Conclusions from EMR Assessments and Mombasa Harmonisation Meeting

1. Conclusions from EMR Assessments and Mombasa Harmonisation Meeting National EMRS Framework Meeting, November 11 2009, Mamba Village Saade, Abdallah, NASCOP

2. Focus of EMR Assessments by HMIS, CDC and NASCOP General system characteristics Hardware and infrastructure requirements Human capacity and perceptions Data use for clinical and managerial decision making Data reporting and output capabilities Data security and quality Linkages with other systems

3. Software: Key Findings • 33 different software applications in health sector. • Software existence: 1-19 yrs (HMIS) to 1-4 yrs (NASCOP). • Types of software identified: • EMRs or Patient Management Software – 24/33 • 7 EMRs for HIV/ART (OpenMRS, APHIA II Coast, IQCare, ICAP, Fuchia, Care 2000, EDMS) • Hospital HMIS Software /ERP Systems • Data Collection and Reporting Software • Data Analysis Software • Administration/Management Software • External Systems

4. EMR Software: Current Features Most EMRs Windows based, MS-Access database platform. Few EMR were connected to other software, 5 were web-based Most serve individual patient/program needs at 1-2 sites. Weak technical support No local transfer of technical know-how.

5. EMR Software for Future Upgrade and Scale Up • CDC and NASCOP assessments: • OpenMRS & IQCare for large sites; • APHIA II Coast EMR & ICAP software for smaller ART sites. • HMIS • No EMRs considered appropriate for future scale up • AMREF CBHMIS recommended for Community based HIS • FTP and FIS recommended for District HRIOs

6. EMR Software: Recommendations EMRs tailored to MOH and other user needs; Integration and interoperability with other existing EMRs User friendly graphical user interface (GUI); Web-based connectivity and technical support; Cross platform for multiple operating systems; Integrated automated report writing capability Identification of ‘software champion’ per targeted EMR site to facilitate smooth roll out.

7. Clinical Patient Management: Findings Only 2 EMRs (KQ EMR, Care2000) had interactive clinical modules for data entry by care providers Only 3 EMRs (Care2000, KQ EMR, IQCare, OpenMRS) interoperable and integrated with other software. Tedious data capture forms; Data primarily used for upward reporting rather than being used to enhance clinical care or facility administration; No reporting capability; Lack of a decision support system; Confidentiality on patient data not assured.

8. Clinical Patient Management: Recommendations Facility-level sub-committees for EMR change management Standardize procedures for clinical care and data capture User friendly EMR data capture screens aligned to clinical care functions (OPD, IPD) and patient flow Build provider competency with EMR system at all facility levels International disease and drug coding standards e.g. MFL, Patient ID, SNOMED, LOINC, AHLS, ICD – 9CM etc. Confidentiality of patient information within daily clinical care Security for paper based and electronic patient records Electronic data and reports used at source for patient care

9. Health Records Management: Findings • Only 4 EMRs (OpenMRS, FUCHIA, APHIA II Coast, IQCare) capture or report data for MOH 257 and/or MOH 726 or 711 indicators. • Linkages between data reporting and transmission not clear • All EMRs have limited capacity for automated reporting • Lack of consistency with EMR data quality and uniformity • No SOPs to ensure quality documentation and data entry • Inadequate data security and back up procedures • Limited human resource capacity for EMRs: • disparity in staff deployment: 1-20 staff per EMR site (NASCOP); 2-7 dedicated staff per EMRs (CDC). • few HRIOs & other providers computer literate

10. Health Records Management: Recommendations Standard (MOH) data capture tools, Minimum data set for recording and reporting with open standards Data quality audits SOPs for data recording, retrieval and archiving Restrict data access/usage rights with audit trail for amendments Easy & secure data transmission between systems via encrypting Messaging and transmission standards e.g. Health Level 7 Decision making support: clinical alerts/reminders, display trends Central repository or data warehouse at district or higher levels Automated Hospital Management systems & reporting for decentralised levels Confidentiality &information security training for health records staff Regular and automated data back-up and data recoveryguidelines

11. Health Records Management: Recommendations for Human Resources EMR competency for data entry clerks & HRIOs at facility to provincial levels Decision makers can access HMIS data for evidence-based planning Updated training curriculum for health records information officers (electronic data management, ICT, data security and quality control) Accredited Records Management degree course at local universities Core HMIS ICT Technical Staff skilled in systems development, database administration and networking training Capacity for data analysis and use for decision making at all levels Competency in data and information management for data clerks and other cadres, including nurses Improved scheme of service and deployment of HRIOs

12. Infrastructure and Hardware: Findings Inadequate at most institutions for ongoing EMRs data management and storage of equipment and health records. Electronic security systems lacking at all sites. Power supply frequently interrupted or absent. Some sites had UPS or generators for power back up. Inadequate ICT support at facility, or district level, & over-reliance on external ICT support (Nairobi or US-based HQ). OpenMRS relies on internet based software support. Disparity in IT staff deployment: 5 IT staff at central level per EMR (CDC); 1/300 to 1/3,000 IT staff per facility

13. Infrastructure and Hardware: Recommendations Procure standard ICT and communication equipment where practicable. Distribution of communication equipment for multi-channel access based on workload of target facilities. Enhance connectivity for up and down stream data transmission Leverage government’s rollout of fibre optic cable to district HQs (e-government project). Full automation of every facility for linking/transfer of data where practicable. Central data storage and back-up systems at district and national levels Adequate infrastructure and security for district health records offices Adequate personnel with ICT skills for technical support.

14. Governance and Regulatory Environment: Findings Current EMRs developed ad hoc, via donor funds or private initiatives. No supportive policies and regulations for definition of standards and enforcement of data security SOPs for health information systems

15. Governance &Regulatory Environment: Recommendations Supportive EMR policies and regulatory mechanisms for EMR development, rights to information Multi-sectoral committees to coordinate EMR roll out at national and decentralised levels Development and enforcement of EMR standards EMR operational guidelines and SOPs for EMR development, installation, implementation and M&E EMR accreditation and version control via local/open source code, ownership and hosting of EHRs Recruit, training, deployment and retention of core EMR focal persons Partnership building, resource mobilisation and allocation Cultivate local ICT expertise and technical support for EMR EMR inventory, performance monitoring and documentation Advocacy for EMR and dissemination of best practices

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