PIH-EMR

The PIH informatics team’s blog

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OpenMRS in the news!

Posted by pihemr on June 25, 2008

Coming off the heels of a successful conference in Durban, Paul Biondich from the Regenstrief Institute was interviewed by the BBC about OpenMRS. A podcast of the interview is available online, as is the article resulting from the interview.

Keep an eye out for upcoming blog entries about the OpenMRS Conference and the latest developments from PIH project sites!

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Collaboration with OpenELIS, an open source lab information system

Posted by jblaya on April 27, 2008

In the last few weeks the OpenMRS team along with collaborators from the University of Washington have been meeting with members of the OpenELIS team, an open source laboratory information management system (LIMS) that’s been implemented in Minnesota, Kansas, Missouri, and Vietnam. The members of this team are from the Association of Public Health Laboratories (APHL) and from labs in the US. Conversations have focused on how the OpenELIS group can learn from the community building experience of OpenMRS and how the two systems can connect to provide countries with the possibility of implementing both systems.

Our first meeting last month was extremely productive. Dr. Gail Cassell was also present. We’re now coordinating meetings to meet the two goals mentioned above: helping in creating an OpenELIS developer community and connecting both systems.

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Getting Connected

Posted by evanjmwaters on April 3, 2008

The last few weeks we have been working to keep the momentum from Hamish’s visit to Malawi in early February going by laying the groundwork for a rollout of the touchscreen-based Patient Registration / Patient Diagnosis Module.

Work had already begun in late 2007 as I travelled up to Lilongwe to work with Mike McKay and the team at Baobab to build the Patient Registration component of the system. We took the basic structure of Baobab’s existing registration module, which was integrated into their ART system and based on Version 1.0 of the OpenMRS datamodel, and rebuilt it as a standalone module writing directly to OpenMRS Version 1.1. We were able to make this application work side-by-side with our current implementation of the PIH EMR in Malawi. Since then we have been using it for creating the patients in our backlog of ART data, taking advantage of the unique National ID number that the application generates. Baobab has already issued id numbers for more than 500,000 patients in Malawi, or roughly 4% of the country’s 13 million people.

Going forward our intention is to fix a few remaining bugs in Patient Registration so that it is ready for real-time use at Neno Rural Hospital, and add the Patient Diagnosis component to capture the primary and secondary diagnosis, treatment prescribed and clinician comments. In the existing workflow at the hospital, clinicians record the diagnosis in the patient’s medical passport, a data clerk transcribes the information into the ‘Outpatient Register’, one of the many medical registries issued by the Ministry of Health, and the patient proceeds to the Pharmacy. To create a smooth transition, we intend to add the Patient Registration / Patient Diagnosis module as an intermediate step between the clinical visit and the paper registry. Once the hospital staff grows accustomed to the new electronic systems, we hope to modify the workflow slightly so that clinicians can record the diagnosis information directly during the consultation.

Our next steps include:

1.) Demonstration of the existing Patient Registration module to Ministry of Health staff working at Neno Rural Hospital

2.) Generating a list of diagnoses and prescriptions common to Neno

2.) Working with Baobab Developers to write the remaining code for the Patient Diagnosis module

3.) Interior and exterior renovations at the hospital to create the Patient Registration area

4.) Creating a wireless network link between the hospital, our offices at the Neno District Assembly, other offices, and our warehouse in Neno

The final details of our plans for Patient Registration / Patient Diagnosis are falling into place, and we are excited about the prospect of having the system up and running at Neno Rural Hospital sometime in the next few months. In the meantime we are also busy entering the existing data for ART patients at Neno Rural Hospital, and planning for a more robust integration of Baobab’s Ruby on Rails interface within OpenMRS.

Patient queue

 

Patients queue to have their diagnoses recorded in the Outpatient Register at Neno Rural Hospital

Concept

A room adjacent to the existing registration area will be converted to allow data clerks to register patients and record diagnoses using the new Patient Registration / Patient Diagnoses module.

 Pharmacy

A pharmacy technician fills prescriptions at Neno Rural Hospital. The Patient Diagnoses module will allow clinicians to print labels for prescriptions during the consultation, eventually this could be linked to a wharehouse/pharmacy stock management system.

New hospital

Patients queue at the Outpatient Register; construction of the new Neno District Hospital is visible in the background. Neno District Hospital is scheduled to open midyear, dramatically improving access to inpatient care for residents of Neno District.

Posted in Malawi | Tagged: , | 3 Comments »

How do you scale up (even a small system)?

Posted by jblaya on April 3, 2008

Over the past 3 years, we have implemented a tuberculosis (TB) laboratory information system to connect the laboratories and health centers in the Peruvian public health system. This laboratory information system, named “e-Chasqui” after the ancient Inca messengers, permits entry of all TB results at regional and national laboratories and immediate viewing of those results by clinical staff. In addition, the system includes applications to assess quality control, generate aggregate reports, notify health centers of new results or contaminated samples, and track enrolled patients and the status of pending laboratory tests. In 2005, we started the pilot with two laboratories and 12 health centers. It took about a year of working with the labs and the health centers to both get the system exactly right and for them to realize the benefits of it. I say that because since 2006 the use of the system by the health centers has exploded, increasing over 3 fold over the past year and a half. At the request of public health officials we have now expanded the use of this system to a total of four laboratories and 42 health centers that cover over three million people in Lima. But there are still about another 70 health centers that we’ve been asked to train in the next 3 months in one of the health districts and another 60 or so in the second health district. So how am I and the e-Chasqui data administrator going to be able to do all of the activities required for the randomized controlled trial we are performing, continue to support the current health institutions and the overarching study that we are a part of, and at the same time triple the number of users of the system? Well, we’ll know the answer in a few months…

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Power to the Clinics

Posted by pihemr on April 3, 2008

It’s something most people take for granted when they talk of implementing an EMR system anywhere, even in a developing country. We know to ask questions about Internet bandwidth, or how frequent blackouts might be, are there staff members with enough computer skills to operate the systems, etc. But in general, we take it for granted that there will be some kind of power. The rural mountains of Lesotho, however, don’t afford us the luxury of making this assumption. The tiny Sesotho villages operate much as they did when this mountain kingdom was formed in the 1800’s. Thatch-roofed rondavels dot the mountainsides with rows of maize filling in every spot of arable land and sheep grazing on the land above that. Fire and the traditional Basotho Blanket are the only measures for keeping warm in the harsh winters and transportation is primarily on horseback, although the occasional truck does wind its way through the mountains to provide stocks of lamp kerosene, Coca-Cola and Hansa beer to the rural shops. While the power grid has made its way to the primary townships in the mountains, the “last-mile” still remains far out of reach for all of the rural villages where PIH operates. The lack of a market in the impoverished villages have made the likelihood of the grid extending into these areas any time soon low at best. Generators, with relatively low initial costs seem like a good alternative, but factor in rising fuel costs and the sheer difficulty of hauling liters of petrol up to the sites and this option too becomes infeasible. The villages do enjoy plenty of year-round sunshine however, so when the Solar Electric Light Fund (SELF) was approached by PIH to bring solar power to the clinics it seemed like a perfect solution.

After months of planning, procuring and the shipping of two containers from the other side of the world had been completed, we were ready to begin the installation of the equipment at our sites. Our team was comprised of our leader Walt Ratterman, a solar expert from SELF, three local electricians and a couple of IT guys. The first task was to unpack and sort the shipping containers full of equipment into piles for each of the four sites. From there we loaded the equipment onto 4 ton trucks for the slow and arduous journeys to the sites. The equipment included solar panels, 140lb. batteries, racks, mounting poles and a whole host of electrical equipment. Two of the trucks completed their journeys without incident, while the other two got stuck at river crossings that required their offloading and reloading onto boats or smaller 4×4 pickups for the rest of the journey. With the equipment onsite and the team in place we began assembling the various components that after a few days of work, resulted in the lights being flipped on for the first time in these villages. The idea of these rural villages skipping entire generations of electrical production and jumping right to an eco-friendly and sustainable solution is heartening indeed. Patients can now be attended to at night, doctors have the facility for crucial laboratory equipment and our laptops running OpenMRS now have a place to plug into. Soon Internet will follow and these clinics will take a leap forward into the 21st century with all the advantages that modern communication, telemedicine and electronic record keeping have to offer.

-Jeremy

 

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Observing a Usability Test at Kayak.com

Posted by hsiung on March 20, 2008

On Monday 3/17, Darius & Bob had the privilege of attending a Kayak.com usability session. Paul English, one of the founders of Kayak.com, is both a usability evangelist/guru and a huge PIH supporter. Since we are actively working on redesigning the OpenMRS user interface, he generously invited us to take an inside peek at how they conduct their usability tests there.

The set up was pretty simple. The test user was given a set of tasks to perform and was instructed to talk through his thought process aloud as he tried to perform the tasks. We sat in an adjacent room with 4-5 Kayak employees watching a projected copy of his monitor and listening to him talk.

It was pretty fascinating – especially with Paul (what is it with guys named Paul?) sitting there adding his insights. Obviously an airline ticket/hotel search application is very different from an open source medical records system, but there are definitely basic principles that hold true for both applications. Principles like – “Faster is better.”, “Not making people think is good.”… Not exactly rocket science, for sure, but it was eye-opening to watch an actual user make assumptions and mull over interfaces that everyone assumed were completely intuitive.

Here’s just one small example from this test. People in the room were shaking there heads when this particular user expressed surprise that a certain fare was more expensive than he thought it should be. “It’s a first class ticket! It says ‘1st’ right there!” someone said.

“Well… why isn’t he seeing it? Maybe that indicator should be right next to the price rather than on the side (everyone slaps their foreheads), maybe it should say ‘first class ticket’ rather than just ‘1st’ (more forehead slaps) Or maybe he really needs to be told explicitly that there are no available economy class tickets for this route. (doh!)”

“Actually, we really should continue to focus on the test & not talk about potential solutions at this point,” Paul said to us quietly. “The really important thing is that we’ve identified a problem that this user is having and if he’s having it, you can bet that there are a whole lot of other users out there having the same sort of problems.

Our attention to usability has given us a lot of success, but we can’t afford to let that make us arrogant. We have to stay humble. We will always have a lot to learn from our users to help us to continue to improve their user experience. This is why these tests are essential.”

(For more on the progress of the OpenMRS redesign, check out the OpenMRS wiki – http://openmrs.org/wiki/WorkingGroup/EndUserInterface)

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Synchronization… at last

Posted by christianallen on March 4, 2008

It’s not time to throw the confetti yet. But maybe we can throw just a little for now.

In November, the EMR Team attempted to rollout an edition of the EMR at the Rwanda Project that included “Synchronization”. Synchronization, for those of you that haven’t heard this little buzzword, is the ability for different machines to automatically communicate data about our patients back and forth with each other. The benefits of this are many. We can have offline entry in at sites with no computers or electricity by bringing a laptop and then have that data copied back to a central database. In sites like Lesotho where there is no internet connectivity at some of the sites, a single roaming data team member can go from site to site collecting data on a flash drive and then have it merge in to a central EMR database back in Maseru. Theoretically, data from all project sites could be accumulated in Boston for high-level analysis.

The rollout of the Synchronization Edition of the EMR was a tricky process for 2 reasons. For one, Synchronization was the single largest change to the system since the creation of the new EMR (EMR 2.0, aka OpenMRS), not to mention the most likely to cause corruption of medical data. Secondly, the rollout had to take place in a relatively short window of time during which a member of the EMR Team was actually in Rwanda. Sadly, on the day of launch the shuttle failed inspection, and Synchronization was held at Cape Canaveral indefinitely, until another window opened.

In Febuary, the skies opened again for the Synchronization Edition of the EMR to launch. This time, with luck and hard work on the part of a few dedicated developers, it passed inspection and the countdown began.

5…4…3…2…1…

On February 7, the button was pushed, and another, identical EMR came online in Kirehe. For the remainder of the day, all changes and entries that were done in Rwinkwavu magically appeared minutes later in Kirehe. Changes made in Kirehe magically appeared minutes later in Rwinkwavu. A team of extremely nerdy people looked on from a control room with anxiety and awe. By 5pm, the data entry teams had gone home for the day, and the shuttle appeared to still fly straight. It was a brief but welcomed victory.

The next day, Synchronization held strong again. And the next day. And the next. By the end of the first week of usage, the team encountered their first minor setback, but the problem was quickly corrected and the launch back on target. Another week went by. Still no problems.

At this point, Synchronization has been running without error, copying all kinds of data back and forth between the distant project sites for almost 4 weeks. To date, it has successfully copied over 75,000 changes between the sites. It is done so automatically and in the background. The entry teams working at the sites don’t even notice that it is happening, but instead can focus on the priorities and daily tasks. The only thing they really notice is that now entry is fast and efficient, since they have their own, local version of the EMR.

Most hospital systems in the Western world are unable to successfully set up systems that provide universal access to patient data, such that a patient can check in to multiple facilities and those facilities have instant (yet secure) access to their patient charts. But we have it in the Eastern Province of Rwanda. And we’ll have it soon at our other sites.

So why no confetti yet? Because we’re not finished. There still remain a growing number of sites in Rwanda that don’t have their server set up yet. Or they have a server that is being tested, but hasn’t been shipped out to the site yet. Also, Synchronization is not yet ready for the greater OpenMRS community – the vast number of people who have started to use our EMR. It still needs a simpler and more intuitive setup process.

No – there will be no confetti and champagne for Hamish, Darius, and their team yet. But maybe, just maybe, we could throw a *little* bit for this one small step for the EMR Team.

Posted in Rwanda, Uncategorized | Tagged: , | 3 Comments »

Haiti Trip – Chloe’s last week

Posted by djazayeri on February 26, 2008

I just spent a short and hectic week in Haiti, getting to meet our new data manager Wislene, and doing some planning with Patrice, Chloe, and Louise, as we prepare for Chloe to leave us. We’ve always intended for the blan data manager position to be a temporary one. And Wislene seems very capable of taking over that role. But we did share a brief and heartfelt conversation: “I’m nervous.” “Me too.” Chloe, like Mary Montgomery before her, leaves some big shoes to fill.

My last trip to Haiti was a year ago, in February of 2007. Coming back exactly twelve months later gave me an opportunity to reflect on a few things:

We’ve come a long way in the last year
A year ago, Chloe wasted literally weeks every month comparing EMR-generated numbers numbers to the sites’ reported numbers, making sure that box 2 + box 3 = box 7 + box 8, and retyping all that into Excel.
Today the EMR just generates the Excel file with the right numbers. If that sounds a lot easier, it is.

Implementing new systems takes a lot of time
It took most of that intervening year to make all those changes, both on the programming end and the human end. You just have to accept that nothing is ever easy and quick, even obviously-beneficial changes.

The reporting system that Chloe, Mike, and I put together last year has changed everything
Really, it’s made all the difference. That and the countless hours that the Haitian data team has spent entering data.

Kompa dancing is fun
Not strictly related to the previous points, but it had to be mentioned. Someday I have to make it to Haiti for Carnival.

I feel confident
Perhaps I should be more worried, but I really am feeling confident that, if we can just get the Haitian team a few specific resources, they’ll have no problem doing an unexpected and very fast transition from having an expat data manager to doing that work within the team. A year ago I would have thought that was crazy talk. Did I mention we’ve come a long way in a year?

What was that about resources?
Funny you should ask: we need to get another couple data clerks, and a car.

As a side-note there have been two ground-shifting developments since my last Haiti trip:

  1. There’s cellphone coverage over the whole central plateau. On the downside I won’t be able to blame skype connections for my poor Creole skills when I talk to Wislene. There are probably upsides too.
  2. There’s a paved road up Mon Cabri. Remember that whole bit in Mountains Beyond Mountains about the dirt road? Well, it’s somewhat less true today.

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January visit to Peru

Posted by ellenball on February 25, 2008

The January trip to Peru was very successful. I spent the majority of time working with Juan Tomayllo to prepare for the Fitness Study (Meche’s R01/Estudio Epi). By the time I left, all the Estudio Epi V2.1 forms were implemented on OpenMRS. There are currently a total of 17 forms. Juan had done so much work. I was happy to help complete a few forms, troubleshoot some problems, discuss testing, and update the OpenMRS application and database. The server for the project is http://estudioepi.pih-emr.org:8080/openmrs.

Juan has also built a field database application using .NET and MySQL which has 2 other forms with demographic information about the contacts and indices (names and addresses). This data will be kept separately from the study data. Juan has done a great job with this application. It looks very simple to use.

Most of one day was spent at the warehouse in Carabayllo. The trip and tour were very interesting. The IT staff in Lima (Pablo Rordiguez and Jorge Rojas) are building a pharmacy system in the Peru EMR1 (following Pablo’s training here). It should be ready soon. This system will replace 2 other systems (LOLCLI and SESALM), and it’s great that Peru is writing new code and putting together this cleaner interface along with the current EMR1. I spent lots of time with Jorge and Pablo installing a new Linux server with RedHat, Oracle, etc for the warehouse software, and also added their new software (logistics) to subversion.  Ceviche restaurant in Carabayllo

It was a thrill to go to Lima, Peru. In my 4 years with PIH, this was my first trip. I was fortunate have such great colleagues visiting at the same time — Darius, Molly, Sasha, Joaquin, Evie and Rachel. It was great to see old friends (Pablo), meet colleagues that I feel like I already knew (Odalys, Juan, Nadia, Jorge and Reiko), and see the casa, office and Lima.

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PIH EMR plans in Malawi

Posted by hfraser on February 12, 2008

I just returned from a 10 day visit to Malawi to finalize plans for the EMR system for the newest PIH hospitals and clinics in Neno. The clinic there belongs to the Malawian government and we have been partnering with them and the Clinton-Hunter Foundation initiative to build a new hospital and build or renovate several smaller clinics in the area. Neno is in the hills of southern Malawi about 90 minutes drive from the main Lilongwe to Blantyre road, and has a post office, a large market and a local government building as well as the clinic. PIH is providing primary care currently with three expat physicians as well as local nurses and other healthcare worker (Malawi has about the lowest number of physicians per head in the world). We are also running an HIV clinic and have several hundred patients on ARV treatment at present. The site has stable power from the grid, and Satellite Internet access set up by PIH.

Malawi is not new to the EMR business, Baobab Health Partnership (www.baobabhealth.org) led by Gerry Douglas have been working there for 7 years and have deployed innovative touch screen electronic data systems in hospitals in Lilongwe and Blantyre. Baobab have recently re-factored their system to run on the OpenMRS data model using Ruby on Rails as the development environment. This has given us the opportunity to explore using their well developed interface and workflow tailored to the Malawi health system while also using all the tools of OpenMRS and the strength of the OpenMRS collaborative. Our plan is to start with a simple patient registration system that prints out a bar coded patient ID card and link that with a tool to allow the physicians to code the patient diagnoses. We will the adapt the Baobab touch screen HIV data capture module to the PIH forms and add a third module for socio-economic data. Initially the two systems are running side by side on the same instance of MySQL but we are exploring the creation of an API to allow Ruby to talk to the OpenMRS middle layer and so become a robust development environment for new forms and interfaces. One of the current SSOC students, Jeff is working with Baobab on an initial version of these tools. More soon…

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