementation to be driven with the counterpart and government priority, rather than the donor priority at that time so you can success and provide real implementation and success implementation. Here's for example, one of the requirement document that we shared it with the Ministry of Health get the clearance before start the configuration for the family health what included inside the family health so we started with that document. It takes time from us, but it helps a lot in the implementation because we can we considered the stakeholders, the requirements rather than our perspective. And in this slide you can see what type of program we implemented. We have a tracker program. We have now currently 100,000 patient record of PSE. Now it's available for utilization. We have aggregated the program that aggregated the program. And now is the only source that the Ministry of Health is using and relying on it to publish the annual report and really this is an achievement, because before that they use a paper based on Excel and Microsoft Access to generate the routine statistics. They are using the DHS to for generating the annual report, the event program, for example, including the School of Health Services and other activities provided as an event, not aggregated and not patient based. We have also like a meta data and health dictionary. We have more than 4000 data elements now available in the system from all paper based was collected and revisited and reviewed and build it configure it inside the DHS to and these data elements now can be like ready made data dictionary to be used in the future for the data interoperability between primary care and secondary care. And we also have KPIs and dashboard and I will show you a live demo in the last five minutes about the type of indicator are generated from the system. There is the patient through the FHIS, the Family Health Information System, or what I called at the beginning the EHR because we compiled all requirements and services, make it digitalized and available in the primary health care sitting as from one URL from one user name and password you can look in from one place so you can see all trucker programs in one place. And really this, this is also a unique because in the other countries we noticed that they use, for example, a program for the child, another program for the mother, another program for the vaccination, and another program for the dental health. So it's like asylum and vertical programs, but here in our design we consider all program in one place and that's include birth registry, all of these information now are longitudinal where the person starts the journey from the DHS to and finish the journey in this cases in the DHS to. And this is a snapshot from the system about the indicator of the betas, hybrid disobedience, hybrid disobedience, etc. So this is a real snapshot from the system and I can show you also from the system. This is the as is designed before we started it was like as I mentioned the silos and every tracker has a separate entity then we compile it together in this model as you see electronic record. So all it all patient based records are available now in one instance, so you can link it with with other data sources with Ministry of Interior with the arm are in the hospital with with with insurance. Federation or insurance companies with HMIS routine statistics and all of these records now are available to be linked with the governmental network with what is called the x rod in Palestine. It's like an intergovernmental online service for the Palestinian government for all other ministries, they can connect and interconnected with the same network and fill the data with the privilege and considering the privacy and confidentiality issues. The program are in here already be I listed before while what is replicable from what I mentioned before, we have certain things we can replicate the different but the government the governance experience user user involvement thought the experience in the future. Implementation meta data bucket system configuration, I will go quickly for them. For example, to make sure that the implementation is working you can see the upper part of the iceberg. But in fact at the end, and that's why I use that metaphor because really it's helpful just to show the level of complexity and the level of workload at the bigger part of the iceberg, where we have users involvement and everybody and we have an expert committee from formulated from different committee from the Ministry of Health, communicate with them, tens of technical meetings and sensitization meetings were held just to make sure that they are involved and they are part of the design. In the infrastructure installation we have more than 2500 network points and more than 2000 PCs are distributed the software configuration we configured more than 4000 data element inside the system. And as I mentioned the system sensitization meeting training, the end of user training including 1500 end users so all these efforts are really essential and crucial for a successful implementation to see the upper part of the iceberg. In bit chart this one slide for each replicable experience. This is the starting point of governance, how to do governance for the digital transformation and establish what is called country team and really this is recommended from the UI to have like an internal team to maintain and sustain the details to in the Ministry of Health this is an essential for follow up for the maintenance of implementing the system. And as you see the picture here we implemented that team from the Ministry of Health and from the P9PH, the Brazilian National Institute of Public Health. Another thing could be replicated from Palestine is the experience of feedback and acceptance, really it's early involvement for the core, care provider in design and development of family health record, really it's very important to have tailored solution by and minimize resistance to change when it comes to the implementation. TOT training, really this is an important as well before going to the field, before going to the clinics or hospital, you have to have to have like a system champion, you have to select some people nominated from official side, sorry for the voice. So those nominated people will be like a system champion and the messenger, like a messengers in the field to promote and advocate for the system. Another thing that should be also replicated, if it's done well, the end users training. So we invite all stakeholders, all end users, doctors, nurses, lab technician, cardiology technicians, pharmacists, all of end users, to have what is called hands on a training or feedback orientation session and readiness for the implementation. All these factors really are crucial and essential for make the implementation successful. Otherwise, it's not like, you know, other training, it's like just to give the slides for them and you have to go back to the home. No. For the implementation, it's very complex process. You have to start from the country team sensitization meeting, TOT training, district training and end users training and finally, the real implementation. The real implementation really means that on-site training, you have to go for the clinic with the end users for one day at least one day support to make sure that they are dealing with the computer. They know because some of them they have a computer literacy issue. So you have to make sure that the system is really implemented and how to reflect all people, as you see in the table, inside the system properly and to build trust between the system and the end user. What are the main challenges? Really, there are many challenges, finance and budget, team formulation and governments because governments because this is not an easy issue. You have to have an official meeting at official political well from the government. So requirement management, stakeholder involvement, interoperability issue, change management issue, request management to manage all requests from the field in a proper way without neglecting the end users' willingness and requirement because then it will backfire on you in the future and they will show resistance to change the software. And finally, continuity of technical support. This is essential for making the system sustainable. Really, this is the take-home message from the larger scale implementation. And really I put the tortoise and the rabbit as you see, sometimes the decision maker like a rabbit and the implementation goes like a tortoise because everyone has their own priority. So it's very important to make sure that both of them have a clear understanding and a clear vision about how the implementation should be like and it's not like a shake-and-bake process or like a plug-and-play. It's a very complex process. So you have to establish a clear vision and goal, political well, engage a stakeholder to have a national consensus and the plan for data privacy and security very well, invest in entertaining and support, monitor and evaluate the system, and consider your operability in your mind while you are proposing the use case for the user and continuous improvement. Finally, I don't know if I have time for two minutes, just Mike. Yes, go ahead. Can you see my screen now? Yes. Okay, great. And this is the, really, this is the attacker captain. As you see, you can see the, now, the list of programs that are already built from one place. This is really one of the big achievements. Make all the programs navigated from one place. We have a central registration program accounting and pricing, cause of death, child program, family health file, immunization, laboratory, immunogram, pin approach, pharmacy, and radiology. For example, if you need just anyone in the primary care, no need to just start from several vertical tracker program. From one place, you can register the person and just add the reason purpose of the visit. Then you will move for, for example, the family health file, inside the family health file, you can add the history, and you can see the previous visit as you see here, family history, and surgical history, patient history, and other modules. This is the next record. You can add a doctor record. Once you say that you can ask the ICD and the doctor note, the present illness, and systematic review, physical examination management plan and based on the management plan, that system will guide you for the rest of the process. You can also make a laboratory test for that patient in a few seconds. You can make the lab request. Really, utilizing such data systems, and I mentioned that to the conference now in the University of Oslo, just show you that the detail is too like, you can modify it based on your resources and based on your, sorry, Mike, just one second. Sorry, Mike, it was like an urgent thing to response. Okay, so this is the lab test. You can do the lab test quickly. As you see, for example, fast blood sugar, random blood sugar, cholesterol, et cetera, and the lab mission will fill the result. And the same thing you can do for the pharmacy. You can make the pharmacy from here from the same place. As you notice, you can make a pharmacy request based on the, for example, this is the most frequently requested medication for the patient. And very quickly, you can make a request, for example, for the mid-forming, for aspirin, for paracetamol, et cetera, and this was a frequency. And once you hear the right feedback, you can see all requested drugs. Then finally, the doctor will return back to the family health file and write final conclusion. All transactions I did now you can see it here in the dashboard. And this is one of the big achievement that, okay, all these transactions, it's not only for clinical use, it's for statistical use as well. So you can see, for example, in the NCD program, and in the NCD program, this is not routine statistics, not N-M-I-S or aggregated. This is the patient-based data that generated from the patient records and presented as a dashboard here. So we have another dashboard for NCD-M-I-S, but really this is generated from the patient record. You have also for the financial report, all revenues are coming from all leftist pharmacy and other are coming from a different transaction in the system. You can also see it. We also have like a dashboard for the training material to make one centralized library for the end user and get this off, making the end users are lost in the field, so they can go for the VCO. They can download the, for example, the manual, as you see, can you see the manual, user manual? It's a BDS. Yes, yes we see it. All resource material also are available here for the child program, and all other programs now, hundreds of thousands of indicators available now for them. And one of the, I see it's like a creative solution for them. We cannot promote the end user that, we cannot promise them, we have a stock management system, but we have a workaround solution where we added all the expensive drugs for them in one list. So they can compare it, they can present it on daily basis, and then they can use it for count, how to do count for the current stock, and really they were, they like that workaround solution. We see the same for the other programs, we have the same thing. Maybe one of the important things that I have to mention about this HR in the Eastern Mediterranean Regional Office requesting us officially that let us find a way to make this data system for other countries to deal with EHR like in the DHIS too, not only for routine statistics, but for the treatment of the end users. Okay, it's not linked with the pharmacy and the stock and inventory with the APIs yet, but at least it gives more than 95% of PSE requirement in any country. And you will not be any maintenance contract for any company at the end of the year, because and that's, that's why the MOH in Palestine adopted the DHIS too, while they are paying hundreds of thousands of dollars for other software in the hospital and other healthcare settings. But for the DHIS too, since 2015 till now, they are utilizing the core DHIS too and one of the crucial and important factor for sustaining the DHIS too in any country is to adopt the core DHIS too, without any customization, customization means dependency on other extra hand from outside and from the developers or from outside the Ministry of Health, which is against the sustainability and maintainability of the system. Sorry if I have maybe five minutes extra, but that's the whole story in a quick way. Thank you very much. Thank you so much, Mama. You're a round of applause yesterday. Mama. I predict a lot of questions because there was so much there but I was going to try just because our presenters really wish you could have been with us here in person but I'll at least try to turn on the camera here so you can see the room. And then maybe and have some, some conversations if this works at all. I was looking very blurry, but that's my best to see the room and Mohammed if you maybe well no you can go ahead and leave your slides on the screen I was going to say that we'd be happy to have you and our other presenters turn on your cameras at some point to say hello as well but maybe at this point. I have a lot of questions I could ask but I'd rather hear from the audience. If anybody has a starting point. There has to be somebody that wants to say tracker is not an EHR. That's why I see, I see a question here so maybe you'll be able to respond to that. Yeah. Just, I'm handing it over for the question. Mohammed, how are you. Good. Thank you. Thank you very much. This is a very fantastic presentation, very insightful and actually very encouraging. I like you to speak a little bit to the audience about saying that tracker is an EHR, because to be honest, we know EHR as very high intensity records with a lot of interaction data, especially if inpatient or outpatient. So, we would prefer, I would prefer that you delineate a little bit the difference between tracker and EHR. For me, tracker is a smart EHR. It's not your standard thinking of what electronic health records are needed at the facility level for patient management. I'll stop there and pass it over to Mike. Yep. Can I answer now. Yes, please. Thank you very much. Really, I, that's why that's why I mentioned we call it EHR because in the hospital we have an EMR, electronic medical record, because there is an inventory, and there is a stock in the stock management system, etc. So in the primary healthcare setting, we call EHR electronic health record because we compile all digital health services, all healthcare services, let me say that, all healthcare services in digitalised mode in one place, in one instance, by using one unified identifier, the unique identifier, the Palestinian ID, in one database, and you can navigate all the program from one place. So if the definition, okay, officially this is a tracker, yes, but in branding wise, branding wise, if you call it EHR and compare the function between two other, two things, you can see that the countries, they can utilise it at that way, but really yes, okay, you can use that the term, you see it in the way you need to see, but at least it serves the all functions you needed on country level. So I don't know if I answered that. Thank you. I think we have a follow up here. Yeah, actually, thank you so much for the presentation. Actually, for me, myself and I'm trying to make a line or draw a line between the tracker and electronic medical record, I'm asking the list of the indicators. And when I have the indicators, I'm asking how many more field of data I am collecting compared to this. Because the main purpose of tracker is to make sure that you are receiving very essential informations and not making it a long list of the data that makes it almost impossible for many, many facilities with a lot of burden of patients to handle this. I don't know about the Palestinian situation, but many other facilities are suffering from the shortage of human resource. And when you are doing this, I have several examples. When you are asking them to complete all those fields and click all all those items check box drop box and many other things in the end of the day, what you are receiving is a low quality of data, which is not even answering the primary purpose of the developing this system. What I'm asking now is, have you done any time analysis and how much time analysis or even click analysis, how many clicks they have to do to finalize a file or how much time they have to spend to enter the data for one specific patient. Thank you so much. Yeah, thank you very much for the question. Mohamed, it seems it seems we had one person that wanted to follow up quickly to that and then I'll let you. Before he answers that one I wanted to understand if the system is used at point of care or they enter the data retrospectively at some time later. All right, go ahead now Mohamed. Thank you. In fact, we agreed with the Minister of Health to have what is called a design review, okay design review workshop, where we will review all metadata and data elements in a workshop and to agree to minimize the level of data entry, because one of the issues we faced at the beginning, the Minister of Health insists to reflect all data elements in the data file into the electronic system. We try many times to convince okay, let us just focus on the minimum datasets or on the data that are essential for the doctor to fill it. They insist this is a medical file, legal file, so all data available in the paper based form should be configured inside the system as is. But after that, they find themselves, they have many clicks, 10 of the clicks just to finalize the record and they are looking for certain data element, not all data elements. So they return us to back, okay, can you please just now do the review that you propose for us at the beginning, and now we are at that position. Now we are standing here, just we need to review all data elements inside the system and propose a minimum data element just to minimize the number of clicks. And the number, the navigation cycle inside the system because just I agree with you it's long because that's the requirement, but it affects the implementation, yes, I agree with you. And that's why now we agree together with the Minister of Health to revisit the previous design and propose a new design with minimal data entry. I'm sorry about the second question Mike about or complimentary comments. It was it was just to clarify that this is being used at the point of care and is not secondary data entry. Yes, it's a primary healthcare in Palestine, this is the way we utilize it in the primary healthcare sitting. Because we are lucky at the beginning they don't have any electronic system so the only technology available in the primary healthcare clinics in West Bank. It's the DHS to and in the hospital they have a Turkish system called the Visanna system. So, yes, it's in primary healthcare and hospital, we don't have the choice to. And they are entering the data into the system directly or they still capturing on paper first. No, they entering the data while they are encountering the, the, the patient, so that the patient will come to the clinic and while the doctor talking with the, with the patient he has an eye contact for both for the computer to do that and for the patient as well. So it's not retrospective data entry it's real time data entry, while the opposite of care is running and active. So the data entry is done automatically in real time. Yes, thanks. And I can say just because I'm very familiar with this implementation. The starting point also was with research project, working with the Norwegian Institute of Public Health, and as part of that there was a long period of time of doing the formative research before working on the ANC component of this which was their starting point, including doing time and motion studies and working with them and so one of the most significant findings was that you can't do this and paper. So from the beginning a plan about how to phase out paper and that was before moving on to this system so just saying that it's a fairly stark I think contrast if you're trying to have them enter everything on paper and into a system like this, but I have a another question here that perhaps as a follow up. Sure. Congratulations to you and the team I think this is like a very impressive setup. I think we saw last year as well. I have a few questions. The first is linked to the tracker EHR kind of debates. The biggest challenge of the main characteristic of EHR is really where the hard part of the data dictionary. So I'm curious what kind of standards, what categories you're using. Perhaps ICD 10 but maybe more complex SNOM SCT and how that's implemented with your setup. And if you are going paperless I wonder how you're handling things like growth monitoring for example. My maybe second question is when you're having a unique patient enrolled in multiple tracker programs. Assuming you're completely online. Have you had any issues with multiple people accessing the same patient in different tracker programs. So let me start with the last question about the concurrent user. If you're asking about the concurrent users or the online data entry. We have more than for all the programs, you can see you can say we have more than 600 concurrent users. Sometimes reach to 800. It depends on the service and for other service needs for 1000 concurrent users on the same time are looking into the system for for the data entry because I mentioned it's we have 308 clinics are utilizing the for example mch and for the other program as well. So yes, we have concurrent users the current users are you are looking in the same time. The internet at the beginning was a challenge but finally we saw that because Ministry of Health with Ministry of Telecom, telecommunication ministry, they convinced and agreed at the end. Yes, this is a real investment. So we will upgrade the internet speed and really the they upgraded to a good level for time being. As for the offline solution, we don't have that solution we have a backup procedure like a standby procedure. The standby procedure of the internet is connected or the electric city is connected, you know, you are living in Palestine and there is an Israeli occupation. Some some issues happened really to be realistic. So we have a paper based are already printed and distributed for the clinics to be used at that time if the internet or electric city happened but really it's it's very rare, you know, it's not happened frequently and that's why they adopted the system. If happened frequently and they need to re capture or re enter the data know they will, they will not decide to use the system, but really now they adopted because the offline solution, the level of data entry is is not an issue for them. And for the classification ICD 10, the medical coding. Yes, we utilize them. We already configured the ICD 10 in the system and the CPT current procedural terminology for the lab for the laboratory. All these are added in the system as an option set and already configured inside the system. As for other data elements. In fact, we utilize what is called the Palestinian health data dictionary was developed and published in 2005 2005. The need, it need upgrade but at least this is the official dictionary we have in Palestine, but we added money from w two and from CDC. Great. Thanks, and we have a at least one more question and just a warning our microphone here is about to die of battery so if we go silent for a minute just give me a minute to fix it. Okay, thank you. Thanks. Thanks. The system from what I saw part of what I saw. It seems very comprehensive and it's great. I do, however, maybe I might have missed it. I wanted to find out how do you guys verify your clients. Do you have a separate system or using data as to verify that the client that you're serving at that time is the same one. When we started off when you start off with paper, a client comes in they sign a piece of paper. Then you those that those details. So how have you been able to overcome that maybe I might have missed it if you mentioned it. If I understand you will. If is there an alternative of the choice to or what is that your exact question, please. So I'm testing microphone. Can you hear me mom and. Yes, yes, very well. Okay, I just switched microphones so I'll allow a clarification. Right. I'm saying, even if you're using this right now what are you using to verify that the client that you've been admitted is the client was supposedly registered before that's basically what I'm asking. Because we have one database and one instance so once the day that the patient is admitted, or has an outpatient visit inside the primary care sitting. All of them are on one database so you can do a query the system will present all previous record for the same patient. And what do you this is what do you use as the unique identifier. Yes, the ID national ID. It's nine digits from the Ministry of Interior, like a national ID for all citizen. It's a unique identifier on the same identifier are used in the hospital, even both system is not connected yet. We don't have interoperability between primary and secondary care, but at least both of them are using the same identifier. So, if any patient go for any clinic in the West Bank in the around 400 clinics, the same record you can navigate from by using the same unique ID. And I know we're, we're, thank you mama that's great I know we're going to run out of time but we of course we have one of your former colleagues with us, honey and so I thought I would give honey and a chance also to make a comment and also this way after the session to come to ask additional question to so. Yes, honey is a good messenger for Palestine and for the details to store in Palestine. Well, thank you. Thank you. Thank you. So, I would like to thank you for this great presentation. It's a huge effort. So for this regard. It's not a question but it's more like a request. If you could make like a short demo video and send it to us, maybe we can put it somewhere at the community of practice, because when I started here in the his center dealing with many countries in the Middle East region, they wanted to ask me a lot about the workflow of the system and they want to know more so if you can please just if it's applicable to do or to make a short video and we can put it in the community so all countries who are interested maybe they can look at it and maybe to have like an idea of the system. Again, thank you. Thank you for this great presentation. So huge effort and thank you also for the Palestinian team. Thank you honey and really we will show work on that video and make it on our YouTube channel. And so it's going to be easy to navigate through the YouTube maybe. So definitely and thank you Mike honey and you are all for for for having us in this great that 2023 and hopefully that 24, I will be with you. Insha Allah, insha Allah. I hope you'd give Muhammad another round of applause and also the FHI 316 from Nepal. So, of course, as I mentioned that you can follow up with Hanim Abdul Rahman also is familiar with the system there are people that you can ask some additional questions about the Palestinian system, I'm also happy to talk with you we can always have the EHR tracker Additionally, also wanted to thank again the team from Nepal so much for joining and apologies to both of you that we were not able to do this in person but we really do hope 2024 that you can join us so thank you again everybody and we'll finish here.