We have described many factors which contribute to the challenge of implementing a national, networked EMR in Haiti, not least of which is the scarcity of clinical resources. Staff, time, and money are in short supply, with no evident limit on the need for services. As is typical for an EMR implementation, significant investment is required before users receive tangible benefits from the system. Some sites still face a large backlog of unentered patient records, which lowers the utility for both clinical practice and M&E, so we developed a “registry” model, which allows a subset of patient treatment information to be entered, sufficient for reporting and clinical summary.
Incentives for use:
Making the system useful for clinical care, automated reporting, and local site quality improvement, is a practical way to ensure good data quality – retrospective auditing and correction are very expensive. At one site, manual reporting takes 2 weeks of each month. But, until data are complete and accurate, the benefit of automated reporting cannot be realized, even if the system has clinical utility for a subset of patients. Yet, the funding for these systems is typically driven by reporting. We had to address reporting needs initially, but increasingly turn our attention to enhancing local utility to improve care.
Within the past year, sites that have resolved their backlog, and have sufficient computers, began to directly enter forms into the EMR during patient visits. This concerned us as there is no longer a paper backup for those visits. Recently, we learned that some physicians devised a workflow using prescription forms as computerized physician order entry (CPOE), entering prescription data, flagging the form “for review”, and sending the patient to the dispensary where the pharmacist charts the medicines given on the form, and clears the form status. This creativity shows a desire to exceed the current system capabilities, and reminded us that our preconceptions of the limitations in developing countries must constantly be questioned.
Low licensing cost is important for sustainability, as is local technical expertise. We tried both open source and mixed platforms to accommodate these criteria. However, we feel that simplified installation and configuration are also critical for sustainability, and best supported by open source. While we have not yet created a development community around the EMR, open source approaches may better support that goal.
Our experience strongly supports implementation in conjunction with a paper-based system, with paper as both an initial way of introducing uniform workflows, and as a fault-tolerant strategy to deliver clinical care in the face of computers that are broken, missing, or lack power..
Our data model has evolved as the system has been enhanced; addition of linkage between intake/followup visits and labs/prescriptions, tracking of next visit information, and addition of pediatric patients are just three feature areas that required database schema changes. Changes to the data model have in turn required us to develop more sophisticated tools for manipulating the schema, for generating reports, and for facilitating data entry. The greater system complexity creates challenges in changing the schema, but permits performance optimization. Compared to large scale banking or finance applications, these databases are relatively small--often full table scans yield acceptable performance. Our use of asynchronously generated summary warehouse tables supports generally good performance for interactive use and for reporting. Sites still using our ASP server in Seattle often face poor internet performance; the rapid adoption of in-country local clinic servers is due in large part to unhappiness with network response times.