Presenting a Revolution in health care.    The effective use of e-clinical data for   Clinical Decision Making, Education ...
WHY DO WE NEED AN E-HEALTH        BASED REVOLUTION?• The current models of health care are;  – Costly and non sustainable ...
PRESENTATION CONTENTS• DEFINITIONS• CURRENT HEALTH CARE DELIVERY AND RESEARCH   • Moving from “benchtop to bedside” to ‘‘b...
HEALTHCARE RESEARCHTo answer clinical questions“benchtop to bedside” to “bedside to benchtop”• Specific discoveries –yes, ...
DEFINITIONS         Health care is an information business Information is not a necessary adjunct to care, it     is care,...
WHY DO WE NEED CHANGE?               HEALTH CARE IS UNAFFORDABLE!Fineberg HV. Shattuck Lecture. A successful and sustainab...
Australian Health Care System(2008)              [The Research base]                2005-06: ~ $87 billion 9% of GDP      ...
IS MORE $ ON HEALTH –CURRENT                      MODELS?BetterHealth                  THE ANSWER-NO                  Indi...
FAILURE TO COMPLY WITH GUIDELINES-COMMON2011-Jha, A.K. and D.C. Classen, Getting moving on patient safety--harnessing elec...
Unsupported Clinical Decision Making                                                             RESOURCE UTILISATION-OVER...
Technology is NOT the problem. RMRS 2012    Regenstrief Institute: April 2012: 18 hospitals    • >32 million physician ord...
SLOW LEARNERS-ON QUALITY AND PATIENT SAFETY2000-To Err Is Human Building a Safer Health System. INSTITUTE OF MEDICINE.2005...
Health care is a service business• What clinicians deliver…        –       advice        –       medication        –      ...
Health care is an information business29 March 2013
Health care is an information business• What clinicians actually do…      –    find information (prior records)           ...
Patient-oriented information systems that may be found in aclinical environment. J.Van Bemmel. MEDINFO.Seoul 1998         ...
Overview of patient-oriented information systems that may be   found in a clinical environment. J.Van Bemmel. MEDINFO.Seou...
DATA/INFORMATION/KNOWLEDGE          TSUNAMI29 March 2013
29 March 2013
We are moving to a                single worldwide A future of high-                     It’s (Web 3.0) the data          ...
Patient Centered Computing-taking control/ Data sources                  “The Wisdom of Crowds”2015-every adult in the wor...
PubMed Searches per Month, January 1997 through September 2005                   HUNGER FOR KNOWLEDGE                    H...
CURRENT HEALTH DATA MEASURMENT TOOLS• Lack of a robust measurement program• No nationally agreed-on methods for systematic...
CURRENT HEALTH DATA MEASURMENT TOOLS                       “To improve care you have to measure it”• Data collected in a p...
CCDSS & RESOURCE UTILISATION $3 million per year savings(1995)      0     -2     -4                                       ...
CCDSS(EHR) AND LONGITUDINAL COMPLEX CARE-1996-                      WE KNOW WHAT WORKS                      160,000 patien...
Goals of implementation.(2)1. Eliminate logistic problems of paper record-   clinical data timely, reliable, complete.2. R...
AIDS in Africa-2000        How can e-Health work here?       The Global AIDS Pandemic at a Glance-2000• Leading infectious...
AIDS in Kenya-2000       How can e-Health work here?•  2.5 million persons infected (15% of adults)  – Disease burden• 4th...
Face of HIV in Kenya(Africa)50% HOSPITAL BEDS          POVERTY / EDUCATION29 March 2013
COMMUNICATION INFRASTRUCTURES   ACCESS 29 March 2013
20 years of medical records
Knowing there is a 14% prevalence of HIV/AIDS. How did we meet the health information management                    needs ...
Academic collaboration-essential          “Cannot do it alone!”• 14-year collaboration between IU and MU  1st 11 years → f...
Clinical Information Management-       the report that changed HIV/AIDS in Africa!Use of OpenMRS(MMRS was precursor)allowe...
Clinical Information Management-            the report that changed HIV/AIDS in Africa!Use of OpenMRS                     ...
Clinical Information Management-            the report that changed HIV/AIDS in Africa!Use of OpenMRS                     ...
Clinical Information Management-            the report that changed HIV/AIDS in Africa!                                   ...
E-health and social/political change“We have lit a candle in the darkness (of HIV/AIDS) inAfrica”. Prof. William Tierney. ...
Musafa        HIV is a treatable disease, but          treating millions requires         information management.29 March ...
WHY OPENMRS?• OpenMRS was created in response to  HIV/AIDS (millions). Indiana University School  of Medicine had been col...
END USER INVOLVEMENT CRITICAL TO SUCCESS-CPOE                  An innovative home-care program using                  hand...
Measuring Care-the impacts   Effective clinical information management using OpenMRSThe Past…                            T...
DESIGN GOALS OF OPENMRS•   COLLABORATION:•   SCALABILITY:•   FLEXIBILITY:•   RAPID FROM DESIGN:•   USE OF STANDARDS:•   SU...
AMPATH [Academic Model Providing Access to Healthcare] clinical and           support programs capturing electronic data. ...
CUMULATIVE CLINICAL DATA            AMPATH 2001-2012•   Patients Enrolled     From ~100 to ~ 14,000 /M•   Cumulative patie...
Data capture in Kenya using the AMPATH record system                  Researchers Pot of GoldCumulative AMRS Observations ...
GLOBAL EXPANSION (REVOLUTION)   The Millennium Development Goals Eight Goals for 2015   PARTNERSHIP: Earth Institute Colum...
CORE PRINCIPLES FOR AN E-HEALTH SYSTEMData capture and management is critical to measuring health care“We must remove ours...
Features of OpenMRS –RELEVANCE TO AUSTRALIA                       No. 1Security:Privilege-based access:Patient repository:...
Features of OpenMRS –RELEVANCE TO AUSTRALIA                    No 2.Patient workflows:Cohort management:Relationships:Pati...
GN for                         AIDSMTCT-Plus                                  Women’s &                        ClinicalPro...
SCALABILITY 2000-2012 -May 2012 WHY NOT OZ? 29 March 2013
THE SUCCESSFUL REVOLUTION.        "Talkin about a revolution":2009“Now HIV/AIDS programs are not only in place butsome of ...
Two YouTube videos.1. Data capture for MDRTB in Pakistan-   direct patient care level-mHealth-data   transfer.2. Populatio...
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Menzies final hobart 29 feb13

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Presentation given to the Menzies Research Institute, Hobart in March 2013 on e-heallth and the Kenyan AMPATH and OpenMRS projects.

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  • OpenMRS was created in response to HIV/AIDS. Indiana University School of Medicine had been collaborating with Moi University Faculty of Health Sciences (Eldoret, Kenya) for over a decade when their focus, by necessity, turned toward the HIV pandemic.
  • But patients like Musa, who you’ve already met, showed that HIV was a treatable disease. The problem wasn’t how to treat HIV, but how to scale that up to 100,000 and millions of patients. That kind of scale could only be obtained through effective information management.
  • Menzies final hobart 29 feb13

    1. 1. Presenting a Revolution in health care. The effective use of e-clinical data for Clinical Decision Making, Education and Research MENZIES RESEARCH CENTRE HOBART 7th MARCH 2013 Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI29 March 2013
    2. 2. WHY DO WE NEED AN E-HEALTH BASED REVOLUTION?• The current models of health care are; – Costly and non sustainable – Continue to deliver suboptimal care – Do not provide adequate access to care – Despite technology advances better outcomes do not always happen – For developing nations e-Health is “essential” for managing their treatable disease epidemics e.g. HIV/AIDS
    3. 3. PRESENTATION CONTENTS• DEFINITIONS• CURRENT HEALTH CARE DELIVERY AND RESEARCH • Moving from “benchtop to bedside” to ‘‘bedside to benchtop”CURRENT ASSESSMENTS OF HEALTH CARE DELIVERY• Current measures of care delivery• Technology beneficial and problematical• Health care funding• e-health solving BIG problems world wide• 2 short videos-making e-Health (including m-Health) work• Q&A
    4. 4. HEALTHCARE RESEARCHTo answer clinical questions“benchtop to bedside” to “bedside to benchtop”• Specific discoveries –yes, but, • Effectiveness/practice variations/CDM/Errors • Knowledge accessData Capture: Manual vs. electronic.
    5. 5. DEFINITIONS 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
    6. 6. WHY DO WE NEED CHANGE? HEALTH CARE IS UNAFFORDABLE!Fineberg HV. Shattuck Lecture. A successful and sustainable health system--how to get there from here. N Engl J Med. 2012;366(11):1020-7. 29 March 2013
    7. 7. Australian Health Care System(2008) [The Research base] 2005-06: ~ $87 billion 9% of GDP • 3.8% in 1960-61 • 9.0% in 2005. • 16-20% by 2045 Australian Institute of Health and Welfare (AIHW) , Australia‟s Health (2008) http://www.ahmac.gov.a29 March 2013
    8. 8. IS MORE $ ON HEALTH –CURRENT MODELS?BetterHealth THE ANSWER-NO Individual US StatesWorseHealth Less state Less state spending spending 29 March 2013
    9. 9. FAILURE TO COMPLY WITH GUIDELINES-COMMON2011-Jha, A.K. and D.C. Classen, Getting moving on patient safety--harnessing electronic data for safer care. N Engl J Med.More medical resources or spending more on Medicare is notassociated with more effective care.[Costs/quality/Access} 29 March 2013
    10. 10. Unsupported Clinical Decision Making RESOURCE UTILISATION-OVERUSE Duplicate Lab Tests* by Group, BC, 2005. 0.45 2003 0.4 # Duplicate Lab Tests in 2005 = 1.14M 2004 0.35 COST = $4.55M 2005 Number of Lab Tests (Millions) 0.3 0.25 0.2 0.15 0.1 0.05 0 CVD DM-CVD CKD-CVD-DM CKD-CVD DM CKD DM-CKD * duplicate test defined as same test within 30 daysDr. Adeera Levin, Director, Kidney Function Clinic, St. Pauls Hospital, University of British Columbia, Rm.6010-A, 1081 Burrard St., Vancouver BC V6Z 1Y6; fax 604 806-8120; alevin@providencehealth.bc.ca
    11. 11. Technology is NOT the problem. RMRS 2012 Regenstrief Institute: April 2012: 18 hospitals • >32 million physician orders entered by CPOE • Data base of 6 million patients • 900 million on-line coded results • 20 million reports-diagnostic studies, procedure results, operative notes and discharge summaries • 65 million radiology images • CLINICAL DECISION SUPPORT- BLINK TIMES 29 March 2013
    12. 12. SLOW LEARNERS-ON QUALITY AND PATIENT SAFETY2000-To Err Is Human Building a Safer Health System. INSTITUTE OF MEDICINE.2005 -Leape, L.L. and D.M. Berwick, Five years after To Err Is Human: what have we learned? JAMA.2011- Health Information Technology Institute Of Medicine, Health IT and Patient Safety Building Safer Systems for Better Care, The National Academies Press: Washington D.C.2011-Jha, A.K. and D.C. Classen, Getting moving on patient safety--harnessing electronic data for safer care. N Engl J Med. 29 March 2013
    13. 13. Health care is a service business• What clinicians deliver… – advice – medication – devices – surgery – physical therapy29 March 2013
    14. 14. Health care is an information business29 March 2013
    15. 15. Health care is an information business• What clinicians actually do… – find information (prior records) “There is no healthcare without – gather informationand therephysical, lab) management, (history, is no – record information (notes,information.” management without reports, etc.) – process information (risks/benefits → Neto Gonzalo Vecina decisions) – transmit information (advice, orders, Health Head, Brazilian National letters) Regulatory Agency• The quality, efficiency, and effectiveness of care depend on our ability to manage information29 March 2013 → Electronic Health Records
    16. 16. Patient-oriented information systems that may be found in aclinical environment. J.Van Bemmel. MEDINFO.Seoul 1998 Clinical Support Systems PACS MRI nuclear medicine CT Radio- Pathology lung function DSA Therapy EEG RIS ECG Hospital Clinical Function Radiology Pharmacy Chemistry Labs Endoscopy intensive care Hematology perinatal care Endocrinology Obstetrics Surgery Neurology post-surgical care Nephrology peri-operative care Oncology coronary care Internal Pediatrics Cardiology Psychiatry Patient Medicine Monitoring Clinical Departmental Systems- the patient(s) journey through this maze 29 March 2013
    17. 17. Overview of patient-oriented information systems that may be found in a clinical environment. J.Van Bemmel. MEDINFO.Seoul 1998 Clinical Support Systems PACS MRI nuclear medicine CT Radio- Pathology lung function DSA Therapy EEG RIS ECG Hospital Clinical Function Radiology Pharmacy Chemistry Labs Endoscopy intensive care Hematology perinatal care Endocrinology Obstetrics Surgery Neurology post-surgical care Nephrology peri-operative care Oncology coronary careInternal Pediatrics Cardiology Psychiatry PatientMedicine Monitoring Clinical Departmental Systems-29 March 2013 the patient(s) journey through this maze
    18. 18. DATA/INFORMATION/KNOWLEDGE TSUNAMI29 March 2013
    19. 19. 29 March 2013
    20. 20. We are moving to a single worldwide A future of high- It’s (Web 3.0) the data computer all about affordable quality, Apple created the depends on care innovation platform (e.g., iPhone) but not the apps → driving innovation29 March 2013
    21. 21. Patient Centered Computing-taking control/ Data sources “The Wisdom of Crowds”2015-every adult in the world will have a mobile phone-(WHO) 29 March 2013
    22. 22. PubMed Searches per Month, January 1997 through September 2005 HUNGER FOR KNOWLEDGE How much is “litter-ature”?[Ioannidis -2005] >70 million/month Steinbrook, R. N Engl J Med 2006;354:4-729 March 2013
    23. 23. CURRENT HEALTH DATA MEASURMENT TOOLS• Lack of a robust measurement program• No nationally agreed-on methods for systematically identifying, tracking, and reporting adverse events.• A shortage of good patient-safety metrics• Poor quality measures are plentiful. Current patient-safety indicators, which use billing data Poor sensitivity and specificity- their utility varies with hospitals‟ billing practices.[Case-Mix, DRGs, ABF]Ashish K. Jha, David C. Classen, M.DGetting Moving on Patient Safety — Harnessing Electronic Data forSafer Care..NEJM 365;19 NEJM.org 1756 November 10, 2011 29 March 2013
    24. 24. CURRENT HEALTH DATA MEASURMENT TOOLS “To improve care you have to measure it”• Data collected in a post hoc fashion-NOT at the time of care• Fail to engage clinicians at the time of care delivery• Data unavailable for review until years after the care is delivered.Getting Moving on Patient Safety — Harnessing ElectronicData for Safer Care Ashish K. Jha, M.D., M.P.H., and David C. Classen, M.D.NEJM 365;19 NEJM.org 1756 November 10, 2011 29 March 2013
    25. 25. CCDSS & RESOURCE UTILISATION $3 million per year savings(1995) 0 -2 -4 TOTAL BED -6 TEST -8 DRUG -10.5 -10 OTHER -12.7 -11.9 -12.5 LOS -12 -14 -15.3 -15.2 -16Physician inpatient order writing on microcomputer workstations-effects on resource 29 March 2013utilisation. WM Tierney and others. JAMA 1993;269:379-383 25
    26. 26. CCDSS(EHR) AND LONGITUDINAL COMPLEX CARE-1996- WE KNOW WHAT WORKS 160,000 patient over 4 yearsOverall 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 levelsINCREASED during this period, meaning we were treatingsicker and sicker patients while better utilizing the delivery ofantibiotics. (******WENNBERG 2012)Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic practice guidelines throughcomputer-assisted decision support: clinical and financial outcomes.Ann Intern Med 1996 May 15 29 March 2013
    27. 27. Goals of implementation.(2)1. Eliminate logistic problems of paper record- clinical data timely, reliable, complete.2. Reduce the work of clinical bookeeping-no more missed Dx, or forgotten preventive care.3. Information „gold‟ within medical records available to clinical, epidemiological, outcomes and management research. The Regenstrief Medical Record System. IJMI 54 (1999) 225-25329 March 2013
    28. 28. AIDS in Africa-2000 How can e-Health work here? 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• 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• Fewer than 8% receiving it SOURCES: Quinn and Chaisson, 2004; WHO, 2003a,b .
    29. 29. AIDS in Kenya-2000 How can e-Health work here?• 2.5 million persons infected (15% of adults) – Disease burden• 4th behind South Africa, India, and Nigeria – International problem• 1 million AIDS orphans (of 31 million citizens) – Social causes and outcomes• Life expectancy has dropped 18 years in the past 5 years, from 65 → 47 years – Human and economic social burdens
    30. 30. Face of HIV in Kenya(Africa)50% HOSPITAL BEDS POVERTY / EDUCATION29 March 2013
    31. 31. COMMUNICATION INFRASTRUCTURES ACCESS 29 March 2013
    32. 32. 20 years of medical records
    33. 33. Knowing there is a 14% prevalence of HIV/AIDS. How did we meet the health information management needs here? Confidentiality and Historical “doctor communication knows it all” tools Use ofHierarchical limiteddecision resourcesmaking Bed block/ Access
    34. 34. Academic collaboration-essential “Cannot do it alone!”• 14-year collaboration between IU and MU 1st 11 years → focus= educational exchange Kenyan request for an “EMR”• In 2000-pre EMR >50% of the beds in Moi Hospital were filled with young people dying of AIDS no ARVs, few antibiotics for opportunistic infections despair, depression, resignation
    35. 35. Clinical Information Management- the report that changed HIV/AIDS in Africa!Use of OpenMRS(MMRS was precursor)allowed us to managecare in a timely manner
    36. 36. Clinical Information Management- the report that changed HIV/AIDS in Africa!Use of OpenMRS Collecting this clinical(MMRS was precursor) information allowedallowed us to manage effective measurement ofcare in a timely manner the AIDS epidemic and therefore the ability to manage it in the future.
    37. 37. Clinical Information Management- the report that changed HIV/AIDS in Africa!Use of OpenMRS Collecting this clinical(MMRS was precursor) information allowedallowed us to manage effective measurement ofcare in a timely manner the AIDS epidemic and therefore the ability to manage it in the future.
    38. 38. Clinical Information Management- the report that changed HIV/AIDS in Africa! Collecting this clinicalUse of OpenMRS HIV and TB = 0 information allowed(MMRS precursor)allowed us to manage Not measured! effective measurement ofcare in a timely manner the AIDS epidemic and therefore the ability to manage it in the future.
    39. 39. E-health and social/political change“We have lit a candle in the darkness (of HIV/AIDS) inAfrica”. Prof. William Tierney. Government response!“This record system must be in every clinic in Kenya!”Kenyan Gov’t response. 29 March 2013
    40. 40. Musafa HIV is a treatable disease, but treating millions requires information management.29 March 2013
    41. 41. WHY OPENMRS?• OpenMRS was created in response to HIV/AIDS (millions). Indiana University School of Medicine had been collaborating with Moi University Faculty of Health Sciences (Eldoret, Kenya) for over a decade when their focus, by necessity, turned toward the HIV pandemic.
    42. 42. END USER INVOLVEMENT CRITICAL TO SUCCESS-CPOE An innovative home-care program using hand-held computers being piloted in the region. Monica Korir, who is living with HIV and is trained as an outreach worker Outreach workers download completed forms into Mosoriot clinics data management system daily. Automated alerts flag any alarming new symptoms/missed appointments/medication compliance. WHO/Evelyn Hockstein
    43. 43. Measuring Care-the impacts Effective clinical information management using OpenMRSThe Past… The Present… The Impact… Clinical information management
    44. 44. DESIGN GOALS OF OPENMRS• COLLABORATION:• SCALABILITY:• FLEXIBILITY:• RAPID FROM DESIGN:• USE OF STANDARDS:• SUPPORT HIGH QUALITY RESEARCH:• WEB-BASED AND SUPPORT INTERMITTENT CONNECTIVITY:• LOW COST:• CLINICALLY USEFUL: feedback to providers and caregivers is critical. If the system is NOT CLINICALLY USEFUL it will not be used.
    45. 45. AMPATH [Academic Model Providing Access to Healthcare] clinical and support programs capturing electronic data. ALL DISEASE STATES NOT JUST HIV/AIDS Adult HIV/AIDS clinics Oncology clinics Social worker assessments Pediatric HIV/AIDS clinics Mental health clinics Outreach – patient follow-up Primary care – rural health Diabetes clinics Drug adherence assessments clinics Tuberculosis clinics Nutrition assessments Primary care – urban well-child Clinic pharmacies Food supplement distribution clinics Clinical laboratories Microfinance program Antenatal and postnatal clinics Mother-baby registerAMPATH maintenance cost only $175/patient/year in 2007 and is now less than $100/patient/year in 2009 [dividing all direct USAID/PEPFAR funding per year by the number of patients actively receiving treatment.] 29 March 2013
    46. 46. CUMULATIVE CLINICAL DATA AMPATH 2001-2012• Patients Enrolled From ~100 to ~ 14,000 /M• Cumulative patients enrolled 450,000+• Patient visits/month ~100->70,000• Cumulative patient visits > 3,500,000• Clinical obs. /month ~2.5-3 million• Creating the Researchers “pot of gold”………>
    47. 47. Data capture in Kenya using the AMPATH record system Researchers Pot of GoldCumulative AMRS Observations By Month: Mar ’06 – Jan ‘12
    48. 48. GLOBAL EXPANSION (REVOLUTION) The Millennium Development Goals Eight Goals for 2015 PARTNERSHIP: Earth Institute Columbia University, UNDP, Millennium Promise and national governments.1 Eradicate extreme poverty and hunger2 Achieve universal primary education3 Promote gender equality and empower women4 Reduce child mortality5 Improve maternal health6 Combat HIV/AIDS, malaria and other diseases7 Ensure environmental sustainability8 Develop a global partnership for development
    49. 49. CORE PRINCIPLES FOR AN E-HEALTH SYSTEMData capture and management is critical to measuring health care“We must remove ourselves from the ‘unscientific, non data drivenpersonal recommendations’ for care”. Dr M. Smith CHCF AMIA 2009“The ability to feedback immediately to the people at the point ofcare is critical for measuring and improving the quality of care.[comparable and timely data from multiple sources/countries inmultiple languages] –requires a different kind of informationsystem to what exists now. “ A/Prof Andy Kanter April, 2011. MillenniumVillages Project
    50. 50. Features of OpenMRS –RELEVANCE TO AUSTRALIA No. 1Security:Privilege-based access:Patient repository:Multiple identifiers per patient:Data entry:Data export:Standards support:Modular architecture: 29 March 2013 50
    51. 51. Features of OpenMRS –RELEVANCE TO AUSTRALIA No 2.Patient workflows:Cohort management:Relationships:Patient merging:Localization / internationalization:Reporting tools:Person attributes: 29 March 2013 51
    52. 52. GN for AIDSMTCT-Plus Women’s & ClinicalProgram Children’s Trials Health Group Research NHLBI Global Health IeDEA Initiative
    53. 53. SCALABILITY 2000-2012 -May 2012 WHY NOT OZ? 29 March 2013
    54. 54. THE SUCCESSFUL REVOLUTION. "Talkin about a revolution":2009“Now HIV/AIDS programs are not only in place butsome of them, ……(partnerships)…..(AMPATH) …areopenly speaking of bringing the pandemic to itsknees over the next 5 years through widespreadscreening and effective treatment and prevention ofHIV [and other diseases] .”Braitstein, P., et al., "Talkin about a revolution": How electronic health records can facilitate the scale-upof HIV care and treatment and catalyze primary care in resource-constrained settings. J Acquir ImmuneDefic Syndr, 2009. 52 Suppl 1: p. S54-7. 29 March 2013
    55. 55. Two YouTube videos.1. Data capture for MDRTB in Pakistan- direct patient care level-mHealth-data transfer.2. Population disease monitoring –based on concepts in movie (1) using OpenMRS and mHealth-macro level data- bidirectional use. • THANK YOU 29 March 2013 • Q&A

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