Andrew S. Kanter

The OpenMRS Implementers Network

OBJECTIVE OpenMRS (www.openmrs.org) is a configurable open source electronic medical record application developed and maintained by a large network of open source developers coordinated by the Regenstrief Institute and Partners in Health and mainly used for HIV patient and treatment information management in Africa. Our objective is to develop an open Implementers Network for OpenMRS to provide regional support for the growing number of OpenMRS implementations in Africa and to include African developers and implementers in the future growth of OpenMRS. METHODS We have developed the OpenMRS Implementers Network using a dedicated Wiki site and e-mail server. We have also organized annual meetings in South Africa and regional training courses at African locations where OpenMRS is being implemented. An OpenMRS Internship program has been initiated and we have started collaborating with similar networks and projects working in Africa. To evaluate its potential, OpenMRS was implemented initially at one site in South Africa by a single implementer using a downloadable OpenMRS application and only the OpenMRS Implementers Network for support. RESULTS The OpenMRS Implementers Network Wiki and list server have grown into effective means of providing implementation support and forums for exchange of implementation experiences. The annual OpenMRS Implementers meeting has been held in South Africa for the past three years and is attracting successively larger numbers of participants with almost 200 implementers and developers attending the 2008 meeting in Durban, South Africa. Six African developers are presently registered on the first intake of the OpenMRS Internship program. Successful collaborations have been started with several African developer groups and projects initiated to develop interoperability between OpenMRS and various applications. The South African OpenMRS Implementer group successfully configured, installed and maintained an integrated HIV/TB OpenMRS application without significant programming support. Since then, this model has been replicated in several other African sites. The OpenMRS Implementers Network has contributed substantially to the growth and sustainability of OpenMRS in Africa and has become a useful way of including Africans in the development and implementation of OpenMRS in developing countries. The Network provides valuable support and enables a basic OpenMRS application to be implemented in the absence of onsite programmers.

Millennium Global Village-Net: bringing together Millennium Villages throughout sub-Saharan Africa.

The Millennium Villages Project (MVP), based at The Earth Institute at Columbia University, is a bottom-up, community led approach to show how villages in developing countries can get out of the poverty trap that afflicts more than a billion people worldwide. With well-targeted, practical inputs can help the community invest in a path leading to self-sustaining development. There are 80 Millennium Villages clustered in 10 countries throughout sub-Saharan Africa. MVP is an important development process for empowering communities to invest in a package of integrated interventions aiming to increase food production, improve access to safe water, health care, education and infrastructure. The process benefits from synergies of the integrated approach and relies on community leadership as empowered by proven technological inputs. MVP is committed to a science-based approach to assess and monitor the progress of the communities towards clear objectives; the Millennium Development Goals (MDGs) and to do so with mechanisms that are scalable and sustainable. This approach offers much more than simply collecting and analyzing data since the mechanism used for recording progress would provide a bridge over the divide which separates the haves and the have-nots (by facilitating the sharing of solutions from one community to another bidirectionally). By so doing, it allows people to enhance their own futures in a sustainable manner. Solutions found in one community are transferable to similar communities in other MVP villages. To achieve this goal, the MVP requires an information and communication system which can provide both necessary infrastructure for monitoring and evaluation, and tools for communicating among the villages, cities and countries. This system is called the Millennium Global Village-Net (MGV-Net). It takes advantage of the latest in open source software (OpenMRS), databases (MySQL), interface terminology, a centralized concept dictionary, and uses appropriate technology locally for data entry.

A toolkit for e-health partnerships in low-income nations.

Collecting, managing, and communicating information is a critical part of delivering high-quality, efficient health care. Low-income countries often lack the information technology that is taking root in developed countries to manage health data and work toward evidence-based practice and culture. Partnerships between academic and government institutions in high- and low-income countries can help establish health informatics programs. These programs, in turn, can capture and manage data that are useful to all parties. Several partnerships among academic institutions and public and private organizations, in areas such as sub-Saharan Africa, Haiti, and Peru, are leading the way.

Capitalizing on the Characteristics of mHealth to Evaluate Its Impact

The field of mHealth has made significant advances in a short period of time, demanding a more thorough and scientific approach to understanding and evaluating its progress. A recent review of mHealth literature identified two primary research needs in order for mHealth to strengthen health systems and promote healthy behaviors, namely health outcomes and cost-benefits (Mechael et al., 2010). In direct response to the gaps identified in mHealth research, the aim of this paper is to present the study design and highlight key observations and next steps from an evaluation of the mHealth activities within the electronic health (eHealth) architecture implemented by the Millennium Villages Project (MVP) by leveraging data generated through mobile technology itself alongside complementary qualitative research and costing assessments. The study, funded by the International Development and Research Centre (IDRC) as part of the Open Architecture Standards and Information Systems research project (OASIS II) (Sinha, 2009), is being implemented on data generated by 14 MVP sites in 10 Sub-Saharan African countries including more in-depth research in Ghana, Rwanda, Tanzania, and Uganda. Specific components of the study include rigorous quantitative case-control analyses and other epidemiological approaches (such as survival analysis) supplemented by in-depth qualitative interviews spread out over 18 months, as well as a costing study to assess the impact of mHealth on health outcomes, service delivery, and efficiency.

Health worker perceptions of integrating mobile phones into community case management of malaria in Saraya, Senegal

BACKGROUND Although community case management of malaria increases access to life-saving care in isolated settings, it contends with many logistical challenges. Mobile phone health information technology may present an opportunity to address a number of these barriers. METHODS Using the wireless adaptation of the technology acceptance model, this study assessed availability, ease of use, usefulness, and job relevance of mobile phones by health workers in Saraya, Senegal. RESULTS This study conducted seven key informant interviews with government health workers, and three focus groups and 76 surveys with lay health workers. Principal findings included that mobile phones are already widely available and used, and that participants valued using phones to address training, stock management, programme reporting, and transportation challenges. CONCLUSIONS By documenting widespread use of mobile phones and health worker perceptions of their most useful applications, this paper provides a framework for their integration into the community case management of malaria programme in Saraya, Senegal.

Using social networking to understand social networks: analysis of a mobile phone closed user group used by a Ghanaian health team.

Background The network structure of an organization influences how well or poorly an organization communicates and manages its resources. In the Millennium Villages Project site in Bonsaaso, Ghana, a mobile phone closed user group has been introduced for use by the Bonsaaso Millennium Villages Project Health Team and other key individuals. No assessment on the benefits or barriers of the use of the closed user group had been carried out. Objective The purpose of this research was to make the case for the use of social network analysis methods to be applied in health systems research—specifically related to mobile health. Methods This study used mobile phone voice records of, conducted interviews with, and reviewed call journals kept by a mobile phone closed user group consisting of the Bonsaaso Millennium Villages Project Health Team. Social network analysis methodology complemented by a qualitative component was used. Monthly voice data of the closed user group from Airtel Bharti Ghana were analyzed using UCINET and visual depictions of the network were created using NetDraw. Interviews and call journals kept by informants were analyzed using NVivo. Results The methodology was successful in helping identify effective organizational structure. Members of the Health Management Team were the more central players in the network, rather than the Community Health Nurses (who might have been expected to be central). Conclusions Social network analysis methodology can be used to determine the most productive structure for an organization or team, identify gaps in communication, identify key actors with greatest influence, and more. In conclusion, this methodology can be a useful analytical tool, especially in the context of mobile health, health services, and operational and managerial research.

Standardizing Health-Care Data Across an Enterprise

Abstract Interoperability is achieved when two computing systems exchange information and the receiving system can meaningfully use the information exchanged. A key to achieving interoperability is data standardization, which is the translation of data into its canonical form in which there is a unique representation for each concept. By normalizing data into reference terminologies, data from various sources in the heath care ecosystem can be queried, aggregated, analyzed, and reused for a variety of purposes. However, conversion from locally used terminologies into normalized, reference terminologies can be a complex and resource-intensive process. Data standardization therefore requires substantial advance planning, focused implementation, and robust support services, as well as ongoing evaluation and improvement. Terminology Services is a collection of hardware and software components that can be used to facilitate data standardization across enterprise health information exchange. This chapter describes the process of and challenges inherent in data standardization, and it provides guidance for the design and implementation of Terminology Services.

Mobile phones and social structures: an exploration of a closed user group in rural Ghana

BackgroundIn the Millennium Villages Project site of Bonsaaso, Ghana, the Health Team is using a mobile phone closed user group to place calls amongst one another at no cost.MethodsIn order to determine the utilization and acceptability of the closed user group amongst users, social network analysis and qualitative methods were used. Key informants were identified and interviewed. The key informants also kept prospective call journals. Billing statements and de-identified call data from the closed user group were used to generate data for analyzing the social structure revealed by the network traffic.ResultsThe majority of communication within the closed user group was personal and not for professional purposes. The members of the CUG felt that the group improved their efficiency at work.ConclusionsThe methods used present an interesting way to investigate the social structure surrounding communication via mobile phones. In addition, the benefits identified from the exploration of this closed user group make a case for supporting mobile phone closed user groups amongst professional groups.

Development and Deployment of the OpenMRS-Ebola Electronic Health Record System for an Ebola Treatment Center in Sierra Leone

BACKGROUND Stringent infection control requirements at Ebola treatment centers (ETCs), which are specialized facilities for isolating and treating Ebola patients, create substantial challenges for recording and reviewing patient information. During the 2014-2016 West African Ebola epidemic, paper-based data collection systems at ETCs compromised the quality, quantity, and confidentiality of patient data. Electronic health record (EHR) systems have the potential to address such problems, with benefits for patient care, surveillance, and research. However, no suitable software was available for deployment when large-scale ETCs opened as the epidemic escalated in 2014. OBJECTIVE We present our work on rapidly developing and deploying OpenMRS-Ebola, an EHR system for the Kerry Town ETC in Sierra Leone. We describe our experience, lessons learned, and recommendations for future health emergencies. METHODS We used the OpenMRS platform and Agile software development approaches to build OpenMRS-Ebola. Key features of our work included daily communications between the development team and ground-based operations team, iterative processes, and phased development and implementation. We made design decisions based on the restrictions of the ETC environment and regular user feedback. To evaluate the system, we conducted predeployment user questionnaires and compared the EHR records with duplicate paper records. RESULTS We successfully built OpenMRS-Ebola, a modular stand-alone EHR system with a tablet-based application for infectious patient wards and a desktop-based application for noninfectious areas. OpenMRS-Ebola supports patient tracking (registration, bed allocation, and discharge); recording of vital signs and symptoms; medication and intravenous fluid ordering and monitoring; laboratory results; clinician notes; and data export. It displays relevant patient information to clinicians in infectious and noninfectious zones. We implemented phase 1 (patient tracking; drug ordering and monitoring) after 2.5 months of full-time development. OpenMRS-Ebola was used for 112 patient registrations, 569 prescription orders, and 971 medication administration recordings. We were unable to fully implement phases 2 and 3 as the ETC closed because of a decrease in new Ebola cases. The phase 1 evaluation suggested that OpenMRS-Ebola worked well in the context of the rollout, and the user feedback was positive. CONCLUSIONS To our knowledge, OpenMRS-Ebola is the most comprehensive adaptable clinical EHR built for a low-resource setting health emergency. It is designed to address the main challenges of data collection in highly infectious environments that require robust infection prevention and control measures and it is interoperable with other electronic health systems. Although we built and deployed OpenMRS-Ebola more rapidly than typical software, our work highlights the challenges of having to develop an appropriate system during an emergency rather than being able to rapidly adapt an existing one. Lessons learned from this and previous emergencies should be used to ensure that a set of well-designed, easy-to-use, pretested health software is ready for quick deployment in future.

A Communicative Landscape of Health Information Needs for Malaria Management in the Millennium Villages Project in Bonsaaso, Ghana

We performed a qualitative study (n=39) mapping the health information needs of stakeholders involved with malaria prevention and treatment in rural Ghana as part of a larger effort to develop integrated, scalable eHealth tools. Initial results can be categorized into four areas: health care delivery, data quality, technical problems and workforce‐related problems. This comprehensive review of information challenges in one area identifies fertile ground for potential improvement using health information technology. Introduction: Health Information Technology has the potential to improve health care in developing countries. Information tools that seamlessly integrate into the workflow of health care workers are essential to achieving this goal. In this paper we present a formative study to identify information gaps and needs of the different stakeholders involved in the prevention and treatment of malaria in rural Ghana. Our study maps the communication chains within the Millennium Villages Project (MVP) malaria program in Ghana with the following objectives: 1) To identify stakeholders that directly influence the halt and reduction of malaria incidence (boundary partners). 2) To identify the tasks related to their work and specifically to outline obstacles and challenges they face. 3) Assess the information needs for new potential eHealth support tools. Methods: This is a qualitative methods study involving interviews with key informants and review of existing documents. We developed a semi‐structured interview instrument. We conducted detailed interviews in the field with 36 persons and three others were performed via Skype. The interviews were conducted in English and Twi. The data were collected using hand‐written notes and some photos were taken of registries, medications, clinics and health workers. All the interviews were recorded and transcribed into English. The transcripts were analyzed using a descriptive content analysis approach. Results: We present initial findings based on a subset of 16 interviews with the remainder to follow. The current challenges were categorized into: health care delivery, data quality, technical problems and workforce‐related problems. Health Care Delivery challenges included difficulty with managing prescriptions, trouble with misdiagnosis, and drug and testing kit shortages. Some workers reported communication issues due to language barriers with the patients and some patients did not attend the clinics when they were referred and were not followed up. Data Quality problems specific to this environment included: poor timeliness of reports due to work overload, and transportation problems in the community. Lengthy and complex manual completion allowed for miscalculations and errors in aggregated data. Data are …