The document discusses implementing electronic medical record (EMR) systems in low resource hospitals in developing countries. It notes that such settings often have intermittent power, lack of IT staff and internet access, and sparse mobile coverage. The proposed approach is to use low-cost, appropriate technologies like smartphones, SMS, and offline/disconnected solutions. Examples of EMR systems developed using this approach include IQCare and IQSMS, which have been implemented across several African countries to digitize medical records and facilitate mobile phone-based reporting. The results shown include improved data quality, data use, and reduced costs through streamlining patient workflows.

1. Implementing eHealth EMR for Low Resource
Hospitals in Developing Countries
Bobby Jefferson, Senior Health Informatics Advisor, Futures Group
• Principal Investigator CDC HMIS Grant Kenya
• CDC Strengthening HIV Strategic Information Activities In The Central Asia Republics Columbia University
• CDC Partners in AIDS Care and Treatment in Kenya, University of Maryland Institute of Human Virology
• CDC National Teaching and Referral Hospitals Centers of Excellence in Kenya, University of Maryland Institute of Human
Virology

2. Outline
 Description
 Low Resource Environment
 Approach
 Low cost, appropriate technology
 Solutions
 Sharing Lessons

3. Low Resource Environment
We are working across 15 Countries, 1,033 Hospital Facilities + Satellites Clinics ,
Antenatal Care - PMTCT sites (535 in Tanzania)
Rural, remote, mission hospitals “serving poorest of poor” and Ministry of Health
(MOH) facilities
• Intermittent power,
• Lack IT staff,
• Lack internet,
• Sparse mobile coverage

5. Results
# of Facilities
• No Internet
• Sparse Mobile Coverage
• Intermittent Power
• Mobiles, SMS
• Smartphones
• Internet
Rural, Remote
City Online Mobile Offline, Disconnected
Solutions Solutions Solutions

6. Low Resource Environment
Nurses, Clinicians, Adherence Counselors, need health data, M&E program
data in knowledge repository
• Lack of referrals, or linkage between HIV, PMTCT, TB, or to existing
technology systems
• Cost effectiveness and sustainability -- no funds for proprietary licenses,
or yearly maintenance fees

7. Approach
Use of freely available, reusable, tools, “coded in country”
Creative commons approach
Reusable software and technology across countries and
programs
Offline Solutions, Disconnected model
Local programmers, all IT staff in country (Africa)
- Programmer training SQL, coding C#, Agile process
Low costs, Inexpensive $200-$350 Netbooks , Solar netbooks
Solar mobile phones, SMS instead of Smartphones
- Use of inverters to address power

8. Health IT Solutions
Collectively referred to as IQSolutions
1. Electronic medical records
1. IQCare - Technical Assessment by CDC Atlanta, WHO,
USAID, NASCOP and MOH
2. IQChart - French language Rwanda
2. Mobile Phone solution (IQSMS technology)
3. Visual Dashboards
4. Monitoring & Evaluation Electronic reporting
5. SQL Training, Programmer Training, Virus Remediation
Training
6. Data Demand and Information Use (DDIU) and reducing
operational costs

9. IQCare
*Paper-based records automated
*Clinicians able to review individual patient histories, prescribed drugs, ordered tests and results, and progress on care and
treatment during the exam

10. Clinicians able to review individual patient
histories
*Clinicians review patient histories, prescribed drugs, ordered tests and results, and progress on care and treatment
during the exam

11. Browser, SQL Express, .NET, openSSL
Artifacts
• Entity Relationship Diagram (ERD)
• Data Dictionary
• Use Case Document
• Business Rules Document

12. Donors District Indicators,
Intel World Ahead OGAC, CDC, HRSA, USAID DHIS v2.0 software,
Netbooks, low cost, MOH National Reports
low power Next Gen Indicators (NGI)
SDMX-HD
Laboratory Partners
HL7 v2.4 OpenELIS
Pharmacy , Supply Chain EMR System Bika Labs
Management Sciences Health, TherapyEdge
ARV dispensing tool (ADT)
IQCare
(Facility Level)
Other EMR
mHealth
Clinical/Medical Partners
School of Medicine, Faith Based Orgs
Mennonite Christian Charities
CHAK, IMA Community Mobile health solutions Financial Mgmt Partners
Integrated HIV, TB, PMTCT Dimagi, mHealth Alliance, Pastel Software,
Nethope Tableau Dashboard

13. Kenya Results
• PMTCT forms
• Integrated HIV, TB, PMTCT 3IPMS
MOH 711 , MOH 257 “blue card”
• Improved Data Quality
• Improved Data Use at health facility
• 200 Data Managers trained
• Reducing Costs, Improved Patient Workflow
Visit Type
ART
Total Follow Up Lab pharmacy
Total Patients served Non ART ART Transactions UniqueVisits Visits visits Visits
31 118,820 67,806 51,014 4,178,313 2,005,502 1,405,984 741,075 1,501,027

14. This is to sincerely thank you for having come to our users’ training that was held at Baraton from 1st – 5th August 2011. We had a successful
meeting attended by 60 users from South Rift, Kisumu West and KDoD. From their feedback, they liked the IQCare because of its robustness,
ease of use and especially the way it captures our forms. We shall be having more of this especially refresher courses in future after we have rolled
out IQCare. As of now we are confident on the system and ready to implement the system.

15. demo
http://173.203.65.108/iqcare/frmLogin.aspx
 Username: user1
 Password: 1
 Facility/Satellite: 001-01-01-Demo Site

17. IQSMS PMTCT Reports
PMTCT Currently consists of 4 types of monthly reports
1. PMTCT Antenatal Clinic (ANC) Monthly Summary Form
2. PMTCT Care Register Monthly Summary Form
3. PMTCT Maternity (L&D) Monthly Summary Form
4. PMTCT Mother - Child followup SummarForm

18. IQSMS – Mobile Phone Reporting by Health Workers

19. PMTCT Report
Data Quality Checks
Must Pass All Data Quality Rules,
District Office
Monthly and Quarterly
Reports

20. NUMBER OF CLIENT HAD HIV TEST AT ANC

21. technology isn’t the barrier to scale up
• Nurses and community health worker receive per diem or transports
costs for picking up or bringing their list and reports back and forth
to health facilities, district offices, etc.,– they’re not interested in
losing out in reimbursement;
• After early adopters, health care workers not keen sending message
unless they have free airtime and toll free number available from their
mobile telecom provider ; we increase use by 50% when toll free is
available
• The older staff have more difficulty using mobile for messaging and
reporting;
• Often other people have access to the phones (25% share phone
vs. Own) and often those text message can be forwarded to others
• Staff in rural areas want their SMS messages in Swahili or local language;
Detailed instructions in Swahili to how to do reporting and use phones
for reporting

22. Tanzania
Distance from Time spent to
Facility Name District Facility to Deliver PMTCT Bus Fare (Tsh)
District (KM) Report (Hrs)
MWANZA Region
NYAMAGANA DISTRICT
Mwamashimba Health Centre Kwimba 50 1.30hrs 10000
Malya Health Centre Kwimba 25 1hr 5000
Kikubiji Dispensary Kwimba 102 4hrs 20000
Kiliwi Dispensary Kwimba 100 4hrs 20000
KWIMBA DISTRICT
Nyakalilo Health Center Sengerema 46 2 HRS 8000
Mwangika Health Centre Sengerema 98 4 HRS 10000
Sengerema Health Centre Sengerema 10 20MIN 3000
SENGEREMA DISTRICT
Kharumwa Health Centre Geita 115 3HRS 20000
Nzera Health Centre Geita 48 2HRS 8000
Katoro Health Centre Geita 50 45MIN 6000
Nkome Dispensary Geita 80 2HRS 6000
Nyang'hwale Health Center Geita 85 2HRS 7000
Kasamwa Health Centre Geita 25 30MIN 4000
Bukori Health Centre Geita 60 1:30HRS 6000

23. • Delays with data flow and information reporting from the District and
Regional level to the National level
• Inaccuracy of reports being received thus requiring further on site data
verification
• High cost of supervision and sending report to district in regards to travel
costs to access the 535 health facilities
• Ever used the phone
for SMS services
No 52.17%
Yes 47.83%
Total 100
– All staff own the
telephone handset and
share it in daily personal
uses

24.  Instruction on
 Any problems with
Swahili critical to
small buttons on the
using IQSMS
phone?
 Response Freq %
 Response Freq %
 No 6 17.14
 No 30 85.71
 Yes 29 82.86
 Yes 5 14.29
 Total 35 100
 Total 35 100
• Reasons For Not Sending Monthly Report
– Majority said they don’t understand English
language
– Need message understandable in Swahili language

25. IQSMS Instructions in Swahili

26.  Barriers to implementing • Anything that can be
mobile phone reporting for improved on report
submitting all four reports submission to make
each month report to be on time
 Mobile Network Problem/failure • Response Freq %
 Server don’t respond on time • No 14 40.00
 PCR report type is hard • Yes 21 60.00
 It have been found that free • Total 35 100
Airtime is critical for scale up

27. Health IT Solutions
*EMRS – Electronic Medical Records System

28. Health IT Solutions
Tanzania mobile phone coverage and mobile penetration
Vpdacom Tanzania
•
*EMRS – Electronic Medical Records System

29. M&E Electronic Reporting System
Solar Power Cell phones
Orphans Vulnerable Children
PDA device
(OVC), Most At Risk
Population (MARPS),
Maternal Child Health (MNH)
Ms Access Database
Excel
PMTCT MONTHLY REPORT
PMTCT Antenatal Clinic (ANC) Monthly
Excel Only Summary Form Web Internet
118 Desktop
ANC 01. New ANC clients this month 8
ANC 02. Previously known to be HIV
positive 17
ANC 03. Total number tasted 574
ANC 04. Number of new client had HIV test
at ANC 277
ANC 05. Tested HIV-Positive 37
ANC 06. Post-test counseled for positive
and negative 574
ANC 07. Number of partners tested for HIV 16
ANC 08. Tested HIV-Positive 4

30. Site Capacity Dashboard

31. demo
http://scademo.dyndns.org
 Username: demo
 Password: demo

32. Collaborators and Users
Southern Sudan
Rwanda Intra Health International
ICAP Columbia University 44 sites
Intra Health International 17 sites
Elizabeth Glaser EGPAF 16 sites Kenya
Family Health Inter FHI 45 sites Catholic Relief Services - 32
Catholic Relief Services 13 sites Pathfinder International
Gertrude Children Hospital
DOD Walter Reed - 28
Mount Kenya University
MOH Kenya Sites
Nigeria
Mennonite Christian Charities
Guatemala AIDSRElief 35 sites Uganda
Ministry of Health AIDSRelief
Ministry of Education John Snow International
Rakai Health Services Vaccine Research
Tanzania
Zambia
PMTCT , ANC sites 535 sites
Elizabeth Glaser EGPAF
World Vision
NETHOPE

33. For more information
 http://www.iqstrategy.net/frmiqcare.shtml
 Source Forge
 Contact
 Bjefferson at futuresgroup.com
 Lburrows at futuresgroup.com
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: www.atsdr.cdc.gov