Cure the common code: OpenMRS aims to improve medical record systems in developing countries

OpenMRS developers work on solutions during an annual OpenMRS Hackathon. (OpenMRS Photos)

Consider the difficulties many of us face when we need medical procedures, tests or referrals. Now imagine you lived in a developing country where these challenges can be significantly greater.

For instance, getting a critical blood test might mean being given an informal slip of paper you have to take to a lab somewhere on the other side of town. After traveling for two hours, you wait another three hours to have your blood drawn, then are told to come back two days later for the results. When you return, you collect the handwritten results which you have to deliver back to your referring practitioner two hours away. Clearly, there are many points where the lines of communication could break down.

Unfortunately, such challenges have long been the reality in many parts of the world. Thats largely due to the costs and other demands of establishing standardized electronic medical records systems that can be reliably and securely used by practitioners in low-income developing countries.

This was some of the motivation behind OpenMRS, an open-source medical record system that launched in 2004 to improve healthcare delivery in resource-constrained environments. The program is supported by funding from the Gates Foundation through the PATH Digital Square funding program; U.S. Centers for Disease Control; Mozilla Foundation; Pineapple Fund; Rockefeller Foundation; and others.

The project was initially conceived as a way of improving existing records systems for managing critical healthcare initiatives in developing countries. The program has since expanded to become the worlds largest open-source digital health community and is supported by institutes and teams from around the world.

OpenMRS initially launched to support a clinical care and treatment project in Kenya called AMPATH, an Academic Model for the Prevention and Treatment of HIV/AID project.

It was modeled in a way that made sense for global health specifically, so people in other low resource settings started adopting it, said Jan Flowers, chair of the board of directors for OpenMRS.

Left to right: Steve Wanyee, OpenMRS Board member and founder and director of Kenya-based IntelliSOFT; Jan Flowers, chair of the board of directors for OpenMRS; and Jennifer Antilla, director of community at OpenMRS.

Flowers is also the faculty co-lead and founder with Dr. Nancy Puttkammer of DIGI (Digital Initiatives Group at I-TECH), the global health informatics center at University of Washington. Over the years, Flowers has been involved in national-scale health informatics projects based in Mozambique, Kenya, Cote dIvoire, Haiti, Vietnam, and Namibia.

Today, OpenMRS has been installed at more than 6,520 healthcare clinics, serving 12.6 million patients in 40 countries. These numbers are even more impressive when you consider how much difference exists between healthcare systems around the world. Beyond just the matter of the local language itself, medical terminology, lab test results, billing codes and local regulatory requirements can all differ widely, calling for a system that is highly customizable.

OpenMRS achieves this through its modular construction, the use of what are known as standard concept dictionaries and an Open Concept Lab that enables further customization. This allows each site installation to standardize its different concepts and medical terminology in order to meet local needs without having to alter the programs core code or back-end structure.

In the end, the primary goal is to enable better, more efficient healthcare around the world, a goal thats been a huge inspiration for the open-source component of the project.

Around 2010, we suddenly started to see national-scale implementations of OpenMRS, said Jennifer Antilla, the organizations director of community who is also based in Seattle.

While the OpenMRS software makes all of this possible, as a matter of principle, the organization doesnt perform the clinic installations itself. Instead, they generally partner with other organizations, such as DIGI, to support health ministrys wanting to use OpenMRS.

The managing partner then teams up with developers and implementers in the country where the installation site is located. This allows the software to be customized and contextualized on the ground. Thats essential because each countrys health ministry has different regulations, different governance, different languages, and different data collection elements they want to monitor and measure.

From the OpenMRS Implementers Conference 2016 in Uganda.

All of that has to be thought through with those who will actually be working with the system. This often means training local developers and IT professionals, raising their skill levels and building the available talent pool that can later be tapped into for other types of projects.

At OpenMRS, were really committed to equality and making sure that people feel equal, that were all peers, said Flowers. So, part of our mission is to equip these ministries and organizations with the skillsets and systems that they need to own and sustain the systems themselves for the long term.

Beyond this, the project connects the end users to an open-source community that has grown to approximately 5,000 members with 75-to-100 main developer contributors consistently active in core activities of the software.

The OpenMRS community has even extended to Googles Summer of Code (GSoC), which has been involved with the project for several years. The people coming through GSoC or those who are just interested in contributing to the community, either as developers or software engineers, are supported by the OpenMRS fellowship program. That program provides mentors to bridge the gap between how far people get with GSoC and the more advanced skill sets that OpenMRS implementers need. This allows them to advance from junior-level to mid-level developers to eventually become the OpenMRS gurus who actually perform implementations in the field.

The success of the program in developing countries has been extensive, benefiting patients, facilities, tech ecosystems and communities. Its also demonstrated the many advantages electronic records keeping can offer.

For instance, Haiti has used OpenMRS nationally for its HIV program for many years. When the COVID outbreak hit in 2020, they used their records to determine that issues around COVID were actually interrupting many patients HIV treatments. This kind of disruption can have a huge impact and without good records management, they wouldnt have been able to tell whether people had maintained and adhered to their treatments. Better records management made it possible to do case follow-ups to make sure patients didnt become infectious and contribute to new infections.

Seventeen years ago, no one imagined how much of an impact this software project would have one day. Literally millions of lives have been improved and made healthier because of this single idea and the commitment of a talented community that wants to improve the world by coding for good.

OpenMRS was founded by Paul Biondich and Burke Mamlin of Indiana Universitys Regenstrief Institute; Hamish Fraser of Partners in Health; and Chris Seebregts of JEMBI Health Systems in South Africa.

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