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). 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.
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
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.
(continue..)
HSF Fraser, P Biondich, D Moodley et al
