Opportunities for mHealth in the Developing World: OpenMRS

Hamish SF Fraser MBChB, MSc, FACMI Assistant Professor, Division of Global Health Equity, Brigham and Womens Hospital and Harvard Medical School Senior advisor for medical informatics, Partners In Health

What do we use EMR data for?

•  Clinical care and quality improvement

•  Reporting to clinicians, managers, funders

•  Logistics and supply chain management

•  Clinical research

OpenMRS: a modular, open source, EMR platform

•  Uses concept dictionary for data storage •  Modular design simplifies adding new functions and linking

to other systems •  Released with open source license (April 2007) •  Core of paid programmers with growing community support •  Clinical use in over 50 developing countries •  Secure logins and auditing of data access and changes •  Developed as a collaboration of PIH, the Regenstrief

Institute and the South African MRC • 

Partners  In  Health   Regenstrief  Ins1tute   Medical  Reseach  

Council  South  Africa  

www.openmrs.org

OpenMRS spread: > 50 countries, (more not yet mapped

Physician looking up ARV patients

Photo Rockefeller Foundation

Clinical consults

Lara Kellet, funding CDC

La Colline, Haiti Patient visits & diagnoses

Using patient registration data

Image, Jitka Hiscox

Standards and Interoperability

•  Standardized concept dictionary with mapping to ICD10, SNOMED and others (CEIL)

•  Maternal Concept Lab (MCL) •  Interoperability with mHealth software •  Modular architecture •  SMART Apps

mHealth Platforms linked to OpenMRS

•  Sana – MIT

•  Open Data Kit: U. Washington

•  ComCare: DiMagi, Cambridge

•  OpenXdata: Bergen

Support for SMART Apps

Childrens Hospital Informatics Program

Open Development

•  Sharing source code •  Sharing modules •  Sharing concept dictionary

– Comparing outcomes – Sharing de-identified data – Sharing decision support tools

•  Analysis of system performance with sharing of data on adverse events – a problem with HIPAA

Evaluation: RCT of Alerts for HIV care

Printed reminders from OpenMRS for pediatric HIV care in Kenya:

• overdue 6-week HIV DNA polymerase chain reaction tests • 18-month (ELISA) antibody tests • CD4 tests • routine laboratory studies • chest radiographs • initiating Anti-Retroviral Therapy • referring malnourished children for nutritional evaluation and assistance

Were MC, et al. Pediatrics. 2013 Mar;131(3):e789-96

Evaluation

•  They randomized 1611 patients, (30 providers)

•  They studied completion of overdue clinical tasks over the five months of the study

•  Showed improvement in task completion when the providers had the reminders: (68% intervention vs 18% control, P< .001).

•  Tasks occurred earlier in the intervention group (77 days, SD 2.4 days) control group (104 days, SD 1.2 days) (P< .001).

Call to Action on Global eHealth Evaluation

Consensus Statement of the WHO Global eHealth Evaluation Meeting,

Bellagio, September 2011

“To improve health and reduce health inequalities, rigorous evaluation of eHealth is necessary to generate evidence

and promote the appropriate integration and use of technologies.”

University hospital of Mirebalais, Haiti

OpenMRS 2.0 point of care EMR PIH, OpenMRS, Thoughworks Inc.

Collaborators and Funders •  Partners In Health •  Regenstrief institute •  World Health Organization •  US Centers for Disease Control •  Brigham and Women hospital •  Harvard Medical School •  Millennium Villages Project •  International Development Research

Centre, Ottawa •  Rockefeller Foundation •  Thoughtworks inc. •  Google Inc

OpenMRS is growing fast •  Wide deployment to more than 50 LMICs •  Large scale rollouts in Rwanda, Kenya, the

Philippines •  Wider range of diseases: Oncology, Heart

Disease, Diabetes, Primary Care, Surgery •  More direct point of care use •  Wider use as part of mHealth projects •  Linking to broader eHealth architecture

projects

You need “bottom up” and “top down”

•  Bottom up – Address clinical needs and problems – Ensure data quality – Local ownership and priorities

•  Top down – Plan for wide use – Horizontal approach to disease healthcare – Core data set and use of open standards – Evaluation and evidence based decision making

Problems and Challenges

•  Entry level solutions can be hard •  Easy configuration for non-programmers •  Getting data out of OpenMRS and

simplifying reporting •  Making it more user friendly •  Infrastructure, infrastructure…

Levels of development of OpenMRS

1.  Site specific implementation/customization 2.  Distribution/implementation package:

– specific clinical requirements and organization 3.  Develop application tools/components

–  forms, reports, summaries, data visualization, flow sheets, data import and export tools etc.

4.  Interoperability with related applications – Labs, pharmacy, mHealth, MOH reporting etc.

5.  Modify the OpenMRS Platform and API

2005 2007 2006 2010 2008 2009 2011

The PIH OpenMRS timeline and creation of new components.

HTML forms

Synchronization

Reporting framework

Patient registration 2012

New UI