OpenMRS primary care EHR

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.

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. 

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.

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.

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. 

OpenMRS provides a unique set of tools and an international community to develop and implement EHRs especially in low income settings. OpenMRS combines open design processes, open source software, an open concept dictionary with mappings to standard coding systems (ICD10, SNOMED-CT, LOINC) and a modular architecture.  This gives developers and health systems great control of the software and data collected, and the ability to share innovations through the OpenMRS community. This supports many innovators and programmers in LMICs to build their own versions of the system customized to their local needs. OpenMRS Inc and the community work together to build new releases and to work on major improvements. This includes the recent work on an improved user interface, CDSS, interoperability improvements, data export and reporting. The 2021 annual reports showed 4736 total members on OpenMRS Talk and Slack, and between 400 and 700 new contributors per year. 

The modularity of OpenMRS allows it to be customized to local workflows and needs. Currently, the OpenMRS community has been heavily focused on CDC and USAID funded-projects targeting HIV and TB care, delivering a much more modern and usable system for these patients and clinicians. We will translate these improvements into an easy-to-install primary care-focused interface that builds on the same core EHR. This will enable users with less technical ability and resources to easily deploy a version of OpenMRS to get them up and running, while enabling further local innovations and customization on top of the provided software.

Innovative EMR features that are especially valuable for primary care in low income settings include:

-      A user interface (UI) that is much more amenable to point-of –care use, especially leveraging UI features optimized for tablet use, and an offline mode to accommodate the frequent problem of unreliable network connectivity

-       Improved support for an efficient clinical workflow to help reduce wait times for patients who may be acutely ill and have had hardship to get the time and transport to attend the clinic.  Features that streamline the flow from patient check in, screening, and through to services such as pharmacy and lab tests.  Of course these are useful for any clinical area, but the high volume and diverse patient needs in a primary care setting, and common “walk in” availability means that having an efficient, fast workflow is critical in this environment and patient group.

-        Exchange of information with community health programs (which may be using an mHealth application like CommCare or ODK), and with referrals to specialists and other next level care, and other services that help keep patients in care and completing treatments.

-       Easy point of care lookup of patient records, history, medications, lab tests, and other information to support prompt and accurate care decisions.

-        Flexible options for point of care data entry that does not burden the clinician and cut significantly into valuable time with the patient, with options for retrospective data entry to meet requirements for ministry of health data collection and other data management requirements that are not feasible for point of care data collection. There must be robust strategies and tools to recover from down time such as use of low cost Optical Mark Recognition.

-        Expansion of automated data pipelines to provide easy to use and timely reporting. This must include quality of care, clinical operations, population health insights and disease surveillance. These are currently not available from typical disease-specific EMRs and very hard to do with paper records or registers.

One year goals:

• Develop detailed workflows for the pilot sites based on current experience with early solutions and implement those in the prototype

• Establish a robust collaborative design process with clinicians at PIH primary care facilities, in partnership with local health information and monitoring and evaluation teams

• Develop the core data dictionary for the primary care application with our partners in Mexico and Sierra Leone

• Carry out user evaluation and workflow studies in multiple clinical sites to optimize speed, accuracy and efficiency of data collection processes

• Train local development and implementation teams to support and scale the implementation

• Deploy initial version of the OpenMRS Primary Care EHR in 5 sites in LICs including Mexico and Sierra Leone

  
  

  Five year goals:
  

• Support the deployment of the primary care EHR in more the 200 health facilities including Sierra Leone, Mexico, Malawi, Liberia,Haiti, Kenya and other countries that have scaled OpenMRS

• Include a fully configured stand alone PC EHR for new sites without current OpenMRS implementation

   Partner with existing implementations to roll out versions in large scale OpenMRS implementation

One year goal:

• Evaluate the usability and clinical users experience of currentthe prototype OpenMRS use for primary caresystem

• Monitor time taken for data entry, quality and completeness of data, missed cases etc. through audit logs and systems data 

• Evaluate the local and central use of reporting and analytics to define the gaps in reporting and analytics forprovide more insight into primary care 

Five year goal:

• Implement the upgraded EMR at PIH clinics in Mexico and Sierra Leone, as well as for selected facilities in Haiti and Malawi

• Carry out evaluation of the system use at scale through the system data and audit logs, combined with user survey and interviews

• Demonstrate wide use of clinical data from the system for quality improvement strategies, reporting, surveillance and clinical research for primary care

The Theory of Change for the OpenMRS Primary Care EHR (PC EHR) is shown in the diagram. The long standing experience of OpenMRS use in the project team and organizations and the experience of evaluating EHRs in low income settings are key components to the development, deployment and evaluation of the system. A primary goal of OpenMRS has always been to strengthen and empower local staff and encourage local innovation. We expect this to take place with the OpenMRS PC EHR with adaption and new solutions being created and in many cases shared back to the community.

OpenMRS is an open source, modular electronic health record, built around a standardized concept dictionary that enables clear and consistent coding of clinical data. On top of this core, OpenMRS also provides a great deal of optional functionality in the form of modules, such as modules to handle appointment scheduling, SMS text capabilities, integration with other health systems using standard technologies like HL7 FHIR. This modular architecture enables a wide variety of customized versions of EHRs to be built on top of OpenMRS.

OpenMRS was co-founded by Dr Fraser in 2004 and first deployed in Kenya, Rwanda and South Africa in 2006. Currently OpenMRS is used clinically in at least 44 LMICs at over 6000 health facilities and serving over 12 million patients[OpenMRS annual report 2021]. It is primarily used to support HIV and TB care, with growing use for maternal and child health care, non-communicable diseases and cancer. OpenMRS is supported by an NGO -OpenMRS Inc based in Indiana, USA and a worldwide community with major partner organizations. These include Partners In Health (USA, Haiti, Mexico, Rwanda, Malawi, Sierra Leone and other countries), The Regenstrief Institute(USA), the AMPATH project (Kenya), University of Washington (USA, Haiti, Ethiopia) Brown University (Rwanda, Zimbabwe), Uganda Ministry of Health, Rwanda Biomedical Center, KenyaEMR, Soldevelo (Poland) and others. 

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 primary care data for the OpenMRS Primary Care EHR will be collected primarily by the clinicians caring for the patients. These staff are mostly nurses and other clinical staff with a smaller number of physicians. They currently collect data in paper charts or registers and are required to do so. The benefit of a system like this is that data is accessible and searchable for future visits, referrals, follow on care activities, appointments, medications etc. With well designed, lightweightlight weight systems the benefits can outweigh the effort of data entry. The secondary benefits include time saving for reporting activities and ability to efficiently carry out surveillance and reporting activities. 

Currently, for PIH EMRs used in primary care settings, data is collected both at point of care and added retrospectively from paper forms when the clinical workflow or infrastructure needs are not well aligned enough with the system to enable point of care data entry.  The data pipeline varies.  In PIH Mexico, once data is retrieved from laptops, there is an automated pipeline to a data warehouse that provides exports for reporting.  In Sierra Leone, data management is still manual, relying on ad hoc exports and manual data transformation, indicator calculation, and visualization.

The partners in health Equity, Diversity and Inclusion team works to align our work with the OnePIH EDI Statement, including the hiring and performance review processes, establishment of employee resource groups and strengthening evaluation of our institutional EDI goals.and supporting ongoing anti-racism initiatives and a framework for decolonizing global health.  PIH doctors continue to lead innovation in racial equity in health care, including a recent paper in the New England Journal of Medicine: Leveraging Clinical Decision Support for Racial Equity: A Sociotechnical Innovation.

The PIH board of directors, trustees and leadership council have strengthened focus on diversity  and inclusion and ensuring that our US based office works in the service of and under the direction of our care delivery site priorities.

Brown university has a strong focus on  Diversity, Equity, and Inclusion in student recruitment, hiring and collaborative work. https://www.brown.edu/academic... A fundamental goal of Dr Frasers Clinical and Global Health Informatics lab is to support the design, development and implementation of global Health informatics solutions for some of the most underserved populations world wide. The open design and open source software of OpenMRS allows local healthcare and technical organizations in low income countries to use and improve the software and create local solutions and acquire local expertise. Along with PIH and OpenMRS inc we support a large and diverse team of paid and volunteer developers and users world wide. We also encourage women and minorities to join th organization and take leadership roles. 

The Brown University Brown Center for Biomedical Informatics provides technical expertise in Global health informatics for OpenMRS, PIH and other partners. This work is funded by a range of grants and gifts. This project is an ongoing initiative of BCBI led by Dr Fraser in collaboration with PIH. 

Partners in Health has forged strong partnerships medical and academic institutions, national governments, and our generous supporters.  We are primarily funded by donations and investments, but also have sustaining grants from foundations who seek to improve global health.  A list of our partners in sponsoring organizations is on the PIH web site.

The plan for ongoing financial stability covers the individual organizations leading this work and the broader OpenMRS community. 

Dr Fraser's lab at BCBI as part of an academic organization receives support primarily from grants, charitable gifts and contracts for research and development work. 

PIH as described above continues to be funded by grants, government contracts and gifts. 

OpenMRS has been working as a partnership since 2004 and as an NGO since 2009. It has been funded throughout that time by a range of grants and some donations. Currently PIH receives funds from Digital Square for several improvements to the EHR as well as a large grant from CDC PEPFAR to several OpenMRS partner organizations (OHRI grant) to create OpenMRS 3.0 for HIV care initially. Other funds come from gifts and previously foundations including Rockefeller.

The development of this new OpenMRS Primary Care EHR will improve patient care and health system functioning. It will also further our ability to share our impact and demonstrate how patient care is being improved at scale, and support further fundraising. 

Examples of funding received in the last year for Dr Fraser's lab at BCBI are: a global health informatics foundation grant to support software design and development and student training, and (2) a large NIH grant to develop machine learning based clinical decision support tools to support HIV care in Kenya. Both projects support development of key OpenMRS technologies relevant to this challenge.

Examples of current funding to the PIH health informatics team include

Kellogg Foundation, Helmsley charitable trust, and the US PEPFAR program. The primary source of funding for the Information attics team is unrestricted gifts from corporate and individual donors.