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Experience in implementing point of care systems

By Naomi Muinga Moderator | 11 Jun, 2015

I am curious to hear your experience with implementing EMRs in low income settings. In particular how do you deal with implementing a point of care model system given challenges such as minimal staff, computer literacy and high workload?



A/Prof. Terry HANNAN Moderator Replied at 8:57 AM, 11 Jun 2015

Hi Naomi. it is approaching midnight here and I am on call for the hospital. I will formulate a more detailed response tomorrow or over the weekend. (I am presuming this is directed to me).Terry

Naomi Muinga Moderator Replied at 9:48 AM, 11 Jun 2015

Hi Terry, to you and anyone else who has had such experience.

Patrick Crisp Replied at 2:36 PM, 11 Jun 2015

Hi Naomi

An organisation that has had experience implementing such a system is Wild4life (http://www.wild4life.org/).

Patrick Crisp

A/Prof. Terry HANNAN Moderator Replied at 8:56 PM, 11 Jun 2015

Hi Naomi, I am prefacing all my comments with two quotes from Bill Tierney with whom I helped co-found the original EMR system in Kenya.
1. "A major component of our success is that we sat in the dirt physically and metaphorically with the end users for 18 months" at the start of the program.
2. After 18 months of implementation a report 'produced by the end users' "lit a candle in the darkness of Africa (HIV management)".
I am attaching some of the original papers we wrote on this project and also some later ones that collate the experiences and lessons learnt.
Key points
1. Involved end users at ALL stages
2. Support within the governance structures must be unflinching i.e. the governance organisations (those who pay the money) must believe in and understand the system(s)
3. eHealth projects take TIME and progress is INCREMENTAL

Ignacio De Gabriel Hernández Replied at 9:18 PM, 11 Jun 2015

Naomi Munguia: La verdad hay fenómenos que jamás entenderé,porque nos los practico: Mira tengo un servicio de cirugía ambulatoria donde mi mesa de cirugía es una del Dr. Pilcher,que cuesta como unos 15 000 pesos Mexicanos,equivalentes a 914 dólares,donde llevo operando por mas de 10 años..una lámpara de cirugía reacondicionada que en su tiempo me costó 3500 dólares... y me pregunto qué es mas importante en la s inversiones..la respuesta no es fácil..todo es importante pero hay que adaptarse a la economía y a los medios..

Naomi Muinga Moderator Replied at 12:44 AM, 12 Jun 2015

I like your first statement there...sitting in the dirt...
What of the experience from the clinicians?

Steven Wanyee Macharia Replied at 12:53 AM, 12 Jun 2015

Hi Naomi!
After directly managing over 340 site level KenyaEMR implementations within just over 2 years with >65% of those as POC, I can tell you times have changed especially with changing political landscape for example in Kenya. Nevertheless, a couple of very important factors to consider;
1. Thorough design and for POC, comprehensive workflow analysis, which will should influence process improvement and efficiencies. Remember, culturally, there's a perception and practice of clear compartmentalization of tasks which doesn't augur well for health team based care, role based responsibilities, etc, and therefore, you immediately run into dealing with attitudes and mental shifts.
2. Clear problem analysis, assessment and plan.
3. Effective stakeholder engagement and strong leadership especially from county governments in Kenya. This has re-introduced problems like need to guide them on selection of right product to use, and hence more than ever, need to ensure buy-in and compliance to standards and guidelines fur health information systems.

4. Implementation which again should be informed by facility readiness assessment results.
5. Effective support and maintenance which includes strategies like subscribing to communities of practice that coalesce around a product, distributed HelpDesk with timely detection and response happening as close as possible to the facilty (maybe over time as telecoms gets better, remote support will improve, but for now it doesn't work).
6. Sustainability - this of course is a process that starts right from problem analysis and solution planning, and it's embedded in every activity along that continuum.

Thanks and hope this is helpful.

A/Prof. Terry HANNAN Moderator Replied at 12:56 AM, 12 Jun 2015

We ARE/WERE the CLINICIANS. There was only one "doctor" (administrator) in the Mosoriot Clinic. We achieved what we did with allied clinical staff who had NO IT experience prior to our arrival but KNEW we we were MEETING THEIR NEEDS. I will send some lovely representative photos if you give me your email address. Mine is

A/Prof. Terry HANNAN Moderator Replied at 12:59 AM, 12 Jun 2015

Steven, a great reply and echoes the criteria for eHealth implementations formulated by Dr Burke Mamlin and Prof Paul Biondich from their work in Kenya.

LOW COST: preferably free/open source
CLINICALLY USEFUL: feedback to providers and caregivers is critical. If the system is NOT CLINICALLY USEFUL it will not be used.

AMPATH Medical Record System (AMRS): Collaborating Toward An EMR for Developing Countries Burke W. Mamlin, M.D. and Paul G. Biondich, M.D., M.S. Regenstrief Institute, Inc. and Indiana University School of Medicine, Indianapolis, IN

Steven Wanyee Macharia Replied at 11:56 AM, 12 Jun 2015

Hi Terry! I agree - its been such a long road filled with great lessons, there's always something new to learn as long as HIT implementation continues.

Naomi Muinga Moderator Replied at 12:05 AM, 14 Jun 2015

Wonderful insights Steve and Terry....
Who would join supporting communities of practice? Is it the implementers? Or the users?

A/Prof. Terry HANNAN Moderator Replied at 1:04 AM, 14 Jun 2015

Naomi, it is like "family" - we are all in this together but if the users are not involved they need another "family"!!!
We have "implementitus" and "pilotitis" coming out of our ears often with minimal success and at great expense

Joaquin Blaya, PhD Moderator Replied at 11:58 AM, 18 Jun 2015

A bit of history into the KenyaEMR, it's based on a lot of implementations
of OpenMRS where a majority of them where not point of Care, but rather
based on paper and then entered by a data clerk. Probably the one with the
largest number of patients was the one Terry mentioned amrs by the
Regenstrief institute in Eldoret, Kenya. There has been a lot of work done
on learning how to implement a poc emr and also in improving the software
to be as flexible as is needed for those requirements, so I wouldn't
underestimate how difficult it is, Steven and Terry I think give great
examples and tips for doing that.

One type of poc implementation is using touch screens which Baobab Health
started in Malawi and Partners In Health also for on board there by
extending it to OpenMRS. I would look up papers by Gerry Douglas,
Especially these two

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