April 10, 2023April 10, 2023

Demonstrating the success of the e-health in resource poor (and developed)

economies. Making it work.

AIHI, UNSW28th June 2012.

DR TERRY J HANNAN MBBS;FRACP;FACHI;FACHI

HEALTH INFORMATICIAN

April 10, 2023April 10, 2023

Schema for presentation.

•The journey to Kenya•POWH-OCIS to CCCIS-lessons learnt•AMIA November 1999•Eldoret January 2000•MMRS to AMPATH to OpenMRS•AMIA 2007•Update on status of OpenMRS project•3 x short movies (~3-4mins each)• Questions

1982-1984 Non clinical evaluation

1984-1986 physician involvement and evaluation

1986-1987 Modification of program / dictionaries /screen displays / reports / units of measurement

1984-1987 ABSTRACT[SUMMARISATION] modification and implementation (Continuing evolution)

1986 MANUAL data entry of laboratory data

1987 MANUAL data entry by NURSING STAFF of clinical / protocol / chemotherapy data

1988-1989 AUTOMATED LABORATORY DATA TRANSFER

1989 REPORT GENERATOR functions(FLOWS &PLOTS)

1990-1992 Protocol generated care plans tested and evaluated

1990DRG diagnostic data electronically collated for administration [2nd art to CLINICAL DATA]. CLINICAL TRAILS module implemented

10 yearsHannan, T., International transfer of the Johns Hopkins Oncology Center clinical information system. MD Comput, 1994. 11(2): p. 92-9.

April 10, 2023April 10, 2023

“Bibles of Health Informatics”

April 10, 2023April 10, 2023

ACKNOWLEDGEMENTS FOR AMPATH/OPENMRS INFORMATION

W. TierneyAndrew S Kanter, Hamish SF Fraser,

Christopher J. Seebregts, Paul Biondich, Burke Mamlin,

Sylvester Kimaiyo, Charles Safran, Joaquin BlayaDave ThomasJoe Mamlin

Sylvester KimaiyoOpenMRS consortium participants www.openmrs.org

April 10, 2023April 10, 2023

Collaborators and Funders Collaborators and Funders Partners In HealthPartners In Health Regenstrief instituteRegenstrief institute Medical Research Council, South AfricaMedical Research Council, South Africa World Health OrganizationWorld Health Organization US Centers for Disease ControlUS Centers for Disease Control Brigham and Women hospitalBrigham and Women hospital Harvard Medical SchoolHarvard Medical School University of KwaZulu-NatalUniversity of KwaZulu-Natal Millennium Villages ProjectMillennium Villages Project International Development Research Centre, OttawaInternational Development Research Centre, Ottawa Rockefeller FoundationRockefeller Foundation Fogarty International Center, NIHFogarty International Center, NIH Boston Consulting GroupBoston Consulting Group Google IncGoogle Inc PEPFARPEPFAR

April 10, 2023April 10, 2023

Health care is an information business

Information is not a necessary adjunct to care, it is care, and effective patient management requires effective

management of patients’ clinical data. Donald M. Berwick President and CEO, Institute for

Healthcare Improvement

There is no health without management, and there is no management without information.

Gonzalo Vecina Neto, head of the Brazilian National Health Regulatory Agency

April 10, 2023April 10, 2023

TECHNOLOGY IS NOT THE PROBLEM[30 years EMR experience and research]

Retrieval times-Fast (blink times)Data and information-ComprehensiveData storage- Long-term-lifelongData applications-Introspective of total databaseData storage-

200 million coded observations3.25 million narrative reports15 million prescriptions212,000 ECG tracingsMore than 1.3 million patients

Access-1300 medical nurses1000 physicians220 medical studentsAcross health care institutions (16)Data access more than 628,000 / monthC.J. McDonald, et al, The Regenstrief Medical Record System: A quarter century experience. Int J

Med Inform 54 (1999), 225‑253.)

By products of the care processRESEARCH-accuracy / $ EPIDEMIOLOGYADMIN SUPPORT“Record once use many times”

April 10, 2023April 10, 2023 99

CCDSS TOOLS IN CLINICAL MEDICINE-REQUIREMENTS

1.ALERTING 2. REMINDING3. INTERPRETATION4.ASSISTING5.CRITIQUING6.DIAGNOSING7.MANAGING8. KNOWLEDGE ACCESS /COUPLING [“Medicine in Denial.” L.Weed,L.Weed.2011]

Pryor TA, Clayton PD. Decision support systems for clinical medicine. Tutorial 11.15th SCAMC.Nov. 17. 1991.

SUMMARISATION

1. Communication of health care is maintained using a Summary patient format in the ambulatory setting.Fries. J. Alternatives in medical record formats. Medical care. 1984;12:871-881

2. Summary patient record - information accessible four times faster- contains up to four times more information- Tabulated results allow physicians to better predict future trends in results Whiting-O’Keefe QW,Simborg DW,Epstein WV,Medical Care 1980;18:842-852

April 10, 2023April 10, 2023

USING PHYSICIAN INPATIENT ORDER WRITING ON MICROCOMPUTER WORKSTATIONS. REDUCTION IN HEALTH CARE RESOURCE UTILISATION

-12.7 -11.9-12.5

-15.3 -15.2

-10.5

-16

-14

-12

-10

-8

-6

-4

-2

0

TOTALBEDTESTDRUGOTHERLOS

Physician inpatient order writing on microcomputer workstations-effects on resource utilisation. WM Tierney and others. JAMA 1993;269:379-383

$3 million per year savings-(USA $65b)

April 10, 2023April 10, 2023

Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes.Ann Intern Med 1996 May 15

Intermountain Health Care, Salt Lake City, Utah, USA

STUDY DESIGN• Computer-based EMR system• Patients discharged January 1, 1988 to December 31, 1994• 162,196 patients

•Goal: to determine clinical and financial outcomes of the• antibiotic practice guidelines implemented through the • computer system

April 10, 2023April 10, 2023

Intermountain Health Care, Salt Lake City, Utah, USA

Overall antibiotic use: decreased 22.8%Mortality rates: decreased from 3.65% to 2.65%Antibiotic-associated ADE: decreased 30%Antibiotic resistance: remained STABLEAppropriately timed preoperative a/biotics: 40% to 99.1%Antibiotic costs per treated patient: decreased $122.66 to $51.90Acquisition costs for antibiotics: fell 24.8% to 12.9% ($987,547) to ($612,500)

Our Case-Mix index which measures patient acuity levels INCREASED during this period, meaning we were treating sicker and sicker patients while better utilizing the delivery of antibiotics.

Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes.Ann Intern Med 1996 May 15

April 10, 2023April 10, 2023

AMIA – November 1999An invitation from Prof. Bill TierneyTo KENYA Jan 2000

AIDS in AfricaAIDS in Africa The Global AIDS Pandemic at a Glance-2000

Leading infectious cause of adult death in the world Leading cause of death in adults aged 15–59 First case of AIDS recognized in 1981 40 million persons now living with HIV/AIDS, 50% women >70% of HIV-infected persons living in Africa 14,000 new infections daily Sexual transmission responsible for more than 85% of

infections 6 million in need of immediate treatment and fewer than 8%

receiving it

SOURCES: Quinn and Chaisson, 2004; WHO, 2003a,b.

AIDS in AfricaAIDS in Africa

In Kenya…In Kenya…2.5 million persons infected (15% of adults)2.5 million persons infected (15% of adults)44thth behind South Africa, India, and Nigeria behind South Africa, India, and Nigeria1 million AIDS orphans (of 31 million citizens)1 million AIDS orphans (of 31 million citizens) life expectancy has dropped 18 years in the life expectancy has dropped 18 years in the

past 5 years, from 65 → 47 yearspast 5 years, from 65 → 47 years

14-year collaboration between IU and MU14-year collaboration between IU and MU11stst 11 years → focus=educational exchange 11 years → focus=educational exchange In 2001 Joe Mamlin returnedIn 2001 Joe Mamlin returned

found >50% of the beds in Moi Hospital were found >50% of the beds in Moi Hospital were filled with young people dying of AIDSfilled with young people dying of AIDS

no ARVs, few antibiotics for opportunistic no ARVs, few antibiotics for opportunistic infectionsinfections

despair, depression, resignationdespair, depression, resignationThen…DanielThen…Daniel

One solution: Academic One solution: Academic collaborationcollaboration

April 10, 2023April 10, 2023

Limited resourcesLimited resources

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

A response to HIVA response to HIV

April 10, 2023April 10, 2023

Existing systems overburdenedExisting systems overburdened

30-40 million cases HIV/AIDs

April 10, 2023April 10, 2023

PreMMRS

Assignment: knowing there is a 14% prevalence of HIV/AIDS.What are the health information management needs here?

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

PreMMRS

Assignment: knowing there is a 14% prevalence of HIV/AIDS.What are the health information management needs here?

April 10, 2023April 10, 2023

MMRS data (2 years)63,728 visits

Diagnoses # Visits Drugs # Visits

Malaria 17,495 Paracetamol 24,944

URI 8,479 Fansidar 11,550

Septic wound 1,329 Quinine, injected 8,769

Gastroenteritis 964 Penicillin, injected 8,058

Tonsilitis 938 Quinine, oral 7,851

Wound (unspec.) 791 Penicillin, oral 4,753

Myalgia 700 Amoxicillin 4,725

Amebiasis 629 Depoprovera 4,443

Laceration 618 Piriton 3,766

Worms (unspec.) 544 Brufen 3,323

April 10, 2023April 10, 2023

MMRS data (2 years)63,728 visits

Diagnoses # Visits Drugs # Visits

Malaria 17,495 Paracetamol 24,944

URI 8,479 Fansidar 11,550

Septic wound 1,329 Quinine, injected 8,769

Gastroenteritis 964 Penicillin, injected 8,058

Tonsilitis 938 Quinine, oral 7,851

Wound (unspec.) 791 Penicillin, oral 4,753

Myalgia 700 Amoxicillin 4,725

Amebiasis 629 Depoprovera 4,443

Laceration 618 Piriton 3,766

Worms (unspec.) 544 Brufen 3,323

NO HIV

and NO T

B

April 10, 2023April 10, 2023

“We have lit a candle in the darkness of Africa”William Tierney.

Kenyan Gov’t: “This record system must be in every clinic in Kenya!”

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

A Year of Growth?A Year of Growth?

April 10, 2023April 10, 2023

A Year of Growth… One Year LaterA Year of Growth… One Year Later

April 10, 2023April 10, 2023

WHO/Evelyn HocksteinOutreach workers download completed forms into Mosoriot clinic's data management system daily. Automated alerts flag any alarming new symptoms to the attention of the responsible clinical officer, or when a patient has missed an appointment so that outreach workers can find out what is wrong.

An innovative home-care programme using hand-held computers is also being piloted in the region. Monica Korir, who is living with HIV and is trained as an outreach worker, interviews Paul Ekorok, 52, at his home in Captarit village and records his answers.

April 10, 2023April 10, 2023

WHO/Evelyn HocksteinIn Eldoret, Erika Muthoni Kigotho supervises 17 data entry specialists who have received training on HIV care and in spotting potential errors in record-keeping. Electronically generated paper charts, along with reminders for appropriate tests and treatment, are returned to Mosoriot within 48 hours of receipt.

Ezekiel Muruli transports charts daily from Mosoriot to Eldoret, about 25 kms away, where data from paper records are entered into a central electronic system. Direct electronic data transfer is not feasible because Mosoriot does not have high-speed Internet access.

April 10, 2023April 10, 2023

Early PHRS

April 10, 2023April 10, 2023

Salina- “Rattling bones syndrome”

Starvation!

April 10, 2023April 10, 2023

Salina on anti-retroviral therapy

April 10, 2023April 10, 2023

HIV is a treatable disease, but treating millions requires information management.

HIV is a treatable disease, but treating millions requires information management.

April 10, 2023April 10, 2023

Adult HIV/AIDS clinicsPediatric HIV/AIDS clinicsPrimary care – rural health clinicsPrimary care – urban well-child clinicsAntenatal and postnatal clinics Mother-baby register

Oncology clinicsMental health clinics Diabetes clinics Tuberculosis clinicsClinic pharmaciesClinical laboratories

Social worker assessmentsOutreach – patient follow-upDrug adherence assessments

Nutrition assessmentsFood supplement distributionMicrofinance program

AMPATH clinical and support programs capturing electronic data.ALL DISEASE STATES NOT JUST HIV/AIDS

AMPATH maintenance cost only $175/patient/year in 2007 and is now less than $100/patient/year in 2009

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

Birth of OpenMRS Collaboration-Regenstrief/PIH MEDINFO San Francisco 2007

Prof. Paul Biondich

A/Prof. Hamish Fraser

A/Prof. Burke Mamlin

The plural of anecdote is not data.The plural of anecdote is not data.

““we must remove ourselves from the we must remove ourselves from the

‘unscientific, non data driven personal ‘unscientific, non data driven personal

recommendations’ for care”. recommendations’ for care”.

Dr. M. Smith CHCF AMIA 2009Dr. M. Smith CHCF AMIA 2009

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,0002001NOV

DEC

2001JAN

FEB

MAR

APR

MAY

JUN

2002JUL

AUG

SEP

OCT

NOV

DEC

2003JAN

FEB

MAR

APR

MAY

JUN

2003JUL

AUG

SEP

OCT

NOV

DEC

2004JAN

FEB

MAR

APR

MAY

JUN

2004JUL

AUG

SEP

OCT

NOV

DEC

2005JAN

FEB

MAR

APR

MAY

JUN

2005JUL

AUG

SEP

OCT

NOV

DEC

2006JAN

1/02/2006

1/03/2006

1/04/2006

1/05/2006

1/06/2006

1/07/2006

1/08/2006

1/09/2006

1/10/2006

1/11/2006

1/12/2006

1/01/2007

1/02/2007

1/03/2007

1/04/2007

1/05/2007

1/06/2007

1/07/2007

1/08/2007

1/09/2007

1/10/2007

1/11/2007

1/12/2007

1/01/2008

1/02/2008

1/03/2008

1/04/2008

1/05/2008

1/06/2008

1/07/2008

1/08/2008

1/09/2008

1/10/2008

1/11/2008

1/12/2008

1/01/2009

1/02/2009

1/03/2009

1/04/2009

1/05/2009

1/06/2009

1/07/2009

1/08/2009

1/09/2009

1/10/2009

1/11/2009

1/12/2009

1/01/2010

1/02/2010

1/03/2010

1/04/2010

1/05/2010

1/06/2010

1/07/2010

1/08/2010

1/09/2010

1/10/2010

1/11/2010

1/12/2010

1/01/2011

1/02/2011

1/03/2011

1/04/2011

1/05/2011

1/06/2011

1/07/2011

1/08/2011

1/09/2011

1/10/2011

1/11/2011

1/12/2011

1/01/2012

Patients Enrolled by Month: Nov ’01 – Jan ‘12

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Cumulative Patients Enrolled: Nov ’01 – Jan ‘12

05,000

10,00015,00020,00025,00030,00035,00040,00045,00050,00055,00060,00065,00070,000

Patient Visits By Month: Nov ’01 – Jan ‘12

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

Cumulative Patient Visits: Nov ’01 – Jan ‘12

0200,000400,000600,000800,000

1,000,0001,200,0001,400,0001,600,0001,800,0002,000,0002,200,0002,400,0002,600,0002,800,0003,000,000

AMRS Observations By Month: Mar ’06 – Jan ‘12

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

80,000,000

90,000,000

100,000,000

110,000,000

120,000,000

Cumulative AMRS Observations By Month: Mar ’06 – Jan ‘12

April 10, 2023April 10, 2023

To improve care, you have to measure it. Not possible using current paper-based medical record systems. W.Tierney, Regenstrief Institute, Indiana.

The foundation for quality patient care is information – Comprehensive, Accurate, Up-to-the-minute clinical Information. Information management is care- E. Shortliffe, Stanford.

AMPATH PEER REVIEWED PUBLICATIONS SINCE 2000 ~160

ALL GRANTS AND CONTRACTS CURRENTLY FUNDED TO DATE (N=74) $40,928,084US

April 10, 2023April 10, 2023

MTCT-PlusProgram

AIDS ClinicalTrialsGroup

GN for Women’s &Children’s

HealthResearch

NHLBI Global Health

InitiativeIeDEA

April 10, 2023

OpenMRS

A web-based EMR…A web-based EMR…

April 10, 2023

Patient summaryand alerts

April 10, 2023April 10, 2023

OpenMRS is…OpenMRS is…

An Electronic Medical Record System

A data model

An API

An HIV system

A TB system

A Primary Care system

A developer community

An implementer community

… and more.… and more.

April 10, 2023April 10, 2023

Multiple usesMultiple uses

Turbo

Burnt ForestMosoriot

50 km

Amukura

Chulaimbo

Naitiri

Webuye

Teso

Kapsakwony

Kapenguria

Kitale

April 10, 2023April 10, 2023

OpenMRS sites - fall 2008OpenMRS sites - fall 2008

400,000 patients

April 10, 2023April 10, 2023

OpenMRS sites – Spring 2010

600,000 patients

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

OpenMRS in Peru March 2006-2007

In total, e-Chasqui will serve a network of institutions providing medical care for over 3.1 million people.

benefits the test always available during clinical decision making reducing duplicate tests performed

reducing the time and money spent by staff checking the status of their samples.

The cost to maintain this system is ~US$0.53 per sample or 1% of the National Peruvian TB program's 2006 budget.

Government support to distribute throughout Peru

A web-based laboratory information system to improve quality of care of tuberculosis patients in Peru: functional requirements, implementation and usage statistics. Blaya, J.A., et al., BMC Med Inform Decis Mak, 2007. 7: p.33

April 10, 2023April 10, 2023 7373

Features of OpenMRS Part 1

Security: User authentication Privilege-based access: User roles and permission system Patient repository: Creation and maintenance of patient data, including demographics, clinical observations, encounter data, orders, etc. Multiple identifiers per patient: A single patient may have multiple medical record numbers Data entry: With the FormEntry module, clients with InfoPath (included in Microsoft Office 2003 and later) can design and enter data using flexible, electronic forms. With the HTML FormEntry module, forms can be created with customized HTML and run directly within the web application. Data export: Data can be exported into a spreadsheet format for use in other tools (Excel, Access, etc.) Standards support: HL7 engine for data import Modular architecture: An OpenMRS Module can extend and add any type of functionality to the existing API and webapp.

April 10, 2023April 10, 2023 7474

Features of OpenMRS Part 1Patient workflows: An embedded patient workflow service allows patient to be put into programs (studies, treatment programs, etc.) and tracked through various states. Cohort management: The cohort builder allows you to create groups of patients for data exports, reporting, etc. Relationships: Relationships between any two people (patients, relatives, caretakers, etc.) Patient merging: Merging duplicate patients Localization / internationalization: Multiple language support and the possibility to extend to other languages with full UTF-8 support. Support for complex data: Radiology images, sound files, etc. can be stored as “complex” observations Reporting tools: Flexible reporting tools Person attributes: The attributes of a person can be extended to meet local needs

Lessons learnedLessons learned

Clinical information systems are possible in Clinical information systems are possible in even the most resource-constrained placeseven the most resource-constrained places

CollaborationCollaboration with established informatics with established informatics programs is a mustprograms is a must

Primary goals → Primary goals → sustainabilitysustainability of the EMR, of the EMR, independenceindependence of the developing country of the developing country

Start Start smallsmall and build to and build to serve local needsserve local needsAnticipate challenges and prepare for themAnticipate challenges and prepare for themMaintain hope and enthusiasmMaintain hope and enthusiasm

April 10, 2023April 10, 2023 AMPATH Medical Record System (AMRS): Collaborating Toward An EMR for Developing Countries Burke W. Mamlin, M.D. and Paul G. Biondich, M.D., M.S. Regenstrief Institute, Inc. and Indiana University School of Medicine, Indianapolis, IN

April 10, 2023April 10, 2023

WHAT OTHERS SAY ABOUT THE INDIANA-KENYA PARTNERSHIP

Nominated for the 2007 Nobel Peace Prize; featured in The Wall Street Journal

“The people working on this program are public health heroes. They are doing things that many people thought could never be done, and it is going to have a huge multiplier effect.”

--Dr. Tim Evans, former director of health equity for the Rockefeller Foundation

“Much more accurately described as an Academic MIRACLE in response to AIDS.”

--Michael E. Ranneberger, U.S. Ambassador to Kenya

“The most important and comprehensive HIV/AIDS effort in all of Africa.”

- James Morris, former executive director, United Nations World Food Program

April 10, 2023April 10, 2023

“Now HIV/AIDS programs are not only in place but some of them, including the partnership between the United States Agency for International Development (USAID) and the Academic Model Providing Access to Healthcare (AMPATH) are openly speaking of bringing the pandemic to its knees over the next 5 years through widespread screening and effective treatment and prevention of HIV.”

Braitstein, P., et al., "Talkin' about a revolution": How electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings. J Acquir Immune Defic Syndr, 2009. 52 Suppl 1: p. S54-7.

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023

April 10, 2023April 10, 2023