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Creating an evaluation and research strategy and an evidence base for eHealth systems to improve the quality of data collection and care in low and middle income settings

Periodic Reporting for period 1 - Global eHealth (Creating an evaluation and research strategy and an evidence base for eHealth systems to improve the quality of data collection and care in low and middle income settings)

Reporting period: 2015-06-01 to 2017-05-31

Healthcare in low and middle income countries (LMICs) is undergoing rapid change allowing treatment of a widening range of diseases. The needs of the disadvantaged, underserved and remote communities are increasingly recognized, and there is an emphasis on surveillance to detect infectious disease outbreaks, measuring and improving quality of care, and reducing preventable adverse events including medical errors. The timely and accurate collection, analysis and use of health information is at the core of all these initiatives, and Electronic Health Information Systems (eHealth systems) including mHealth are becoming essential components of successful health systems worldwide.

The Researcher has led several multi-national eHealth projects in LMICs for over 15 years including developing and implementing electronic medical record systems (EMRs). In 2004 he co-founded and currently co-leads the OpenMRS open source Electronic Medical Record (EMR) system [openmrs.org] now deployed in more than 60 LMICs. He supported the initial roll out of OpenMRS in Rwanda, now in over 300 clinics. Previously he had led many innovative evaluation studies of eHealth systems demonstrating impacts on clinical care processes and access to laboratory results, including the first large randomized controlled trial of a laboratory information system in a LMIC to show a clinical benefit for patients.

The objectives of the Fellowship were to: (1) evaluate with a randomized controlled clinical trial the clinical and health service impacts/benefits of an eHealth systems in an LMIC, to evaluate system’s performance and use, and the costs of developing and implementing it. (2) to improve the quality and use of clinical data from EMR systems for care and research in both the EU and in LMICs, focusing on chronic diseases like heart disease and diabetes, and (3) to create a Global eHealth group at Leeds University to strengthen European and Global capacity in eHealth development, implementation and evaluation. The Fellowship built on the innovative and internationally recognized work of the Fellow, in collaboration with the supervisor Professor Jeremy Wyatt a world leading expert on eHealth evaluation at the University of Leeds, UK.
This fellowship has had a very positive impact on the researchers’ scientific training, research productivity and career, and integration into European Research and International Development. It has also allowed him to attend a range of important conferences, workshops and training courses and to hold workshops and meetings of his own including a workshop on Process Evaluation of eHealth Systems in Leeds in May 2017. The extensive work accomplished will form a strong foundation for the next stage of his career.

Several key innovations have occurred through the fellowship. A new research protocol for the evaluation of electronic medical records was developed for the study in Rwanda. It is designed around the new guidelines for treating HIV that require patients to be started on anti HIV medication as soon as possible after diagnosis, and the use of a more effective test for monitoring HIV treatment called Viral Load. The study is in the process of enrolling 112 clinic sites in a cluster randomized controlled clinical trial, with 56 receiving the Enhanced EMR software. The study also includes the use of a System Monitoring Tool to track the “health” and usage by clinical staff of EMRs in remote sites. Data is automatically uploaded daily (in sites with an internet connection) to a central monitoring system (based on the DHIS2 District Health Information System). The study has also collected data on the costs of developing, rolling out and supporting the EMR system. Objective two included work on the usability and use of EMR systems and assessing cardiovascular risk. Several evaluation studies were carried out of diagnostic decision support systems for patients or clinicians, including testing accuracy of a leading diagnosis system ISOBEL with data from an earlier study on heart disease diagnosis.

The researcher achieved a range of publications during the fellowship including two journal articles in prestigious journals published in summer 2017. The first describes the development, implementation and use of a version of the OpenMRS EMR to support patient care in Sierra Leone during the Ebola crisis [J Med Internet Res 2017;19(8):e294]. The second paper is based on the result of a survey of pharmacists in Kenya on an electronic reporting system for adverse events regarding medications [Agoro O et al, JAMIA 2017 in press] . This was carried out by an MSc student under the researcher’s supervision and showed a range of problems with the system that could explain its low usage. A text book on Global Health Informatics was published with fellow editors from MIT in April 2017, which is now being used by students in courses worldwide [https://mitpress.mit.edu/books/global-health-informatics]. Three chapters were authored or co-authored by the researcher: “Electronic Health Records”, “Monitoring and Evaluation”, and “OpenMRS the Open Medical Record System: Software, Community, Philosophy”. The researcher also published a letter to the editor of the leading journal JAMA Internal Medicine on diagnostic decision support tools for patients, and had three presentations or posters at international conferences, with two more to be presented later in 2017. His work was featured in a short article in the technology magazine “Wired UK” (Sept. 2017). There are four more journal articles at late stage of preparation or under review.
During the fellowship the researcher was promoted to head of the Yorkshire Centre of Health Informatics, at the University of Leeds, was a scientific program committee member for the American Medical Informatics Association (AMIA) annual symposium in 2016. He was also elected head of the Global Health Informatics working group at AMIA which has given him a key platform to promote this field. He was also appointed external examiner for an MSc program in Health Informatics at Manchester University. He met with researchers and policy makers in several countries including being invited to attend the opening meeting of the “All-Party Parliamentary Group on Personalized Medicine” at the Houses of Parliament, London in March 2016, and meeting leading MOH officials at conferences in Atlanta, Singapore and Uganda. Finally he taught, mentored or supervised many MSc and PhD students in Leeds, Edinburgh and Imperial College. These students projects included evaluation of electronic medical records in Bangladesh and Tanzania, evaluation of disease surveillance systems in Tanzania, evaluation of the national pharmaco-vigilance system in Kenya, and evaluation of the performance of the maternal and new born care in Zimbabwe.

Impacts from this fellowship should be seen in the management of health care in LMICs in particular care of HIV and TB and other chronic diseases. This work should have positive impacts on the effective roll out of EMR systems to hundreds of clinical sites, and the effective use of these systems for clinical care and research. It should also improve training in Global eHealth and evaluation of eHealth systems worldwide, and benefit emergency response to international crises like Ebola. Along with work on evaluation of diagnostic decision support systems, it should support improvement in quality of care generally.
OpenMRS being used for patient registration in Rwanda
OpenMRS-Ebola EHR system being used in Kerry Town, Sierra Leone