Exploring the potential of Open Source solutions to deliver Clean, Clear Information for Health Service Improvement
Lead Research Organisation:
University of Oxford
Department Name: Tropical Medicine
Abstract
Electronic Health Records (EHR) systems are computer systems used by hospitals and clinics to record medical information about patients. They include information about patients' symptoms, medical diagnoses, treatment, operations, blood tests, x-ray results and how they are progressing.
Although EHR systems have been used in hospitals in high-income countries for many years now, in low-resource countries such as Kenya, they are just beginning to be used at scale. This proposal is the result of the the research team in Kenya being asked by the Kenyan Ministry of Health (MoH) and the World Health Organisation (WHO, Kenya office) to explore how EHR systems could be used, not just to help doctors and hospital workers in managing their patients, but to also re-use the information that is collected for improving health services more widely. The information needed to improve care locally and across the health system needs to be clean and clear if it is to be used effectively to make the right decisions in the same way that drinking water needs to be clean and clear to be safe to drink.
The aim of this proposal is to allow us to develop the partnerships (both academic and institutional) and knowledge necessary to create a new large programme of research around the development and use of clean, clear information contained in EHR systems for improving health.
To achieve this aim, the first part of this proposal will find out which EHR systems are currently in use in Kenya, why they have been implemented, whether they are meeting expectations of users, whether they contain the kind of information that would be useful to improve care and whether they adhere to best practice international standards for safe and effective use.
We will then investigate how a particular open-source EHR system called OpenMRS is being used in Machakos County in Kenya. This system is used in lots of HIV clinics across Africa (and the rest of the world) but is not usually used in more general forms of care or in hospitals. A recent project supported by the Kenyan MoH and WHO is attempting to implement OpenMRS widely in Machakos County but early experience suggests challenges and we aim to find out what lessons can be learned to support the further introduction of EHR systems in Kenya and how best to gain advantage from the open source (voluntary) community that can help develop and improve these not-for-profit systems.
Finally, we will look at what kind of information from EHR systems could be useful enough to incentivise hospital and county administrators to invest in implementing and sustaining EHR systems that include the ability to collect medical information as well as the kind of financial information that is commonly the first priority for these kinds of system.
Once we know what kind of EHR systems are in use and the type of data they are collecting, how EHR systems are currently being implemented, and what kind of data is of use to policy-makers, administrators and health workers, we can identify the specific objectives of our planned larger programme of research. This new programme will aim to ensure that EHRs in developing countries such as Kenya are implemented efficiently and effectively with minimal disruption to healthcare workers but that will also enable the re-use of clean, clear information throughout the health care system to foster improvements in health.
Although EHR systems have been used in hospitals in high-income countries for many years now, in low-resource countries such as Kenya, they are just beginning to be used at scale. This proposal is the result of the the research team in Kenya being asked by the Kenyan Ministry of Health (MoH) and the World Health Organisation (WHO, Kenya office) to explore how EHR systems could be used, not just to help doctors and hospital workers in managing their patients, but to also re-use the information that is collected for improving health services more widely. The information needed to improve care locally and across the health system needs to be clean and clear if it is to be used effectively to make the right decisions in the same way that drinking water needs to be clean and clear to be safe to drink.
The aim of this proposal is to allow us to develop the partnerships (both academic and institutional) and knowledge necessary to create a new large programme of research around the development and use of clean, clear information contained in EHR systems for improving health.
To achieve this aim, the first part of this proposal will find out which EHR systems are currently in use in Kenya, why they have been implemented, whether they are meeting expectations of users, whether they contain the kind of information that would be useful to improve care and whether they adhere to best practice international standards for safe and effective use.
We will then investigate how a particular open-source EHR system called OpenMRS is being used in Machakos County in Kenya. This system is used in lots of HIV clinics across Africa (and the rest of the world) but is not usually used in more general forms of care or in hospitals. A recent project supported by the Kenyan MoH and WHO is attempting to implement OpenMRS widely in Machakos County but early experience suggests challenges and we aim to find out what lessons can be learned to support the further introduction of EHR systems in Kenya and how best to gain advantage from the open source (voluntary) community that can help develop and improve these not-for-profit systems.
Finally, we will look at what kind of information from EHR systems could be useful enough to incentivise hospital and county administrators to invest in implementing and sustaining EHR systems that include the ability to collect medical information as well as the kind of financial information that is commonly the first priority for these kinds of system.
Once we know what kind of EHR systems are in use and the type of data they are collecting, how EHR systems are currently being implemented, and what kind of data is of use to policy-makers, administrators and health workers, we can identify the specific objectives of our planned larger programme of research. This new programme will aim to ensure that EHRs in developing countries such as Kenya are implemented efficiently and effectively with minimal disruption to healthcare workers but that will also enable the re-use of clean, clear information throughout the health care system to foster improvements in health.
Technical Summary
This mixed-methods health systems research project aims to use semi-structured interviews with managers and clinicians involved in Electronic Health Record (EHR) system implementation. Interviewees will be identified through a snowballing technique until saturation of new information from interviewees is reached. A specific case study will be performed of an individual EHR implementation project in Machakos County that uses open-source EHR software (OpenMRS) to identify the barriers and opportunities of using open-source EHR software in the county public health system in Kenya. The results of the case study will inform the development of an innovative in-silico simulation of the Machakos County health system as it would be envisaged in the planned roll out of open-source technology to support clinical care, centralised data collection and on-demand registry services (such as the Master Patient Index and a Master Facilities Index). Finally, a co-design workshop will be held with key EHR stakeholders in Kenya (including policy-makers, researchers, hospital administrators, clinicians, patients, EHR vendors, IT companies, programmers and consultants). The workshop will aim to bring together the results of the survey, case report and simulation with experience from across Kenya to develop a set of research objectives to inform the development of the next stage of research aimed at development and re-use of clean, clear information from data gathered by EHR systems to improve health systems broadly while fostering growth of innovative health services research.
Planned Impact
The potential for Electronic Health Records systems to improve healthcare delivery is significant and there is a potential for a county like Kenya to "leapfrog" developed countries like the UK and US in terms of their healthcare IT provision as they will be implementing more modern technology with less need for backwards compatibility with legacy systems. This means that "lightweight" EHR systems that use modern web and mobile development techniques could be implemented for less money and at a faster rate than many previously developed EHR systems. Yet it is important that such developments draw on the many lessons learned about HER introduction in developed country settings.
As detailed in our Pathways to Impact statement, the results from this development grant will help inform this transformation by building a picture of EHR adoption in Kenya, informing policy development and bringing together stakeholders.
However, the greatest impact from this seed project will be the development of researcher, policy-maker and practitioner partnerships (spanning multiple sectors) and a set of research objectives to inform the next stage of research aimed at developing and re-using the data from EHR systems to provide "clean, clear" information for health systems research and improvement.
As detailed in our Pathways to Impact statement, the results from this development grant will help inform this transformation by building a picture of EHR adoption in Kenya, informing policy development and bringing together stakeholders.
However, the greatest impact from this seed project will be the development of researcher, policy-maker and practitioner partnerships (spanning multiple sectors) and a set of research objectives to inform the next stage of research aimed at developing and re-using the data from EHR systems to provide "clean, clear" information for health systems research and improvement.
Publications
Kumar P
(2016)
I've got 99 problems but a phone ain't one: Electronic and mobile health in low and middle income countries.
in Archives of disease in childhood
Muinga N
(2020)
Digital health Systems in Kenyan Public Hospitals: a mixed-methods survey.
in BMC medical informatics and decision making
Muinga N
(2018)
Implementing an Open Source Electronic Health Record System in Kenyan Health Care Facilities: Case Study.
in JMIR medical informatics
English M
(2016)
Building Learning Health Systems to Accelerate Research and Improve Outcomes of Clinical Care in Low- and Middle-Income Countries.
in PLoS medicine
Kobayashi S
(2018)
The Privacy and Security Implications of Open Data in Healthcare.
in Yearbook of medical informatics
| Description | This study provides an important benchmark of digital health adoption in a low-resource country. The findings that most hospitals have implemented digital patient administration and laboratory systems but are not using digital systems for day-to-day clinical management has important implications for global health funders and policymakers. There are currently high expectations that large-scale digital health systems could revolutionise the provision of healthcare in low-resource settings. However, our study shows that reality is that very little data is currently collected on the clinical management of patients through routine systems and most local digital health investment is for supporting hospital management such as through purchasing systems that enable the collection of patient co-payments. We saw that using open source technology (that does not have a licence fee) only saves costs in terms of licensing software (a significant saving as EHR systems used in high-income countries would be prohibitively expensive for a country like Kenya), but even open source systems still require hardware, training and support which, at the current time, may be unaffordable for low-income country public hospitals. This study therefore has important policy implications for global health organisations and funders and suggests that better paper-based data records systems may be a more practical option for improving healthcare delivery in the short to medium term. |
| Exploitation Route | This study highlights the need for much more intensive research in the area of digital health adoption in low- and middle-income settings as many large-scale international digital health projects are now underway that need critical evaluation and investigation to ensure that they genuinely support healthcare workers to deliver high-quality care for patients. Governments and NGOs need to rapidly build capacity for developing, implementing and evaluating digital health systems in LMICs as implementations are very contextually dependent and require both technical competence and local clinical leadership if systems are to deliver their intended benefits. |
| Sectors | Digital/Communication/Information Technologies (including Software),Education,Electronics,Financial Services, and Management Consultancy,Healthcare,Government, Democracy and Justice,Manufacturing, including Industrial Biotechology,Pharmaceuticals and Medical Biotechnology |
| Description | Our findings have been used to inform the Pathways for Prosperity Commission, co-chaired by Melinda Gates and international leaders from business, government and the not-for-profit sector, that aimed to examine how new digital technologies could support prosperity in low- and middle-income countries (LMICs). We used the findings from this research project to write a background paper for the commission on the potential for electronic health records systems in LMICs, which was then used to develop the main outputs of the commission including the "Positive disruption: Health and education in a digital age" and the "Digital Lives: Meaningful Connections for the Next 3 Billion" reports. We have also used the findings of our research in invited presentations to government agencies (including DFID and the British Consulate General in Vietnam) and healthcare funders (including Wellcome Trust and NIHR) about how to best implement new digital health projects in LMICs as investment is scaled up and adoption of digital health systems becomes a global priority. |
| Sector | Digital/Communication/Information Technologies (including Software),Healthcare,Government, Democracy and Justice,Manufacturing, including Industrial Biotechology,Pharmaceuticals and Medical Biotechnology |
| Impact Types | Societal,Economic,Policy & public services |
| Description | Kenya Health Informatics Association (KeHIA) |
| Organisation | Kenya Health Informatics Association (KeHIA) |
| Country | Kenya |
| Sector | Private |
| PI Contribution | Our research team co-organised the inaugural KeHIA Big Data Analytics meeting and is providing leadership to the KeHIA membership and community engagement working groups. |
| Collaborator Contribution | The KeHIA leadership have been supporting our research by introducing us to key stakeholders in the health informatics community in Kenya. Through these introductions we have evaluated a number of new EHR systems and developed deeper links with County health administrators and eHealth leadership at the Ministry of Health. |
| Impact | KeHIA Big Data Analytics Meeting |
| Start Year | 2015 |
| Description | Ministry of Health |
| Organisation | Ministry of Health, Uganda |
| Country | Uganda |
| Sector | Public |
| PI Contribution | We have been supporting the Ministry of Health with advice and feedback on plans for national ehealth projects including a national roll out of the OpenMRS EHR system. |
| Collaborator Contribution | The Ministry of Health eHealth and Systems Development Unit are assisting us to conduct our hospital visits for our EHR survey and providing information and introductions relating to ongoing ehealth projects in Kenya. |
| Impact | `The Ministry of Health eHealth and Systems Development Unit are contributing to our case study of their roll out of OpenMRS in County facilities and also contributed to the KeHIA Big Data Analytics meeting that was co-organised by our research team. |
| Start Year | 2015 |
| Description | Crossing Boundaries Conference (Oxford) |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Crossing Boundaries is a one-day conference on health research in low and middle income countries. The conference was held on the 8th December 2015 at the Said Business School, University of Oxford, and brought together researchers across Oxford University and beyond, to showcase the diversity and quality of health research. I presented on our ongoing research into EHR use in Kenya under the title: Global Health Informatics and the Learning Health System. The talk was recorded and published on the University of Oxford website. |
| Year(s) Of Engagement Activity | 2015 |
| URL | http://www.ndm.ox.ac.uk/chris-paton-global-health-informatics |
| Description | Digital Health Oxford Meetup |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Professional Practitioners |
| Results and Impact | Dr Paton chaired this Digital Health Oxford event which discussed the use of Open Data Standards and Open Source Software in the NHS and the wider healthcare sector. |
| Year(s) Of Engagement Activity | 2016 |
| URL | https://www.meetup.com/Digital-Health-Oxford/events/233824294/ |
| Description | KCL-Oxford Symposium on Ethics of Innovative Technologies for Improving Health in Low-Income Countries |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | Dr Paton participated in a workshop hosted at the Oxford Martin School to discuss the ethics of innovative technologies for improving health in low-income countries. |
| Year(s) Of Engagement Activity | 2016 |
| URL | https://www.eventbrite.co.uk/e/kcl-oxford-symposium-on-ethics-of-innovative-technologies-for-improvi... |
| Description | Kenya Health Informatics Association Inaugural Big Data Analytics Meeting (Nairobi, Kenya) |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | Our research team co-organised this meeting to bring together health informatics stakeholders from across Kenya to discuss the collection and analysis of large health datasets for research and health improvement purposes and to inform our ongoing research and support the development of the health informatics community. It was the first meeting of a new organisation called the Kenya Health Informatics Association (KeHIA) which has been formed to support the growing community of health informatics professionals in Kenya and was hosted by the University of Strathmore School of Business. Organisations present included the Ministry of Health, CDC, NHIF, Global Communities, NASCOP, KEBS, Medic Mobile, Savannah Informatics, USAID/AfyaInfo, KEMRI/Wellcome Trust Research Programme, Institute of Healthcare management - SBS, Palladium, mHealth Kenya, PATH, Baringo County, Moi University, ICFI, NOPE, UON-PSRI, East African Community-MOH, Kenyatta National Hospital, PSK, University of Nairobi, MSH, IBM, Kenyatta University, IntelliSOFT Consulting Limited. The meeting provided a range of support to our research including developing Ministry of Health support for our project and obtaining new contacts and leads for our national survey of EHR systems in use in the country. |
| Year(s) Of Engagement Activity | 2016 |
| URL | http://www.kehia.org/ |
| Description | Lecture: MSc in International Health and Tropical Medicine |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Postgraduate students |
| Results and Impact | Dr Paton delivered a lecture on "Health Information Systems and Monitoring" for the MSc in International Health and Tropical Medicine at the University of Oxford. |
| Year(s) Of Engagement Activity | 2016 |
| URL | https://www.ox.ac.uk/admissions/graduate/courses/msc-international-health-and-tropical-medicine?wssl... |
| Description | MSF Scientific Days Conference |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Third sector organisations |
| Results and Impact | Dr Paton chaired a panel discussion for the MSF Scientific Days conference at the Royal Society of Medicine to discuss "Big data & health information systems (HIS)" in low-resource countries. |
| Year(s) Of Engagement Activity | 2016 |
| URL | https://www.msf.org.uk/msf-scientific-days-agenda-innovation-21-may |
| Description | OpenMRS Worldwide Summit (Singapore) |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | OpenMRS is an open source Electronic Health Record systems that has been widely deployed in Kenya and is the system we are studying for our project's case study. The OpenMRS Worldwide Summit is a 2.5-day summit, where OpenMRS leaders and contributors share new strategies, new technologies, and new ideas with each other in an interactive setting. We were able to discuss the use of OpenMRS in Kenya with multiple stakeholders (OpenMRS founders, developers and leaders of large OpenMRS deployments in Kenya and other countries). |
| Year(s) Of Engagement Activity | 2015 |
| URL | https://wiki.openmrs.org/display/RES/OpenMRS+Worldwide+Summit+2015 |
| Description | Talk at the KEMRI-Wellcome Trust Research Programme in Kilifi |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Professional Practitioners |
| Results and Impact | Dr Paton gave a talk about our research project, "Exploring the potential of Open Source solutions to deliver Clean, Clear Information for Health Service Improvement" to researchers and staff at the KEMRI-Wellcome Trust Research Programme in Kilifi, Kenya. |
| Year(s) Of Engagement Activity | 2016 |
| URL | http://kemri-wellcome.org/ |