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The OpenMRS Field Guide is a new and incomplete resource that aims to help implementers with the nuts and bolts of beginning and sustaining a successful implementation of OpenMRS, from securing electricity to maintaining data quality.
If you don't find what you're looking for in this general guide, please ask the Implementer's mailing list (subscribe on the community page). The list is full of people just like you who would be happy to answer your questions promptly.
There is also an OpenMRS Book for Implementers available: http://booki.flossmanuals.net/openmrs-guide
Get the stories and work flows of:
Find out how all medical information is supposed to be managed , as well as how it is actually managed. Note that practices may vary seasonally, for example if the hospital is much busier due to increased malaria during rainy season or malnutrition before harvest.
- You need to know the reporting and regulatory requirements for the Ministry of Health in your country. If you are working at a public clinic or hospital, it is important to learn those before completing the design of the model. For multiple sites, begin talking with the Ministry of Health as early as possible to consider how the model could be replicated.
- If there are NGOs in the area that already use OpenMRS or plan to use it, consider the possibilities for sharing a system of unique national IDs , and/or sharing a concept dictionary so that medical information can be more easily transferred from one site to the next.
- You can begin to reach out to other NGOs by asking the implementers mailing list (Template:Email:implementers) if there are any other implementers in your region. Whether or not you end up collaborating with them, it can be very helpful to communicate with a local experienced implementer during the design phase of your project.
- A central server with remote sites connected via Internet
- Local servers connected to work stations with a wireless local area network
- Local server connected to work stations by ethernet Ethernet cable
- A collection of sites, each with its own server, are connected by Remote FormEntry module or sync feature
- Paper forms are completed at remote sites and brought to a central location where they are entered into a local server
Entering data at point of care vs. retroactively
See Point of Care page.
Using a vertical program model vs. primary/comprehensive care model
In the future it would be great to collect brief descriptions of diverse implementation models that could use a case study format to highlight how past projects have navigated these project design issues. Maybe on the Reference_implementations page?.
Existing infrastructure is a critical factor in designing your project. Implementing an electronic medical records system can be a good motivation to build infrastructure such as stable electricity or Internet connectivity that has tangential benefits for other aspects of the health facility. However, it is critical that project goals are modest enough that they will be successfully implemented, embraced by local staff, and have sufficient long-term financial support.
OpenMRS is only as reliable as the power system that supports it. Unless electricity is almost 100% stable in your area, you will probably want a primary power source and a backup.
- Include surge protection and voltage stabilization – Generator or partial-grid power can easily damage computers and networking equipment. Spikes in power or low voltage are the most common cause. The equipment to protect against this danger is relatively inexpensive and readily available in most places , and offers cheap insurance against damage to more costly equipment. These components should always be used with an AC power source.
- Size systems carefully and conservatively – Where power is scarce, it is valuable. If you allow staff staffs to use your power source for charging personal cell phones, DVD players etc., they will . Consider consider isolating ICT power systems from others. If your server relies on a battery backup, make sure the battery powers only the OpenMRS system.
- Build around locally available inputs -- Imported parts that are not available locally tend not to be replaced if they unexpectedly stop working. Develop relationships with several suppliers of high-quality batteries, chargers, solar panels , etc.
Organizations that have helped OpenMRS implementers set up power systems:
- Remote servers connected via Internet. Work stations connected to Internet via wireless router or ethernet Ethernet cable
- Local server connected to work stations with a wireless local area network
- Local server connected to work stations by ethernet Ethernet cable
Some projects require significant investment to protect ICT and power infrastructure , while others do not. Consider Considering the context. Only , only local knowledge can guide this decision.
- Use "passive" security as much as possible (e.g. bars versus locking shutters)
- Have metal doors with locks, and bars on all windows
- Use a large, sturdy, lockable metal cabinet to store the server, fans, and backup batteries (such as Baobab proivdes for each implementation).
- Avoid glass , especially at ground level
- Having a relatively public location can help minimize theft , but only if solid basic protections are in place
- Secure solar arrays with locking frames. Based on local conditions, wire mesh or other screening may be required to protect glass from rocks, etc. If available, use impact resistant panels.
- Widespread community support for the ICT system and/or the services they support can help to minimize the likelihood of theft or vandalism.
- A laptop may be more likely to be stolen because it is portable and can be used for purposes other than the EMR. A desktop computer is less portable, and a thin client such as a basic touch-screen device may be less vulnerable to theft if it can't act as a standalone computer - i.e. can't function when it isn't connected to a central server. Using a thin client has the added benefit of ensuring that staff will use the device for work purposes rather than browsing the web, making Word documents etc.
Once you have a good understanding of the kind of system you want to set up, the amount of data you want to collect over time, and the type of system your infrastructure (either pre-existing or built specifically for this project) can support, you can select server and work stations that meet your needs.
Most installations require a minimum of 2GB RAM , and 250GB hard disk.
At current installations:
HAS Haiti: 600K patients, 4.4 million obs. Average entry of 150 forms and 1400 obs per day. 12GB memory, Dual-Quad Core Intel Xeon 2.33GHz server. Up to 11 users accessing the system simultaneously.
Work stations for retrospective data entry
If you intend for clinicians to enter data on paper forms that are later entered into OpenMRS by data entry clerks, you should estimate the number of work stations you will need based on the amount of data you will enter. As a general rule, it will take a data clerk about one day to enter 80-100 forms with 20 observations per form (this general rule may vary greatly from site to site). For retrospective data entry you may use regular computers that range in cost from $300-$1,000.
If you intend to build a point of care system, you should estimate the number of work stations needed based on the number of clinicians or clinic rooms. You might want to consider using thin clients or , touch-screen devices , and may want to use or mobile devices if for remote clinics. Such devices range from $100 (for a J2ME smartphone capable of running OpenMRS) to $1,000 for some touch-screen appliances.
If you would like to submit forms from the field , and you do not need rich access to patient data, you can do so with mobile devices that cost as little as $20. Forms can be sent via SMS, GPRS, or wifiWiFi. On the other, end of the spectrum are applications that run on more expensive smartphones with features that are nearly equivalent to a regular OpenMRS workstation, except on a smaller screen.
Read about the various mobile tools that integrate with OpenMRS on the Mobile page.
Building forms is an iterative and non-trivial process. Consider various options for creating and submitting forms, including HTML form entry module, XForms module, FormEntry module (uses InfoPath) and Remote FormEntry module (also uses InfoPath).
- Connectivity to the Internet and/ or a local area network
- Computer viruses, software updating and basic computer problems ( e.g. a mouse stops working)
Many organizations lack the internal skills to deal with these issues, so external support can be critical . In in general:
- Budget for support and maintenance – Annual maintenance cost is usually 5% to 15% of the original total budget , but costs will vary significantly based on terms of contract.
- Avoiding problems is easier and less expensive than fixing them -- For example, to keep solar power systems working properly, it is important to clean panels regularly.
- Teach users about proper equipment care – New computer users may inadvertently mistreat equipment. User training should include basics about how to keep equipment in good working condition (e.g. to be careful not to spill food or drink on keyboards, not to cut power to equipment while it is running, etc.) The overall goal should be to make users feel a degree of ownership of the equipment.
- Define a tiered support strategy – Train on-staff system administrator(s) on basic maintenance and troubleshooting and give them a direct link to external expert support. Simple troubleshooting cheat sheets can help in settings where system administrator turnover is high.
- Purchase pro-active site visits – These visits are especially useful during the first 3--6 months, when misuse or equipment failure is most likely. Support providers can often be enlisted to provide training, as needed, for system users.
- Buy support from whoever installed the system – It can be hard to identify the source of ICT problems, much less to assign responsibility for fixing them. Purchasing support from the equipment provider helps to avoid this challenge. Make sure you negotiate for both up front.
Many implementations use existing clerks . Some though some train cleaners to enter data.
If you have more than 4 data entry clerks, it is often useful to train data managers to oversee the data entry clerks and ensure that they are maintaining high data quality.
Common issues and solutions
Issue: The system slows way down every time I try to run a report, making it impossible for the data clerks to enter data.
Eventually this page will document reference implementations using a case study approach aimed at sharing practical experiences in diverse settings with new OpenMRS implementers.
- EMR section of Partners In Health Model Online
- Inveneo Primer on ICT Sustainability: This doc was salvaged , with permission , and re-purposed as the basis for much of this Field Guide's section on dealing with hardware and infrastructure
- HackMySQL: Simple and to the point documents on dealing with MySQL