Presentation on A/Prof. T Hannan's experiences from the Johns Hopkins Onclogy CIS to MMRS. AMPATH to OpenMRS

1. 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 INFORMATICIAN
July 9, 2012

2. 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)
• Questions
July 9, 2012

3. 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.

4. “Bibles of Health Informatics”
July 9, 2012

5. 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.org
July 9, 2012

6. 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 Group
July 9, 2012
 Google Inc
 PEPFAR

7. Health care is an information business
Information 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

8. TECHNOLOGY IS NOT THE PROBLEM
[30 years EMR experience and research]
Retrieval times-Fast (blink times)
Data and information-Comprehensive
Data storage- Long-term-lifelong
Data applications-Introspective of total database
Data 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

9. CCDSS TOOLS IN CLINICAL MEDICINE-REQUIREMENTS
1.ALERTING
2. REMINDING
3. INTERPRETATION
4.ASSISTING
5.CRITIQUING
6.DIAGNOSING
7.MANAGING
8. 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.

10. SUMMARISATION
1. Communication of health care is maintained using a
Summary patient format in the ambulatory setting.
Fries. J. Alternatives in medical record formats. Medical care. 1984;12:871-881
6. 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

11. 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
-16
Physician inpatient order writing on microcomputer workstations-effects on resource
July 9, 2012
utilisation. WM Tierney and others. JAMA 1993;269:379-383

12. 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 system
Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic practice
guidelines through computer-assisted decision support: clinical and financial outcomes.
Ann Intern Med 1996 May 15
July 9, 2012

13. Intermountain Health Care, Salt Lake City, Utah, USA
Overall antibiotic use: decreased 22.8%
Mortality rates: decreased from 3.65% to 2.65%
Antibiotic-associated ADE: decreased 30%
Antibiotic resistance: remained STABLE
Appropriately timed preoperative a/biotics: 40% to 99.1%
Antibiotic costs per treated patient: decreased $122.66 to $51.90
Acquisition costs for antibiotics: fell 24.8% to 12.9%
($987,547) to ($612,500)
Our Case-Mix index which measures patient acuity levels
INCREASED during this period, meaning we were treating
sicker and sicker patients while better utilizing the delivery of
antibiotics.
Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic
practice guidelines through computer-assisted decision support: clinical and
financial outcomes.Ann Intern Med 1996 May 15
July 9, 2012

14. AMIA –
November 1999
An invitation from
Prof. Bill Tierney
To KENYA Jan
July 9, 2012

15. 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 it
SOURCES: Quinn and Chaisson, 2004; WHO, 2003a,b.

16. AIDS in Africa
In 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

17. 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

19. Limited resources
July 9, 2012

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28. A response to HIV
July 9, 2012

29. 30-40 million
cases HIV/AIDs
Existing systems overburdened
July 9, 2012

30. Assignment: knowing there is a 14% prevalence of HIV/AIDS.
What are the health information management needs here?
PreMMRS
July 9, 2012

31. July 9, 2012

32. July 9, 2012

33. July 9, 2012

34. July 9, 2012

35. Assignment: knowing there is a 14% prevalence of HIV/AIDS.
What are the health information management needs here?
PreMMRS
July 9, 2012

36. MMRS data (2 years)
63,728 visits
Diagnoses # Visits Drugs # Visits
Malaria 17,495 Paracetamol 24,944
URI 8,479 Fansidar 11,550
Septic wound 1,329 Quinine, injected 8,769
Gastroenteritis 964 Penicillin, injected 8,058
Tonsilitis 938 Quinine, oral 7,851
Wound (unspec.) 791 Penicillin, oral 4,753
Myalgia 700 Amoxicillin 4,725
Amebiasis 629 Depoprovera 4,443
Laceration 618 Piriton 3,766
Worms (unspec.) 544 Brufen 3,323
July 9, 2012

37. MMRS data (2 years)
63,728 visits
T B
Malaria
Diagnoses # Visits
17,495
Drugs
Paracetamol
NO # Visits
24,944
URI
Septic wound
8,479
1,329
n d
Fansidar
Quinine, injected
11,550
8,769
Gastroenteritis 964 a
Penicillin, injected 8,058
Tonsilitis
Wound (unspec.)
HIV
938
791
Quinine, oral
Penicillin, oral
7,851
4,753
Myalgia
Amebiasis
N O 700
629
Amoxicillin
Depoprovera
4,725
4,443
Laceration 618 Piriton 3,766
Worms (unspec.) 544 Brufen 3,323
July 9, 2012

38. “We have lit a candle in the darkness of Africa”
William Tierney.
Kenyan Gov’t: “This record system must be in every
clinic in Kenya!”
July 9, 2012

39. July 9, 2012

40. July 9, 2012

41. A Year of Growth?
July 9, 2012

42. A Year of Growth… One Year Later
July 9, 2012

43. 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 clinic's 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

44. 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

45. Early PHRS
July 9, 2012

46. Salina- “Rattling bones syndrome”
Starvation!
July 9, 2012

47. Salina on anti-retroviral therapy
July 9, 2012

48. HIV is a treatable disease, but
treating millions requires
information management.
July 9, 2012

49. AMPATH clinical and support programs capturing electronic data.
ALL DISEASE STATES NOT JUST HIV/AIDS
Adult HIV/AIDS clinics Oncology clinics Social worker assessments
Pediatric HIV/AIDS clinics Mental health clinics Outreach – patient follow-up
Primary care – rural health Diabetes clinics Drug adherence assessments
clinics Tuberculosis clinics
Primary care – urban well-child Clinic pharmacies Nutrition assessments
clinics Clinical laboratories Food supplement distribution
Antenatal and postnatal clinics Microfinance program
Mother-baby register
AMPATH maintenance cost only $175/patient/year in 2007 and is now less than
$100/patient/year in 2009
July 9, 2012

50. July 9, 2012

51. July 9, 2012

52. Birth of OpenMRS Collaboration-Regenstrief/PIH
MEDINFO San Francisco 2007
Prof. Paul Biondich
A/Prof. Hamish Fraser
A/Prof. Burke Mamlin
July 9, 2012

53. The plural of anecdote is not data.
“we must remove ourselves from the
‘unscientific, non data driven personal
recommendations’ for care”.
Dr. M. Smith CHCF AMIA 2009

54. 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
/ 6/2010
Patients 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

55. 450,000
400,000
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
Cumulative Patients Enrolled: Nov ’01 – Jan ‘12

56. 70,000
65,000
60,000
55,000
50,000
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
Patient Visits By Month: Nov ’01 – Jan ‘12

57. 3,500,000
3,000,000
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
Cumulative Patient Visits: Nov ’01 – Jan ‘12

58. 3,000,000
2,800,000
2,600,000
2,400,000
2,200,000
2,000,000
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
AMRS Observations By Month: Mar ’06 – Jan ‘12

59. 120,000,000
110,000,000
100,000,000
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

60. To improve care, you have to measure it. Not possible using current
paper-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 ~160
ALL GRANTS AND CONTRACTS CURRENTLY FUNDED TO
DATE (N=74) $40,928,084US
July 9, 2012

61. July 9, 2012

62. GN for
AIDS
MTCT-Plus Women’s &
Clinical
Program Children’s
Trials
Health
Group
Research
NHLBI
Global Health IeDEA
Initiative

63. OpenMRS
A web-based EMR…
July 9, 2012

64. Patient
summary
and alerts
July 9, 2012

65. OpenMRS is…
 An Electronic Medical Record System
 A data model
 An API
 An HIV system … and more.
 A TB system
 A Primary Care system
 A developer community
 An implementer community
July 9, 2012

66. Multiple uses
July 9, 2012

68. Kapenguria
Kapsakwony
Kitale
Naitiri
Webuye
Amukura Turbo
Teso
Mosoriot Burnt Forest
Chulaimbo
50 km

69. 400,000 patients
OpenMRS sites - fall 2008
July 9, 2012

70. 600,000 patients
OpenMRS sites – Spring 2010
July 9, 2012

71. July 9, 2012

72. 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 program's 2006
budget.
 Government support to distribute throughout Peru
A 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

73. Features of OpenMRS Part 1
Security: User authentication
Privilege-based access: User roles and permission system
Patient 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 numbers
Data entry: With the FormEntry module, clients with InfoPath (included in
Microsoft Office 2003 and later) can design and enter data
using
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 import
Modular architecture: An OpenMRS Module can extend and add any type
July 9, 2012 73
of functionality to the existing API and webapp.

74. Features of OpenMRS Part 1
Patient 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 patients
Localization / 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” observations
Reporting tools: Flexible reporting tools
Person attributes: The attributes of a person can be extended to
meet local needs
July 9, 2012 74

75. 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

76. 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 of
Medicine, Indianapolis, IN

77. 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 health
heroes. They are doing things that many people thought
could never be done, and it is going to have a huge multiplier
effect.”
--Dr. Tim Evans, former director of health equity for the Rockefeller Foundation
“Much more accurately described as an Academic
MIRACLE in response to AIDS.”
--Michael E. Ranneberger, U.S. Ambassador to Kenya
“The most important and comprehensive HIV/AIDS effort
in all of Africa.”
- James Morris, former executive director, United Nations World Food Program
July 9, 2012

78. “Now HIV/AIDS programs are not only in place
but some of them, including the partnership
between the United States Agency for
International Development (USAID) and the
Academic Model Providing Access to
Healthcare (AMPATH) are openly speaking of
bringing the pandemic to its knees over the next
5 years through widespread screening and
effective treatment and prevention of HIV.”
Braitstein, P., et al., "Talkin' about a revolution": How electronic health records can
facilitate the scale-up of HIV care and treatment and catalyze primary care in
resource-constrained settings. J Acquir Immune Defic Syndr, 2009. 52 Suppl 1: p.
S54-7.
July 9, 2012

79. July 9, 2012

80. July 9, 2012

81. July 9, 2012