The Zanmi Lasante Electronic Medical Record (ZL EMR) system was deployed for primary care at Partners In Health (PIH) program in Haiti, known locally as Zanmi Lasante (ZL), operates clinics and hospitals at 12 sites across the Central Plateau and the lower Artibonite, two of the country's poorest regions. Zanmi Lasante connects vulnerable people in Haiti to comprehensive primary care services and HIV prevention while working in support of the Ministry of Health’s goal of universal treatment coverage. Across all of our sites, PIH/ZL is prioritizing investing in systems that support high-quality, longitudinal care for our patients.
Most of our HIV clinics utilize a pre-OpenMRS HIV electronic medical records (EMR) system with retrospective data entry leading to data backlogs and lower quality data. Since 2009, OpenMRS implementations have been introduced for MDRTB, Primary Care, Physical Rehabilitation, and Mental Health at ZL health facilities. PIH/ZL expanded the stable, point-of-care OpenMRS EMR utilized at University Hospital at Mirebalais to our supported clinics at Thomonde Health Center in Thomonde, Haiti (October 2016) and Lacolline Health Center in Lascahobas, Haiti (December 2016). This point-of-care system is used by clinicians and data archivists: Clinicians capture vital signs and clinical consultation data; Archivists capture patient registration and workflow. Based on experiences at Thomonde and Lacolline Health Centers, additional EMRs will be deployed at Zanmi Lasante Health Centers and Hospitals.
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This timeline describes the various ZL EMR systems since 2001. All these systems are built with OpenMRS except the HIV EMR.
Goals of EMR
Identify and register all patients at a facility, regardless of program.
Enable clinicians to enter data directly at the point-of-care, leading to reduced data backlogs, higher quality data and improved access to data for patient care. This is accomplished through local server installations that eliminate previous barriers due to internet access.
In the future, leverage this base platform to support our clinical programs by providing timely, accurate, complete data on patients enrolled in HIV, TB, Nutrition, Maternal & Child Health, and other strategic clinical areas. Assist programs with referrals into care, eliminate loss to followup, and evaluate clinical outcomes. Understand the burden of disease along with expanding universal health coverage (UHC).
System description
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The System
The ZL EMR systems will both enable clinicians and impact patients at all points of the care continuum, from recording diagnosis to mapping treatment plans and retaining patients in our care. Through implementing upgrades, our goals are to identify and register all primary care patients, enable clinicians to enter patient data at the point-of-care, and eventually leverage these systems to provide comprehensive and complete data on all patients. This point-of-care system is used by clinicians and data archivists: Clinicians capture medical information; Archivists capture patient registration and workflow. The ZL EMR primary care functionality includes patient registration, check-in, vital signs, and primary care visit information, including history, vaccinations, allergies, physical exam, diagnoses, and treatment plan.
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The same OpenMRS software is used at all three sites (Mirebalais, Thomonde and Lacolline), but with various features toggled on or off, based on the capabilities of and workflow at the health facility. (For example, the Radiology interface is only accessible at Mirebalais where there is a PACS system exchanging data with the EMR).
The ZL EMR primary care functionality includes patient registration, check-in, vital signs, and primary care visit information, including history, vaccinations, allergies, physical exam, diagnoses, and treatment plan.
The Thomonde EMR started capturing patient registration and visit notes on October 14, 2016, after a training program of registration staff and clinicians. (As of November 8, 2016, 332 patients were registered in the EMR along with 167 vital signs encounters and 164 visit notes.)
The Lacolline EMR (V2) started on December 5, 2016. 60K patient demographics records were migrated from the Lacolline EMR V1. These were patients who were seen at the Lacolline outpatient clinic between 2012 and 2015. In the first month, over 1000 patients were checked in at the clinic.
The Mental Health EMR is also based on the same software but deployed on multiple OpenMRS servers.
All data is entered into the EMR at point-of-care. Registration of all new patients is completed by data archivists (name, gender, birthdate, address, insurance info, mother’s name, contact information, etc).
New and returning patients are “checked in” by cashiers who collect payment. The registration and check-in software is exactly the same as used at University Hospital in Mirebalais. At check-in, the reason for visit is recorded (ie. HIV, TB, etc) (Figure 1).
| For Thomonde and Lacolline, the system was expanded to collect the entire visit note so that data would be easily available for patient care and decision support. A clinical dashboard (Figure 2) was created for a simple summary of the most recent information (ie. vitals, diagnoses, visits, allergies).
| After a patient visit is started, the clinician selects the appropriate action (vitals, intake or followup; adult or pediatric). There are many sections in the various forms (Figure 3) -- but there is a summary available for all the data captured in each section. A printout is available from this page that can be added to the patient file.
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Reports
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The Thomonde EMR started capturing patient registration and visit notes in October 2016, after a training program of registration staff and clinicians. (As of February 2017, 1,200 patients were registered in the EMR along with 2,100 encounters.)
The Lacolline EMR (V2) started on December 5, 2016. 60K patient demographics records were migrated from the Lacolline EMR V1. These were patients who were seen at the Lacolline outpatient clinic between 2012 and 2015. In the first 2 months, over 2,500 patients visited the clinic.
Reports
Data is generated from the EMR. Data can be exported for various patient encounters (ie. registration, vitals, visit note, etc.) (Figure 4) . The user customizes data output by date range. Some data is viewed directly by using the web browser and all data can be exported as csv/excel files.
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The Future
Based on experiences at Thomonde and Lacolline Health Centers, additional EMRs will be deployed at other Zanmi Lasante Health Centers and Hospitals.
In the next year and beyond, the ZL EMR will be expanded for HIV, NCD, Specimen tracking, and Oncology. The cost and complication of ID cards is driving the need for alternative identification technology (ie. fingerprinting). DHIS2 is a powerful and popular technology which is driving integration. PIH and ZL continues to improve collaboration with the Haiti Ministry of Health (MSPP) and other important Haiti-based partners. Finally, PIH would like to have consistent EMR systems at all our ZL and other PIH health facilities.
The Team
There were many collaborators for this project: ZL Leadership and Information technology; Boston PIH Development, Finance, and Medical Informatics; Thomonde and Thomonde Lacolline leadership (Lazare), clinicians, and staff. Gratitude to MAC AIDS for funding.
Zanmi Lasante (ZL) IT (L-R) Wesly Official, Peterson, Dupuy Rony Charles, Claude, Pierre Charles Mingot, Edwenson Raphael, Jean Baptiste Prince, Pierre Charles Mingot |  Partners In Health (PIH) Boston Medical Informatics (L-R) Mike Seaton, James Mbabazi, Ellen Ball, Mark Goodrich, Cosmin Ioan, and Dave DeSimone |
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Background
The Partners In Health (PIH) program in Haiti, known locally as Zanmi Lasante (ZL), operates clinics and hospitals at 12 sites across the Central Plateau and the lower Artibonite, two of the country's poorest regions.
ZL HIV EMR (2001 - present): The HIV EMR system was introduced in Haiti around 2001 and is still operational at all ZL health facilities. That system continues to be an invaluable tool for our many HIV patients and funders. Data entry clerk transcribe lengthy paper forms into this EMR which pre-dates OpenMRS.
Currently all ZL facilities have OpenMRS implementations. Functionality differs between these implementations.
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Lacolline V1 (2012 - 2015): Patient registration was introduced at the Lacolline health center to replace an EpiInfo system. The Lacolline EMR produced plastic ID cards to patients, registered new patients with demographic information, collected information at check-in to the clinic, and recorded diagnoses from paper dossier by data entry clerk after the visit in the outpatient clinic. Patient registration and payments were entered at point-of-care. This EMR guided requirements and development of the sophisticated Mirebalais EMR. OpenMRS V1.9 with custom modules.
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MDRTB EMR (2014 - present): Multidrug-resistant TB (MDRTB) EMR in Cange and Hinche with local servers. An earlier ZL MDRTB EMR (2009) was cloud-based and required reliable internet. OpenMRS V1.9 with MDRTB module.
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Mirebalais EMR (2013 - present): The initial implementation of the ZL EMR. Record every patient who arrives for care at the University Hospital at Mirebalais (HUM) (Outpatient (SSPH), Emergency, Inpatient, Surgery, Women’s Health, Radiology, Dental, etc) and data entered at point-of-care (new patient registration, patient check-in, clinical consult, vitals, radiology orders, PACS integration, surgery, chemotherapy, appointment scheduling, drug dispensing, etc). Recent additions include mental health assessment, emergency triage workflow, mental health assessment, insurance information, and medical procedures. The Mirebalais EMR MVP was used to create the OpenMRS 2.0 and the OpenMRS Reference Application.
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Mental Health EMR (2016 - present): All ZL mental health patient assessments are captured on multiple laptops while at University Hospital at Mirebalais, patient data is recorded directly into the Mirebalais EMR. For the other clinical facilities, OpenMRS is installed on the laptops of the Mental Health staff. This is necessary because internet is unavailable at those facilities. The laptop is their local EMR server. On a monthly basis, the laptops are brought to a centralized location with internet where data export and backups are possible. The Mental Health EMR has the same software as the Mirebalais EMR, but the deployment is different with these "mobile" laptops and disconnected databases. OpenMRS 1.10 + Reference Application.
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Technical specifications
The ZL EMR is built with the OpenMRS Reference Application and Platform 1.10 along with customized of workflow, htmlforms, and reports. The ZL EMR is available in Haitian Kreyol, French, and English.
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