Solving a Health Information Management Problem. An international success story.

The management of health care delivery requires the availability of effective 'information management' tools based on e-technologies [eHealth]. In developed economies many of these 'tools' are readily available whereas in Low and Middle Income Countries (LMIC) there is limited access to eHealth technologies and this has been defined as the "digital divide". This paper provides a short introduction to the fundamental understanding of what is meant by information management in health care and how it applies to all social economies. The core of the paper describes the successful implementation of appropriate information management tools in a resource poor environment to manage the HIV/AIDS epidemic and other disease states, in sub-Saharan Africa and how the system has evolved to become the largest open source eHealth project in the world and become the health information infrastructure for several national eHealth economies. The system is known as Open MRS [www.openmrs.org). The continuing successful evolution of the OpenMRS project has permitted its key implementers to define core factors that are the foundations for successful eHealth projects.

The sustainability of Medical Morning Handover Reporting: adherence in a regional hospital.

BACKGROUND: The Medical Morning Handover Report is a form of clinical handover and is considered to be an essential mechanism for continuity of care and adverse event minimisation within a hospital environment. It is considered a significant Quality of Care activity recommended in Australian Medical Association clinical handover guidelines. The sustainability of such activities has not been reported. AIM: We aimed to assess the sustainability of Medical Morning Handover Reporting (MMHR) in the Department of Medicine at the Launceston General Hospital since its implementation in 2001. METHODS: We conducted a quality improvement survey amongst the medical staff (pre-graduate and post graduate medical faculties) to assess its sustainability since implementation in 2001. RESULTS: There were 30 respondents of whom 19 attended MMHR daily, four attended weekly, and only five attended less than weekly. Attendance rates at MMHR were maintained from 2001 to 2009 based on comparisons with previously conducted surveys. CONCLUSIONS: This study shows MMHR is sustainable and has evolved in format to incorporate advances in Health Information Technology. We believe adherence is dependent on providing leadership and structure to MMHR.

The AMPATH medical record system: creating, implementing, and sustaining an electronic medical record system to support HIV/AIDS care in western Kenya.

Providing high-quality HIV/AIDS care requires high-quality, accessible data on individual patients and visits. These data can also drive strategic decision-making by health systems, national programs, and funding agencies. One major obstacle to HIV/AIDS care in developing countries is lack of electronic medical record systems (EMRs) to collect, manage, and report clinical data. In 2001, we implemented a simple primary care EMR at a rural health centre in western Kenya. This EMR evolved into a comprehensive, scalable system serving 19 urban and rural health centres. To date, the AMPATH Medical Record System contains 10 million observations from 400,000 visit records on 45,000 patients. Critical components include paper encounter forms for adults and children, technicians entering/managing data, and modules for patient registration, scheduling, encounters, clinical observations, setting user privileges, and a concept dictionary. Key outputs include patient summaries, care reminders, and reports for program management, operating ancillary services (e.g., tracing patients who fail to return for appointments), strategic planning (e.g., hiring health care providers and staff), reports to national AIDS programs and funding agencies, and research.

An electronic medical record system for ambulatory care of HIV-infected patients in Kenya.

Administering and monitoring therapy is crucial to the battle against HIV/AIDS in sub-Saharan Africa. Electronic medical records (EMRs) can aid in documenting care, monitoring drug adherence and response to therapy, and providing data for quality improvement and research. Faculty at Moi University in Kenya and Indiana and University in the USA opened adult and pediatric HIV clinics in a national referral hospital, a district hospital, and six rural health centers in western Kenya using a newly developed EMR to support comprehensive outpatient HIV/AIDS care. Demographic, clinical, and HIV risk data, diagnostic test results, and treatment information are recorded on paper encounter forms and hand-entered into a central database that prints summary flowsheets and reminders for appropriate testing and treatment. There are separate modules for monitoring the Antenatal Clinic and Pharmacy. The EMR was designed with input from clinicians who understand the local community and constraints of providing care in resource poor settings. To date, the EMR contains more than 30,000 visit records for more than 4000 patients, almost half taking antiretroviral drugs. We describe the development and structure of this EMR and plans for future development that include wireless connections, tablet computers, and migration to a Web-based platform.

Installing and implementing a computer-based patient record system in sub-Saharan Africa: the Mosoriot Medical Record System.

The authors implemented an electronic medical record system in a rural Kenyan health center. Visit data are recorded on a paper encounter form, eliminating duplicate documentation in multiple clinic logbooks. Data are entered into an MS-Access database supported by redundant power systems. The system was initiated in February 2001, and 10,000 visit records were entered for 6,190 patients in six months. The authors present a summary of the clinics visited, diagnoses made, drugs prescribed, and tests performed. After system implementation, patient visits were 22% shorter. They spent 58% less time with providers (p < 0.001) and 38% less time waiting (p = 0.06). Clinic personnel spent 50% less time interacting with patients, two thirds less time interacting with each other, and more time in personal activities. This simple electronic medical record system has bridged the "digital divide." Financial and technical sustainability by Kenyans will be key to its future use and development.

A national survey of medical morning handover report in Australian hospitals.

OBJECTIVE: To investigate the prevalence and format of medical morning handover report (MMHR) in Australian hospitals. DESIGN, SETTING AND PARTICIPANTS: Questionnaire survey faxed to 76 Australian hospitals accredited for basic physician training by the Royal Australasian College of Physicians (RACP). The survey was conducted in 2005. MAIN OUTCOME MEASURES: Use of MMHR; structure and format of meetings. RESULTS: 53 of 76 (70%) hospitals responded. However, some data (1.7% of possible responses) were missing or illegible. Prevalence of the use of MMHR in respondent hospitals was 58% (31/53). Analysing the data by RACP accreditation level, 18/24 Level 3 hospitals (75%) conducted MMHR compared with 5/9 Level 2 hospitals (56%) and 7/18 Level 1 hospitals (39%) (odds ratio [OR] for trend, 2.17; 95% CI, 1.12-4.23; P = 0.023). 44 of 53 respondents reported their Rural, Remote and Metropolitan Areas (RRMA) classification. MMHR is less likely to be held in hospitals in regions classified as RRMA 2-4 (8/21 [38%]) than those in capital cities (RRMA 1) (16/23 [70%]) (OR, 0.27; 95% CI, 0.08-0.95; P = 0.042). In 62% of hospitals, MMHR was chaired by a consultant, and at most hospitals (23/31 [74%]), meetings were 15-30 minutes long. CONCLUSIONS: In spite of RACP accreditation requirements, the use of MMHR in Australian hospitals accredited for basic physician training is low.

A call for collaboration: building an EMR for developing countries.

Millions of people are either living with or dying from HIV/AIDS; most of this living and dying is taking place in developing countries. There is an immediate need for electronic medical record systems to help scale up HIV/AIDS prevention and treatment programs, reduce critical human errors, and support the research necessary to guide future efforts. Several groups are working on this problem, but most of this work is occurring within silos. To be more effective, we must find ways to collaborate.

Crossing the "digital divide:" implementing an electronic medical record system in a rural Kenyan health center to support clinical care and research.

To improve care, one must measure it. In the US, electronic medical record systems have been installed in many institutions to support health care management, quality improvement, and research. Developing countries lack such systems and thus have difficulties managing scarce resources and investigating means of improving health care delivery and outcomes. We describe the implementation and use of the first documented electronic medical record system in ambulatory care in sub-Saharan Africa. After one year, it has captured data for more than 13,000 patients making more than 26,000 visits. We present lessons learned and modifications made to this system to improve its capture of data and ability to support a comprehensive clinical care and research agenda.