HEARTS (Hypertension, Diabetes, and Related Cardiovascular Risk Factors) is the Pan American Health Organization (PAHO) initiative to reduce the burden of cardiovascular disease through integrated management of hypertension and diabetes at the primary care level.
This repository contains the official DHIS2 metadata package for the HEARTS - Chronic Disease Management Tracker (HeaProg001A), a tracker program for the individual-level registration and longitudinal follow-up of patients with hypertension, diabetes, and related cardiovascular risk factors.
The package was developed under the PAHO Eastern Caribbean Countries (ECC) initiative and is designed for deployment in national DHIS2 instances across the Eastern Caribbean.
| Attribute | Value |
|---|---|
| Minimum DHIS2 version | 2.38 |
| Tested on | 2.40.1 |
| Program type | Tracker (WITH_REGISTRATION) |
| Tracked entity type | Person |
| Type | Count |
|---|---|
| Programs | 1 |
| Program Stages | 4 |
| Data Elements | 73 |
| Tracked Entity Attributes | 17 |
| Option Sets | 42 |
| Options | 136 |
| Program Indicators | 29 |
| Program Rules | 66 |
| Program Rule Variables | 35 |
| Program Rule Actions | 98 |
| Visualizations | 16 |
| Maps | 1 |
| Dashboards | 1 |
| Stage | Purpose |
|---|---|
| Baseline Assessment | Initial enrolment assessment — demographics, diagnosis, baseline vitals, labs, risk stratification |
| Follow-up Visit | Recurring visit — BP, glucose, medications, adherence, counselling |
| Laboratory & Diagnostics | Lab results — HbA1c, lipid panel, renal function, glucose |
| Annual Examination | Yearly comprehensive review — anthropometry, complications screening, eye/foot exam |
Key analytics indicators computed from tracker data:
- HEARTS - Total Patients on Registry
- HEARTS - BP Controlled / BP Controlled Rate (%)
- HEARTS - BP Controlled at 6 Months
- HEARTS - DM Complications Screened
- HEARTS - HbA1c <7% / HbA1c >7%
- HEARTS - Mean SBP / Mean DBP (last 12 months)
- HEARTS - Mean HbA1c at Baseline / at Follow-Up
- HEARTS - Patients Active (Annual Exam)
- HEARTS - Patients on Treatment (this year)
- HEARTS - Lost to Follow-up (>90 days overdue)
- HEARTS - High/Very High Risk Patients (this year)
- HEARTS - Follow-up Visits (Total)
- HEARTS - Patients with Diabetes / Hypertension (this year)
- HEARTS - Patients Deceased
- (and 15 additional indicators)
HEARTS - Program Dashboard includes 16 visualizations and 1 map covering:
- Registry summary (total, by sex, by condition)
- BP and glycaemic control rates
- Active patients, lost to follow-up, deceased
- Patient distribution by diagnosis
- Follow-up visits by month
- Facility-level registry summary
All clinical data elements and tracked entity attributes are annotated with internationally recognised terminologies:
Applied to all 73 data elements and 8 clinical tracked entity attributes, including:
| Data Element | LOINC | SNOMED CT |
|---|---|---|
| Systolic Blood Pressure | 8480-6 | 271649006 |
| Diastolic Blood Pressure | 8462-4 | 271650006 |
| HbA1c Result | 4548-4 | 43396009 |
| Fasting Glucose | 1558-6 | 442311009 |
| Total Cholesterol | 2093-3 | 166830008 |
| LDL Cholesterol | 2089-1 | 412806003 |
| HDL Cholesterol | 2085-9 | 412808005 |
| Serum Creatinine | 2160-0 | 70901006 |
| eGFR | 62238-1 | 80274001 |
| BMI | 39156-5 | 60621009 |
| Body Height | 8302-2 | 50373000 |
| Body Weight | 29463-7 | 27113001 |
| Waist Circumference | 8280-0 | 276361009 |
| Tobacco Use | 72166-2 | 229819007 |
| Diagnosis | 29308-4 | 439401001 |
Applied to all clinical diagnosis, comorbidity, and family history options:
| Condition | ICD-11 Code | Chapter |
|---|---|---|
| Hypertension | BA00 | 11 — Circulatory system |
| Type 2 Diabetes Mellitus | 5A11 | 05 — Endocrine & metabolic |
| Type 1 Diabetes Mellitus | 5A10 | 05 — Endocrine & metabolic |
| Prediabetes | 5A21 | 05 — Endocrine & metabolic |
| Obesity | 5B81 | 05 — Endocrine & metabolic |
| Hyperlipidaemia | 5C80 | 05 — Endocrine & metabolic |
| Atherosclerotic CVD | BA80 | 11 — Circulatory system |
| Heart Failure | BD10 | 11 — Circulatory system |
| Stroke | 8B20 | 08 — Nervous system |
| Chronic Kidney Disease | GB61 | 16 — Genitourinary system |
- DHIS2 instance version 2.38 or higher
- Superuser or metadata import rights
- Existing Person tracked entity type (or use the one bundled in the package)
- Download
metadata.jsonfrom this repository. - Log in to your DHIS2 instance as an administrator.
- Navigate to Import/Export → Metadata Import.
- Select the
metadata.jsonfile. - Set the following options:
- Import mode: Commit
- Identifier scheme: UID
- Import strategy: Create and update
- Atomic mode: Non-atomic (recommended for first import)
- Merge mode: Replace
- Click Import and review the summary report.
- After import, assign the program to the relevant organisation units via Maintenance → Program.
If importing via the API, use this sequence to respect metadata dependencies:
- Options & Option Sets
- Tracked Entity Attributes, Data Elements
- Tracked Entity Types, Program Stages, Programs
- Program Rule Variables, Program Rules, Program Rule Actions, Program Indicators
- Visualizations, Maps, Dashboards
- Assign organisation units to the program (they are stripped from the package as org unit hierarchies differ between instances).
- Set up user groups and sharing as appropriate for your instance.
- Run Analytics to populate dashboard visualizations.
HEARTS-Individual-Tracker/
├── metadata.json # Full DHIS2 metadata package (programs, DEs, indicators, dashboard, etc.)
└── README.md # This file
| Object | UID |
|---|---|
| Program | HeaProg001A |
| Tracked Entity Type (bundled) | HeaTETy001A |
| Dashboard | HeaDash001A |
Issues and pull requests are welcome. Please open an issue before submitting large changes.
See LICENSE.
Pan American Health Organization Office for Barbados and the Eastern Caribbean Countries (PAHO-ECC)
For technical support or deployment assistance, contact the PAHO Office for Barbados and the Eastern Caribbean Countries.