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  • 2009 Implementers Group Meeting Program Scaling up to a Country
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<html><head><title></title></head><body>Scaling up to a country:

Hamish Fraser: OpenMRS is designed and intended to serve as a framework for multiple health program applications and to be flexible enough to work in different environments and across platforms. Need to decide though on specific applications, constraints and requirements in order to have a baseline system and then allow particular sites to customize forms, reports, etc. This needs to be in a limited controlled method though to create a balance between a supportable, high-level system and to respond to specific needs at individual sites.

Chris Bailey: Discussions should take into account other systems in the country and how OpenMRS can fit into that environment.

Ada imPath, Kenya: Need to collect a minimum data set for MOH, how to capture particular indicators. Biggest challenge is infrastructure among sites, centralized data entry at Eldoret. Has now tried to decentralize data entry back to the clinics, but this is dependent on synchronization. Electricity rationing makes implementation difficult at remote sites. Data quality activities include clinician training, how to properly fill forms, help to ensure proper interpretation of form filling. Data manager conducts random samples of files. Using incentive-based performance reviews for data quality.

Q: How did you modify the workflow of the clinics? How did you get permission to do this? How did you link this with other processes that are going on in parallel.

Ada: For pharmacy, only collect drug orders, compare between what is ordered and what is dispensed. Certain pharmacy data can be moved between the pharmacy system and OpenMRS.

Q: Have you had any reason to make the system interoperable with other systems?

Ada: For right now MOH, are still in discussions about what kind of EMR will be used nationally.

Q: Have you encountered standards, drug coding, HL7 standards?

Ada: For now we are primarily focused on HIV data, but are expanding to oncology, primary care, etc. For now the system complies to standards, but as the system expands, would need to adopt standards.

Q: Three areas investigated for developing a national system. 1) Capacity of staff, infrastructure 2) Sustainability, interoperability, 3) Resources
Chile has adopted a standard in systems communications, measurable investments,

Q: How do you achieve synchronization between the different sites

Ada: Using remote form entry, and doing synchronization from the site up to the central server and then back down from the central server to the clinic

From SQS, Ghana: Are just beginning to rollout nationally, have setup a central system that feeds in the data and are moving to the clinics to collect data from the clinic. Basic complications include: different levels of adaptability, finding it difficult to catch-up into the system. Specifically, if a form has to be changed, or to adapt an existing form, reporting, etc. . Do not have the capacity, to implement themselves.

Hamish: Needs to be a government level investment in localized support.

Ghana: Difficult to find challenges for documentation

Hamish: Yes, implementers need to publish their experiences and people should contribute to communal experiences by way of
publishing experiences.

Bill Lober, UW-Seattle: Data managers, infrastructure, support need to be scaled up as the rollout happens. Additionally, need to scale how you make changes at individual sites, in terms of human systems.

Ada: Key is training, hands on experience, onsite training,

Eric, from Mozambique: Trying to use OpenMRS in Mozambique. Is curious to know how you go about transitioning from scaling up at a few sites to scaling up at a national level. Would like to know what kinds of policy changes need to be made, how do you go about getting MOH to adopt a national system? How do you resolve the link between getting policies in place that allow for the system to be implemented and develop/decide policies for things like patient confidentiality, etc. Standardize the rollout for hardware, network configuration, embedded Linux server, decreased maintenance. Web based-monitoring of all sites so that alerts can be made when there are problems. Sites vary greatly in terms of infrastructure.

Chris Bailey: Sounds like there will be different models in different countries. There is an attempt in some countries to adopt national standards, but other countries are not. Two different questions “Scaling up software to many sites†vs. “Developing a national HMIS systemâ€Â.

Hamish: Would like to develop a deliverable from this meeting, proposing that we should come up with a set of prerequisites for scaling.

Richard, Rwanda: Must have a national plan. Does the country have a national e-health plan? Need to identify data exchange needs, discussing about which systems and which priorities should take precedent? Thought it was worth building OpenMRS into a much wider system for primary care, stock management, etc.

Evan, Malawi: Could perhaps be better to identify a few small problems that can be used to demonstrate and build up from there.

Hamish: But it takes a very long time to do something “simpleâ€Â.
Chris Bailey: Having a national system does not necessarily mean a top-down approach, best approach is to allow multiple systems to exist and see which systems naturally rise

What are standards that need to be established early on?

From Kenya: Kenya has a partnership between the MOH. Started by doing an analysis of all the EMRs in the country. And then identified a harmonized report based on what systems were out there. Debate was about whether to start from ART with the big picture in mind or start from a top-down primary care system. Looked at issues of infrastructure and then looked at software issues, data management, data quality, capacity building, governance and legislation. Working towards a big framework for evaluating potential solutions.

Peru: Mistakes should be published. Should have many systems that compete for which systems should be adopted.

Gilbert, Rwanda: System requirements should be gathered in order that clinicians drive the software development process. Local people should own the system.

Pakistan: Is there an example of a particular application that has been developed, scaled up vertically, and then broadened horizontally?

Hamish: Due to the relative youth of the systems I don’t think we’ve seen such a system as yet.

Chris Bailey: That’s the idea behind OpenMRS,

Cheryl, Rwanda: The model that worked was working closely with MOH in order to break-away from the rigid system and to try something different. Can then share experiences with MOH . Difficult thing is to figure out how you get that relationship with the government.

Q: How were partnerships developed?

Cheryl: Happens at both levels. Partnership developed by top PIH officials and MOH officials and simultaneously at the clinic level.

Q: What have been concerns the government has raised?

Richard, Rwanda: National e-Health committee has discussed any policy-level decisions before decisions can be taken at the clinic-level

Bill Lober: National Health Plan should identify components of health information system architecture, functions of the e-health system, identifying the information exchanges,
 
• Working with the government
• Having a national Plan
• Standardizing Components
• Breaking it down into components -> Data exchange
• Scaling from the bottom up
• Evaluation of systems
• Identify concrete goals early
• Business case and requirements
• Include non-government players & clinics
• Governance structure & iterative meetings
• Use data clinically & for program management
• Document everything that you do & communicate that transparently
• Training: development of the system, IT Support, data managers/data entry, training users

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