In a 1999 review of the major EMR systems in the world that are the models for future EMRs, these were the data/information and performance values for the Regenstrief system in Indian. They emphasize that technology is not the problem for EMRs and information retrieval must function at these levels of recall time.
Core decision support tools for all E.H.Rs regardless of the complexity of the decision support required.
Tierney’s study into the use of of a longitudinal CBPR to reduce resource utilization. (Refer to the Johns and Blum study on costs, resource utilization, and clinical decision making)
Slides 114-122 display the results of the above study. It is important to look at this study from many aspects. The size of the study (not possible with a paper-based record-time, costs, data accuracy), the alteration of process, the measurements of outcome, the definition of patient cohorts. This is the only institution that has shown the stabilization of antibiotic resistance – a major problem with antibiotic usage. The study also demonstrates that the rewards from CBPR systems are the result of an INCREMENTAL process with verification of benefits and or failures along the way.
At the time, there was a lot of work to be done.
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.
And existing systems were overburdened and getting pushed beyond their capacity.
He knew the enterprise would be information-intensive, so he pushed me to create the first ambulatory electronic medical record system in sub-Saharan Africa. Because the HIV protocols had been created in the U.S. and Europe, they had little relevance to resource-poor countries. So Joe also pushed me to create and lead a multidisciplinary HIV research program.
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.
We’ve built a web-based EMR atop the OpenMRS platform to serve our community’s needs, but that doesn’t prevent other things to be built atop the API.
So, OpenMRS is an EMR, a data model (some folks have chosen to simply use our data model and build their own system), an API, an HIV system, a TB system, a Primary Care system, a strong developer community, and a vibrant implementer community. We’re all in this together.
And we’ve already seen evidence of the flexibility of a platform approach. Folks in Maryland have wired a different primary care system atop the OpenMRS API, so docs work within another system, but all data are stored within an instance of OpenMRS. Shaun Grannis developed a disease surveillance system using OpenMRS. In Skid Row of Los Angeles, OpenMRS is being used to manage data for homeless patients with TB. And Paul’s pediatric decision support system has been rebuilt and now runs within OpenMRS.
Up to 1991there had been accumulating evidence that clinical decision support tools were of benefit to health care delivery. The IOM designed an 18 month study to evaluate the CBPR in health. The title of its report defines this critical focus point in EMR developments and provided the focus for all new and existing EMR developments.
UNSW from OCIS to OpenMRS
Demonstrating the success of the e-health in resource poor (and developed) economies. Making it work. AIHI, UNSW 28th June 2012. DR TERRY J HANNAN MBBS;FRACP;FACHI;FACHI HEALTH INFORMATICIANJuly 9, 2012
Schema for presentation.•The journey to Kenya•POWH-OCIS to CCCIS-lessons learnt•AMIA November 1999•Eldoret January 2000•MMRS to AMPATH to OpenMRS•AMIA 2007•Update on status of OpenMRS project•3 x short movies (~3-4mins each)• QuestionsJuly 9, 2012
1982-1984 Non clinical evaluation 1984-1986 physician involvement and evaluation 1984-1987 ABSTRACT[SUMMARISATION] modification and implementation (Continuing evolution) 1986-1987 Modification of program / dictionaries /screen displays / reports / units of measurement 1986 MANUAL data entry of laboratory data 1987 MANUAL data entry by NURSING STAFF of clinical / protocol / chemotherapy data 1988-1989 AUTOMATED LABORATORY DATA TRANSFER 1989 REPORT GENERATOR functions(FLOWS &PLOTS) • DRG diagnostic data electronically collated for administration [2nd art to CLINICAL DATA]. CLINICAL TRAILS module implemented 1990-1992 Protocol generated care plans tested and evaluated 10 years Hannan, T., International transfer of the Johns Hopkins Oncology Center clinical information system. MD Comput, 1994. 11(2): p. 92-9.
ACKNOWLEDGEMENTS FOR AMPATH/OPENMRS INFORMATION W. Tierney Andrew S Kanter, Hamish SF Fraser, Christopher J. Seebregts, Paul Biondich, Burke Mamlin, Sylvester Kimaiyo, Charles Safran, Joaquin Blaya Dave Thomas Joe Mamlin Sylvester Kimaiyo OpenMRS consortium participants www.openmrs.orgJuly 9, 2012
Collaborators and Funders Partners In Health Regenstrief institute Medical Research Council, South Africa World Health Organization US Centers for Disease Control Brigham and Women hospital Harvard Medical School University of KwaZulu-Natal Millennium Villages Project International Development Research Centre, Ottawa Rockefeller Foundation Fogarty International Center, NIH Boston Consulting GroupJuly 9, 2012 Google Inc PEPFAR
Health care is an information businessInformation 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 July 9, 2012
TECHNOLOGY IS NOT THE PROBLEM [30 years EMR experience and research]Retrieval times-Fast (blink times)Data and information-ComprehensiveData storage- Long-term-lifelongData applications-Introspective of total databaseData storage- 200 million coded observations By products of the care process 3.25 million narrative reports RESEARCH-accuracy / $ 15 million prescriptions EPIDEMIOLOGY 212,000 ECG tracings ADMIN SUPPORT More than 1.3 million patients “Record once use many times”Access- 1300 medical nurses 1000 physicians 220 medical students Across health care institutions (16) Data access more than 628,000 / month C.J. McDonald, et al, The Regenstrief Medical Record System: A quarter century experience. Int J July 9, 2012Inform 54 (1999), 225‑ 253.) Med
CCDSS TOOLS IN CLINICAL MEDICINE-REQUIREMENTS1.ALERTING2. REMINDING3. INTERPRETATION4.ASSISTING5.CRITIQUING6.DIAGNOSING7.MANAGING8. KNOWLEDGE ACCESS /COUPLING[“Medicine in Denial.” L.Weed,L.Weed.2011] Pryor TA, Clayton PD. Decision support systems for clinical medicine. July 9, 2012 9 Tutorial 11.15th SCAMC.Nov. 17. 1991.
SUMMARISATION1. Communication of health care is maintained using aSummary patient format in the ambulatory setting.Fries. J. Alternatives in medical record formats. Medical care. 1984;12:871-8816. Summary patient record- information accessible four times faster- contains up to four times more information- Tabulated results allow physicians to better predict future trends in results Whiting-O’Keefe QW,Simborg DW,Epstein WV,Medical Care 1980;18:842-852
USING PHYSICIAN INPATIENT ORDER WRITING ON MICROCOMPUTER WORKSTATIONS. REDUCTION IN HEALTH CARE RESOURCE UTILISATION $3 million per year savings-(USA $65b) 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 July 9, 2012utilisation. WM Tierney and others. JAMA 1993;269:379-383
Intermountain Health Care, Salt Lake City, Utah, USA STUDY DESIGN • Computer-based EMR system • Patients discharged January 1, 1988 to December 31, 1994 • 162,196 patients •Goal: to determine clinical and financial outcomes of the • antibiotic practice guidelines implemented through the • computer systemPestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic practiceguidelines through computer-assisted decision support: clinical and financial outcomes.Ann Intern Med 1996 May 15 July 9, 2012
Intermountain Health Care, Salt Lake City, Utah, USAOverall 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.Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibioticpractice guidelines through computer-assisted decision support: clinical andfinancial outcomes.Ann Intern Med 1996 May 15 July 9, 2012
AMIA –November 1999An invitation fromProf. Bill TierneyTo KENYA JanJuly 9, 2012
AIDS in Africa 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 First case of AIDS recognized in 1981 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 and fewer than 8% receiving itSOURCES: Quinn and Chaisson, 2004; WHO, 2003a,b.
AIDS in AfricaIn Kenya… 2.5 million persons infected (15% of adults) 4th behind South Africa, India, and Nigeria 1 million AIDS orphans (of 31 million citizens) life expectancy has dropped 18 years in the past 5 years, from 65 → 47 years
One solution: Academic collaboration 14-year collaboration between IU and MU 1st 11 years → focus=educational exchange In 2001 Joe Mamlin returned found >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 Then…Daniel
An innovative home-care programme using hand- held computers is also being piloted in the region. Monica Korir, who is living with HIV and is trained as an outreach worker, interviews Paul Ekorok, 52, at his home in Captarit village and records his answers. WHO/Evelyn Hockstein Outreach workers download completed forms into Mosoriot clinics data management system daily. Automated alerts flag any alarming new symptoms to the attention of the responsible clinical officer, or when a patient has missed an appointment so that outreach workers can find out what is wrong.July 9, 2012
Ezekiel Muruli transports charts daily from Mosoriot to Eldoret, about 25 kms away, where data from paper records are entered into a central electronic system. Direct electronic data transfer is not feasible because Mosoriot does not have high-speed Internet access. WHO/Evelyn Hockstein In Eldoret, Erika Muthoni Kigotho supervises 17 data entry specialists who have received training on HIV care and in spotting potential errors in record-keeping. Electronically generated paper charts, along with reminders for appropriate tests and treatment, are returned to Mosoriot within 48 hours of receipt.July 9, 2012
Salina- “Rattling bones syndrome” Starvation! July 9, 2012
Salina on anti-retroviral therapy July 9, 2012
HIV is a treatable disease, but treating millions requires information management.July 9, 2012
AMPATH clinical and support programs capturing electronic data. ALL DISEASE STATES NOT JUST HIV/AIDSAdult HIV/AIDS clinics Oncology clinics Social worker assessmentsPediatric HIV/AIDS clinics Mental health clinics Outreach – patient follow-upPrimary care – rural health Diabetes clinics Drug adherence assessmentsclinics Tuberculosis clinicsPrimary care – urban well-child Clinic pharmacies Nutrition assessmentsclinics Clinical laboratories Food supplement distributionAntenatal and postnatal clinics Microfinance programMother-baby register AMPATH maintenance cost only $175/patient/year in 2007 and is now less than $100/patient/year in 2009 July 9, 2012
Birth of OpenMRS Collaboration-Regenstrief/PIH MEDINFO San Francisco 2007 Prof. Paul BiondichA/Prof. Hamish Fraser A/Prof. Burke Mamlin July 9, 2012
The plural of anecdote is not data.“we must remove ourselves from the‘unscientific, non data driven personalrecommendations’ for care”.Dr. M. Smith CHCF AMIA 2009
0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 2 1N 00 OV DEC 2 1JA 00 N 16,000 F B E MR A APR MY A JUN 2 2JU 00 L AUG SEP OCT NO V DEC 2 3JA 00 N F B E MR A APR MY A JUN 2 3JU 00 L AUG S P E OCT NO V DEC 2 4JA 00 N FEB MR A APR MY A JUN 2 4JU 00 L AUG S P E OCT NO V DEC 2 5JA 00 N F B E MR A APR MY A JUN 2 5JU 00 L AUG SE P OCT NO V DEC 2 6JA 00 N 1 0 / 2/2006 1 0 / 3/2006 1 0 / 4/2006 1 0 / 5/2006 1 0 / 6/2006 1 0 / 7/2006 1 0 / 8/2006 1 0 / 9/2006 1 1 / 0/2006 1 1 / 1/2006 1 1 / 2/2006 1 0 / 1/2007 1 0 / 2/2007 1 0 / 3/2007 1 0 / 4/2007 1 0 / 5/2007 1 0 / 6/2007 1 0 / 7/2007 1 0 / 8/2007 1 0 / 9/2007 1 1 / 0/2007 1 1 / 1/2007 1 1 / 2/2007 1 0 / 1/2008 1 0 / 2/2008 1 0 / 3/2008 1 0 / 4/2008 1 0 / 5/2008 1 0 / 6/2008 1 0 / 7/2008 1 0 / 8/2008 1 0 / 9/2008 1 1 / 0/2008 1 1 / 1/2008 1 1 / 2/2008 1 0 / 1/2009 1 0 / 2/2009 1 0 / 3/2009 1 0 / 4/2009 1 0 / 5/2009 1 0 / 6/2009 1 0 / 7/2009 1 0 / 8/2009 1 0 / 9/2009 1 1 / 0/2009 1 1 / 1/2009 1 1 / 2/2009 1 0 / 1/2010 1 0 / 2/2010 1 0 / 3/2010 1 0 / 4/2010 1 0 / 5/2010 1 0 / 6/2010Patients Enrolled by Month: Nov ’01 – Jan ‘12 1 0 / 7/2010 1 0 / 8/2010 1 0 / 9/2010 1 1 / 0/2010 1 1 / 1/2010 1 1 / 2/2010 1 0 / 1/2011 1 0 / 2/2011 1 0 / 3/2011 1 0 / 4/2011 1 0 / 5/2011 1 0 / 6/2011 1 0 / 7/2011 1 0 / 8/2011 1 0 / 9/2011 1 1 / 0/2011 1 1 / 1/2011 1 1 / 2/2011 1 0 / 1/2012
450,000400,000350,000300,000250,000200,000150,000100,000 50,000 0 Cumulative Patients Enrolled: Nov ’01 – Jan ‘12
70,00065,00060,00055,00050,00045,00040,00035,00030,00025,00020,00015,00010,000 5,000 0 Patient Visits By Month: Nov ’01 – Jan ‘12
3,500,0003,000,0002,500,0002,000,0001,500,0001,000,000 500,000 0 Cumulative Patient Visits: Nov ’01 – Jan ‘12
3,000,0002,800,0002,600,0002,400,0002,200,0002,000,0001,800,0001,600,0001,400,0001,200,0001,000,000 800,000 600,000 400,000 200,000 0 AMRS Observations By Month: Mar ’06 – Jan ‘12
120,000,000110,000,000100,000,000 90,000,000 80,000,000 70,000,000 60,000,000 50,000,000 40,000,000 30,000,000 20,000,000 10,000,000 0 Cumulative AMRS Observations By Month: Mar ’06 – Jan ‘12
To improve care, you have to measure it. Not possible using currentpaper-based medical record systems. W.Tierney, Regenstrief Institute,Indiana.The foundation for quality patient care is information –Comprehensive, Accurate, Up-to-the-minute clinical Information. Information management is care- E. Shortliffe, Stanford.AMPATH PEER REVIEWED PUBLICATIONS SINCE 2000 ~160ALL GRANTS AND CONTRACTS CURRENTLY FUNDED TODATE (N=74) $40,928,084US July 9, 2012
OpenMRS in Peru March 2006-2007 In total, e-Chasqui will serve a network of institutions providing medical care for over 3.1 million people. benefits the test always available during clinical decision making reducing duplicate tests performed reducing the time and money spent by staff checking the status of their samples. The cost to maintain this system is ~US$0.53 per sample or 1% of the National Peruvian TB programs 2006 budget. Government support to distribute throughout PeruA web-based laboratory information system to improve quality of care of tuberculosis patients in Peru: functional requirements, implementation and usage statistics. Blaya, J.A., et al., BMC Med Inform Decis Mak, 2007. 7:July 9, 2012 p.33
Features of OpenMRS Part 1Security: User authenticationPrivilege-based access: User roles and permission systemPatient repository: Creation and maintenance of patient data, including demographics, clinical observations, encounter data, orders, etc.Multiple identifiers per patient: A single patient may have multiple medical record numbersData entry: With the FormEntry module, clients with InfoPath (included in Microsoft Office 2003 and later) can design and enter datausing flexible, electronic forms. With the HTML FormEntry module, forms can be created with customized HTML and run directly within the web application.Data export: Data can be exported into a spreadsheet format for use in other tools (Excel, Access, etc.)Standards support: HL7 engine for data importModular architecture: An OpenMRS Module can extend and add any type July 9, 2012 73 of functionality to the existing API and webapp.
Features of OpenMRS Part 1Patient workflows: An embedded patient workflow service allows patient to be put into programs (studies, treatment programs, etc.) and tracked through various states.Cohort management: The cohort builder allows you to create groups of patients for data exports, reporting, etc.Relationships: Relationships between any two people (patients, relatives, caretakers, etc.)Patient merging: Merging duplicate patientsLocalization / internationalization: Multiple language support and the possibility to extend to other languages with full UTF-8 support.Support for complex data: Radiology images, sound files, etc. can be stored as “complex” observationsReporting tools: Flexible reporting toolsPerson attributes: The attributes of a person can be extended to meet local needsJuly 9, 2012 74
Lessons learned Clinical information systems are possible in even the most resource-constrained places Collaboration with established informatics programs is a must Primary goals → sustainability of the EMR, independence of the developing country Start small and build to serve local needs Anticipate challenges and prepare for them Maintain hope and enthusiasm
AMPATH 2012 July 9, Medical Record System (AMRS): Collaborating Toward An EMR for Developing Countries Burke W.Mamlin, M.D. and Paul G. Biondich, M.D., M.S. Regenstrief Institute, Inc. and Indiana University School ofMedicine, Indianapolis, IN
WHAT OTHERS SAY ABOUT THE INDIANA-KENYA PARTNERSHIP Nominated for the 2007 Nobel Peace Prize;featured in The Wall Street Journal “The people working on this program are public healthheroes. They are doing things that many people thoughtcould never be done, and it is going to have a huge multipliereffect.” --Dr. Tim Evans, former director of health equity for the Rockefeller Foundation “Much more accurately described as an AcademicMIRACLE in response to AIDS.” --Michael E. Ranneberger, U.S. Ambassador to Kenya “The most important and comprehensive HIV/AIDS effortin all of Africa.” - James Morris, former executive director, United Nations World Food Program July 9, 2012
“Now HIV/AIDS programs are not only in placebut some of them, including the partnershipbetween the United States Agency forInternational Development (USAID) and theAcademic Model Providing Access toHealthcare (AMPATH) are openly speaking ofbringing the pandemic to its knees over the next5 years through widespread screening andeffective treatment and prevention of HIV.”Braitstein, P., et al., "Talkin about a revolution": How electronic health records canfacilitate the scale-up of HIV care and treatment and catalyze primary care inresource-constrained settings. J Acquir Immune Defic Syndr, 2009. 52 Suppl 1: p.S54-7. July 9, 2012