Electronic Medical Records can improve the monitoring, evaluation, efficiency and quality of clinical services.  Implementation in a small rural clinic setting poses significant challenges.

 

Overview Action Steps Initial Phases EMR Evaluation and Piloting EMR Financial Planning EMR Roll-out Notes on EMR Options OpenMRS Patientos Baobab List of open-source EMR software systems:

 

Overview

Implementation in a rural, resource-deprived environment is challenging, owing to issues in hardware and software support, electricity reliability, low computer literacy, and lack of interfaces in non-English languages.  Nyaya Health aims to implement an EMR that has the following characteristics: 

1. able to be utilized by all providers, from physicians to midwives to community health workers
2. integrated across sites of clinical care (central hospital, satellite clinics, home-based care)
3. easily implementable in our setting; i.e., requires little software maintenance and minimal hardware requirements and does not require an on-site programmer
4. easily modifiable as new clinical needs arise
5. accessible to our global board of directors for evaluation and technical assistance
6. rapidly de-identifiable and sync-able with public, online databases for transparency and collaboration
7. rapidly sync-able with public reports, charts, and graphs that are accessible to individuals without an epidemiological or database background.
8. underlying software code be open-source
9. scalable to other sites throughout Nepal, including at government clinics

 

Action Steps

Initial Phases

In the initial roll-out of clinical services, Nyaya Health made the strategic decision to implement a "comprehensive patient database" rather than a true EMR.   This is implemented using Microsoft Access.  These data are used by our team to dialogue about improving clinical quality.  The database includes:

• patient reqistry
• outpatient visit notes
• registries of specific programs (e.g., TB, HIV, malnutrition, antenatal care, and safe delivery)
• registry of CHW services
• pharmaceuticals prescribed 

 

EMR Evaluation and Piloting

We need to develop a customized EMR that is feasible in our setting and test it out with our staff.  We need to:

• develop a provider interface that ideally would require only literacy in Nepali and minimal computer literacy
• pilot this interface with our midwives
• set up a program for data extraction and analysis
• set up the necessary computing/networking infrastructure

 

EMR Financial Planning

What are the costs of EMR implementation, including:

• hardware: laptops, servers, screens
• software: costs of any ancillary software, including the operating system of the computer
• personnel: upfront costs of programmer, then costs of maintenance personnel, including those who have a programming/technical background and who are lay persons.

 

EMR Roll-out

Ideally, we would aim for implementation in the summer of 2009. Nyaya has currently customized a version of PatientOS for testing at its site.

 

Notes on EMR Options

OpenMRS

OpenMRS (http://openmrs.org/wiki/OpenMRS).  Characteristics: 

• is widely used by international health groups
• has a large community developing it
• specifically aimed at developing world
• well-funded project, important for a free, open-source program
• designed more for a hiv/tb cohort studies than as a true EMR that is entered in and utilized by providers
• difficult user interface and a number of
• troublesome bugs that require a large IT team
• functional restrictions: not yet any kind of patient registration module built into OpenMRS, meaning that creating new patients isn't a registration-workflow friendly process.  Also, there's not a pharmacy system in OpenMRS yet either.
• not rapidly updated by lay persons, which is essential for a small clinic with evolving clinical needs  

Patientos

Patient OS (http://www.patientos.org).  Characteristics:

• fully customizable by a lay person, including updating all med supply lists and pharm lists and lab lists using just .csv files. 
• designed in XML allowing for customized interfaces
• less computer-resource-intensive
• implementable by a non-technical team
• only has a few developers at most working on it

 

Baobab

http://www.baobabhealth.org/

 

List of open-source EMR software systems:

http://en.wikipedia.org/wiki/List_of_open_source_healthcare_software#Electronic_health_or_medical_record