Electronic medical record systems in developing countries (4)

Implementation in the other country

(3) The HIV-EMR system, Haiti
Background: Since 1999, PIH has run a communitybased HIV treatment programme in Haiti with its sister organisation Zanmi Lasante, expanding to seven public health clinics in an area with virtually no roads, electricity or telephone service.
Design: Based on the PIH-EMR. Satellite-based internet access at each site supports email and web communication.
Sites: Seven in rural Haiti.
Number of patients: 4000; 2000 full patient records.
Data entry: Doctors enter case histories and medications directly, whereas technicians enter laboratory results and pharmacists enter stock records. The data entry staff is being expanded.
Design: Open source web system backed by an Oracle database (the same as the PIH-EMR) with an additional offline client for data entry and review. Bilingual English and French.
Functions: History, physical examination, social circumstances and treatment recorded. Decision support tools provide allergy and drug interaction warnings, and generate warning emails about low CD4 counts. An offline component of the EMR was developed to overcome unreliable internet communications in some sites. This allows data entry and case viewing when the network is down, and has proven to be reliable and popular with clinical staff.
Pharmacy management: Full inventory system and drug regimen analysis.
Significance: The HIV-EMR shows the feasibility of implementing a medical record system in remote clinics in a remote area with virtually no infrastructure and limited technical expertise.

(4) Careware, Uganda32
Background: A team at the US Department of Health and Human Services has developed a medical record system to support HIV treatment via the Careware system.
Design: Stand-alone database built with MS Access.
Sites: US: 350; Africa: Two.
Number of patients: Several hundred in Africa, many thousands in the USA.
Data entry: Both direct by users, and on paper forms.
Functions: Provides comprehensive tools for tracking HIV patients and their treatment, including clinical assessment, medications and billing data. It is widely used in health centres and hospitals in the US, and has recently been internationalised and deployed in Uganda in October 2003.
Pharmacy management: Drug inventory support in international version.
Significance: Careware is an example of a US-based stand-alone EMR that is being adapted to developing country environments. An internet-accessible version that is under development will allow local data entry offline but provide networked communications and back-up.

(5) Lilongwe EMR, Malawi13
Background: Kamuzu Central Hospital located in Lilongwe, Malawi has made extensive use of a touchscreen patient management information system for a wide range of clinical problems in the 216-bed paediatric department since 2001.
Design: Runs over a local area network built on Linux/MySQL with Visual BasicTM for the client programs.
Sites: One.
Number of patients: 160 000 total; 6000 with HIV.
Data entry: Physicians, nurses and pharmacists perform all data entry using touch screens, including medication orders.
Functions: Data are collected on patient demographics, medication, laboratory tests and X-rays. A potential limitation of the touch screen approach is that it is difficult to enter free text, though an ‘on-screen’ keyboard is available and has been used by local staff to enter all the patients’ names.
Pharmacy management: Recording of regimens only.
Significance: The extensive use of this system directly by healthcare workers in a poor country with limited IT skills is a convincing demonstration of the potential of EMRs with user-friendly data entry mechanisms.

(6) SICLOM, Brazil
Background: The Brazilian public health system uses the ‘Computerized System for the Control of Drug Logistics (SICLOM)’ to deliver ARV treatment to over 100 000 patients – by far the largest group in the developing world.
Design: Separate EMR databases on each physician’s desktop periodically connect to the central server by dial-up to update records.
Language: Portuguese.
Number of sites: Widespread throughout Brazil.
Number of patients: More than 100 000.
Function: Used to support prescribing and track medication supplies (limited information available).
Significance: It is considered a ‘key factor(s) helping to overcome logistical challenges to delivery of antiretroviral treatment in Brazil’

Other EMR systems in developing countries
FUCHIA was developed by Epicentre, the epidemiology group of Me´decins Sans Frontie`res, to support their HIV treatment projects.35 It supports clinical care and long-term follow-up of patients, including scheduling of visits; it includes data on medications and investigations and generates reports. It was developed as a standalone system using MS Access and the Delphi programming language.
An information system was developed in Botswana to support the TB programme and is built using EpiInfo (a free stand-alone program from the US Centers for Disease Control [CDC] designed for data collection and analysis in developing countries). It includes reporting and analysis tools and has been successfully deployed to multiple sites in several countries.
PDA/Palm systems
A variety of PDA-based medical information systems have been proposed or implemented for projects in developing countries on the basis that handheld devices will be easier to use and support in remote sites. Such devices would seem to provide particular benefits for community health care, being simple and relatively unobtrusive to carry around. Palm-based devices tend to be favoured due to their excellent battery life and generally lower cost. In KwaZuluNatal, South Africa, a Palm-based system allows secure access to HIV results in remote clinics. In rural India, a Pocket PC-based system has been used to store health records for community nurses visiting remote villages. Palm or Pocket PC systems can be easily set up to view pages offline from a web-based EMR, though care is required to maintain data security. Satellife is using the mobile phone network in Uganda to link PDA-based medical records to a central site. Local healthcare workers collect data on Palm PilotsTM and then connect to a local battery-powered server that connects to a central database via a mobile phone modem.
Web-based collaboration and telemedicine systems
The web allows data sharing for remote consultation, and several projects have established systems that can be used to support diagnosis and treatment decisions in remote sites with limited bandwidth. The RAFT project permits remote collaboration, case discussion and data sharing over low-bandwidth networks between Geneva University Hospitals and Bamako, Mali. The IPATH server is a web-based tool for image sharing in pathology and radiology being used in South Africa and the Pacific as well as Switzerland. Telemedmail is a secure email and web-based telemedicine system under evaluation in South Africa and Peru.

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Electronic medical record systems in developing countries (3)

Electronic medical record in case summaries of existing systems

Despite the difficulties in deploying information systems in developing countries, several have successfully integrated into clinical workflows. While none represent a complete or ideal solution, their successful use over several years, with combined patient records numbering in the hundreds of thousands, offers valuable insights into successful future deployments. This is not intended to be an exhaustive list; other systems might contain important ideas and designs but need to be validated in appropriate environments. Box 2 includes brief descriptions of other known systems deployed in developing countries. A recent report includes an assessment of medical information needs in African clinics and some additional systems.

(1) AMRS, Kenya

Background: Indiana University School of Medicine and Moi University School of Medicine (Eldoret, Kenya) have been collaborating for over 15 years. In February 2001, this collaboration led to the Mosoriot Medical Record System (MMRS). The Mosoriot Medical Record System (MMRS) was installed in a primary care healthcare centre in rural Kenya. In November 2001, the Mosoriot Medical Record System (MMRS) software was adapted to support the AMPATH (Academic Model for the Prevention and Treatment of HIV/AIDS) project and renamed to AMRS.
Design: Two networked computers running Microsoft (MS) AccessTM, powered by a UPS with solar battery back-up. For the AMPATH project, the network has expanded to seven networked computers linked to a single MS Access database.

Number of patients entered: 60000 patients and over 150 000 visits in four years. For HIV care, 8000 patients, 3300 of whom are currently receiving anti-retroviral drugs (ARVs).

Sites: Two, with the AMPATH site serving as a central repository for eight remote clinics.
Data entry: In the Mosoriot Medical Record System (MMRS), patients are registered in the system upon arrival, travel through the clinic with a paper visit form, and present the visit form as they depart. Clerks perform the registration and transcribe visit data. AMRS data are collected on paper forms at each visit, delivered to a central location for data entry, and then returned to the patient’s paper chart.
Functions: the Mosoriot Medical Record System (MMRS) provides both patient registration and visit data collection functions. Data are collected on all patients seen in the medical clinic, including their laboratory results and medications. AMRS supports comprehensive HIV care as well as mother-to-childtransmission prevention,while serving as a rich database for quality improvement and answering research questions.
Pharmacy management: Based on drug regimens analysis available.
Evaluation: A comparison of the clinic before and after adoption of the Mosoriot Medical Record System (MMRS) showed patient visits were 22% shorter, provider time per patientwas reduced by 58% (P < (P < style="font-weight: bold; font-style: italic; color: rgb(102, 0, 0);">Significance: The growing AMRS and the Mosoriot Medical Record System (MMRS) databases serve both clinical and research needs, generating clinical summary reports for providers and providing a centralised source of data for epidemiological research.
The next generation of the database, called AMRS, has a completely revamped data model, and uses new technology (MySQL, Python-based Zope and Plone, andMSInfoPath to allow web-based data entry). See http://amrs.iukenya.org for more information.

(2) PIH-EMR, Peru

Background: In 1996 Partners In Health (PIH) started a treatment programme for drug-resistant tuberculosis in the slums of Lima, Peru. (A patient that is multi-drug resistant is infected with bacteria resistant to isoniazid and rifampin, the two most efficacious anti-tuberculous drugs.) The Partners In Health (PIH)-Electronic Medical Record (EMR) is a webbased Electronic Medical Record developed to support the two-year treatment regimen for these patients. It was implemented in 2001.
Number of sites: Peru: three; The Philippines: one.
Number of patients: 4300; 2900 have received treatment to date.
Design: Open source web system backed by an Oracle database. Bilingual English and Spanish.
Data entry: Forms filled out by the chest physicians, as well as laboratory result forms. Medication data is entered by the nurses and their assistants who manage the patients in each district on advice from the chest physicians.
Functions: The Partners In Health (PIH)-Electronic Medical Record (EMR) includes a clinical record with initial history, physical examination, laboratory results and medications on all patients receiving individualised treatment for MDR-TB. The custom medication order entry system provides advice on potential problems and feedback to the nurses, who can consult the physicians if, for example, a patient has new evidence of resistance to the drug they have been prescribed. Laboratory tests for second-line drug resistance are entered in Boston and Peru and accessible by staff in both sites.
The Partners In Health (PIH)-Electronic Medical Record (EMR) is also used to create monthly reports for the Global Fund and the Health Ministry. There is an extensive suite of web-based analysis tools for reporting and outcome monitoring. These include graphs of culture conversion rates (time until sputum culture becomes negative) and search tools for patients with particular resistance patterns and drug regimens.
Analysis tools are used to assess drug requirements based on the medications prescribed. The system is being extended to include all MDR-TB patients in Peru and linked to the main tuberculosis laboratories there.
Pharmacy management: Full inventory system and drug regimen analysis.
Evaluation: The medication order entry system was shown to produce significantly fewer errors than the previous paper and spreadsheet approach (17.4% to 3.3%, P < 0.0075). Drug requirements analysis tools are based on the medications prescribed, and have been shown to match the usage data in the pharmacy to within 3%
Significance: The Partners In Health (PIH)-Electronic Medical Record (EMR) demonstrates the strength and flexibility of a web-based approach when internet connectivity is available.
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HSF Fraser, P Biondich, D Moodley et al

Electronic Medical Record in developing country (2)

Potential benefits of Electronic Medical Records systems in developing countries

Although Electronic Medical Records systems have been shown to be feasible in developing countries, the problem of limited resources begs several questions. Do Electronic Medical Records systems contribute important benefits to healthcare projects? Is this use of information technology (IT) practical beyond a few well-funded pilot sites? Does it have a beneficial impact on patient care or the management of such healthcare organisations? What lessons can we pass on to other healthcare organisations to help them identify the most effective and sustainable technologies for Electronic Medical Records systems in these environments?
Rapid developments in IT have greatly reduced the costs of setting up information systems. Plans have recently been announced to develop a laptop PC for $100.16 Internet access is now relatively widely available in many developing countries (Peru, Ghana, etc.) and there exists a broad range of robust and flexible devices to manage data, including personal digital assistants (PDAs) and mobile phones.
In developing countries, healthcare information systems have been driven mainly by the need to report aggregate statistics for government or funding agencies.
Such data collection can be performed with simple paper forms at the clinic level, with all electronic data entry done centrally, but that approach tends to be difficult and time-consuming and may provide little or no feedback to the staff collecting data. Individual patient data that are collected and accessible at the point of care can support clinical management.
Clinicians can easily access previous records, and simple tools can be incorporated to warn of potential problems such as incompatible drugs. Physicians or nurses can check on the outcomes of individuals or groups of patients and perform research studies. Many of these functions will work well on paper or with simple spreadsheets for up to 100 patients but become very time-consuming and potentially unreliable with more than 1000 records, and virtually impossible with 10 000 or more.
Networked Electronic Medical Records systems allow laboratory data to be entered from distant sites, assisting prompt and effective patient management. Access to email or web communications allows staff to seek specialist advice from remote physicians. Assessing resource requirements and preventing drug stock shortages, while not normally a consideration for medical staff in developed countries, can be a critical issue in the developing world. It requires an accurate knowledge of numbers of patients with particular regimens or types of disease and knowledge of drug stocks and supply. Electronic Medical Records systems can also be used to track patient outcomes, compliance with therapy and to record surgical procedures. Finally, point-of-care data can be used to rapidly generate aggregate reports, which should be more complete and accurate because users will more likely recognise errors regarding their own patients. Incorporating multiple functions into the same information system allows reuse of data and should help to justify the basic costs of set-up and technical support. For example, in sites with no modern communications, a satellite internet connection might be justified purely to allow regular communication by email and possibly internet telephony. The benefits of web access for data management and medical education are additional.
summarises the benefits of Electronic Medical Records systems.

1. Improvement in legibility of clinical notes
2. Decision support for drug ordering, including allergy warnings and drug incompatibilities
3. Reminders to prescribe drugs and administer vaccines
4. Warnings for abnormal laboratory results
   
5. Support for programme monitoring, including reporting outcomes, budgets and supplies
6. Support for clinical research
7. Management of chronic diseases such as diabetes,hypertension and heart failure

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HSF Fraser, P Biondich, D Moodley et al

Electronic Medical Record in developing country (1)

Introduction

The developing world currently faces a series of health crises that threaten the lives of millions of people. Many of the worst-affected developing countries lack resources and robust healthcare infrastructures.
Recent statistics suggest that treating the rising tide of human immunodeficiency virus (HIV) in developing countries requires that large-scale interventions are immediately put into place, and ambitious worldwide initiatives such as the Global Fund and the World Health Organization (WHO) 3 by 5 Initiative have begun to mobilise resources and manpower in response.
Early lessons from treatment programmer indicate that new systems of care are required to allow these efforts to scale rapidly to thousands or even hundreds of thousands of patients. Programmer must also support healthcare providers, many of whom have limited training. To achieve these ends requires the ability to manage large and often complex projects, including the initiation of new treatments, the followup and monitoring of chronic diseases, medication procurement, and reporting to governments and funders. Research must also occur concurrently with these efforts, as the pathophysiology of these diseases is not fully understood in these environments, and continues to change in response to our interventions.
Many of these goals require excellent information management in order to be successful. Concerns have been expressed that the lack of infrastructure and skills in developing countries will prevent large-scale treatment of such diseases as HIV and multi-drug-resistant tuberculosis (MDR-TB). While HIV, TB and malaria are the best known, other important problems must be addressed, including maternal and infant mortality, other infectious diseases, trauma, and rising levels of hypertension, diabetes and cardiovascular disease in developing countries.
Growing use of electronic medical record (EMR) systems in Europe and the United States (US) has been driven by the belief that these systems can help to improve the quality of health care. Decision support systems, particularly for drug order entry, are becoming important tools in reducing medical errors. Email is important and widely used in healthcare systems, and access to medical data including online journals is expanding.
Even in resource-rich nations, the development of electronic medical record (EMR) systems is still an uncertain and challenging task, calling for a sensitive matching of local needs to available technologies and resources. Experience with creating electronic medical record (EMR) systems for the developing world is much more scarce; requirements, priorities and local constraints are less well understood and probably more heterogeneous.
Some settings in the developing world are similar to a European or US healthcare environment and can use similar software; other environments have very limited resources. It is impossible, therefore, to suggest a single electronic medical record (EMR) systems architecture and implementation that will fit all environments and needs. In this paper we focus on systems that can support health care in the very challenging impoverished environments where the vast majority of the world’s population live. A handful of projects in developing countries have now met the test of actual implementation in such settings and are in day-to-day use.
We first discuss the potential benefits of electronic medical record (EMR) systems in developing countries and then present short descriptions of several systems with which we are familiar that are in regular use.We then provide a taxonomy of system architectures and technology choices and comment on their applicability in particular kinds of environments, drawing on our practical experiences and the examples of deployed systems.We also present a number of challenging issues including reliable patient identification, data quality management, and data confidentiality and security. Finally, we conclude with mostly non-technical lessons learned from experience in successfully deploying systems.
This is intended as a practical guide for deploying and using electronic medical record (EMR) systems in developing countries rather than a review of all existing projects. Unfortunately few systems have been described in the literature and fewer evaluated, but a systematic review of such systems was published in 2002. (continue..)
HSF Fraser, P Biondich, D Moodley et al