Hamish S. F. Fraser

Comprehensive Treatment of Extensively Drug-Resistant Tuberculosis

BACKGROUND Extensively drug-resistant tuberculosis has been reported in 45 countries, including countries with limited resources and a high burden of tuberculosis. We describe the management of extensively drug-resistant tuberculosis and treatment outcomes among patients who were referred for individualized outpatient therapy in Peru. METHODS A total of 810 patients were referred for free individualized therapy, including drug treatment, resective surgery, adverse-event management, and nutritional and psychosocial support. We tested isolates from 651 patients for extensively drug-resistant tuberculosis and developed regimens that included five or more drugs to which the infecting isolate was not resistant. RESULTS Of the 651 patients tested, 48 (7.4%) had extensively drug-resistant tuberculosis; the remaining 603 patients had multidrug-resistant tuberculosis. The patients with extensively drug-resistant tuberculosis had undergone more treatment than the other patients (mean [+/-SD] number of regimens, 4.2+/-1.9 vs. 3.2+/-1.6; P<0.001) and had isolates that were resistant to more drugs (number of drugs, 8.4+/-1.1 vs. 5.3+/-1.5; P<0.001). None of the patients with extensively drug-resistant tuberculosis were coinfected with the human immunodeficiency virus (HIV). Patients with extensively drug-resistant tuberculosis received daily, supervised therapy with an average of 5.3+/-1.3 drugs, including cycloserine, an injectable drug, and a fluoroquinolone. Twenty-nine of these patients (60.4%) completed treatment or were cured, as compared with 400 patients (66.3%) with multidrug-resistant tuberculosis (P=0.36). CONCLUSIONS Extensively drug-resistant tuberculosis can be cured in HIV-negative patients through outpatient treatment, even in those who have received multiple prior courses of therapy for tuberculosis.

E-health technologies show promise in developing countries.

Is there any evidence that e-health-using information technology to manage patient care-can have a positive impact in developing countries? Our systematic review of evaluations of e-health implementations in developing countries found that systems that improve communication between institutions, assist in ordering and managing medications, and help monitor and detect patients who might abandon care show promise. Evaluations of personal digital assistants and mobile devices convincingly demonstrate that such devices can be very effective in improving data collection time and quality. Donors and funders should require and sponsor outside evaluations to ensure that future e-health investments are well-targeted.

Planning treatment of ischemic heart disease with partially observable Markov decision processes

Diagnosis of a disease and its treatment are not separate, one-shot activities. Instead, they are very often dependent and interleaved over time. This is mostly due to uncertainty about the underlying disease, uncertainty associated with the response of a patient to the treatment and varying cost of different diagnostic (investigative) and treatment procedures. The framework of partially observable Markov decision processes (POMDPs) developed and used in the operations research, control theory and artificial intelligence communities is particularly suitable for modeling such a complex decision process. In this paper, we show how the POMDP framework can be used to model and solve the problem of the management of patients with ischemic heart disease (IHD), and demonstrate the modeling advantages of the framework over standard decision formalisms.

Roundtable on bioterrorism detection: information system-based surveillance.

During the 2001 AMIA Annual Symposium, the Anesthesia, Critical Care, and Emergency Medicine Working Group hosted the Roundtable on Bioterrorism Detection. Sixty-four people attended the roundtable discussion, during which several researchers discussed public health surveillance systems designed to enhance early detection of bioterrorism events. These systems make secondary use of existing clinical, laboratory, paramedical, and pharmacy data or facilitate electronic case reporting by clinicians. This paper combines case reports of six existing systems with discussion of some common techniques and approaches. The purpose of the roundtable discussion was to foster communication among researchers and promote progress by 1) sharing information about systems, including origins, current capabilities, stages of deployment, and architectures; 2) sharing lessons learned during the development and implementation of systems; and 3) exploring cooperation projects, including the sharing of software and data. A mailing list server for these ongoing efforts may be found at http://bt.cirg.washington.edu.

An information system and medical record to support HIV treatment in rural Haiti.

Lack of infrastructure, including information and communication systems, is considered a barrier to successful HIV treatment programmes in resource poor areas. The authors describe how they set up a web based medical record system linking remote areas in rural Haiti and how it is used to track clinical outcomes, laboratory tests, and drug supplies and to create reports for funding agencies

mHealth for HIV Treatment & Prevention: A Systematic Review of the Literature

This systematic review assesses the published literature to describe the landscape of mobile health technology (mHealth) for HIV/AIDS and the evidence supporting the use of these tools to address the HIV prevention, care, and treatment cascade. The speed of innovation, broad range of initiatives and tools, and heterogeneity in reporting have made it difficult to uncover and synthesize knowledge on how mHealth tools might be effective in addressing the HIV pandemic. To do address this gap, a team of reviewers collected literature on the use of mobile technology for HIV/AIDS among health, engineering, and social science literature databases and analyzed a final set of 62 articles. Articles were systematically coded, assessed for scientific rigor, and sorted for HIV programmatic relevance. The review revealed evidence that mHealth tools support HIV programmatic priorities, including: linkage to care, retention in care, and adherence to antiretroviral treatment. In terms of technical features, mHealth tools facilitate alerts and reminders, data collection, direct voice communication, educational messaging, information on demand, and more. Studies were mostly descriptive with a growing number of quasi-experimental and experimental designs. There was a lack of evidence around the use of mHealth tools to address the needs of key populations, including pregnant mothers, sex workers, users of injection drugs, and men who have sex with men. The science and practice of mHealth for HIV are evolving rapidly, but still in their early stages. Small-scale efforts, pilot projects, and preliminary descriptive studies are advancing and there is a promising trend toward implementing mHealth innovation that is feasible and acceptable within low-resource settings, positive program outcomes, operational improvements, and rigorous study design

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.

Impacts of e-health on the outcomes of care in low-and middle-income countries: where do we go from here?

Introduction Difficulties in achieving health targets, such as the Millennium Development Goals, and growing consumer demand have forced health planners to look for innovative ways to improve the outcomes of health-care and public-health initiatives while controlling service costs. Health systems must address diverse population needs, provide high-quality services even in remote and resource-poor environments, and improve training and support for health-care workers. Services that can be scaled up and are reliable (despite any infrastructural deficits) and cost-effective are in high demand worldwide, especially in low- and middle-income countries. E-health systems have the potential to support these objectives in ways that are both economically viable and sustainable. E-health tools are designed to improve health surveillance, health-system management, health education and clinical decision-making, and to support behavioural changes related to public-health priorities and disease management. (1) Some systematic evidence of the benefits of e-health in general, (2-4) and of specific areas of e-health, such as decision-support systems for clinicians (5,6) or patient-targeted text messaging, (7-10) already exists. The objectives of the current review were to highlight gaps in our knowledge of the benefits of e-health and identify areas of potentially useful future research on e-health. There were three main topics of interest: outcomes among patients with chronic health conditions, the cost-effectiveness of various e-health approaches, and the impact of e-health in low- and middle-income countries. Evidence collection We focused on evidence for the impact of e-health in three areas identified by prior reviews: (1) systems facilitating clinical practice; (2) institutional systems, and (3) systems facilitating care at a distance. (3,4) Systems facilitating clinical practice include electronic medical record systems, picture archiving and communication systems for managing digital medical images, and laboratory information systems that automate laboratory workflow and reporting. Institutional systems include systems for health information and management, early disease warning and disaster management. These systems aggregate data from health facilities and patients to create community-wide views of disease trends and clinical activity. (11,12) Systems facilitating care at a distance include the use of a short message service (SMS) or other text messaging to improve outcomes through patient reminders; between-visit monitoring and/or health education; videoconferencing facilities for live consultations and asynchronous communication between clinicians, and automated telephone calls with recorded messages (sometimes called interactive voice response calls). Multiple systematic reviews have been conducted on some of these e-health approaches, whereas the rest are barely covered in the peer-reviewed literature. To provide a rapid updated summary of the evidence for decision-makers, we conducted a scoping review by gathering information through targeted scans of scientific databases, reviews of reference lists and conversations with other experts. (13) Emphasis was given to projects that provided insights on the impact of e-health on the outcomes of chronic disease management and the scalability of e-health tools and/or data relevant to low- and middle-income countries. Throughout the review we highlight priorities for future research. Systems facilitating clinical practice Examples In developed countries, usage of electronic medical-record systems varies widely. For example, such systems are used for nearly all primary care patients in Denmark, the Netherlands, Sweden and the United Kingdom of Great Britain and Northern Ireland, but for less than 20% of such patients in the United States. (14,15) In low- and middle-income countries, electronic medical record systems, such as Dream, OpenMRS, Baobab Health (in Malawi) and the ZEPRS antenatal system (in Zambia), are available in some larger specialist hospitals but are rarely available in smaller health centres. …

An artificial neural network system for diagnosis of acute myocardial infarction (AMI) in the accident and emergency department: evaluation and comparison with serum myoglobin measurements

Recent studies have confirmed that artificial neural networks (ANNs) are adept at recognising patterns in sets of clinical data. The diagnosis of acute myocardial infarction (AMI) in patients presenting with chest pain remains one of the greatest challenges in emergency medicine. The aim of this study was to evaluate the performance of an ANN trained to analyse clinical data from chest pain patients. The ANN was compared with serum myoglobin measurements--cardiac damage is associated with increased circulating myoglobin levels, and this is widely used as an early marker for evolving AMI. We used 39 items of clinical and ECG data from the time of presentation to derive 53 binary inputs to a back propagation network. On test data (200 cases), overall accuracy, sensitivity, specificity and positive predictive value (PPV) of the ANN were 91.8, 91.2, 90.2 and 84.9% respectively. Corresponding figures using linear discriminant analysis were 81.0, 77.9, 82.6 and 69.7% (P < 0.01). Using a further test set from a different centre (91 cases), the accuracy, sensitivity, specificity and PPV for the admitting physicians were 65.1, 28.5, 76.9 and 28.6% respectively compared with 73.6, 52.4, 80.0 and 44.0% for the ANN. Although myoglobin at presentation was highly specific, it was only 38.0% sensitive, compared with 85.7% at 3 h. Simple strategies to combine clinical opinion, ANN output and myoglobin at presentation could greatly improve sensitivity and specificity of AMI diagnosis. The ideal support for emergency room physicians may come from a combination of computer-aided analysis of clinical factors and biochemical markers such as myoglobin. This study demonstrates that the two approaches could be usefully combined, the major benefit of the decision support system being in the first 3 h before biochemical markers have become abnormal.

Medical Information Systems: A Foundation for Healthcare Technologies in Developing Countries

Among the significant barriers to the provision of health care in developing countries, detailed information concerning disease incidence, health practices and available resources (such as drugs for treatment) are some of the most important. Without detailed information concerning the response to health programs, it is impossible to evaluate the efficacy of a particular program and, hence, effectively allocate funding and resources. Although paper-based systems can provide a partial solution, information transmission is slow and prone to errors. Furthermore, aggregation of data is challenging as patient numbers rise into the hundreds [19], and near impossible with thousands of patients. It is also difficult to impose consistent reporting indicators. The systems described above illustrate the advantages of implementing healthcare technologies within larger collaborations that improve the overall public health infrastructure. One key aspect of the technologies employed in these projects is the use of open standards and open-source development in a collaborative environment. The cases described in this article also demonstrate the need for community data collection, and feasibility of using ICT to enable data collection, and improve information flow in developing countries. Without such approaches, interventions may exacerbate inequalities within countries with weak infrastructure and ingrained social disparities. However, these systems will only work well with carefully designed forms and interfaces, and excellent data management. Furthermore, EMRs can provide a foundational technology that allows for the adoption and evaluation of other health care technologies, such as drug ordering, medical devices, and longitudinal patient follow-ups. Moreover, the projects described above illustrate that the creation of long-term relationships to build infrastructure and solving systemic problems to provide health care can be beneficial to both the patients and the projects involved.