EMR Goes Global: Bringing Technology to Developing Countries

Lately, I’ve been hearing quite a bit about global cancer care. I shouldn’t be surprised. The International Agency for Research on Cancer projects that by 2030 the incidence of all cancer cases will be 22.2 million. To learn more about the trend, I visited the Partners in Health website because they recently helped open a  new oncology hospital in Rwanda.

PIH is a Boston-based non-governmental organization (NGO) that provides “a preferential option for the poor in healthcare.” They provide free health care for patients in the U.S and abroad with an emphasis on primary health care, social services, education, community engagement, and reduction of poverty. Not a small job!

While on their website something caught my eye. Under What We Do, along with advocacy, research and service, was medical informatics. I was intrigued and wanted to learn more about how PIH was using this growing component Health IT in the developing world.

So, the good folks at PIH arranged for me to speak with their Director of Medical Informatics Evan Waters. Waters began working for PIH in 2007 as the information systems manager for the Malawi project. Since his background was in civil engineering, he had to look at the big picture including infrastructure, water, and HIT/EMR. In Malawi,  he and his team implemented OpenMRS, an open-source EMR, to track HIV data.

Waters has been director of medical informatics since July and is now responsible for managing information systems requirements from PIH sites like Haiti, Rwanda, Malawi, and Lesotho. He works with a team of software developers to meet these requirements and collaborates with the clinical, research and monitoring, and evaluation teams to use EMR data to improve program management and patient care.

Again, no small job!

My conversation with Waters was extremely interesting and covered more than I could include (or do justice to) in a blog post. So, in typical blog fashion, I’ll get to the nitty-gritty and share a few of the points that made me think.

1. Hi-tech means different things

Before I talked with Waters, I had this vision of a hospital equipped with top of the line technology from top to bottom. Smart rooms, bar codes, cell phones – you name it. I don’t know why I thought this. Actually, I do. A few months ago I heard a piece on Chicago Public Radio about how Kenyans are using the M-PESA program to do their banking via cellphones.

As I listened to the report, I remember thinking, “Wow, Kenya is more technologically advanced than I realized.” I must have extended this idea to HIT implementation as well. I probably should have known better since I have spoken to many U.S. health care providers who use paper charting.

Waters clarified this idea for me. “It’s not Epic or Cerner,” he explained. “It doesn’t look like a big EMR.” Instead, it may be a data-entry clerk using a computer to register patients or merging records so patient data is consistent. For example, a patient may have different addresses on different patient records. The EMR would have the patient’s most recent address (an be easily updated) so community workers could contact the patient if he or she missed a follow-up appointment. Simpler than Cerner, yes, but extremely effective in getting patients to continue receiving care.

2. It’s quality not quantity

Americans are often into bells-and-whistles when it comes to technology. We want the latest phone, computer, GPS, to do everything though, in reality, many of us will never use the majority of the features that our gadgets boast.

Waters clearly made the point that more is not always better. “It’s easy to get greedy thinking about the amount of data you can collect,” he said. “It’s better to start simply and get quality data.”

Back to the example of having a patient’s updated address, that data was essential to monitoring patient care adherence. When you can show that data contributes to better patient care people will begin to trust the data and technology.

“If they don’t trust data they won’t collect it,” he said.

3. Useability is key

Waters relayed a story about physician order entry. The team thought the physicians would benefit from being able to click on standing orders to write medication orders. But the physicians thought otherwise. They avoided using the system because it was too time consuming and it was easier for them to write orders by hand. I had to chuckle because this reminded me of my own experience with POE 13 years ago. I’m pretty sure some of the attending physicians I worked with didn’t even know their user names and passwords.

Both in the U.S and abroad, useability is key to getting health care professionals and support staff to use HIT and EMR. If the technology is too difficult to use, creates more work, or causes a workflow bottleneck, users will not embrace it.

4. Technology is a status symbol

I think that in the U.S. we take computer literacy for granted. Even those of us who would be classified as not very tech savvy probably know how to check email and to shop online.

But in developing countries, “You may be hiring someone who’s only used a computer a couple of times,” Waters said. He explained this was particularly common among the data entry clerks and archivists, who would be similar to our admissions and medical records clerks.

What I found interesting is that instead of resisting (which I have seen U.S health care workers do),Waters said most of these employees, “get excited about computers and see that as a status symbol.”

The use of EMR can help stimulate this group of employees.

“There’s the possibility to empower a lower tier of workers,” he said.  “They go from being paper pushers to highly regarded support people for a more dynamic electronic system.”

Those are just a few of the concepts that Waters and I covered during our conversation. He’s a wealth of information and a great resource for anyone looking to implement HIT. And if you’re interested in more about the PIH story, I recommend you pick up Tracy Kidder’s book, “Mountains Beyond Mountains.” It will inspire you to solve problems and create a better world, which as Waters has shown us, can be done with health IT. ♦


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Jennifer Thew, RN, MSJ

Jennifer Thew, RN, MSJ, is a registered nurse and journalist who has covered healthcare issues and how they relate to the nursing profession. She began her nursing career as a neuroscience nurse at Rush University Medical Center in Chicago and then transitioned to journalism after receiving a degree from Roosevelt University in Chicago. She has edited and written numerous articles on a wide range of nursing and healthcare topics like Accountable Care Organizations, evidence-based practice and telehealth.

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