OpenMRS OpenMRS (Open Source Medical Record System) is a community-developed, open-source, enterprise electronic medical record system framework intended to aid resource-constrained healthcare environments. Founded in 2004

Founders and Collaborators OpenMRS is a multi-institution, nonprofit collaborative led by: Regenstrief Institute, Inc. (http://regenstrief.org) Partners In Health (http://pih.org) South African Medical Research Council (MRC) (http://www.mrc.ac.za)

Background Originated by the Regenstrief Institute, University of Indiana and used at the Ampath AIDS clinics in Kenya Operational Sites AMPATH Clinic, Eldoret, Kenya Rwinkwavu Hospital, Rwanda Richmond Chest Hospital, South Africa Pilot Implementation Sites Morogoro Regional Hospital, Tumbi Hospital and Ocean Road Cancer Institute, Tanzania Makerere University (Uganda) Millennium Village Project Cell-Life, South Africa Support Partnerships: CDC/PEPFAR, WHO, Rockefeller Foundation, IDRC

What is OpenMRS? OpenMRS is an application which enables design of a customized medical records system with no programming knowledge (although medical and systems analysis knowledge is required). It is a common framework upon which medical informatics efforts in developing countries can be built. At its core is a concept dictionary which stores all diagnosis, tests, procedures, drugs and other general questions and potential answers.

What does OpenMRS cater for? Aimed at Patient Based Care Allows for the enrolment of Patients Easier storage of patient data Ability to produce accurate reports Reports are defined by the implementers/developers

Key Features Open Source, generic forms-based, web application Uses Microsoft InfoPath for forms development (XForms-like) Standards-based, XML structure and processing, HL7 messaging A basic application can be implemented without significant programming Build on a generic database model allowing it to be highly configurable.

OpenMRS Development Resources OpenMRS web resources: OpenMRS Wiki (http://www.openmrs.org) OpenMRS open source development project (http://trac.openmrs.org) Implementers Wiki OpenMRS List servs Developers list Implementers list Announcements

OpenMRS Application Development Process

OpenMRS Application Development and Data Entry Process Involves the following key steps Define Data and Develop Structured Medical Record Forms Install and Configure OpenMRS Define Concepts and Database Elements Develop Form Schema Develop Electronic Medical Record Forms Data Entry Live demonstration of South African ART/TB application

OpenMRS Application Development Process – Step 1 Define Data and Develop Structured Medical Record Forms Install and Configure OpenMRS Define Concepts and Database Elements Develop Form Schema Develop Electronic Medical Record Forms Data Entry

Define Data and Develop Structured Medical Record Form Data ideally driven by minimum data set, defined vocabulary, clinical information requirements, monitoring and evaluation and reporting Forms developed together by informatics, medical and public health professionals

OpenMRS Application Development Process – Step 2 Define Data and Develop Structured Medical Record Forms Install and Configure OpenMRS Define Concepts and Database Elements Develop Form Schema Develop Electronic Medical Record Forms Data Entry

OpenMRS - API Three code layers Hibernate, Spring, AJAX Database Layer Service Layer Presentation Layer Hibernate, Spring, AJAX

OpenMRS Implementation Software Packaged Open Source Software MySQL (Relational database management system) Java 2SE (Java runtime environment) Apache Tomcat (Server engine) Mozilla Firefox (Web browser) OpenMRS Software OpenMRS web application Commercial Software Microsoft InfoPath or Microsoft Office 2003 Professional (Forms development)

Other Software (not required for implementation) Useful open source software DBDesigner (open source database schema design tool) Commercial Navicat (graphcal user interface to MySQL) Developer Software TortoiseSVN (source code repository manager) Java Developers Kit (Java development environment) Eclipse SDK (Java integrated development environment tool) Apache ANT (Java compile application) OpenMRS OpenMRS Source code

Installing and Configuring OpenMRS Desktop Installation Install required packaged and set environmental variables Configure database (SQL scripts) Deploy OpenMRS web application Client Server Installation Establish standalone server installation Establish network Define user permissions Set global variables Web Installation Establish remote access using Terminal Services, InfoPath, OR; Establish Internet access and configure Tomcat to use SSL

OpenMRS Application Development Process – Step 3 Define Data and Develop Structured Medical Record Forms Install and Configure OpenMRS Define Concepts and Database Elements Develop Form Schema Develop Electronic Medical Record Forms Data Entry

Database OpenMRS database model makes use of a generic database model which has many advantages which are useful in the realm of health especially coming to the dynamic changes and need for longitudinal data for care. This is best explained through means of an example:

Flat Data Set (Analytic Conceptualization) Pat ID Name Visit Date Hgb CD4 SGPT SaO2 WHO Stage 1234-5 Doe Jane 12May05 13 95 39 93 2 1234-5 Doe Jane 1Oct05 12.5 200 60 98 3 8888-3 Doe Sam 4June95 16 78 90 3 1234-5 Doe Jane 23Jan06 14 23 95 3 Each Row: One Patient, or One Patient Encounter (Table Grows Wider)

Stacked Data Set (Application Conceptualization) Pt ID Visit Date Obs. ID Value Units Nl Range Place Provider 1234-5 12-May-05 Hgb 13 mg/dl 12.5-15 Mosoriot Dr. Smith Doe J 12-May-05 CD4 95 cells/mm3 500-1500 Mosoriot Dr. Smith Doe J 12-May-05 SGPT 39 IU/L 80-140 Mosoriot Dr. Smith Doe J 12-May-05 SaO2 93 % 80-140 Mosoriot Dr. Smith Doe J 13-May-05 WHO Stage 2 1-4 Mosoriot Dr. Smith Doe J 1-Oct-05 Hgb 12.5 mg/dl 12.5-15 Mosoriot Dr. Jones Each Row: One Clinical Observation (Table Grows Longer)

OpenMRS Data Model v1.00

AMRS Data Model v0.70

Encounter User Patient Form Concept Obs Order Business AMRS Data Model v0.70

Encounter User Patient Form Concept Obs Order Business Concept: “Dictionary” of all medical concepts (terms) within our system.. Concepts exist for both questions (urine ketone level?) and answers (large). Class (Drug) and Datatype (Numeric) Synonyms (Hgb) Sets (CBC) Encounter User Patient Form Concept Obs Order Business AMRS Data Model v0.70

Encounter User Patient Form Concept Obs Order Business Patient (The “Who”): Comprehensive list of all known patient demographics.. matching! Tribe -> Coded Equivalent of Ethnicity Archive of all addresses (patient_address) Archive of all patient names (patient_name) Archive of all identifying IDs: MRNs, national IDs, etc. (patient_identifier) User Patient Form Concept Obs Order Business AMRS Data Model v0.70

Encounter User Patient Form Concept Obs Order Business Observation (The “What”): All things clinically measured or observed Weight Platelet Count Cardiac Exam Findings Alcoholic Drinks / day Value Groups (complex answers) Obs Groups (complex questions) Complex Data? User Patient Form Concept Obs Order Business AMRS Data Model v0.70

Encounter User Patient Form Concept Obs Order Business Encounter (The “Where”): Tables that describe “places” within the healthcare setting, each observation or order is labeled with one of these. Encounter: describes a health care provider <-> patient interaction Encounter Type: describes various types of encounters (inpatient, outpatient initial visit, outpatient return visit, etc.) Obs Order Location: describes the physical location where observations and orders occur (clinics, hospitals, labs, etc.) Business AMRS Data Model v0.70

Encounter User Patient Form Concept Obs Order Business Order (The “How”): Tables that record care provider actions (Dr. Mamlin ordered a CXR), (Start Joe on AZT), etc Start vs. Completion vs. Discontinue Drug Orders vs. Orders … still working through consensus.. Encounter User Patient Form Concept Obs Order Business AMRS Data Model v0.70

Database Key Points Advantage: Disadvantage: Highly scalable Highly configurable Disadvantage: Direct Database reporting is slightly tricky

Other Major Sections Form: collection of questions asked during a patient interaction Each form consists of “fields”, each field relates to a concept Key is in defining “set of questions” once Relationship: defines relationships between people Various types of relationships (familial, primary care provider, etc.)

Demo: Concept Dictionary Development

Translating Forms to Vocabularies

Coded Data from Encounter Forms

OpenMRS Application Development Process – Step 4 Define Data and Develop Structured Medical Record Forms Install and Configure OpenMRS Define Concepts and Database Elements Develop Form Schema Develop Electronic Medical Record Forms Data Entry

Forms and Database Development

Demo: Form Schema Design

OpenMRS Application Development Process – Step 5 Define Data and Develop Structured Medical Record Forms Install and Configure OpenMRS Define Concepts and Database Elements Develop Form Schema Develop Electronic Medical Record Forms Data Entry

XForms Development in Microsoft InfoPath 2003

Demo: InfoPath Form Design

HIV/ART Adult Patient Registration

OpenMRS Application Development Process Define Data and Develop Structured Medical Record Forms Install and Configure OpenMRS Define Concepts and Database Elements Develop Form Schema Develop Electronic Medical Record Forms Data Entry

Selecting Forms

Conclusions

CONCLUSIONS OpenMRS is a powerful application for development of medical data collection and electronic medical record applications Low cost and configurable Non-programming application development option Robust control over concept and field definition Powerful mechanisms for data integration Scaleable and extensible database Secure remote access options Compatible with a range of existing infrastructure and tele-medicine implementations

OpenMRS Resources OpenMRS web resources: OpenMRS List servers OpenMRS Wiki (http://www.openmrs.org) OpenMRS List servers Developers list (dev@openmrs.org) Implementers list (implementers@openmrs.org) Announcements (announce@openmrs.org) Google! (http://www.google.com)