[This was a note sent to one of the NGOs working in Haiti who is contemplating implementation of OpenMRS, an open source code electronic medical record system, for their network of clinics. There has been an ongoing single-track focus by several of the funders to address the lack of a medical record system in Haiti, with a special focus on activating a nation-wide electronic medical record. We have been involved in the discussion to highlight the importance of not forgetting we are still in emergency conditions where implementation of an electronic medical record to support better syndromic surveillance cannot be the immediate priority, but rather a complimentary and parallel long-term objective. The reason is due to the length of time it will take to implement such a system, which is on the order of multiple months. Existing electronic medical record systems in Haiti are largely outside of the quake-affected areas, which means the IDP population is not represented- the very people most at risk for the emergence of an infectious disease crisis. Operationally, social networking continues to provide a powerful early warning capability until the realization of more robust infrastructure such as the electronic medical record. Both objectives must be maintained to address the immediate and long-term challenges regarding the specter of a public health crisis in Haiti. To date, public health and several of the incumbent NGOs have unfortunately refused to acknowledge this and engage in the process. This is ironic given the amount of concern they have all expressed about the prospect of an infectious disease crisis with the coming major rainy season. We continue to argue the point. -Editor]
It is important to highlight the importance of implementing OpenMRS from a number of perspectives. The perspective I would like to offer here is the perspective of current challenges in infectious disease event surveillance and response. This concern spans not only long-term development objectives in Haiti but also near-term concerns as we enter the major rainy season. Many of us in operational biosurveillance (infectious disease crisis early warning analysts) remain concerned about a small, select number of infectious disease issues that, if allowed to emerge uncontrolled, may severely compromise the ad hoc, limited and already strained medical infrastructure in place. The primary issue we are concerned about is pediatric diarrheal disease, which appears to currently be in-check perhaps thanks to a focus on sanitation efforts but perhaps more likely a measure of herd immunity has been present due to chronic sanitation challenges. It is unknown whether this apparent stability will be dramatically altered with the coming major rainy season.
Here are key thoughts to consider from this point of view, justifying the need for some form of electronic medical record in Haiti:
Patient Identification. IDP logging and tracking remains a significant challenge in the camps. There is an opportunity for the medical record to provide this function at least until some other form of Government of Haiti (GOH)-approved identification is available.
Medical Logistics. We recently experienced the unnecessary fatality of a 15 year old boy due to diphtheria. It took eleven hours to identify where the supply of anti-toxin was while the child was in respiratory failure at HUEH. Resource tracking remains a critical issue that even beyond implementation of OpenMRS, coordination with PROMESS will be needed. It is obvious to point out that a crisis situation is the last point at which one would want to have difficulty finding a critical resource to save a patient's life. This is dramatically compounded in the context of a community-level crisis where multiple patients are involved. We assess the current medical infrastructure in Haiti is incapable of handling an abrupt surge of patients in the context of a reasonably sized infectious disease crisis.
Documentation of Vaccination Status. Current methodologies employed by PAHO and other public health organizations to validate vaccination status involves walking the camps and randomly interviewing mothers. We have noted there are multiple social perspectives contributing to bias in the mothers' responses that include a) perception that the more vaccines received the better; b) perception that the vaccines are contaminated or make people ill (as evidenced by fever and discomfort in children the day after); c) general avoidance due to pain; and d) deference to traditional healers' recommendations. This obviously reflects challenges in patient education, social dynamics in the public's interaction with NGO personnel, and pre-vaccination campaign education about the expected outcomes of fever and sore arms. Lack of more definitive patient identification and reliable documentation of vaccination status continues to challenge risk assessments in regards to vaccine-preventable disease such as the ongoing diphtheria concern. The above-mentioned method of 'verifying' vaccination status was inadequate, as demonstrated by the recent fatal pediatric diphtheria case- he came from the very same camp where PAHO and CDC attempted multiple times to establish vaccination coverage, and it remains an open question how the child was exposed in the first place. This comment is not intended to criticize the efforts of public health but rather to emphasize the difficulties encountered and the importance of establishing a medical record.
More Efficient Transmittal of Critical Public Health Surveillance Information. A major limitation to the current Internally Displaced Persons Syndromic Surveillance (IDPSS) capability managed by MSPP with the assistance of PAHO and CDC is consistent participation by medical responders in Haiti. This is a reflection of (not in any particular order) a) lack of medical responder experience filling out surveillance forms; b) frequent changes in point of contact email addresses at MSPP and the forms used to fill out surveillance information; c) constant rotation of both public health and medical responder teams (some organizations rotate everyone from the Chief Medical Officer down to nursing staff every 1 to 2 weeks!) with subsequent deficiencies in operations sign-out; d) lack of familiarity with the infectious diseases to be reported; e) retroactive reporting back multiple weeks; f) strain on medical responders' time to fill out forms; g) and so on… The point, as above, is not to criticize public health efforts but to highlight the potential improvement in efficiencies if medical responders could be encouraged to move from manual entry of data to an automated data push.
Coordination of Laboratory Testing. This is related to point #4, but we have seen impressive challenges in coordinating laboratory results within the field even within the same hospital. Non-Haitian laboratory technicians are donating their time in Haiti as with nurses, physicians, and a host of others, so they are rotating in and out of field as often. Haitian laboratory technicians struggle with lack of funding to support their salary and access to resources. NGOs highlight the inconvenience of identifying laboratories capable of processing certain tests, payment for the tests, and travel times involved with transporting samples. Having a foundation of electronic tracking for requested labs, where they were sent, and diagnostic results begins the process of mapping out the available infrastructure and highlighting deficiencies to be addressed. From a public health perspective, we have seen significant time delays in laboratory results where identification of a particular pathogen may prompt a complicated, expensive, and time sensitive response measure such as an emergency vaccination campaign.
Obviously, implementation of OpenMRS and realization of the above benefits will take quite a bit of time, arguably several months depending on the circumstances, however I applaud your efforts to begin now. The sooner the better in my opinion, from the operational biosurveillance viewpoint of 50,000 feet trying to make sense of multiple sources of information to assess emerging risk in the Haiti response theater.
Dear ---,
It is important to highlight the importance of implementing OpenMRS from a number of perspectives. The perspective I would like to offer here is the perspective of current challenges in infectious disease event surveillance and response. This concern spans not only long-term development objectives in Haiti but also near-term concerns as we enter the major rainy season. Many of us in operational biosurveillance (infectious disease crisis early warning analysts) remain concerned about a small, select number of infectious disease issues that, if allowed to emerge uncontrolled, may severely compromise the ad hoc, limited and already strained medical infrastructure in place. The primary issue we are concerned about is pediatric diarrheal disease, which appears to currently be in-check perhaps thanks to a focus on sanitation efforts but perhaps more likely a measure of herd immunity has been present due to chronic sanitation challenges. It is unknown whether this apparent stability will be dramatically altered with the coming major rainy season.
Here are key thoughts to consider from this point of view, justifying the need for some form of electronic medical record in Haiti:
Patient Identification. IDP logging and tracking remains a significant challenge in the camps. There is an opportunity for the medical record to provide this function at least until some other form of Government of Haiti (GOH)-approved identification is available.
Medical Logistics. We recently experienced the unnecessary fatality of a 15 year old boy due to diphtheria. It took eleven hours to identify where the supply of anti-toxin was while the child was in respiratory failure at HUEH. Resource tracking remains a critical issue that even beyond implementation of OpenMRS, coordination with PROMESS will be needed. It is obvious to point out that a crisis situation is the last point at which one would want to have difficulty finding a critical resource to save a patient's life. This is dramatically compounded in the context of a community-level crisis where multiple patients are involved. We assess the current medical infrastructure in Haiti is incapable of handling an abrupt surge of patients in the context of a reasonably sized infectious disease crisis.
Documentation of Vaccination Status. Current methodologies employed by PAHO and other public health organizations to validate vaccination status involves walking the camps and randomly interviewing mothers. We have noted there are multiple social perspectives contributing to bias in the mothers' responses that include a) perception that the more vaccines received the better; b) perception that the vaccines are contaminated or make people ill (as evidenced by fever and discomfort in children the day after); c) general avoidance due to pain; and d) deference to traditional healers' recommendations. This obviously reflects challenges in patient education, social dynamics in the public's interaction with NGO personnel, and pre-vaccination campaign education about the expected outcomes of fever and sore arms. Lack of more definitive patient identification and reliable documentation of vaccination status continues to challenge risk assessments in regards to vaccine-preventable disease such as the ongoing diphtheria concern. The above-mentioned method of 'verifying' vaccination status was inadequate, as demonstrated by the recent fatal pediatric diphtheria case- he came from the very same camp where PAHO and CDC attempted multiple times to establish vaccination coverage, and it remains an open question how the child was exposed in the first place. This comment is not intended to criticize the efforts of public health but rather to emphasize the difficulties encountered and the importance of establishing a medical record.
More Efficient Transmittal of Critical Public Health Surveillance Information. A major limitation to the current Internally Displaced Persons Syndromic Surveillance (IDPSS) capability managed by MSPP with the assistance of PAHO and CDC is consistent participation by medical responders in Haiti. This is a reflection of (not in any particular order) a) lack of medical responder experience filling out surveillance forms; b) frequent changes in point of contact email addresses at MSPP and the forms used to fill out surveillance information; c) constant rotation of both public health and medical responder teams (some organizations rotate everyone from the Chief Medical Officer down to nursing staff every 1 to 2 weeks!) with subsequent deficiencies in operations sign-out; d) lack of familiarity with the infectious diseases to be reported; e) retroactive reporting back multiple weeks; f) strain on medical responders' time to fill out forms; g) and so on… The point, as above, is not to criticize public health efforts but to highlight the potential improvement in efficiencies if medical responders could be encouraged to move from manual entry of data to an automated data push.
Coordination of Laboratory Testing. This is related to point #4, but we have seen impressive challenges in coordinating laboratory results within the field even within the same hospital. Non-Haitian laboratory technicians are donating their time in Haiti as with nurses, physicians, and a host of others, so they are rotating in and out of field as often. Haitian laboratory technicians struggle with lack of funding to support their salary and access to resources. NGOs highlight the inconvenience of identifying laboratories capable of processing certain tests, payment for the tests, and travel times involved with transporting samples. Having a foundation of electronic tracking for requested labs, where they were sent, and diagnostic results begins the process of mapping out the available infrastructure and highlighting deficiencies to be addressed. From a public health perspective, we have seen significant time delays in laboratory results where identification of a particular pathogen may prompt a complicated, expensive, and time sensitive response measure such as an emergency vaccination campaign.
Obviously, implementation of OpenMRS and realization of the above benefits will take quite a bit of time, arguably several months depending on the circumstances, however I applaud your efforts to begin now. The sooner the better in my opinion, from the operational biosurveillance viewpoint of 50,000 feet trying to make sense of multiple sources of information to assess emerging risk in the Haiti response theater.
This is a great summary of the issues and the facts.
As a parallel and possibly complementary point of view, and electronic health record could be patient-centric and if web based would also be fully portable by the patient to any health provider.
LifetimeHealthDiary.com is just that. You can share your personal record with anyone you choose. All the patient needs to open the free service is a working email address.
We would love to be helping Haiti and you awesome folks on the ground. Let us know if we can collaborate to support your work.
Rebecca Caroe
LifetimeHealthDiary
Posted by: LifeHealthDiary | 05/31/2010 at 09:14 PM