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AMIA Annu Symp Proc. 2006; 2006: 840.
PMCID: PMC1839720

Rapid deployment of electronic medical records for ARV rollout in rural Rwanda

Introduction

While most people with AIDS do not yet have access to anti-retroviral drugs (ARVs), large ARV treatment programs are being rolled out in many areas in Sub-Saharan Africa. ARV programs have substantial data management needs, which electronic medical record systems (EMRs) are helping to address. While most sophisticated EMRs in low-income regions are in large cities, where infrastructure and staffing needs are more easily met, Partners In Health (PIH) has pioneered web-based EMRs for HIV and TB treatment in rural areas. The HIV-EMR, developed in Haiti [1], was deployed in two Rwandan health districts starting in August 2005. The addition of new features and adaptation to local needs is happening concurrently with the rapid scale-up and evolution of the medical program itself.

Overview

Our EMR provides support for patient monitoring, program monitoring, and research. Patient monitoring includes information for care of individuals, such as historical medical summaries and alerts, e.g., if an ARV dosage is not correct for a patient’s weight. Program monitoring involves aggregate information, such as the percentage of patients on whom alerts fire, and trends in enrollment. This is especially useful given the large distances between the clinics. The EMR fulfills internal and national reporting requirements. The EMR also has an instrument to predict drug requirements and aid pharmacists in packing. Finally, the EMR contains data for observational research.

Strategy and implementation

The main site, Rwinkwavu hospital, is on Rwanda’s power grid. PIH installed a satellite Internet connection and generators, but connectivity and power remain problematic. The remote clinics currently lack power, but paper records are brought to Rwinkwavu, and printed reports are brought to the clinic. We are moving to install solar power and station data clerks at each clinic. The EMR runs on a server in Boston, with an Oracle database and several open source software packages. We used a Java form entry and viewing application, designed for intermittent connectivity in Haiti, to enter our initial data.

Results and Lessons Learned

While building on past experience, we continue to learn a great deal from this deployment.

Forms

We initially adapted the Haiti EMR for use with the paper forms for HIV care suggested by the Rwandan government. We have found that incremental paper forms, i.e. where information is accumulated over time in a longitudinal dossier, is much less conducive to accurate data collection than are encounter paper forms, in which a new form is filled out on each patient visit. Early on, we instituted an encounter form to record changes in patients’ drug regimens. We are now switching to encounter forms for all visits, to improve clinical workflow and data collection.

Flexibility

It is hard for us to imagine deploying this system without a programmer on site to discover and adapt to the evolving needs of the clinicians. We are actively working (see below) on producing free and sharable EMR code, but customization to local work patterns is very important to any system’s usability.

Staff

Well-trained data entry persons are required to maintain an EMR; we found more than 4 months of on-the-job-training was needed. Data entry persons must have the ability to problem solve and follow up ambiguous or suspect data, and IT support persons must be available. Care providers must be trained to properly report changes in treatment. The majority of our Rwandan IT staff moved from the capital, Kigali, to join our operation. Recruiting may have been more challenging, had we not been only 2 hours by public transportation from a major urban area.

Infrastructure

Electricity and Internet are required, but offline and offsite data entry can accommodate clinics that do not have electricity.

Despite many challenges, internal and external reports, clinical records, and drug predictions are produced on time. In less than 6 months (Aug-05 through Jan-05), the EMR tracked over 800 patients on ARV treatment. Data entry, reporting, and management are performed by a data team of 5 persons.

Future work

We are part of a multi-institution effort to increase sharing and decrease duplication of effort among EMR projects. Our experience has helped guide the design of a new EMR system (OpenMRS) for developing countries that is more flexible in configuration, extension, and use of multiple languages. An EMR system that can be maintained with complete local support would be the ideal outcome.

Acknowledgements

The Clinton Foundation and Global Fund for support.

References

1. Fraser HSF, Jazayeri D, Nevil P, et al. An information system and medical record to support HIV treatment in rural Haiti. BMJ. 2004;329:1142–1146. [PMC free article] [PubMed]

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