African Health Clinics Use AHRQ Research on EMRs to Improve Care for HIV/AIDS Patients

An electronic medical record (EMR) system developed to help African health clinics better care for HIV/AIDS patients was influenced by and has links back to AHRQ-funded research in the 1980s. The research, conducted by William Tierney, MD, and his colleagues at the Indiana University School of Medicine and the Regenstrief Institute, identified factors that were important to the design and successful implementation of EMR systems.

The Regenstrief Medical Record System was the outcome of this AHRQ-funded research and essentially served as the foundation for OpenMRS, an open-source shareware EMR system that is the heart of a multinational collaboration of EMR developers. OpenMRS grew from Indiana University's work developing the first and most successful outpatient EMR system in sub-Saharan Africa, which currently stores and manages data for 29 clinics serving more than 50,000 patients in western Kenya. Of the more than 38 million persons with HIV worldwide; 25 million—63 percent—of those live in sub-Saharan Africa.

The original site for EMRs in sub-Saharan Africa was a rural clinic in Western Kenya, the Mosoriot Rural Health Centre.

The computer-based AMPATH Medical Record System (AMRS), implemented in Kenya in 2001, has since been modified from a system originally programmed in MS-Access as a set of spreadsheets into OpenMRS. OpenMRS is a comprehensive EMR capable of collecting, managing, and reporting clinical data in multifaceted HIV/AIDS care programs across the continent. The transformation to OpenMRS was necessary when the number of patients exceeded 10,000 and visits exceeded 100,000. Researchers needed to modify the system to accommodate the volume of patients and visits and the increasing complexity of clinical data. The modified model was even more closely aligned with the original AHRQ-funded Regenstrief model.

As a result of the success of the original experience at the Mosoriot Rural Health Centre led by Tierney, and after obtaining additional program funding, the EMR program has significantly expanded in size and scope to include an additional 29 urban and rural primary care and HIV clinics in Kenya. By late 2007, the database contained more than 25 million observations from more than 800,000 visits made by more than 60,000 patients. Between 1,500 and 2,500 new patients are being enrolled each month.

In addition to clinical data, OpenMRS in Kenya also stores and manages data for the following programs:

• A comprehensive nutrition program feeding 30,000 a week.
• An outreach program that has contacted more than 10,000 patients who missed clinic appointments.
• A psychosocial support program that has enrolled over 24,000 patients and family members.
• A program supporting more than 7,000 orphans and vulnerable children.
• An HIV testing program that has screened more than 180,000 individuals.

Tierney notes, "Providing high-quality HIV/AIDS care requires high-quality, accessible data on individual patients and visits. AMRS has succeeded because it provides useful information to a wide variety of clinical and non-clinical personnel."

The EMR system helps staff in many ways. Clinicians use the forms, patient summaries, and computer reminders for daily patient care. Clinic managers use monthly reports to assess productivity and anticipate personnel needs. Data managers report AMRS information to governmental and funding agencies. Outreach workers can track patients who fail to keep appointments, thus ensuring visits. Nurses assess reasons for non-compliance and counsel patients.

In addition, social workers assess financial needs and make appropriate referrals. Prevention workers help pregnant mothers and newborns to lower their HIV risk and care for those who become infected. Nutritionists provide underfed patients with weekly deliveries of food supplements meeting their specific nutritional needs. Researchers and quality improvement officers assess and improve processes and outcomes of care.

When originally creating OpenMRS in 2004, Tierney and the Regenstrief Institute developers teamed up with Boston-based Partners in Health. They created the system as a free open-source framework for medical records. Based on the AMRS, the OpenMRS Consortium aimed to enhance the productivity and accountability of HIV and tuberculosis patient care programs by developing local expertise to adapt and implement custom EMRs. It has since been expanded to support a broad range of health care.

Based on the principle that information should be stored in a way that makes it easy to summarize and analyze, OpenMRS uses minimal free text and maximum coded information. At its core is a concept dictionary which stores all diagnosis, tests, procedures, drugs, and other general questions and potential answers. OpenMRS is designed to work in many environments, from a single stand-alone computer (or hand-held device) to a wide-area, Internet-based network where many client computers access the same information on a remote server.

Using standard messaging formats and data coding, OpenMRS allows local users to design a customized medical record system with no programming knowledge (although medical and systems analysis knowledge is required). It is a common framework upon which medical informatics efforts in developing countries can be built.

OpenMRS has been translated into Spanish, French, and Portuguese and implemented in the following African countries: Kenya, Tanzania, Uganda, Rwanda, South Africa, Zimbabwe, Mozambique, Lesotho, Congo, Ethiopia, and Malawi. In addition, the Millennium Villages Project is installing OpenMRS in its clinics worldwide. OpenMRS is also beginning to be used in other developing and developed countries, including Canada and the U.S.

For more information on OpenMRS, go to http://www.openmrs.org.