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