PIH-EMR

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OpenMRS Workshop for Central America

Posted by jblaya on July 12, 2009

Workshop participantsWe just finished a 3 day (July 8-10, 2009) workshop on OpenMRS in Guatemala for Ministry of Health and CDC personnel from different Central American countries, though unfortunately those from Honduras were not able to make it because of the current conflict there.

During this workshop we addressed:

  • The current state of medical informatics in the world and lessons learned from developed countries in the implementation of Electronic Medical Records (EMRs)
  • Overview of the PEPFAR program and CDC’s involvement in the region
  • Overview of OpenMRS, it’s vision, and current implementations
  • Other open source projects working with OpenMRS such as mobile devices (OpenROSA) and DHIS.
  • Installation of OpenMRS and modules
  • Creation of concepts and forms
  • Working with cohort builder
  • Creating reports and exports

In a broad group discussion we also found what were the benefits and disadvantages of OpenMRS that were most important in this region.  They will be included in a separate document to be attached. Finally, we had small group discussions about possible implementations of OpenMRS in projects and clinical sites throughout the different countries represented at the meeting.  All were excited about the ability of OpenMRS to unify the many disparate information systems that were being implemented for all of the different programs in their respective countries.  Overall, the meeting ended with a lot of enthusiasm showing the need for a Latin American OpenMRS Implementers meeting, which should happen in Lima in late september.

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A Check Digit for Polyphemus

Posted by chaseinrwanda on June 26, 2008

“‘Cyclops, you asked my noble name, and I will tell it; but do you give the stranger’s gift, just as you promised. My name is Nobody. Nobody I am called by mother, father, and by all my comrades.’

“So I spoke, and from a ruthless heart he straightway answered: ‘Nobody I eat up last, after his comrades; all the rest first; and that shall be the stranger’s gift for you.’

–Odyssey, Book IX

Ever since the age of myth, the human race has been engaged in an epic struggle against mistaken identity. Oedipus unknowingly kills his father and marries his mother, because he does not know their true identity. The unlucky neighbors of Baucis and Philemon in Ovid’s tragic tale could have been spared if only they had a better way to accurately identify guests. Belle was lucky enough that the Beast’s true identity was a handsome prince, but most of us would prefer to know in advance. And of course, “Nobody” knows better than the now-blind cyclops the importance of accurately identifying visitors.

In the medical world, mistaking a patient’s identity can also have severe consequences. Imagine the following scenario. Annie Nonymous goes to the clinic for a scheduled visit and has blood work done. Annie Nonymous has a system ID of 12543912. The lab technician, who enters hundreds of lab tests into his computer every day, mistakenly types in Annie Nonymous’s system ID as 12543412 (which is actually the ID for Anne Nonymous). The next day, the doctor sees Annie’s CD4 count in Anne’s file and mistakenly starts Anne on ART instead of Annie! Of course, this is a simplified scenario, and in reality there are more opportunities to catch mistakes before they result in a change in drug regimen, but medical mistakes based on mistaken identity are indeed a serious problem. In fact, according to the Institute of Medicine, in the United States alone medical errors lead to around 100,000 patient deaths per year [1].

At Inshuti mu Buzima, we are taking a big step forward to prevent mistaken patient identity. From the beginning, we have been issuing patient identifiers that are verified with a check digit, generated according to Verhoeff’s Dihedral Check Digit Algorithm [2]. A check digit is a simply a letter appended to the end of an identifier that is calculated from the rest of the identifier string. You can play with generating check digits here: http://rwanda.pih-emr.org/verhoeff.html.

Although we have been issuing identifiers with check digits from the beginning, until now we had not actually been checking that check digit anywhere in the EMR. OpenMRS used to have the Luhn Check Digit Algorithm hard-coded into place, but we have recently rewritten the OpenMRS core to allow the addition of any check digit algorithm of the one’s choosing. We prefer the Verhoeff algorithm over Luhn because the Verhoeff algorithm guarantees to catch all single digit replacements and transpositions of adjacent digits. For example XXXaXXX will never have the same check digit as XXXbXXX, and XXXabXX will never have the same check digit as XXXbaXX. Luhn can also detect any single digit replacements, but it does not catch all transpositions of adjacent digits.

Now that we have the tools to detect mistaken identifiers, Cheryl, our data manager, is feverishly working to correct identifiers in the system we know are invalid, with the peace of mind to know that more will not be created. Although check digits are not able to prevent all cases of mistaken identity, we’re confident that together with the other systems of checks and balances we have in place, mankind’s ancient struggle against mistaken identity may be drawing to a close.

[1] To Err is Human:Building a Safer Health System. Institute of Medicine. Washington, DC: 1999.

[2] Wagner, Neal. “Verhoeff’s Decimal Error Detection”. The Laws of Cryptography with Java Code. p 54. San Antonio, TX: 2003. http://www.cs.utsa.edu/~wagner/lawsbookcolor/laws.pdf

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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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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 »

Welcome

Posted by pihemr on February 4, 2008

Welcome to the PIH-EMR Team Blog! We are a team of 12 people working on medical information systems for Partners In Health (PIH), a health care non-profit that works in developing countries. PIH provides free, high-quality health care in some of the poorest parts of the world including rural Haiti, Rwanda, Lesotho, Malawi and Mexico. We provide primary care, and specialize in the treatment of HIV. We also provide specialized treatment fro drug resistant tuberculosis in Peru and Russia, and now Haiti and Lesotho as well.

The EMR team develops and deploys electronic medical records – EMRs – for patients being treated for HIV or MDR TB who need long-term treatment. The need to closely monitor these patients and track their laboratory data and drug regimens presents a major challenge, especially in the resource-poor areas in which PIH works. All our EMR systems are web-based, starting with the original system for MDR TB patients in Peru in 2000-2001. We are now concentrating most of our effort on developing and deploying the OpenMRS system, a new open source EMR architecture jointly developed by PIH and the Regenstrief Institute in Indiana and the Medical Research Council in South Africa. This is now a growing open source project with developers and collaborators from the US, several African countries, Peru, Haiti and soon India.

In this Blog we will post our updates on the systems, and the progress in setting them up and using them in the 5 current PIH EMR sites. We will talk about the ideas behind the systems, the challenges we face and the progress in hardware software and useful data and some cool results from evaluation studies.

-Hamish Fraser

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