Paul G. Biondich

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.

The Indiana network for patient care: an integrated clinical information system informed by over thirty years of experience.

Presented in this article is the Indiana Network for Patient Care, an integrated citywide medical record system that promotes health quality by enabling efficient access to clinical information. It begins with a description of the systems infrastructure, which includes an explanation of how the system accomplishes data integration. This is followed by a series of descriptions and rationales behind the many clinical applications that interface these data. In doing so, some of the factors that we feel contribute to the success of the system are illustrated.

The Influence of Information Technology on Patient-Physician Relationships

Interpersonal relationships and information are intertwined as essential cornerstones of health care. Although information technology (IT) has done much to advance medicine, we are not even close to realizing its full potential. Indeed, issues related to mismanaging health information often undermine relationship-centered care. Information technology must be implemented in ways that preserve and uplift relationships in care, while accommodating major deficiencies in managing information and making medical decisions. Increased collaboration between experts in IT and relationship-centered care is needed, along with inclusion of relationship-based measures in informatics research.

Targeted screening for pediatric conditions with the CHICA system

OBJECTIVE The Child Health Improvement through Computer Automation (CHICA) system is a decision-support and electronic-medical-record system for pediatric health maintenance and disease management. The purpose of this study was to explore CHICAs ability to screen patients for disorders that have validated screening criteria--specifically tuberculosis (TB) and iron-deficiency anemia. DESIGN Children between 0 and 11 years were randomized by the CHICA system. In the intervention group, parents were asked about TB and iron-deficiency risk, and physicians received a tailored prompt. In the control group, no screens were performed, and the physician received a generic prompt about these disorders. RESULTS 1123 participants were randomized to the control group and 1116 participants to the intervention group. Significantly more people reported positive risk factors for iron-deficiency anemia in the intervention group (17.5% vs 3.1%, OR 6.6, 95% CI 4.5 to 9.5). In general, far fewer parents reported risk factors for TB than for iron-deficiency anemia. Again, there were significantly higher detection rates of positive risk factors in the intervention group (1.8% vs 0.8%, OR 2.3, 95% CI 1.0 to 5.0). LIMITATIONS It is possible that there may be more positive screens without improving outcomes. However, the guidelines are based on studies that have evaluated the questions the authors used as sensitive and specific, and there is no reason to believe that parents misunderstood them. CONCLUSIONS Many screening tests are risk-based, not universal, leaving physicians to determine who should have a further workup. This can be a time-consuming process. The authors demonstrated that the CHICA system performs well in assessing risk automatically for TB and iron-deficiency anemia.

Experience implementing electronic health records in three East African countries.

INTRODUCTION Efficient use of health care resources in low-income countries by providers and local and national managers requires timely access to patient data. OBJECTIVE To implement electronic health records (EHRs) in HIV clinics in Kenya, Tanzania, and Uganda. RESULTS We initially developed and implemented an EHR in Kenya through a mature academic partnership. The EHR was then implemented in six HIV clinics in Tanzania and Uganda in collaboration with their National AIDS Control Programmes. All implementations were successful, but the systems use and sustainability varied depending on who controlled clinic funding. CONCLUSIONS Successful EHR use and sustainability were enhanced by local control of funds, academic partnerships (mainly by leveraging research funds), and in-country technology support.

Changing course to make clinical decision support work in an HIV clinic in Kenya.

PURPOSE We implemented computer-based reminders for CD4 count tests at an HIV clinic in Western Kenya though an open-source Electronic Medical Record System. Within a month, providers had stopped complying with the reminders. METHODS We used a multi-method qualitative approach to determine reasons for failure to adhere to the reminders, and took multiple corrective actions to remedy the situation. RESULTS Major reasons for failure of the reminder system included: not considering delayed data entry and pending test results; relying on wrong data inadvertently entered into the system; inadequate training of providers who would sometimes disagree with the reminder suggestions; and resource issues making generation of reminders unreliable. With appropriate corrective actions, the reminder system has now been functional for over eight months. CONCLUSION Implementing clinical decision support in resource-limited settings is challenging. Understanding and correcting root causes of problems related to reminders will facilitate successful implementation of the decision support systems in these settings.

Shortcomings in infant iron deficiency screening methods

BACKGROUND. Screening for iron deficiency anemia is a well-established practice in pediatrics, but numerous challenges surrounding current recommendations raise questions about the effectiveness of this strategy. OBJECTIVE. To evaluate iron deficiency anemia screening approaches, by assessing rates of follow-up testing and resolution among patients meeting screening criteria in a primary care setting. METHODS. A retrospective cohort study was performed. We extracted electronic medical record data on complete blood counts for infants who received primary care in our clinics in the past 10 years. We calculated rates of positive screening results with 9 different measurement criteria and determined rates of follow-up testing and of documented correction of iron deficiency among those who screened positive. RESULTS. Our cohort consisted of 4984 children who were screened at 9 to 15 months of age, between 1994 and 2004. There was a wide distribution of positive detection rates (range: 1.5–14.5%) among the 9 screening criteria. Follow-up testing rates were low. No more than 25% of infants who screened positive by any criterion underwent a repeat complete blood count within 6 months. Moreover, no more than 11.6% (range: 4.4–11.6%) had documented correction of their laboratory abnormalities. CONCLUSIONS. Significant shortcomings exist in current iron deficiency anemia screening practices. A widely agreed-on, specific, and inexpensive screening criterion, with increased emphasis on systems-based approaches to iron deficiency screening, is needed.

Enabling Better Interoperability for HealthCare: Lessons in Developing a Standards Based Application Programing Interface for Electronic Medical Record Systems

We sought to enable better interoperability and easy adoption of healthcare applications by developing a standardized domain independent Application Programming Interface (API) for an Electronic Medical Record (EMR) system. We leveraged the modular architecture of the Open Medical Record System (OpenMRS) to build a Fast Healthcare Interoperability Resources (FHIR) based add-on module that could consume FHIR resources and requests made on OpenMRS. The OpenMRS FHIR module supports a subset of FHIR resources that could be used to interact with clinical data persisted in OpenMRS. We demonstrate the ease of connecting healthcare applications using the FHIR API by integrating a third party Substitutable Medical Apps & Reusable Technology (SMART) application with OpenMRS via FHIR. The OpenMRS FHIR module is an optional component of the OpenMRS platform. The FHIR API significantly reduces the effort required to implement OpenMRS by preventing developers from having to learn or work with a domain specific OpenMRS API. We propose an integration pathway where the domain specific legacy OpenMRS API is gradually retired in favor of the new FHIR API, which would be integrated into the core OpenMRS platform. Our efforts indicate that a domain independent API is a reality for any EMR system. These efforts demonstrate the adoption of an emerging FHIR standard that is seen as a replacement for both Health Level 7 (HL7) Version 2 and Version 3. We propose a gradual integration approach where our FHIR API becomes the preferred method for communicating with the OpenMRS platform.

Regenstrief medical informatics: Experiences with clinical decision support systems

Publisher Summary Regenstrief scientists have created a 40-year legacy of experience with decision support systems. Among these experiences are many lessons that are helpful to the larger informatics community. The Institute has demonstrated the value of a concurrent focus on standardized, structured data acquisition alongside the development of decision support systems. Having access to these data allowed researchers to perform dozens of reminder studies, many of which serve as foundations for other work in the medical informatics community. The research team has demonstrated that computerized reminders can change clinical behaviors, reduce errors, and improve adherence to practice guidelines. These changes have a strong and persistent effect on patient care. They also promote preventive medicine in both the outpatient and inpatient settings, and have a greater effect than delayed feedback for enhancing preventive care. A series of lessons are culled from the experience inherent in not only developing these systems from scratch, but additionally in serving as both the implementation and direct support team.

Tailoring Interface for Spanish Language: A Case Study with CHICA System

We developed a clinical decision support system (CDSS) --- Child Health Improvement through Computer Automation (CHICA) - to deliver patient specific guidance at the point of clinical care. CHICA captures structured data from families, physicians, and nursing, staff using a scannable paper user interface - Adaptive Turnaround Documents (ATD) while remaining sensitive to the workflow constraints of a busy outpatient pediatric practice. The system was deployed in November 2004 with an English language only user interface. In July 2005, we enhanced the user interface with a Spanish version of the pre-screening questionnaire to capture information from Spanish speaking families in our clinic. Subsequently, our results show an increase in rate of family responses to the pre-screening questionnaire by 36% (51% vs. 87%) in a four month time period before and after the Spanish interface deployment and up to 32% (51% vs. 83%) since November 2004. Furthermore, our results show that Spanish speaking families, on average, respond to the questionnaire more than English speaking families (85% vs. 49%). This paper describes the design, implementation challenges and our measure of success when trying to adapt a computer scannable paper interface to another language.