Exploring the potential of Open Source solutions to deliver Clean, Clear Information for Health Service Improvement

Lead Research Organisation: University of Oxford
Department Name: Tropical Medicine


Electronic Health Records (EHR) systems are computer systems used by hospitals and clinics to record medical information about patients. They include information about patients' symptoms, medical diagnoses, treatment, operations, blood tests, x-ray results and how they are progressing.

Although EHR systems have been used in hospitals in high-income countries for many years now, in low-resource countries such as Kenya, they are just beginning to be used at scale. This proposal is the result of the the research team in Kenya being asked by the Kenyan Ministry of Health (MoH) and the World Health Organisation (WHO, Kenya office) to explore how EHR systems could be used, not just to help doctors and hospital workers in managing their patients, but to also re-use the information that is collected for improving health services more widely. The information needed to improve care locally and across the health system needs to be clean and clear if it is to be used effectively to make the right decisions in the same way that drinking water needs to be clean and clear to be safe to drink.

The aim of this proposal is to allow us to develop the partnerships (both academic and institutional) and knowledge necessary to create a new large programme of research around the development and use of clean, clear information contained in EHR systems for improving health.

To achieve this aim, the first part of this proposal will find out which EHR systems are currently in use in Kenya, why they have been implemented, whether they are meeting expectations of users, whether they contain the kind of information that would be useful to improve care and whether they adhere to best practice international standards for safe and effective use.

We will then investigate how a particular open-source EHR system called OpenMRS is being used in Machakos County in Kenya. This system is used in lots of HIV clinics across Africa (and the rest of the world) but is not usually used in more general forms of care or in hospitals. A recent project supported by the Kenyan MoH and WHO is attempting to implement OpenMRS widely in Machakos County but early experience suggests challenges and we aim to find out what lessons can be learned to support the further introduction of EHR systems in Kenya and how best to gain advantage from the open source (voluntary) community that can help develop and improve these not-for-profit systems.

Finally, we will look at what kind of information from EHR systems could be useful enough to incentivise hospital and county administrators to invest in implementing and sustaining EHR systems that include the ability to collect medical information as well as the kind of financial information that is commonly the first priority for these kinds of system.

Once we know what kind of EHR systems are in use and the type of data they are collecting, how EHR systems are currently being implemented, and what kind of data is of use to policy-makers, administrators and health workers, we can identify the specific objectives of our planned larger programme of research. This new programme will aim to ensure that EHRs in developing countries such as Kenya are implemented efficiently and effectively with minimal disruption to healthcare workers but that will also enable the re-use of clean, clear information throughout the health care system to foster improvements in health.

Technical Summary

This mixed-methods health systems research project aims to use semi-structured interviews with managers and clinicians involved in Electronic Health Record (EHR) system implementation. Interviewees will be identified through a snowballing technique until saturation of new information from interviewees is reached. A specific case study will be performed of an individual EHR implementation project in Machakos County that uses open-source EHR software (OpenMRS) to identify the barriers and opportunities of using open-source EHR software in the county public health system in Kenya. The results of the case study will inform the development of an innovative in-silico simulation of the Machakos County health system as it would be envisaged in the planned roll out of open-source technology to support clinical care, centralised data collection and on-demand registry services (such as the Master Patient Index and a Master Facilities Index). Finally, a co-design workshop will be held with key EHR stakeholders in Kenya (including policy-makers, researchers, hospital administrators, clinicians, patients, EHR vendors, IT companies, programmers and consultants). The workshop will aim to bring together the results of the survey, case report and simulation with experience from across Kenya to develop a set of research objectives to inform the development of the next stage of research aimed at development and re-use of clean, clear information from data gathered by EHR systems to improve health systems broadly while fostering growth of innovative health services research.

Planned Impact

The potential for Electronic Health Records systems to improve healthcare delivery is significant and there is a potential for a county like Kenya to "leapfrog" developed countries like the UK and US in terms of their healthcare IT provision as they will be implementing more modern technology with less need for backwards compatibility with legacy systems. This means that "lightweight" EHR systems that use modern web and mobile development techniques could be implemented for less money and at a faster rate than many previously developed EHR systems. Yet it is important that such developments draw on the many lessons learned about HER introduction in developed country settings.

As detailed in our Pathways to Impact statement, the results from this development grant will help inform this transformation by building a picture of EHR adoption in Kenya, informing policy development and bringing together stakeholders.

However, the greatest impact from this seed project will be the development of researcher, policy-maker and practitioner partnerships (spanning multiple sectors) and a set of research objectives to inform the next stage of research aimed at developing and re-using the data from EHR systems to provide "clean, clear" information for health systems research and improvement.


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Description Ministry of Health 
Organisation Ministry of Health, Uganda
Country Uganda, Republic of 
Sector Public 
PI Contribution We have been supporting the Ministry of Health with advice and feedback on plans for national ehealth projects including a national roll out of the OpenMRS EHR system.
Collaborator Contribution The Ministry of Health eHealth and Systems Development Unit are assisting us to conduct our hospital visits for our EHR survey and providing information and introductions relating to ongoing ehealth projects in Kenya.
Impact `The Ministry of Health eHealth and Systems Development Unit are contributing to our case study of their roll out of OpenMRS in County facilities and also contributed to the KeHIA Big Data Analytics meeting that was co-organised by our research team.
Start Year 2015
Description Crossing Boundaries Conference (Oxford) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Crossing Boundaries is a one-day conference on health research in low and middle income countries. The conference was held on the 8th December 2015 at the Said Business School, University of Oxford, and brought together researchers across Oxford University and beyond, to showcase the diversity and quality of health research. I presented on our ongoing research into EHR use in Kenya under the title: Global Health Informatics and the Learning Health System. The talk was recorded and published on the University of Oxford website.
Year(s) Of Engagement Activity 2015
URL http://www.ndm.ox.ac.uk/chris-paton-global-health-informatics
Description Kenya Health Informatics Association Inaugural Big Data Analytics Meeting (Nairobi, Kenya) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Our research team co-organised this meeting to bring together health informatics stakeholders from across Kenya to discuss the collection and analysis of large health datasets for research and health improvement purposes and to inform our ongoing research and support the development of the health informatics community.

It was the first meeting of a new organisation called the Kenya Health Informatics Association (KeHIA) which has been formed to support the growing community of health informatics professionals in Kenya and was hosted by the University of Strathmore School of Business.

Organisations present included the Ministry of Health, CDC, NHIF, Global Communities, NASCOP, KEBS, Medic Mobile, Savannah Informatics, USAID/AfyaInfo, KEMRI/Wellcome Trust Research Programme, Institute of Healthcare management - SBS, Palladium, mHealth Kenya, PATH, Baringo County, Moi University, ICFI, NOPE, UON-PSRI, East African Community-MOH, Kenyatta National Hospital, PSK, University of Nairobi, MSH, IBM, Kenyatta University, IntelliSOFT Consulting Limited.

The meeting provided a range of support to our research including developing Ministry of Health support for our project and obtaining new contacts and leads for our national survey of EHR systems in use in the country.
Year(s) Of Engagement Activity 2016
URL http://www.kehia.org/
Description OpenMRS Worldwide Summit (Singapore) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact OpenMRS is an open source Electronic Health Record systems that has been widely deployed in Kenya and is the system we are studying for our project's case study.

The OpenMRS Worldwide Summit is a 2.5-day summit, where OpenMRS leaders and contributors share new strategies, new technologies, and new ideas with each other in an interactive setting. We were able to discuss the use of OpenMRS in Kenya with multiple stakeholders (OpenMRS founders, developers and leaders of large OpenMRS deployments in Kenya and other countries).
Year(s) Of Engagement Activity 2015
URL https://wiki.openmrs.org/display/RES/OpenMRS+Worldwide+Summit+2015