OpenMRS primary care EHR

Our Organization

Brown University (and Partners In Health)

What is the name of your solution?

OpenMRS primary care EHR

Provide a one-line summary of your solution.

Upgrade the PIH OpenMRS primary care Electronic Health Record System to streamline and scale its implementation at clinics in low resource settings.

What specific problem are you solving?

Primary care in low-income countries does not have an electronic health record solution designed for its unique needs that can be readily implemented and scaled up. This means that primary care in LICs relies primarily on paper.  Paper records are often inconsistent, incomplete or simply lost. This inhibits not only the ability of individual clinics to provide the best individual patient care, but often makes it time consuming and expensive to conduct quality of care monitoring, disease surveillance and clinical research, thus compounding the problems facing those in LICs. An electronic health record solution can solve these difficulties: it allows rapid data collection once and immediate reuse; recall of data for return visits and emergencies; and secure backups. Data entered and trusted by clinical staff is a foundation for a wide range of critical activities including quality of care improvements, reporting, resource management and forecasting, surveillance and clinical research

Primary care is the core of effective healthcare particularly in low and middle income countries. It is a key goal of health systems working towards universal health coverage as part of the Sustainable Development Goals. An effective primary care solution requires good documentation of diagnoses and problems, medications, referrals, follow up visits and responses to treatment. Effective implementation of universal primary care is empowered by an effective, highly usable, stable and cost effective EHR. Dr Fraser has studied the role of primary care EHRs in low income settings and published a review "The importance of primary care records in low-and middle-income settings for care, resource management and disease surveillance: A review, 2021"  [chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cgi.br/media/docs/...]

Follow up of patients needing a second visit or with significant medical history can be difficult and unreliable. Tracking changes in the case mix of patients, disease outbreaks, and important unaddressed needs such as hypertension care is very challenging. 

Universal primary care EHRs have been critical to improvements in care in countries like the UK that have had universal use for more than 2 decades. This has included improvements in detection and management of chronic diseases like ischemic heart disease and in the tracking and management of COVID-19 through the EMIS and SystmOne EHR research databases. [doi: 10.1038/s41586-020-2521-4].

Digital health solutions have made great progress in low income countries over the last 2 decades with impacts in communities, health centers, hospitals and at national level/Ministry of health level. The digital health landscape in LICs includes, Mobile health (mHealth) applications, clinic and hospital based Electronic Health Records (EHRs), and systems for functions such laboratory, pharmacy and supply chain, radiology, accounting/billing and personal management; and national or regional reporting systems typically collecting aggregate data. Many of the most widely deployed systems are open source and considered "Global Goods" by PATH and WHO[refs]. These include CommCare, ODK and Medic Mobile at community level, OpenMRS (EHR), OpenELIS (lab), OpenBoxes and OpenLMIS (pharmacy) and DCM4CHE (radiology).  Some primary care data may be collected at community level by CHWs but is rarely linked to health facility records.

These solutions have been effective for many clinical areas including specific health areas. EHR systems like OpenMRS have been successfully deployed at scale for HIV care and in some cases for TB, maternal and child health, non-communicable diseases and oncology. These disease specific solutions often have dedicated funding. However the vast majority of patients seeking care in LICs are seen in local clinics for brief primary care type consultations with a physician, nurse or district health officer. Records of those consultations are almost always recorded only on paper either in simple patient charts or registries. 

Although the OpenMRS platform has all of the functionality necessary for a scalable, adaptable Primary Care EMR, its development for that purpose has been ad hoc and localized.  We propose to evolve current EMRs used at Partners In Health (PIH) supported sites for primary care into a system that can be rapidly adapted to local requirements and workflow. It will also designed for scale up to bring the benefits of digital health to primary care in a wide range of low income settings.

What is your solution?

A critical missing component for universal access to health care is effective primary care data capture and management. The unique technology and implementation experience of OpenMRS EHR developer and implementers like Brown University and Partners In Health, coupled with exciting new capabilities in OpenMRS, offers the ability to quickly create a really effective, usable and scalable primary care EHR. 

OpenMRS is an open-source medical record system, widely used across LMICs. The core technology and development of OpenMRS is described below. It is currently completing a major upgrade to OpenMRS 3.0, which includes development of a new user-driven and point-of-care focused interface based on IBM Carbon and utilizes global interoperability standards. This upgrade has been designed from the ground up to improve workflows in the often resource-constrained settings in LICs. Particular attention has been paid to getting the system to work on cheaper devices, including a focus on tablet-friendly designs and a base system that can be run on a laptop. 

While the work done as part of the upgrade has been focused on providing the necessary basics for an EMR and with a focus on chronic disease, a solution for primary care needs more: a simpler deployment process, an easier-to-configure reporting solution, and the tools necessary to allow the software to be run by less technically skilled users. Over the past 3 years, OpenMRS has been making strides in this regard, having completed work on two projects designed to improve its shelf readiness. 

PIH has multiple existing OpenMRS based EHRs used in various ways for primary care. This provides the essential insights and collaboration with clinicians needed to leverage OpenMRS technology and design upgrades to produce a more usable, fast and scalable system.  While our existing implementations of primary care on earlier versions of OpenMRS provide the building blocks and critical experience, considerable work is needed to bring everything together and scale it up.

In particular, OpenMRS as a solution has often been quite technically complex, requiring a dedicated implementation team to run the software. Obviously to scale to LICs across the world our primary care solution needs to be deployable in all kinds of settings from large programs that can run cloud-based systems, to simple installations that can be run from a single computer. A key aim of this project is to round-out our existing solutions into a simple package that can be deployed in primary care clinics, both those with existing technological infrastructure and EHR use, and those with minimal capabilities. 

New technologies in OpenMRS that we will build on include the design of OpenMRS 3.0, HL7 FHIR standards for clinical data interoperability, data export and reporting functions, and advanced clinical decision support tools. 

Dr Fraser has also lead many evaluation studies of OpenMRS. These include a large study of its use at scale in Rwanda, including user experience [https://medinform.jmir.org/2022/5/e32305/], data quality, and development and implementation costs, and the effects of clinical decision support on user experience, data quality and quality of care. Insights from this work and that of Ms Munson and other openMRS collaborators will support the critical need for effective matching to clinical workflow and a fast and simple user interface that maximized data quality.

OpenMRS is developed collaboratively by software designers, developers, implementation teams, user interface designers and subject matter experts from high-, middle- and low-income countries.  It offers a unique platform on which to develop and deploy a new, customized and lightweight primary care application designed to support frontline health care workers in providing high quality patient care. It will also provide strong and easy to use support for reporting, disease surveillance and clinical decision support.  

The OpenMRS primary care system will be used by clinical staff as well as data managers, ideally at the point of care, something which many previous digital health solutions in LMICs have not delivered. Data entry will be split between patient registration staff and clinicians based on workflow from previous projects supported bt PIH. In addition to direct data entry at point of care, we will implement Optical Mark Recognition software to augment the use of paper data capture forms as a backup (an approach currently being tested in Zimbabwe). 

The OpenMRS primary care EHR will be developed based on the requirements of staff in Sierra Leone, Mexico, and Malawi and insights from other partner organizations. If travel conditions allow it will also be scaled in Haiti, where both PIH/ZL and U Washington are planning to deploy versions of OpenMRS with primary care capabilities nationwide. The developed solution will undergo formative evaluation before wider deployment, followed by formal evaluation of user experience (survey, interviews) and data quality (system data and data audits of randomly sampled charts). Engagement in the OpenMRS community and OpenMRS Inc will ensure wide input into the design, development and testing, and opportunities for wide deployment in existing health facilities running OpenMRS as well as new sites. 

Who does your solution serve, and in what ways will the solution impact their lives?

The end users of the primary care EMRs are clinicians who have already seen the benefits of immediate access to patient medical history, test results, and medication information.  Features that help to streamline the clinical workflow, and the work to keep patients in care (such as appointments, notifications, and referrals) benefit the entire health system, including community health and social support programs.

The target population is any patient who is seen in a small or medium sized health facility in a low-income country (although middle income countries may also benefit). The system will support rapid and efficient documentation of the patient condition and care decisions for clinic visits, as well as critical information for continuity of care, including referrals, and information shared with community health workers.. 

This contrasts with the existing EHR systems used in these settings which nearly all focus on subsets of patients with specific, usually chronic diseases, typically designed to meet the needs of external reporting, with data entered retrospectively from paper forms. Tracking repeat primary clinic visits will allow patterns of more serious disease to be detected and monitoring of treatment such as blood pressure control.

Current implementation of different versions of OpenMRS

Considering all versions of OpenMRS, it supports the care of almost 16 million people world wide at over 6700 implementation sites. The majority of those sites primarily focus on HIV care, with growing use for maternal and child care, non-communicable diseases, and pioneering sites supporting oncology, mental health and other specialist areas. See the OpenMRS annual report: 

[https://openmrs.org/2021-openmrs-annual-report/]. 

Partners in Health OpenMRS EMRs that currently best support primary care are implemented in Malawi, Sierra Leone, and Mexico. 

CompañerosCompanero en Salud’s ten primary clinics in Chiapas Mexico serve approximately 22,500 patients.  All clinics are using OpenMRS for primary care and have to manage with limited infrastructure and support staff.  Sites with no internet access use a laptop to run the EHR, and bring a flash drive to a main site to synchronize data to a data warehouse.  One site has connectivity and is a piloting a cloud based approach. 

Partners in Health Sierra Leone has a flagship clinic that has a successful primary care OpenMRS implementation, supporting 43,000 patients on average per year. PIH recently expanded clinical support to seven additional primary care clinics that currently use paper forms only. The number of patients seen annually ranges from 7,656 to 13,390. The initial goal of this initiative in Sierra Leone will be scaling primary care EHR use to the 7 additional clinics.

Abwenzi Pa Za Umoyo in Malawi which is also supported by PIH and has twelve primary care clinics serving more than 116,000 patients annually. There is a local version of OpenMRS that supports an innovative design for screening for a range of diseases in primary care. 

There are some additional examples of use of OpenMRS for primary care in Haiti including clinics affiliated with the Mirebalais teaching hospital. These would likely be later recipients of this work. Outside of PIH there is interest from OpenMRS partner organizations supporting care in several hundred health facilities.

How are you and your team well-positioned to deliver this solution?

Team members:

Hamish Fraser (Lead) (Brown University, US)

Debbie Munson (Co-Lead) (Partners In Health "PIH", US)

Ian Bacher (Brown University, US)

Ricard Pognon (PIH, Sierra Leone)

Jorge Martinez (PIH, Mexico)

A primary goal of the OpenMRS community is to empower local teams to design, develop, implement and scale solutions based on OpenMRS, while sharing designs, code, best practices and lessons learned. Dr Fraser's work on evaluation of health information systems in LMICs helps to ensure systems are effective in the contexts where they are used and local users' experience and views are included. Ms Munson who is leading the project at PIH also has a major role in quality improvement and evaluation of software and implementations. Both have lead roles in the OpenMRS evaluation squad which works to ensure OpenMRS based EHRs are usable, scalable and effective in improving care.

PIH works very closely with local communities in all the countries it serves including Sierra Leone, Mexico, Malawi and Haiti. The Health Information Systems team is distributed across the Boston office and each PIH country, with design and implementation driven by local users. The leadership of this project includes Debbie Munson, global Director of Health Information Systems Success at PIH, Ricard Pognon, Director of Strategic Health Information Systems for PIH Sierra Leone, and Jorge Martinez, Director of Programs for Companeros en Salud, Partners In Health in Chiapas, Mexico.

The design, development and implementation of OpenMRS has been deeply embedded in the communities that use it since its inception. Most of the developers and implementers as well as almost all users are from low- and middle-income countries. Dr Fraser who co-founded OpenMRS in 2004 has worked in Haiti, Peru, Rwanda, Kenya, Malawi, and the Philippines and supported projects in Zimbabwe, Sierra Leone, Nigeria and Indonesia. He is currently Co-PI on a large project to develop, implement and evaluate machine learning-based clinical decision support tools at AMPATH in Kenya. Dr Bacher is a senior data scientist in Dr Fraser’s lab. He is a lead software architect and mentor for OpenMRS developers around the world and a top 5 OpenMRS code contributor in 2021. He has led the design and development of tools for interoperability of OpenMRS with other applications using HL7 FHIR, patient tracking and numerous other features.

Which dimension of the Challenge does your solution most closely address?

• Leverage existing systems, networks, and workflows to streamline the collection and interpretation of data to support meaningful use of primary health care data
• Provide actionable, accountable, and accessible insights for health care providers, administrators, and/or funders that can be used to optimize the performance of primary health care
• Balance the opportunity for frontline health workers to participate in performance improvement efforts with their primary responsibility as care providers

Where our solution team is headquartered or located:

Our solution's stage of development:

How many people does your solution currently serve?

OpenMRS supports care of over 16 million people world wide, with over 160,000 supported by older PIH primary care EHRs

Why are you applying to Solve?

We are applying to accelerate the adaptation and implementation of EHR systems for low income settings for primary care. OpenMRS is widely implemented for a number of clinical areas most commonly HIV care. There are some small scale solutions at PIH and other partners that support primary care in a limited number of sites. To be effective, scalable and sustainable a new primary care EHR version of OpenMRS is needed. This could then be implemented in new sites or rapidly added to existing small or large scale OpenMRS implementations. 

This presents a particular challenge for organizations like PIH in that the disease-specific approach to EMR development also leaves gaps in the ability to easily monitor and evaluate primary care clinical programs. Our previous experience in piloting such systems, and recent evaluation studies and literature reviews provide important insights into the needed solutions, as does our collaboration with PIH clinicians and leadership focused on primary care.

Because of the funding landscape, OpenMRS development is frequently aligned to specific clinical areas, or to objectives for national level systems.  As a result, a specific focus on a scalable solution for primary care has not gotten the attention due to such a foundational component of the health care system.  This solution will address this gap by applying established upgrades to OpenMRS design and technology tailored specifically to primary care, and accelerating the ability for monitoring, evaluation and research.

The recent improvements to OpenMRS particularly the new UI framework and user testing provides a strong substrate. This work now requires a dedicated team with very close involvement with local users and technical staff (locally and internationally) to create a really effective solution. Incremental improvements to existing EHRs are not sufficient for this critical challenge. Funds from this Challenge would support the time of the teams at Brown and PIH for design and development of the solution and usability testing. Most of the funds will be dedicated to developers and implementers in the country sites - Sierra Leone, Mexico, Malawi and possibly Haiti. 

Who is the Team Lead for your solution?

Professor Hamish Fraser