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POC-EMR Lab Infrastructure and Technology Test Protocol | June 2018

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Implementation of Point of Care Electronic Medical Record Management

Information System (POC-EMR) in Mozambique

POC-EMR Lab Infrastructure and

Technology Test Protocol

Maputo, June 2018

"This project is possible thanks to a partnership between Mozambique and the

American people through funding from PEPFAR - CDC"


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POC-EMR Lab Infrastructure and Technology Test Protocol

Introduction

The POC-EMR project aims to implement a point of care electronic medical record (EMR) information

system nationwide to capture HIV patient information. This project is funded by PEPFAR* with the

objective to deploy the system initially in 52 Test and Start Health Facilities (2018-19) and then scaling

up to around 300 health facilities during the following two years.

The POC-EMR laboratory has been set up to simulate real use case scenarios of a health facility (HF)

environment for HIV Care workflows, from the very first moment a patient is admitted into the HF to the

moment when the patient is discharged, including all the station where patient needs to be seen:

patient registration, clinical consultation, monitoring of the clinical state, ordering laboratory tests and

medications, dispensation of medications, and lab test resulting.

The laboratory has the basic required equipment, networking and the server running POC-EMR

software, based on a distributed and centralized (intranet) architecture.

This test protocol is meant to test hardware including network performance as well as operations like

backups, recovery, security of the infrastructure, environmental and database stress tests.

Simulation environment

The POC-EMR laboratory for health facility working environment simulation is composed by: ● 3 dedicated rooms with air-conditioning, users privacy and equipment physical security

requirements to simulate NEP-Reception, Clinician rooms, lab and pharmacy:

○ 1st room: two workstations (NEP and Reception), documents storage and archive

facilities, one printer;

○ 2nd room: three workstations for clinicians;

○ 3rd room: two workstations (Lab and Pharmacy);

● All workstations are touchscreen and have attached also the keyboards and mouse (for optional

use);

● Barcode Scanners, available at each station;

● Server room with network equipment and local “mini-server” running the application and

database for POC-EMR.

The installed applications / software are:

● POC version 2.0 installed in “mini-server”’;

● POC Database with sample data (~1k records) installed in “mini-server”;

● Users workstations installed with browser “chrome” to access the POC web server;

● Automated stress tool to simulate multiple usage of POC;


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Objectives

The main objective is to test the infrastructure and technology installed in simulation environment

(laboratory) of POC-EMR. Specifically and in order to get to the main objective, following are the specific

activities:

1. Confirm the performance of user workstations;

2. Confirm the server performance;

3. Confirm the intranet network bandwidth;

4. Confirm the performance of barcode scanners and laser printers;

5. Ensure equipment physical security;

6. Ensure data/information security;

7. Estimate time to perform POC-EMR database backups;

8. Test power backups and disaster recovery solution;

9. POC-EMR database stress test.

Assumptions for the test

● All users have good computer skills and good knowledge of the electronic systems;

● All users have good familiarity with HIV C&T health facility workflows;

● The stress test plans will be performed using keyboards and mouse;

● Most of the tests will be performed using automation tools;

● The POC-EMR database contains a sample of existing retrospective OpenMRS database

functioning in a health facility with at least 5.000 HIV patients;

Test participants

All the required test of hardware equipment and technology as defined in the objectives above will be

performed by Jembi Health Systems IT team and leaded by the project coordinator. No participation will

be required for people to simulate the workflow, i.e. patients, clinicians, receptionists, etc....

Methodology

This section explains how each specific objectives mentioned above will be achieved.

1. Confirm the performance of user workstations:

The workstations stress tests will be performed using the automated stress test tool and

previously defined test plans based on workflow (Annex 2) and test cases (Annex 3).

The performance metrics information to be collected will be of the processor (CPU), memory

(RAM), hard disk (HDD) and network throughput. Since the workstations operating system

environment is Windows, the native windows tools will be used to confirm the workstation

performance following the steps below:

● Open the browser and run POC application

● In parallel window open Task Manager


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● Go to performance tab

● While using the POC application, verify in performance window how many threads the

workstation can handle and the performance metrics for CPU, RAM, Hard Drive and

Network.

To access more accurately the hardware capabilities the following specialized tool will be used:

● PerformanceTest Easy PC Benchmarking

(https://www.passmark.com/products/pt.htm)

● The standard tests suits to be used will be CPU Tests, 2D Graphics Test, Disk tests and

Memory Tests;

2. Confirm the server performance:

The server stress tests will also be performed using the automated stress test tools.

The performance metrics information to be collected will be of the processor (CPU), memory

(RAM), hard disk (HDD) and network throughput. Since the server operating system

environment is Linux, “stress-ng” alongside with blazemeter and jmeter will be used for

stressing a server mode used to know the performance of the server, although not with specific

application.

3. Confirm the intranet network bandwidth:

Similar to the approach for stress testing the server hardware, to measure the performance of

the intranet (local area network - LAN) the automated network stress test tool will be used, the

“NetStress - Network Benchmarking Tool” (http://nutsaboutnets.com/netstress/). It requires to

run on both side (server and workstations), so for each existing workstation in simulation

environment the following steps will be performed:

● Run the NetStress tool at the workstation;

● Click on the 0.0.0.0 beside the Remote Received IP and select the Server IP address that

is listed in the window and click OK.

● The start button will then be enabled and clicking on it will start sending and measuring

the TCP and UDP throughput.

4. Confirm the performance of barcode scanners and laser printers:

The management application that comes with the devices will be used to test barcode scanner

and laser printer. For barcode reader testing, a sample of 100 barcodes printed labels will be

used to estimate the speed of equipment usage and number of errors occurred. The POC

application will be used at reception station to print around 50 times, to estimate the speed and

number of errors occurred.

5. Ensure equipment physical security:

Physical security check will be performed to avoid the possibility of equipment stealing,

including all equipment existing in the simulated environment. To ensure all equipments are

https://www.passmark.com/products/pt.htm

http://nutsaboutnets.com/netstress/


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secured it must be locked with a safety plan. The test will check list all equipments locks and

produce the safety plan.

6. Ensure data/information security:

Data/Information security check will be performed to avoid unauthorized access. Following

check will be performed:

a. The server Hard Disk Drive (HDD) is encrypted;

b. The start and restart of server operating system is secured by password protected start

or restart of server operating system (BIOS);

c. Password protected start or restart of workstation operating system (BIOS);

d. Password protected server HDD;

e. Password protected workstation HDD;

7. Estimate time to perform POC-EMR database backups:

The database containing a sample of existing retrospective OpenMRS data functioning in a

health facility with at least 5.000 HIV patients will be copied to external drive at least 5 times to

estimate the time required for backup operation.

Similar operation will be performed to copy the database to the disaster recovery site and

estimate the time and test the operation.

8. Test power backups and disaster recovery solution:

Power failure should be simulated (turning off the power supply) at least 20 times to estimate

the time the environment is up and running on batteries while the system is in use. Following

tests will be performed:

a. The power will be switched off manually to let the computers work only with UPS to

estimate the time;

b. The main server should be turned off to test the disaster recovery server, at least 20

times to estimate the time required to get back the system up and running.

c. The database backup will be restored to see if with backup the system is up and

running.

9. POC-EMR Database stress test:

HammerDB tool will be used to perform database stress testing on server. The following steps

will be performed:

● Create a test schema based on POC-EMR database schema;

● Load the test schema with sample data;

● Run the tool to simulate the workload of multiple virtual users against the database for

both transactional and analytic scenarios;

● Save the results about the environment performance including hardware and software

configurations.


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Expected results

The test report will include all the technical details with followed steps and the results as following:

Action Expected Results

1. Confirm the performance of user workstations Report produced by the performance benchmarking tool being used for workstations.

2. Confirm the server performance Report produced by the performance benchmarking tool being used for server.

3. Confirm the intranet network bandwidth Report produced by the tool being used to test the intranet network performance.

4. Confirm the performance of barcode scanners and laser printers

Components description, estimated times to perform reading, printing, and #errors occurred.

5. Ensure equipment physical security Gaps in physical security of equipment (if any) and recommendations for mitigation; Security test plan in a document to be followed on the field.

6. Ensure data/information security Gaps data/information security (if any) and

recommendations for mitigation;

Documents with steps to ensure the security of all the information.

7.Estimate time to perform POC-EMR database

backups

Database backups to external drive performance results; Database backups to disaster recovery site performance results. Backups and Disaster Recovery plans updated.

8. Test power backups and disaster recovery solution Working time after power cut; Time required to have the replicated server up and running.

9. POC-EMR database stress test HammerDB database load testing and benchmarking tool results.

The test report should be shared with CDC, MoH and UCSF, all the findings as well as the

recommendations should be discussed with the stakeholders and decided on the next steps.

Resources


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(1) eSaude HIV C&T POC System Test of Workflow Protocol (UCSF)

ANNEX 1

Overview of POC-EMR Functionalities Source: eSaude HIV C&T POC System Test of Workflow Protocol, pg.4/5

Phase Services Provider Description

1st Visit Demographics Reception/Person opening the process

Provides the demographic data and identifiers of the patient, it also includes the confident of the patient and the referral/location of registration

Social Reception Provides brief summary of

social data

Anamnesis Clinician Provides clinical history of

the patient, it is a simple

questionnaire that

requires no clinical

analysis

Clinical Observation Clinician Provides info based on

clinical observations

made to the patient

All Visits Vitals Clinician, Nurse, Assistant The vitals of the patient

(Blood Pressure, Height,

weight)

Clinical Consultation * Clinician Provides the follow-up

care and treatment info

of the patient

Pharmacy Pharmacist Drug dispensation

Lab Lab Technician CD4, and other lab tests

There are two different phases in a patient’s HIV C&T services. The first phase is conducted initially in a health facility, (1) their entry into the HIV C&T program, called the opening process. The second phase is conducted throughout the remaining lifetime care of an individual patient, (2) called patient follow-up


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process. In addition, patients do not always begin at the registration desk. Follow-up visits have multiple types of workflows depending on the health facility configuration and capacity, as well as, the particular activities needed for that visit. Some involve a clinical encounter, but others only involve a pharmacy or laboratory encounter, thus patient visits do not always begin at registration.

ANNEX 2

POC-EMR Workflows

Source: eSaude HIV C&T POC System Test of Workflow Protocol, pg.6/7

Initial Clinical Visit

A patient will come in for an initial HIV C&T visit. They will need to be registered into the health facility

at the registration station, social information collected, and vitals taken. They will proceed to the

clinician station for their clinical encounter. There they will receive a pre-printed prescription and

laboratory test order. They will go to the pharmacy for a medication dispensation, and to the laboratory

to pick up their pre-printed laboratory test results. They will return to the registration to turn in their

laboratory test results for entry into the system, for review by the clinician in their next visit.

Follow-Up Clinical Visit

Patients have five workflows available to them for follow up clinical visits, depending on where they are

in their treatment and care plan. The following will be conducted during the test:

● Follow-Up Workflow A


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○ Patient Check-In at Registration, Social Information Update, Vitals Entry

○ Clinical Encounter, Receive pre-printed prescription and laboratory test orders

○ Visit pharmacy for dispensation and laboratory for test results

○ Return to registration for laboratory test results entry

● Follow-Up Workflow B

○ Patient Check-In at Registration, Vitals Entry

○ Clinical Encounter, Receive pre-printed prescription and laboratory test orders

○ Visit pharmacy for dispensation and laboratory for test results

○ Return to registration for laboratory test results entry

● Follow-Up Workflow C

○ Patient conducts all activities directly with the clinician, therefore, check-in and vittals

occurs with the clinician, as well as receiving pre-printed prescription and laboratory

orders. Patient then goes to pharmacy for pick-up and laboratory for test results.

Patient returns to clinician with results.

● Follow-Up Workflow D

○ Pharmacy Pick-up Only

1. Test Case: Patient goes directly to the pharmacy, and the patient already exists

in system.

2. Test Case: Patient goes directly to the pharmacy, but the patient does not exist

in system (transfer-in or hasn’t been entered into the system yet).


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ANNEX 3

POC-EMR Test Cases

Test Cases

● User Login

● Search patient

● Register patient

● Patient check-in

● Medical consultation

● Pharmacy

● Display patient information header

● Print patient info

Use Cases

(Based on Patient workflow)

Location: Reception

Actions:

1. User Login

2. Patient check in and registration

a. New Patient Registration

i. Patient Registration (Demographic data)

ii. Create NID (patient ID code)

iii. Print Patient card

iv. Schedule visit

b. Existing Patient

i. Open Patient file

ii. Schedule visit (put in line)

c. Transferred Patient

i. Search for patient information

ii. Update patient details

iii. Schedule Visit (put in line)

3. Check patients scheduled

Location: Consultation Rooms

(Part I)

Actions:


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1. User Login

2. New Patient

a. Fill Patient Form

3. Existing Patient

a. Fill Follow up Form

4. Collect patient clinical data (vitals)

5. Request Lab exams (CD4 count and other blood and urine tests)

(Part II)

Actions:

1. User Login

2. Read exam results

a. Evaluate WHO stage

b. Prescribe medication

3. Evaluate Eligibility to TARV program

a. If eligible, refer to APSS

b. If not eligible, schedule next appointment (done at the reception)

Location: Laboratory

Actions:

1. User Login

2. Check Requested laboratory exams

3. Fill patient form

Location: Counseling Session (APSS)

Actions:

1. User Login

2. Read Patient history

3. Fill Patient counseling form

4. Schedule next appointment (done at the reception)

Note:This use cases are based on the “Workflow do Paciente (AS - IS)”


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