User Perceptions and Use of an Enhanced Electronic Health Record in Rwanda With and Without Clinical Alerts: Cross-sectional Survey.

BACKGROUND: Electronic health records (EHRs) have been implemented in many low-resource settings but lack strong evidence for usability, use, user confidence, scalability, and sustainability. OBJECTIVE: This study aimed to evaluate staff use and perceptions of an EHR widely used for HIV care in >300 health facilities in Rwanda, providing evidence on factors influencing current performance, scalability, and sustainability. METHODS: A randomized, cross-sectional, structured interview survey of health center staff was designed to assess functionality, use, and attitudes toward the EHR and clinical alerts. This study used the associated randomized clinical trial study sample (56/112, 50% sites received an enhanced EHR), pulling 27 (50%) sites from each group. Free-text comments were analyzed thematically using inductive coding. RESULTS: Of the 100 participants, 90 (90% response rate) were interviewed at 54 health centers: 44 (49%) participants were clinical and 46 (51%) were technical. The EHR top uses were to access client data easily or quickly (62/90, 69%), update patient records (56/89, 63%), create new patient records (49/88, 56%), generate various reports (38/85, 45%), and review previous records (43/89, 48%). In addition, >90% (81/90) of respondents agreed that the EHR made it easier to make informed decisions, was worth using, and has improved patient information quality. Regarding availability, (66/88) 75% said they could always or almost always count on the EHR being available, whereas (6/88) 7% said never/almost never. In intervention sites, staff were significantly more likely to update existing records (P=.04), generate summaries before (P<.001) or during visits (P=.01), and agree that "the EHR provides useful alerts, and reminders" (P<.01). CONCLUSIONS: Most users perceived the EHR as well accepted, appropriate, and effective for use in low-resource settings despite infrastructure limitation in 25% (22/88) of the sites. The implementation of EHR enhancements can improve the perceived usefulness and use of key functions. Successful scale-up and use of EHRs in small health facilities could improve clinical documentation, care, reporting, and disease surveillance in low- and middle-income countries.

Building workforce capacity for effective use of health information systems: Evaluation of a blended eLearning course in Namibia and Tanzania.

BACKGROUND: Electronic health information systems (HIS) are critical components of national health systems, and have been identified as a key element in the development and strengthening of health systems globally. Novel approaches are needed to effectively and efficiently train health care workers on the use of HIS. One such approach is the use of digital eLearning programs, either alone or blended with face-to-face learning activities. METHODS: We developed a novel blended eLearning course based on an in-person HIS training package previously developed by the United States Centers for Disease Control and Prevention. We then conducted a pilot implementation of the eLearning course in Namibia and Tanzania. RESULTS: The blended eLearning pilot program enrolled 131 people, 72 (55%) from Namibia and 59 (45%) from Tanzania. The majority of enrollees were female (n = 88, 67%) and were nurses (n = 66, 50%). Of the 131 people who participated in the in-person orientation, 95 (73%) completed some or all of the eLearning modules. Across all three modules, the mean score on the post-test was significantly greater than on the pre-test (p < 0.001). When comparing results from previous in-person workshops and the blended eLearning course, we found that participants experienced strong learning gains in both, although learning gains were somewhat greater in the in-person course. Blended eLearning course participants reported good to very good satisfaction with the overall content of the course and with the eLearning modules (3.5 and 3.6 out of 5-point Likert scale). We estimate that the total cost per participant is 2.2-3.4 times greater for the in-person course (estimated cost USD $980) than for the blended eLearning course (estimated cost USD $287-$437). CONCLUSION: A blended eLearning course is an effective method with which to train healthcare workers in the basic features of HIS, and the cost is up to 3.4 times less expensive than for an in-person course with similar content.

Scaling-up health information systems to improve HIV treatment: An assessment of initial patient monitoring systems in Mozambique.

INTRODUCTION: The rapid scale-up of HIV care and treatment in resource-limited countries requires concurrent, rapid development of health information systems to support quality service delivery. Mozambique, a country with an 11.5% prevalence of HIV, has developed nation-wide patient monitoring systems (PMS) with standardized reporting tools, utilized by all HIV treatment providers in paper or electronic form. Evaluation of the initial implementation of PMS can inform and strengthen future development as the country moves towards a harmonized, sustainable health information system. OBJECTIVE: This assessment was conducted in order to 1) characterize data collection and reporting processes and PMS resources available and 2) provide evidence-based recommendations for harmonization and sustainability of PMS. METHODS: This baseline assessment of PMS was conducted with eight non-governmental organizations that supported the Ministry of Health to provide 90% of HIV care and treatment in Mozambique. The study team conducted structured and semi-structured surveys at 18 health facilities located in all 11 provinces. Seventy-nine staff were interviewed. Deductive a priori analytic categories guided analysis. RESULTS: Health facilities have implemented paper and electronic monitoring systems with varying success. Where in use, robust electronic PMS facilitate facility-level reporting of required indicators; improve ability to identify patients lost to follow-up; and support facility and patient management. Challenges to implementation of monitoring systems include a lack of national guidelines and norms for patient level HIS, variable system implementation and functionality, and limited human and infrastructure resources to maximize system functionality and information use. CONCLUSIONS: This initial assessment supports the need for national guidelines to harmonize, expand, and strengthen HIV-related health information systems. Recommendations may benefit other countries with similar epidemiologic and resource-constrained environments seeking to improve PMS implementation.

Scaling-up health information systems to improve HIV treatment: An assessment of initial patient monitoring systems in Mozambique

Introduction­The rapid scale-up of HIV care and treatment in resource-limited countries requires concurrent, rapid development of health information systems to support quality service delivery. Mozambique, a country with an 11.5% prevalence of HIV, has developed nation-wide patient monitoring systems (PMS) with standardized reporting tools, utilized by all HIV treatment providers in paper or electronic form. Evaluation of the initial implementation of PMS can inform and strengthen future development as the country moves towards a harmonized, sustainable health information system. Objective­This assessment was conducted in order to 1) characterize data collection and reporting processes and PMS resources available and 2) provide evidence-based recommendations for harmonization and sustainability of PMS. Methods­This baseline assessment of PMS was conducted with eight non-governmental organizations that supported the Ministry of Health to provide 90% of HIV care and treatment in Mozambique. The study team conducted structured and semi-structured surveys at 18 health facilities located in all 11 provinces. Seventy-nine staff were interviewed. Deductive a priori analytic categories guided analysis. Results­Health facilities have implemented paper and electronic monitoring systems with varying success. Where in use, robust electronic PMS facilitate facility-level reporting of required indicators; improve ability to identify patients lost to follow-up; and support facility and patient management. Challenges to implementation of monitoring systems include a lack of national guidelines and norms for patient level HIS, variable system implementation and functionality, and limited human and infrastructure resources to maximize system functionality and information use. Conclusions­This initial assessment supports the need for national guidelines to harmonize, expand, and strengthen HIV-related health information systems. Recommendations may benefit other countries with similar epidemiologic and resource-constrained environments seeking to improve PMS implementation.

Automating indicator data reporting from health facility EMR to a national aggregate data system in Kenya: An Interoperability field-test using OpenMRS and DHIS2.

Introduction: Developing countries are increasingly strengthening national health information systems (HIS) for evidence-based decision-making. However, the inability to report indicator data automatically from electronic medical record systems (EMR) hinders this process. Data are often printed and manually re-entered into aggregate reporting systems. This affects data completeness, accuracy, reporting timeliness, and burdens staff who support routine indicator reporting from patient-level data. Method: After conducting a feasibility test to exchange indicator data from Open Medical Records System (OpenMRS) to District Health Information System version 2 (DHIS2), we conducted a field test at a health facility in Kenya. We configured a field-test DHIS2 instance, similar to the Kenya Ministry of Health (MOH) DHIS2, to receive HIV care and treatment indicator data and the KenyaEMR, a customized version of OpenMRS, to generate and transmit the data from a health facility. After training facility staff how to send data using DHIS2 reporting module, we compared completeness, accuracy and timeliness of automated indicator reporting with facility monthly reports manually entered into MOH DHIS2. Results: All 45 data values in the automated reporting process were 100% complete and accurate while in manual entry process, data completeness ranged from 66.7% to 100% and accuracy ranged from 33.3% to 95.6% for seven months (July 2013-January 2014). Manual tally and entry process required at least one person to perform each of the five reporting activities, generating data from EMR and manual entry required at least one person to perform each of the three reporting activities, while automated reporting process had one activity performed by one person. Manual tally and entry observed in October 2013 took 375 minutes. Average time to generate data and manually enter into DHIS2 was over half an hour (M=32.35 mins, SD=0.29) compared to less than a minute for automated submission (M=0.19 mins, SD=0.15). Discussion and Conclusion: The results indicate that indicator data sent electronically from OpenMRS-based EMR at a health facility to DHIS2 improves data completeness, eliminates transcription errors and delays in reporting, and reduces the reporting burden on human resources. This increases availability of quality indicator data using available resources to facilitate monitoring service delivery and measuring progress towards set goals.

What's Past is Prologue: A Scoping Review of Recent Public Health and Global Health Informatics Literature.

OBJECTIVE: To categorize and describe the public health informatics (PHI) and global health informatics (GHI) literature between 2012 and 2014. METHODS: We conducted a semi-systematic review of articles published between January 2012 and September 2014 where information and communications technologies (ICT) was a primary subject of the study or a main component of the study methodology. Additional inclusion and exclusion criteria were used to filter PHI and GHI articles from the larger biomedical informatics domain. Articles were identified using MEDLINE as well as personal bibliographies from members of the American Medical Informatics Association PHI and GHI working groups. RESULTS: A total of 85 PHI articles and 282 GHI articles were identified. While systems in PHI continue to support surveillance activities, we identified a shift towards support for prevention, environmental health, and public health care services. Furthermore, articles from the U.S. reveal a shift towards PHI applications at state and local levels. GHI articles focused on telemedicine, mHealth and eHealth applications. The development of adequate infrastructure to support ICT remains a challenge, although we identified a small but growing set of articles that measure the impact of ICT on clinical outcomes. DISCUSSION: There is evidence of growth with respect to both implementation of information systems within the public health enterprise as well as a widening of scope within each informatics discipline. Yet the articles also illuminate the need for more primary research studies on what works and what does not as both searches yielded small numbers of primary, empirical articles. CONCLUSION: While the body of knowledge around PHI and GHI continues to mature, additional studies of higher quality are needed to generate the robust evidence base needed to support continued investment in ICT by governmental health agencies.

Do interoperable national information systems enhance availability of data to assess the effect of scale-up of HIV services on health workforce deployment in resource-limited countries?

Sub-Saharan Africa (SSA) bears the heaviest burden of the HIV epidemic. Health workers play a critical role in the scale-up of HIV programs. SSA also has the weakest information and communication technology (ICT) infrastructure globally. Implementing interoperable national health information systems (HIS) is a challenge, even in developed countries. Countries in resource-limited settings have yet to demonstrate that interoperable systems can be achieved, and can improve quality of healthcare through enhanced data availability and use in the deployment of the health workforce. We established interoperable HIS integrating a Master Facility List (MFL), District Health Information Software (DHIS2), and Human Resources Information Systems (HRIS) through application programmers interfaces (API). We abstracted data on HIV care, health workers deployment, and health facilities geo-coordinates. Over 95% of data elements were exchanged between the MFL-DHIS and HRIS-DHIS. The correlation between the number of HIV-positive clients and nurses and clinical officers in 2013 was R2=0.251 and R2=0.261 respectively. Wrong MFL codes, data type mis-match and hyphens in legacy data were key causes of data transmission errors. Lack of information exchange standards for aggregate data made programming time-consuming.

An informatics agenda for public health: summarized recommendations from the 2011 AMIA PHI Conference.

The AMIA Public Health Informatics 2011 Conference brought together members of the public health and health informatics communities to revisit the national agenda developed at the AMIA Spring Congress in 2001, assess the progress that has been made in the past decade, and develop recommendations to further guide the field. Participants met in five discussion tracks: technical framework; research and evaluation; ethics; education, professional training, and workforce development; and sustainability. Participants identified 62 recommendations, which clustered into three key themes related to the need to (1) enhance communication and information sharing within the public health informatics community, (2) improve the consistency of public health informatics through common public health terminologies, rigorous evaluation methodologies, and competency-based training, and (3) promote effective coordination and leadership that will champion and drive the field forward. The agenda and recommendations from the meeting will be disseminated and discussed throughout the public health and informatics communities. Both communities stand to gain much by working together to use these recommendations to further advance the application of information technology to improve health.

Building the foundations of an informatics agenda for global health - 2011 workshop report.

Strengthening the capacity of public health systems to protect and promote the health of the global population continues to be essential in an increasingly connected world. Informatics practices and principles can play an important role for improving global health response capacity. A critical step is to develop an informatics agenda for global health so that efforts can be prioritized and important global health issues addressed. With the aim of building a foundation for this agenda, the authors developed a workshop to examine the evidence in this domain, recognize the gaps, and document evidence-based recommendations. On 21 August 2011, at the 2011 Public Health Informatics Conference in Atlanta, GA, USA, a four-hour interactive workshop was conducted with 85 participants from 15 countries representing governmental organizations, private sector companies, academia, and non-governmental organizations. The workshop discussion followed an agenda of a plenary session - planning and agenda setting - and four tracks: Policy and governance; knowledge management, collaborative networks and global partnerships; capacity building; and globally reusable resources: metrics, tools, processes, templates, and digital assets. Track discussions examined the evidence base and the participants' experience to gather information about the current status, compelling and potential benefits, challenges, barriers, and gaps for global health informatics as well as document opportunities and recommendations. This report provides a summary of the discussions and key recommendations as a first step towards building an informatics agenda for global health. Attention to the identified topics and issues is expected to lead to measurable improvements in health equity, health outcomes, and impacts on population health. We propose the workshop report be used as a foundation for the development of the full agenda and a detailed roadmap for global health informatics activities based on further contribution from key stakeholders. The global health informatics agenda and roadmap can provide guidance to countries for developing and enhancing their individual and regional agendas.

The profession of public health informatics: still emerging?

PURPOSE: Although public health informatics (PHI) was defined in 1995, both then and still now it is an "emerging" profession. An emergent profession lacks a base of "technical specialized knowledge." Therefore, we analyzed MEDLINE bibliographic citation records of the PHI literature to determine if a base of technical, specialized PHI literature exists, which could lead to the conclusion that PHI has emerged from its embryonic state. METHOD: A MEDLINE search for PHI literature published from 1980-2006 returned 16,942 records. Record screening by two subject matter experts netted 2493 PHI records that were analyzed by the intervals of previous PHI CBMs 96-4 and 2001-2 for 1980-1995 (I(1980)) and 1996-2000 (I(1996)), respectively, and a new, third interval of 2001-2006 (I(2001)). RESULTS: The distribution of records was 676 (I(1980)), 839 (I(1996)) and 978 (I(2001)). Annual publication rates were 42 (I(1980)), 168 (I(1996)), and 163 (I(2001)). Cumulative publications were accelerating. A subset of 19 (2.5%) journals accounted for 730 (29.3%) of the records. The journal subset average (+/-SD) annual publication rates of 0.7+/-0.6 (I(1980)), 2.9+/-1.9 (I(1996)), and 3.1+/-2.7 (I(2001)) were different, F(3, 64)=7.12, p<.05. Only I(1980) was different (p<.05) from I(1996) or I(2001). Average (+/-SE) annual rate of increase for all journals (8.4+/-0.8 publications per year) was different from the subset of 19 (2.7+/-0.3), t(36)=5.74, p<.05. MeSH first time-to-indexing narrowed from 7.3 (+/-4.3) years to the year (0.5+/-0.8) the term was introduced, t(30)=7.03, p<.05. CONCLUSION: A core set of journals, the proliferation of PHI articles in varied and numerous journals, and rapid uptake of MeSH suggest PHI is acquiring professional authority and now should not be tagged as an "emerging" profession.

Importance of public health informatics: a survey of public health schools and graduate programs in the United States.

This paper examines the importance of data, information, and informatics to public health practice. Forty public health academicians from 40 schools and graduate programs of public health were interviewed. All agreed that informatics was important to public health practice. A qualitative analysis of their comments revealed their beliefs on the importance of informatics skills and knowledge to the practice of public health. The resulting comment groups varied from "some skills are more important than others" to "need all the skills." Eight "importance" comment groups were formed: 1) skills for all professionals; 2) some skills more than others; 3) yes, they need all the skills; 4) skills to become better practitioners; 5) usefulness to practitioners; 6) communication with public; 7) they're [the public] are depending on us; and 8) the future.