PHI conference: Hamish Fraser and EMRs for the developing world

One of the high points of the PHI conference I went to week before last was getting to meet Hamish Fraser and hear him talk about informatics tools to improve drug management and safety in developing countries. He's doing some very important work in Peru and Haiti, so his work has the potential to have a major impact for some of my colleagues in both countries. After his talk, I got to meet him and tell him how impressed I am with the work, especially given some particular infrastructural challenges in Haiti. He is a very gracious and knowledgeable man, and I hope we have the opportunity to collaborate at some point.

He noted that challenges in treating multiple-drug-resistant tuberculosis (MDR-TB) are just one of many obstacles facing an electronic medical record (EMR) system in Haiti. The effective use of drugs for that and other conditions depends on:

• accurate diagnosis and case detection;
  
• understanding appropriate treatments for the conditions in question;
  
• accurate and appropriate prescribing for those conditions;
  
• available drug supplies for those conditions;
  
• correct and timely dispensing of those medications;
  
• monitoring for adverse drug reactions and responding promptly when they are detected;
  
• ensuring adherence to the medication regime and continuity of care.
  

The geography, economy, infrastructure (lack of good roads, for example), and other factors in Haiti make these goals challenging; what I hope to do in future research is to explore ways in which informatics can compensate for these challenges. Dr. Fraser and his research group are already taking the lead in developing applications to address these issues. For example, HIV treatment in Haiti requires, among other things, warehouse and pharmacy management systems, and Dr. Fraser's group is addressing this question using OpenMRS and collaborative development.

Rwanda Partners In Health has set up 6 clinics for HIV and other diseases, and an EMR is currently operational in all sites. They are now implementing a Haitian pharmacy system, and Partners In Health has been asked to set up an EMR system for all planned HIV treatment sites in the country. Additionally, they are scaling up the OpenMRS system to other sites and countries, and collaborating to develop a new design of an EMR system in developing countries. Current or future sites include Rwanda, Kenya, Lesotho, South Africa, Tanzania, Uganda, and Zimbabwe. Projects collaborating with OpenMRS include a lab system in Rwanda with HL7 linked to OpenMRS; the Baobab system in Malawi; the Africa Center, South Africa; Columbia University's Millennium Villages project; the D-TREE handheld system, South Africa; and Google's "Summer of Code" projects.

Important questions remain to research, of course:

• how can we improve the use and safety of drugs in developing countries?
  
• how can we assist in the meticulous observation of therapy which is required for these regimens?
  
• what are the next steps in the develeopment of treatment strategies for MDR-TB, HIV/AIDS, and other chronic diseases?
  
• we need more evaluations! For example:
  
  
  
  • effectiveness and impact of the information systems;
    
  • how well do the systems function in resource-poor areas?
    
  • how to ensure high-quality and timely data entry?
    
  • how can we reduce the time and effort required to use the systems?
    
  • and most important: through the use of these systems, can we show improvement in patient care?
    
  
  

Challenges include training; support and reliability of equipment and software; data management and quality control; and sustainability. He concluded by noting that many tools developed to improve drug use and management in the US can be adapted for use in developing countries. Additionally, the lack of redundant systems in these resource-poor areas only increases the importance of good information systems.

The questioners in the Q&A session afterward raised some very good points: One expressed heartfelt thanks for bringing up lesser-known, chronic diseases, which don't always get the attention that acute infectious diseases garner. He continued that he had heard a lot about implementing systems, but what about backing them up? Is there a way to utilize academic collaboration networks, given the risks onsite of tsunamis, hurricanes, etc.?

The answer was that the system consisted of a secure server with mirror servers and frequent backups. But an ethical question remained in resource allocation-—in case of disaster, is it more important to keep patient treatment going, or concentrate on sites to back up to? Obviously, that decision is a crucial one, and it highlights the importance of disaster recovery plans.

Another questioner raised the issue of information needs--there is a conflicting demand between keeping things simple with aggregate data vs. needing to keep more complicated individual data (which would be useful for, among other things, tracking data on developing drug resistance).

The panel answered that keeping clinical data straightforward is a high priority. They collect 6 discrete parameters for interoperability, but in a number of countries networks for surveillance are set up, which request or require aggregate data, which can be built from the data collected through their systems. Generally, the most important outcome to track is whether the patient got better, and for how long the patient was parasite-free. These are 2 pieces of information which should be routinely collected, starting with sentinel sites.

References:

1: Wolfe BA, Mamlin BW, Biondich PG, Fraser HS, Jazayeri D, Allen C, Miranda J, Tierney WM. The OpenMRS system: collaborating toward an open source EMR for developing countries. AMIA Annu Symp Proc. 2006;:1146.

2: Fraser HS, Blaya J, Choi SS, Bonilla C, Jazayeri D. Evaluating the impact and costs of deploying an electronic medical record system to support TB treatment in Peru. AMIA Annu Symp Proc. 2006;:264-8.

3: Blaya J, Fraser HS. Development, implementation and preliminary study of a PDA-based tuberculosis result collection system. AMIA Annu Symp Proc. 2006;:41-5.

4: Choi SS, Jazayeri DG, Fraser HS. Optimizing data analysis tools to support healthcare workers in Peru. AMIA Annu Symp Proc. 2005;:923.

5: Fraser HS, Biondich P, Moodley D, Choi S, Mamlin BW, Szolovits P. Implementing electronic medical record systems in developing countries. Inform Prim Care. 2005;13(2):83-95.

6: Fraser HS, Jazayeri D, Nevil P, Karacaoglu Y, Farmer PE, Lyon E, Fawzi MK, Leandre F, Choi SS, Mukherjee JS. An information system and medical record to support HIV treatment in rural Haiti. BMJ. 2004 Nov 13;329(7475):1142-6.

7: Choi SS, Jazayeri DG, Mitnick CD, Chalco K, Bayona J, Fraser HS. Implementation and initial evaluation of a Web-based nurse order entry system for multidrug-resistant tuberculosis patients in Peru. Medinfo. 2004;11(Pt 1):202-6.

8: Szot A, Jacobson FL, Munn S, Jazayeri D, Nardell E, Harrison D, Drosten R, Ohno-Machado L, Smeaton LM, Fraser HS. Diagnostic accuracy of chest X-rays acquired using a digital camera for low-cost teleradiology. Int J Med Inform. 2004 Feb;73(1):65-73.

9: Jazayeri D, Farmer P, Nevil P, Mukherjee JS, Leandre F, Fraser HS. An Electronic Medical Record system to support HIV treatment in rural Haiti. AMIA Annu Symp Proc. 2003;:878.

10: Fraser HS, Jazayeri D, Mitnick CD, Mukherjee JS, Bayona J. Informatics tools to monitor progress and outcomes of patients with drug resistant tuberculosis in Peru.
Proc AMIA Symp. 2002;:270-4.

11: Fraser HS, Jazayeri D, Bannach L, Szolovits P, McGrath SJ. TeleMedMail: free software to facilitate telemedicine in developing countries. Medinfo. 2001;10(Pt 1):815-9.

12: Fraser HS, McGrath SJ. Information technology and telemedicine in sub-saharan Africa. BMJ. 2000 Aug 19-26;321(7259):465-6.

13: Fraser HS, Kohane IS, Long WJ. Using the technology of the World Wide Web to manage clinical information. BMJ. 1997 May 31;314(7094):1600-3.