1. The implementation of electronic medical records in a low-resourced urban ED By Dr Paa Kobina Forson

2. Outline Background Objectives Methods Results Challenges Conclusions References

3. Background Emergency Medicine in KATH started in 2009 By Jan, 2012, more than 50,000 patients had visited the ED. More than 100,000 patients by Jan 2014 Up to 40% of all admissions in the ED are discharged home from the ED Records of patients discharged from the ED under 24 hours are difficult to locate due to poor storage. The Biostatistics department of KATH cannot guarantee the integrity of patient records beyond 10 years

4. Take a wild guess?

5. Guess how old these folders are?

6. Is this recent enough?...try the next

7. Was your guess right?

8. Background cont.….. Continuity of care is affected because of missing patient records, so FOLLOW UP greatly affected Increased occurrence of missing folders in the ED Folders are placed at the foot of patient beds – Patient CONFIDENTIALITY compromised ED has no easily accessible repository of data for clinical audit and research Folders of those who died prior to arrival in the ED do not have a consitent place of storage.

9. Out patient records in the ED Discharged patients recordsBID patient records

10. Background There was the need to institute a system to ensure integrity of patient records in the ED and improve patient confidentiality, ensure efficient storage, improve integrity of patient records, allow for monitoring and evaluation of care in the ED and improve patient flow within the ED Electronic medical records was instituted in the NHS between 1988 and 1993; in hospitals in Hong Kong by 1997.

11. Objectives To institute a robust repository that retains patient records which is long lasting. To implement a system where medical records of patients are easily retrievable To implement a system where confidentiality and integrity of patient’s medical records is assured. To improve patient tracking and care pathway monitoring in the ED

12. Methods Regular panel meetings involving emergency medicine physicians, residents and IT specialists in a modified Delphi study form done started in January, 2012. Functional specifications of fields relevant for the local environment was agreed upon after successive panel meetings Open EMR software was suggested in a panel meeting

13. Methods Openemr is an open source electronic medical software which offers a platform for collation of medical records Robust system that has been tested to take up large volumes of medical records and undergoes frequent updating Openemr is a free open source software that allows for very easy modification and implementation

14. Methods Changes were made to Openemr platform following series of panel meetings. Major changes were made to: – Patient registration platform – Triage- the SATS was configured on to Openemr. Automatic triage scoring is done on the platform – Physicians documentation sheet was changed to be in the fashion used at the ED

15. Methods An intranet system was set up in the whole of the ED with a fixed IP address for the KATH EMR All the computers in the floor of the ED can access the KATH EMR using the IP address WLAN has also been created to cover areas in the ED without IJ45 ports Configured Openemr to automatically generate a special ED number for all patients visiting the ED

16. KATH EMR – search page

17. Results After 13 months of panel meetings and configurations the first prototype of the KATH EMR was piloted for 2 weeks in March 2013. The EMR crashed when a configuration error caused an uncontrolled generation of ED patient numbers and due to increasing volume of patient records Reconfigurations and further panel reviews following the feedback from Biostatistics department and EM residents during the pilot commenced in April, 2013

18. Patient Registration

19. Results Following the review meetings and configurations, decision was taken to initiate Openemr in a step wise fashion unlike during the period of the pilot when the full version was initiated In January 01, 2014 we started running the KATH EMR following a short training of the Biostatistics staff in the ED Currently, any patient coming through the ED have their demographics entered on the KATH EMR

20. Results We have successfully been able to upload 110,000 patient demographics spanning 5years Each of these patients have been given a unique ED number which will be their identifier on subsequent visits Medical records of these patients will be retrieved from storage and electronically scanned and attached to each patient demographic on the software

21. Results We have trained all the triage nurses in the ED to use the KATH EMR to triage patients We have acquired tablet devices to be used by triage nurses and physicians via the wireless network set up in the ED Infrastructure for the triage unit is being set up to enable triage nurses to use the software fully Regular panel meetings and feedback from users will enable us to improve the system going forward

22. Triage

23. Challenges We have had the arduous task of making the software user friendly Change is hard : Any change that seems to slow down work rate of staff comes across as being averse Interruptions in designing and reconfiguration due to lack of dedicated IT staff Support of management. It is an added advantage to get the support of management

24. Going forward We are migrating to the field for doctors and nurses, pharmacy and laboratory and billing in the next few months We have set up levels of permissions for the different levels of staff to improve system security. The KATH EMR is hoped to serve as a repository for a number of registries and research initiatives e.g. trauma registry, stroke registry etc. We have plans to link the system to a web based server for back up and also to allow remote access A voice recorder system will also be explored to improve the speed of users.

25. Doctors Page

26. More on Doctors’ Page

27. Consult to other directorates

28. Going Forward Time stamps of at every step of a patient’s care pathway will help managers to improve the throughput processes in the ED Patient flow in the ED will best be monitored using this software Laboratory orders and results could be expedited using the KATH EMR Billing of patients could be vigilantly audited with this system We hope to replicate this initiative in other hospitals in the region

29. Conclusion Open source electronic medical records is an open, FREE, modifiable platform that can transform the health information system of any facility we have set up an efficient EMR at minimal cost with a potential to generate huge revenue for KATH This is the perfect system to ensure privacy and confidentiality of patient especially HIV/AIDS patients A novel electronic software will cost a fortune to a low resource facility This is an opportunity to transform record keeping and enhance clinical research in health facilities in Ghana

30. Appreciation This project would not have been possible without the contributions of Dr George Oduro Dr Rockefeller Oteng Dr Maxwell Osei-Ampofo Dr Maysel Stella Forson Dr Chris Oppong Dr Joseph Bonney Mr. David Kumi All residents and specialists of Emergency Medicine, KATH IT staff of KATH; staff of EM administrative office and EM research office Prof Peter Donkor, Prof Charlie Mock and Prof Ebel We wish to also acknowledge the support of the NIH through MEPI

31. THANK YOU VERY MUCH QUESTIONS