The Perioperative Shared Health Record (PSHR) as a tool to promote health information exchange between surgical patients and their healthcare providers requires interoperability and internationalization for it to be optimally utilized in the fragmented, unequal South African healthcare system. Once these goals are achieved, tailoring the PSHR, as open source software, for use by patients in low resource settings, will allow for implementation through the African Perioperative Network, a platform connecting investigators in the African Perioperative Research Group, administered by Safe Surgery SA.
The Perioperative Shared Health Record (PSHR) is a tool that was developed to collect patient information in preparation for a surgical procedure, allow capturing of patient-reported outcomes up to one year after surgery, and enhance communication between the patient and the clinical team members, in order to track and improve surgical care. The goals of this project are to augment health information exchange using the PSHR by improving interoperability in a fragmented South African healthcare system as it moves on the road to universal health coverage. Furthermore, internationalization will improve the PSHR’s utility in the African continental context. Safe Surgery SA is a clinician-focused non-profit organization with the vision of empowering clinicians to drive surgical care improvement in South Africa and Africa. With the help of digital health, there is the potential to impact on global surgical outcomes on the continent by harnessing the partnerships created through the African Perioperative Research Group collaborative.
Safe Surgery SA (SSSA) is a research-driven non-profit organisation enabling the use of data related to perioperative care, to empower clinicians in providing affordable quality services in optimal settings. This is done by providing research support, promoting access to relevant data, and seeking collaborative partnerships. Key to SSSA efforts is identifying appropriate datasets, and facilitating sharing of data in a safe, effective way. These datasets can be used to promote research and learning/improvement in perioperative care, and include datasets describing the context or setting for patient care (a facility dataset) and a minimum perioperative patient dataset that is feasible for clinicians to collect at the bedside, which can be expanded to form a core perioperative dataset (e.g. through augmentation with data points reported by patients in the PSHR). SSSA has a proven track record in providing research support for multi-centre studies on the African continent, has developed a web-based platform to enhance collaboration between African investigators, and has established important and diverse stakeholder relationships in the South African healthcare environment and the National Department of Health.
The SSSA team currently works with two partner organisations, based in South Africa: Decode and Silicon Overdrive. The PSHR was originally developed by Jembi Health Systems. Decode development is a software development company involved in building, evolving and replacing software products. They were responsible for preparing the PSHR for deployment, to be used in the South African COVID-19 Surgical Outcomes Study (SACSOS), a research project funded by the South African Medical Research Council. Silicon Overdrive is a network service provider with extensive expertise in cloud solutions, software development, security and compliance. They were involved in the deployment of the PSHR and providing technical expertise as a registered AWS Partner and part of the Amazon Partner Network (APN).
The Perioperative Shared Health Record (PSHR) is a secure web-based, patient-centric platform administered by Safe Surgery South Africa NPC and hosted on AWS. The PSHR was deployed in October 2021 and has been used to capture patient-reported measures both preoperatively and postoperatively. Postoperative information can be captured for up to 1 year after a surgery. The capturing of clinical data is done by the clinical team (surgeon and anaesthetists). The PSHR includes a benchmarking module to be used by clinical team members to track their patients’ outcomes and compare these to an aggregated anonymised average of data in the system. This allows for teams to audit and self-regulate clinical practice, leading to improved care. Better surgical care can improve overall population health by treating injuries and non-communicable diseases. The reporting and measuring of surgical outcomes are important to benchmark surgical care in different settings. The use of digital health is an important step in accelerating progress in global health and contributes to lessening the information gap commonly seen in low resource environments. Large disparities and unequal access to surgical care are important factors that can be addressed using a digital platform accessible to all.
The PSHR will be able to integrate with other data sources using similar health data standards. Data in the PSHR will contribute to the basic dataset of a Perioperative Clinical Registry – a clinician driven platform for integrating perioperative case data.
The PSHR architecture is inspired by the OpenHIE Architecture. It consists of a single page web application which communicates through the interoperability layer, currently a fork SafeSurgerySA/openhim-core-js of Jembi/openhim-core-js to the FHIR server, currently a fork SafeSurgerySA/hearth of Jembi/hearth.
In order to increase the impact that the PSHR can make as a tool for perioperative outcomes in South Africa and Africa and to increase interoperability with other systems it is obvious that the system need be compatible with FHIR R4. Since Jembi/hearth is no longer maintained and does not support FHIR R4, HAPI FHIR seems like an obvious choice as a replacement.
The PSHR is composed of a series of Questionnaires targeting patient and guardian registration, practitioner registration as well as preoperative and postoperative outcomes to be completed by both patients and practitioners.
In order to improve standards compliance, reusability and interoperability the plan would be to use an existing or develop a new library for presenting the Questionnaires which follows the FHIR Structured Data Capture Implementation Guide which already supports Questionnaire internalization. This approach would minimise the amount of code required by including the internalized strings within the Questionnaire resource, therefore also making the system reusable and the Questionnaires replaceable with context specific versions.
All the components of the PSHR are containerized as docker containers which are for the current deployment, deployed to AWS Fargate. This approach would be maintained going forward therefore aligning with the Instant OpenHIE initiative.
The investment from Digital Square will go towards replacing Hearth with Hapi FHIR. This will enable the use of FHIR R4 which will increase the interoperability of the platform. Hapi FHIR is the most widely used open-source implementation of the FHIR server specifications and of the HL7 FHIR for healthcare interoperability in Java.
Internationalization will be addressed in parallel during the development process.
We have gained experience in process evaluation during the execution of the African Surgical Outcomes- 2 Trial (ASOS-2), the results of the main project having been published in the Lancet, and will follow a similar but prospective process during implementation of the PSHR in low resource settings.
Deliverables and schedule
Replacing the Hearth with Hapi FHIR, and addressing internationalization, will require 6 to 8 2-week sprints with a development team, totaling a cost of $120 000.
It is possible that despite this investment to improve interoperability, the internationalization efforts, and registration as a global good, the PSHR will still not be accessible to all patients from low resource environments. Further work may be required, such as enabling the use of chat technologies to enhance postoperative data capture, and introducing kiosks at hospitals for preoperative patient engagement. Developing a patient-centered culture in clinical environments is still a challenge in resource-constrained settings, and will require sustained dialogue within the perioperative community.
Although PSHR would benefit from integration with a facility registry that has not been considered in scope for this proposal but could be implemented in a separate project.