Beruflich Dokumente
Kultur Dokumente
Refereed papers
Peter Szolovits
Professor, Computer Science and Articial Intelligence Laboratory and Division of Health Sciences
Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
ABSTRACT
The developing world faces a series of health crises practical lessons in design and implementation
including HIV/AIDS and tuberculosis that threaten from our experience in doing this work. Finally,
the lives of millions of people. Lack of infrastructure we discuss the importance of collaboration between
and trained, experienced sta are considered im- projects in the development of electronic medical
portant barriers to scaling up treatment for these record systems rather than reinventing systems in
diseases. In this paper we explain why information isolation, and the use of open standards and open
systems are important in many healthcare projects source software.
in the developing world. We discuss pilot projects
demonstrating that such systems are possible and
can expand to manage hundreds of thousands of Keywords: databases, developing countries, elec-
patients. We also pass on the most important tronic medical records, HIV
Introduction
The developing world currently faces a series of health initiatives such as the Global Fund and the World
crises that threaten the lives of millions of people. Health Organization (WHO) 3 by 5 Initiative have
Many of the worst-aected developing countries lack begun to mobilise resources and manpower in re-
resources and robust healthcare infrastructures.1 sponse.2,3 Early lessons from treatment programmes
Recent statistics suggest that treating the rising tide indicate that new systems of care are required to allow
of human immunodeciency virus (HIV) in developing these eorts to scale rapidly to thousands or even
countries requires that large-scale interventions are hundreds of thousands of patients.4 Programmes must
immediately put into place, and ambitious worldwide also support healthcare providers, many of whom
84 HSF Fraser, P Biondich, D Moodley et al
have limited training. To achieve these ends requires patient identication, data quality management, and
the ability to manage large and often complex projects, data condentiality and security. Finally, we conclude
including the initiation of new treatments, the follow- with mostly non-technical lessons learned from ex-
up and monitoring of chronic diseases, medication perience in successfully deploying systems.
procurement, and reporting to governments and This is intended as a practical guide for deploying
funders.5,6 Research must also occur concurrently with and using EMR systems in developing countries rather
these eorts, as the pathophysiology of these diseases than a review of all existing projects. Unfortunately
is not fully understood in these environments, and few systems have been described in the literature and
continues to change in response to our interventions. fewer evaluated, but a systematic review of such
Many of these goals require excellent information man- systems was published in 2002.12
agement in order to be successful. Concerns have been
expressed that the lack of infrastructure and skills in
developing countries will prevent large-scale treat-
ment of such diseases as HIV and multi-drug-resistant
tuberculosis (MDR-TB).7 While HIV, TB and malaria Potential benets of EMR
are the best known, other important problems must be systems in developing countries
addressed, including maternal and infant mortality,
other infectious diseases, trauma, and rising levels of
hypertension, diabetes and cardiovascular disease in Although EMR systems have been shown to be feasible
developing countries.8 in developing countries, the problem of limited re-
Growing use of electronic medical record (EMR) sources begs several questions.1315 Do EMRs contrib-
systems in Europe and the United States (US) has been ute important benets to healthcare projects? Is this
driven by the belief that these systems can help to use of information technology (IT) practical beyond a
improve the quality of health care. Decision support few well-funded pilot sites? Does it have a benecial
systems, particularly for drug order entry, are becom- impact on patient care or the management of such
ing important tools in reducing medical errors.9 Email healthcare organisations? What lessons can we pass on
is important and widely used in healthcare systems, to other healthcare organisations to help them identify
and access to medical data including online journals is the most eective and sustainable technologies for
expanding.10 EMR systems in these environments?
Even in resource-rich nations, the development of Rapid developments in IT have greatly reduced the
EMR systems is still an uncertain and challenging task, costs of setting up information systems. Plans have
calling for a sensitive matching of local needs to available recently been announced to develop a laptop PC for
technologies and resources.11 Experience with creating $100.16 Internet access is now relatively widely avail-
EMR systems for the developing world is much more able in many developing countries (Peru, Ghana, etc.)
scarce; requirements, priorities and local constraints and there exists a broad range of robust and exible
are less well understood and probably more hetero- devices to manage data, including personal digital
geneous. Some settings in the developing world are assistants (PDAs) and mobile phones.
similar to a European or US healthcare environment In developing countries, healthcare information
and can use similar software; other environments have systems have been driven mainly by the need to report
very limited resources. It is impossible, therefore, to aggregate statistics for government or funding agencies.17
suggest a single EMR architecture and implementation Such data collection can be performed with simple
that will t all environments and needs. In this paper paper forms at the clinic level, with all electronic data
we focus on systems that can support health care in the entry done centrally, but that approach tends to be
very challenging impoverished environments where the dicult and time-consuming and may provide little
vast majority of the worlds population live. A handful or no feedback to the sta collecting data.18
of projects in developing countries have now met the Individual patient data that are collected and access-
test of actual implementation in such settings and are ible at the point of care can support clinical manage-
in day-to-day use. ment. Clinicians can easily access previous records,
We rst discuss the potential benets of EMR sys- and simple tools can be incorporated to warn of
tems in developing countries and then present short potential problems such as incompatible drugs. Phys-
descriptions of several systems with which we are fam- icians or nurses can check on the outcomes of indi-
iliar that are in regular use. We then provide a taxonomy viduals or groups of patients and perform research
of system architectures and technology choices and studies. Many of these functions will work well on
comment on their applicability in particular kinds of paper or with simple spreadsheets for up to 100 patients
environments, drawing on our practical experiences but become very time-consuming and potentially
and the examples of deployed systems. We also present unreliable with more than 1000 records, and virtually
a number of challenging issues including reliable impossible with 10 000 or more. Networked EMR
Implementing electronic medical record systems in developing countries 85
systems allow laboratory data to be entered from distant to be validated in appropriate environments. Box 2
sites, assisting prompt and eective patient manage- includes brief descriptions of other known systems
ment. Access to email or web communications allows deployed in developing countries. A recent report
sta to seek specialist advice from remote phys- includes an assessment of medical information needs in
icians.19,20 Assessing resource requirements and pre- African clinics and some additional systems.18
venting drug stock shortages, while not normally a
consideration for medical sta in developed countries,
can be a critical issue in the developing world.18 It
requires an accurate knowledge of numbers of patients
(1) AMRS, Kenya
with particular regimens or types of disease and know- Background: Indiana University School of Medicine
ledge of drug stocks and supply.21,22 EMR systems can and Moi University School of Medicine (Eldoret,
also be used to track patient outcomes, compliance Kenya) have been collaborating for over 15 years. In
with therapy and to record surgical procedures. February 2001, this collaboration led to the Mosoriot
Finally, point-of-care data can be used to rapidly Medical Record System (MMRS). The MMRS was
generate aggregate reports, which should be more installed in a primary care healthcare centre in rural
complete and accurate because users will more likely Kenya. In November 2001, the MMRS software was
recognise errors regarding their own patients.15 Incorp- adapted to support the AMPATH (Academic Model
orating multiple functions into the same information for the Prevention and Treatment of HIV/AIDS)
system allows reuse of data and should help to justify project and renamed to AMRS.29,30
the basic costs of set-up and technical support. For Design: Two networked computers running Microsoft
example, in sites with no modern communications, a (MS) AccessTM, powered by a UPS with solar battery
satellite internet connection might be justied purely back-up. For the AMPATH project, the network has
to allow regular communication by email and possibly expanded to seven networked computers linked to a
internet telephony.14 The benets of web access for data single MS Access database.
management and medical education are additional.23 Number of patients entered: 60 000 patients and over
Box 1 summarises the benets of EMR systems. 150 000 visits in four years. For HIV care, 8000 patients,
3300 of whom are currently receiving anti-retroviral
drugs (ARVs).
Box 1 Benets of EMR systems Sites: Two, with the AMPATH site serving as a central
repository for eight remote clinics.
. Improvement in legibility of clinical notes13
Data entry: In the MMRS, patients are registered in the
. Decision support for drug ordering, including
system upon arrival, travel through the clinic with a
allergy warnings and drug incompatibilities24
paper visit form, and present the visit form as they
. Reminders to prescribe drugs and administer
depart. Clerks perform the registration and transcribe
vaccines24,25
visit data. AMRS data are collected on paper forms at
. Warnings for abnormal laboratory results25
each visit, delivered to a central location for data entry,
. Support for programme monitoring, including
and then returned to the patients paper chart.
reporting outcomes, budgets and supplies26,27
Functions: MMRS provides both patient registration
. Support for clinical research
and visit data collection functions. Data are collected
. Management of chronic diseases such as dia-
on all patients seen in the medical clinic, including their
betes, hypertension and heart failure2,28
laboratory results and medications. AMRS supports
comprehensive HIV care as well as mother-to-child-
transmission prevention, while serving as a rich database
for quality improvement and answering research ques-
Case summaries of existing tions.
systems Pharmacy management: Based on drug regimens
analysis available.
Evaluation: A comparison of the clinic before and after
Despite the diculties in deploying information sys- adoption of the MMRS showed patient visits were
tems in developing countries, several have successfully 22% shorter, provider time per patient was reduced by
integrated into clinical workows. While none rep- 58% (P < 0.001), and patients spent 38% less time
resent a complete or ideal solution, their successful use waiting in the clinic (P < 0.06); clinic personnel spent
over several years, with combined patient records 50% less time interacting with patients, two-thirds less
numbering in the hundreds of thousands, oers valu- time interacting with each other, and more time in
able insights into successful future deployments. This personal activities.14 The MMRS has also vastly
is not intended to be an exhaustive list; other systems simplied the generation of mandatory reports to
might contain important ideas and designs but need the Ministry of Health.
86 HSF Fraser, P Biondich, D Moodley et al
Signicance: The growing AMRS and MMRS data- previous paper and spreadsheet approach (17.4% to
bases serve both clinical and research needs, gen-erating 3.3%, P < 0.0075).31 Drug requirements analysis tools
clinical summary reports for providers and providing are based on the medications prescribed, and have
a centralised source of data for epidemiological research. been shown to match the usage data in the pharmacy
The next generation of the database, called AMRS, to within 3%.21
has a completely revamped data model, and uses new Signicance: The PIH-EMR demonstrates the strength
technology (MySQL, Python-based Zope and Plone, and exibility of a web-based approach when internet
and MS InfoPath to allow web-based data entry).30 See connectivity is available.
http://amrs.iukenya.org for more information.
Data entry: Both direct by users, and on paper forms. Functions: Data are collected on patient demographics,
Functions: Provides comprehensive tools for tracking medication, laboratory tests and X-rays. A potential
HIV patients and their treatment, including clinical limitation of the touch screen approach is that it is
assessment, medications and billing data. It is widely dicult to enter free text, though an on-screen
used in health centres and hospitals in the US, and has keyboard is available and has been used by local sta
recently been internationalised and deployed in to enter all the patients names.
Uganda in October 2003. Pharmacy management: Recording of regimens only.
Pharmacy management: Drug inventory support in Signicance: The extensive use of this system directly
international version. by healthcare workers in a poor country with limited
Signicance: Careware is an example of a US-based IT skills is a convincing demonstration of the potential
stand-alone EMR that is being adapted to developing of EMRs with user-friendly data entry mechanisms.
country environments. An internet-accessible version
that is under development will allow local data entry
oine but provide networked communications and
back-up.
(6) SICLOM, Brazil
Background: The Brazilian public health system uses
the Computerized System for the Control of Drug
Logistics (SICLOM) to deliver ARV treatment to over
(5) Lilongwe EMR, Malawi13
100 000 patients by far the largest group in the
Background: Kamuzu Central Hospital located in developing world.33,34
Lilongwe, Malawi has made extensive use of a touch- Design: Separate EMR databases on each physicians
screen patient management information system for desktop periodically connect to the central server by
a wide range of clinical problems in the 216-bed dial-up to update records. Language: Portuguese.
paediatric department since 2001. Number of sites: Widespread throughout Brazil.
Design: Runs over a local area network built on Linux/ Number of patients: More than 100 000.
MySQL with Visual BasicTM for the client programs. Function: Used to support prescribing and track
Sites: One. medication supplies (limited information available).
Number of patients: 160 000 total; 6000 with HIV. Signicance: It is considered a key factor(s) helping to
Data entry: Physicians, nurses and pharmacists per- overcome logistical challenges to delivery of anti-
form all data entry using touch screens, including retroviral treatment in Brazil.33
medication orders.
User interfaces
Hybrid approaches
The thin client approach hinges around 24/7
connectivity and availability of a centralised ser- A wide range of user interfaces are available to allow
ver, probably located in a dierent site. Often this sta to interact with systems.45 The interface choice
is not possible in developing countries. A thick might make a signicant dierence to the user experi-
client approach could be used, but software and ence but should not tie the system to a particular data
database installation at remote nodes and data model or architecture. Ideally any interface should be
synchronisation are major hurdles. An alternative usable with any data model, and most network
is the HIV-EMR in Haiti, where a program installed architectures.
on a remote machine uses a local web-based The choice of user interface (see Box 6) will depend
interface to store data locally and uploads these on the system and user requirements (see next sec-
data to a central server when the network is tion). In larger EMR systems, it is important to design
available.9 This is a hybrid approach as a client and implement the user interface as a separate
program is installed, and local storage is used component. The system should provide a structured
when the network is unavailable, but it is not a full programmatic interface to transfer data to and from
thick client system. Only recent transactions/
modications are stored locally and remote nodes
do not contain a proper local database. Data
Box 6 Dierent user interfaces that can
synchronisation becomes an issue if two users
be used in EMR systems
modify and upload the same record. In this
system the central server still has the denitive . Local Windows forms such as MS Access forms
copy of all data. or Java forms. Generally rapid to develop and
provide a very wide range of functions and
exibility.
. Web pages are more widely understood and
The above systems vary in the degree to which they are used than other interfaces and simple to deploy
networked, in location and in the type of databases at a distance. They are exible but can be more
deployed. Simple systems based on a database on one limited in functions and interactions than
PC are common as they are easy to develop and deploy other forms.
for many basic tasks. Networked systems require more . Personal digital assistants (PDAs) such as Palm
expertise and technical ability to set up, but provide a Pilot or Pocket PC devices. Portable, low cost,
number of benets as given in Box 5. long battery life (Palm) and generally easy to
use.46 Either use custom software, form gener-
ation tools or a web browser that stores local
copies of web pages for review or upload.39
Box 5 Benets of using a networked EMR
Small screen size limits ease of data entry for
. Data are accessible and shared at multiple sites large forms.
. Multiple users can enter data simultaneously . Phone. Can be used to access and enter data
. Data can be backed up automatically at more through a voice interface such as the Voxiva
than one site disease surveillance system in Peru.47 Mobile
. Information can be communicated between phones can also permit limited data entry on
multiple locations such as from laboratory to screen.48,49
physician . Scanned paper forms with optical character
. Wide area networks can link up remote lo- recognition. Allow data recorded in a struc-
cations tured way to be entered automatically into the
. Web-based systems and some other client pro- computer system, for example TeleformsTM.50,51
grams can often be debugged and upgraded over Some systems allow the forms to be faxed to a
the internet without visiting remote sites19 remote site for processing. These systems gen-
erally need data to be checked by an operator
and tend not to handle free text well.
. Email can be generated to send warnings or
The approach chosen largely depends not only on the reminders even when the user does not have
infrastructure and expertise available at individual direct access to the EMR. Some systems allow
sites, but also on the availability and reliability of data to be entered and uploaded by email, which
communication infrastructure between sites. can be helpful when bandwidth is limited.20,42
Implementing electronic medical record systems in developing countries 91
the user interface. Thus it should be possible initially Maintaining regular communication with users through
to build a forms-based interface, and with minimal a data manager and meetings is also important. While
eort introduce a PDA interface at a later stage without some users will oer unsolicited information about
having to redesign the entire system. The user inter- data issues, many do not. Developers can discover
face is also the component of the system that changes valuable information by keeping in close contact with
the most. User interfaces should contain minimal users. A web-based system can be helpful in this respect
functionality and should be easy to change; modifying as user problems and data quality can often be mon-
and creating new forms should be a rapid and painless itored centrally. Regular conference calls to discuss
process that may be delegated to junior IT sta. technical problems and new requirements with users
keep the development team in close touch. Email,
instant messaging, internet video conferencing and
application sharing can all be valuable in supporting
Order entry systems users and can usually be made to work well over
One specic type of interface that requires particular limited internet connections.41 Prompt and eective
care and expertise is that used in order entry systems. help to users is a vital factor in generating support and
These allow physicians or nurses to request medi- ensuring widespread use of an EMR system.
cations and investigations directly online, using rules Low literacy contributes to inconsistent spelling
to guide documentation and clinical decision making of patients names and addresses. Search tools can be
and assist in preventing some types of medical errors.9 used to match similar names and age, gender and
However, these benets come at a price. Order entry address, and either merge the two records or email the
systems require considerable care and expertise to details to the users for advice. Use of patient ID cards
build, evaluate and maintain. Failure can be costly in has also been helpful in several projects in Africa.13 A
time and money, can slow clinical care, and most WAN system can be valuable in enforcing a single
importantly could cause medical errors, thus putting unique identier across sites.
patients at risk.11,52
Technical problems
The choice of system or technology to be implemented . Lack of back-up systems in event of computer
will be inuenced by medical, stang and environ- loss
mental factors. Reference should be made to the . Poor system security leading to viruses and
design issues discussed earlier. Table 1 gives example spyware
costs for satellite internet access, and Box 7 lists pitfalls . Unstable power supplies and lack of battery
and problems that can occur. back-up
. Poor or inadequate data back-ups
. Lack of technical support sta and/or system
Table 1 Typical non-personnel costs of hard to maintain
internet access in remote sites such as
rural Haiti (US$); assumes electrical
supply/generator and limited technical
help with network outages (see (3) Haiti and (6) Brazil
support
case studies). This design also makes sense if there are
multiple sites that need to be covered, particularly if
Satellite dish and modem $6000 certain resources are located at a distance, such as
2 desktop PCs $1500 laboratories or a common drug warehouse.
1 laptop PC $1000
Network cables, power supply, etc. $500 Available infrastructure in sites
Servers need stable power and physical security in a
Total $9000
relatively dry, dust-free and temperature-regulated area.
Annual internet charges $2000 O-site data back-up as well as a second back-up
server in a dierent location is strongly advised.
Approximate cost per year over 4 years $4250
Access to networks
Number and size of sites Internet access allows more exible designs with
A single large hospital will probably need to have external communication of data and o-site back-up.
multiple terminals for data entry and viewing: this Pure web-based systems need reliable networks, but
makes a networked system the logical design. With dial-up connections can work if the pages are designed
good local technical support and stable power the carefully and the system is not required all the time.27
server could be located in the facility (for example,
(4) Malawi case study). If the site has limited infra-
structure, a web-based system is an alternative with Local expertise in development and
the server o-site (see (2) Peru case study). A small technical support
clinic could set up a stand-alone database system (as in A major factor in any design will be the availability and
(1) Kenya case study). Alternatively an internet-based skills of local technical support sta. Managing client
system could be deployed with local data storage to PCs or single Windows machines running a database
Implementing electronic medical record systems in developing countries 93
is within the expertise of many countries (though viruses a signicant component of trial and error, reuse of
and security issues are very important challenges). well-tested components helps reduce technical prob-
Servers need more expertise for setting up and backing lems, especially for complex functions like order
up data; MS Windows tends to be easier for small sites entry.52 This is particularly important in remote sites
to manage. For larger installations open source soft- with limited access to technical support. The software
ware can be cheaper and more future proof, also should also be open-source if possible.54 Small proj-
Linux is very easy to manage and support over the ects are vulnerable to the loss of a key programmer or
internet. Good documentation and easy-to-congure IT company and are likely to fail if source code is not
systems are important. available to other programmers.
Discussion Conclusions
The deployment of signicant numbers of EMR sys- In deciding what EMR systems to develop and deploy
tems in developing countries has blunted some of the in developing countries, promising ideas are not
scepticism about such approaches, but real concerns enough: they need to be validated in the eld. It is
and much resistance remain. The potential diversion important to look closely at systems that have been
of resources from other healthcare needs to support successfully deployed in challenging environments,
information systems has to be weighed against the and any available evaluation data. The introduction
potential to improve quality of care and eciency of of IT systems to remote sites with no communication
care delivery. Successful new IT applications tend to should provide good opportunities to evaluate the
have certain benecial capabilities that overcome un- impact of data management and/or communications
certainties and drive forward their deployment. At tools. Specic outcomes should be measured, such as
present, two examples have emerged as primary ben- time to change patient management in response to
ets for EMR systems in developing countries: the new laboratory results, or better monitoring of patient
ability to get laboratory results to remote clinics in a compliance.15,25 There is some evidence of benet to
timely fashion, and the ability to track drug supplies patient care from access to communication, including
and expected drug usage, particularly for HIV and the use of telemedicine consultations to improve diag-
MDR-TB. The use of EMR systems to reduce medical nostic accuracy and reduce unnecessary patient trans-
errors and improve quality of care is still in its infancy, fers.55,56 Improvements in drug supply management
but initial evaluations are promising despite the chal- using medication data from EMR systems could oer
lenges.31 Improvement of clinical management by the most measurable cost benets at present; a well-
physicians and other healthcare workers has the greatest managed drug supply also improves availability and
potential to benet patients. It also requires more quality of patient care.21
sophisticated tools than just simple patient registries In creating or choosing a new EMR, it is essential
and could therefore take longer to demonstrate. that the underlying data model is designed with a
The development of EMR systems in the US over long-term vision of the functions that will need to
the last two decades has been dogged by problems of be supported: it can be very dicult to scale from a
closed, proprietary and incompatible systems; a recent simple at le data model to a larger clinical system or
survey of US primary care physicians identied 264 one that can be deployed in other sites. Furthermore it
dierent EMRs in use!53 Unfortunately, developing makes little sense to recreate the same functions and
countries are beginning to experience similar prob- tools at each site. Collaborative development between
lems, with many projects building their own basic projects using an open source model (even if the
EMR systems. This stems from a lack of good custom- underlying operating system is not open) has great
isable systems, lack of appropriate foreign language potential to improve quality of software and reduce
options in some cases, and a feeling that each project costs.
is unique.18 There are clear advantages in developing We are now in the fortunate situation of falling
custom software but the cost in time and money can IT costs, improving computer literacy and increasing
be high. Once the system is operational, it needs to be resources, combined with preliminary evidence of
supported and upgraded. Many of the core tasks in EMR successes in resource-poor areas. The critical
building a good EMR are common to most projects challenge is to create well-designed, eective, low-cost
and benet from the feedback of multiple users systems by sharing resources, learning from each
and developers. Because software development has others experience and evaluating our work.
94 HSF Fraser, P Biondich, D Moodley et al
30 Siika AM, Rotich JK, Simiyu CJ et al. An electronic 47 Voxiva. 2005. www.voxiva.net/index.html
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None.
43 Dolin RH, Alschuler L, Beebe C et al. The HL7 clinical
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ADDRESS FOR CORRESPONDENCE
44 Hoch I, Heymann AD, Kurman I, Valinsky LJ, Chodick G
and Shalev V. Countrywide computer alerts to commu- Dr Hamish SF Fraser
nity physicians improve potassium testing in patients 641 Huntington Avenue
receiving diuretics. Journal of the American Medical Boston, MA 02144
Informatics Association 2003;10:5416. USA
45 Spohr M. Information technology for use in HIV/AIDS
Tel: +1 617 432 3930
treatment in resource poor settings. John Snow Inter-
Email: hamish_fraser@hms.harvard.edu
national 2005. rhinonet.org/tikiwiki/tiki-index.php
46 Al-Ubaydli M. Handheld computers. British Medical
Journal 2004;328:11814. Accepted April 2005