Note: As promised during the session, Isaac Holeman set up a Point of Care page where we can focus our efforts to adapt OpenMRS for use at the point of care.
- Point of care: Data entry during clinical visit/encounter.
- Retrospective: Data entry after encounter, usually from paper form.
Expectations for Point-of-care systems:
- Clinics already overburdened - reduce how many times data is written down. No data entry team available. Enter data only once.
- Neal Lesh: 95% of OpenMRS data is retrospective.
- Why is the retrospective data entry happening? What are the barriers?
- Speed is so important - so many patients - typical systems cannot keep up
- OpenMRS not designed for Point-of-care environment - need system designed to flow through the patient encounters
- Problem w/ retroactive entry - data not available throughout the clinic - paper in the wrong place
- Point-of-care system opportunity to improve quality of care - patients do not have to wait so long for their appointments, reduce time to wait from a day to an hour or two
At the moment aggregate data is pushing downwards - external factors are collecting - data is not used or available by clinicians.
What are circumstances that cause us to use Retrospective rather than Point-of-care?
- Connectivity and uptime/consequence of downtime
- Legal requirements - must have paper copy for legal reasons
- Perceived extra hardware complexity - using mobile phones not as big a barrier as pc's - more accepted by indigenous community
- Dr. Aamir Khan, Indus Hospital Research Center, Karachi, Pakistan - They made a move towards thin clients to reduce maintenance issues. It is important to note that as you move to Point-of-care systems, you need more sophisticated tech support.
- Security: Look out for security issues:
- Western cape system w/ 2.5 million patients - some clinics completely cleaned out by thieves. They are considering the use of VMware type systems and thin clients - When thieves steal equipment, it is worthless to them.
- Power - Challenges of thin clients - do not have batteries
- Pakistan - at clinics - use cellphones rather than pc's, since the clinic is less secure than the hospital - but important to close the feedback loop - return data to the clinic
- Daniel's Andriod OpenMRS for mobiles - cellphone app example
Important design points for a Point-of-case system
- Runs on a browser and can run in a thin client model - do not need a ton of servers - especially at the point of care.
- Process are important part of Point-of-care. How to change business processes at the clinics? Does OpenMRS support modeling business processes?
- More than interface: need to be able to track delivery of service
- Baobab very successful at doing this - can see where patients are waiting
- Baobab - some clinics have different roles - flexible roles where anyone can do anything. This is very useful in resource-poor environments where nurses double as pharmacists.
- XForms include skip logic capability - can this (i.e., use of XForms' skip logic) be a useful tool for Point-of-care?
- MOH Uganda: How to develop system that can easily configure workflow to support the local processes?
- Time issue: System must be inherent to the processes so user does not notice it. Do not ask too much of the user, unnecessary fields.
- Performance is very important - cannot wait for a long screen refresh
Types of Point-of-care
- Centralized system
- Distributed - sync issues -
Which type does OpenMRS support?
OpenMRS has a sync feature built-in
- Use of guid to identify records that go up all the way - human resources system example in uganda
- Boabab: If server can connect to other clinics, it can grab data from other peers
- Importance of unique patient identifiers
- Baobab - have unique identifiers for patients. Not using uuid's for baobab - just nat'l unique id.
Access to patient information
Is having instant access to patient record more of a requirement of a Point-of-care system or is this typical of all systems including Point-of-care
- Very important for Point-of-care in order to track patient
- Northern Nigeria - silos of data of maternal health data - now to get this data in front of clinicians? paper system doesn't work - no one knows the utility of some of these fields.
- Opportunity is instant access to data vs. not having historical data avaialble
Patient Health Card - smart card w/ last 10 visits on it.
Separate Point of care data from administrative data - sometimes the data sytems collect too much admin data that is not particularly useful to clinicians.
What does OpenMRS need in order to implement a Point-of-care system?
Is it a ui framework or more modularized?
- Example of mdr-tb module - Model the Point-of-care process and enable programmers to create appropriate modules
- Needs to accommodate different types of clients - pc's, phones, etc.
- Promise for mobile phones and thin clients
- Need analysis for the different contexts - 'device strategy' - rural health centres have different needs from urban hospitals
- In a rural setting they may need a bed rather than a pc, but they need a communication device to send the data to the people who can provision the bed.
- Need wiki pages on equipment recommendations, stories on what works
- Device strategy
- Software design/data model
- Pakistan: one Point-of-care system was being scaled up to over 40 sites, but OpenMRS did not yet have the features to do this.
- Who has deployed Point-of-care systems? - page on wiki to publish success cases
- Look at these stories to filter out some best practices, not just OpenMRS deployments. Don't expect our community to supply all of the solutions.
- Patient registration system in Rwanda is a Point-of-care system currently in development.
Point of Care System Examples
Paper review of HMIS systems
- While developing system, the clinicians worked 3-4 hours a day w/ the programmers in developing each module - therefore they had a strong sense of involvement - they owned it.
- Build flexibility in system - enable clinicians to add extra fields themselves - they may work on a special form of TB and collect extra data.
How to adapt OpenMRS for primary care?
- Don't always know what type if data will be needed when someone comes into the clinic.
- Should the team concentrate on primary care system, or on a subset like HIV?
- Think of the issue on a more general level, on health outcome.
Need for reference implementations. AMPATH has stimulated alot of OpenMRS developments.
- Sign up to the workgroups - Issac will help organise this activity.
- Please add any useful reference material to Point of Care System Examples.
- Idea of funding study of 5-6 Point-of-care sites and gather info for the team.