2Patrice Nevil BS, 1,2,3Hamish SF Fraser MBChB MSc, 1Darius Jazayeri MEng, 1Yusuf Karacaoglu, 1,2Paul Farmer MD PhD, 1,2Joia S Mukherjee MD MPH, 2Fernet Leandre, MD
1Program in Infectious Disease and Social Change, Dept. of Social Medicine, Harvard Medical School, Boston, MA, 2Zamni Lasante, Cange, Haiti, 3Informatics Program, Childrens Hospital, Boston, MA
HIV-AIDS has become the
world’s leading infectious cause of adult deaths. Approximately 5% of Haiti’s
adult population is infected with HIV, making it the most affected nation in
the western hemisphere. The non-governmental organization Zanmi Lasante (ZL)
launched an innovative program 5 years ago to treat HIV patients in the very
impoverished central plateau with highly active anti-retroviral therapy
(HAART). ZL currently follows more than 4000 HIV-positive patients, over 10%
of whom are already on HAART, and was recently awarded funds from the Haitian
grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Expanding
treatment in a region with few doctors and virtually no roads, electricity, or
electronic communication is a major challenge requiring careful coordination of
clinical care, investigations and drug supplies. We describe
prototype Electronic Medical Record system the “HIV-EMR” to support treatment
of HIV and tuberculosis in remote and impoverished areas.
Treatment of HIV requires daily administration of three anti-retroviral drugs (ARVs) plus supplementary medicines, as well as careful monitoring of clinical progression, side-effects, and laboratory results. HAART is more expensive than other essential drugs and must be given daily to maintain control of the disease and minimize resistance. ZL runs a central clinic housing the laboratory and main warehouse, and 5 smaller clinics at expansion sites in neighboring towns.
The project requires a system
to comm u nicate test results from the
central lab to the satellite clinics, and most importantly to monitor inve n tory and
predict future requir e ments of ARV drugs. The
only electronic communication of any sort available in most of our clinical
sites are satellite Internet connections set up by ZL. In the main site (Cange)
there is a 256 kbs bi-directional link using the USA Teleport Satellite signal.
PIH/ZL have established a LAN at the clinic which provides 256 Kbs fractional
T1 line Internet connectivity, VoIP Telephony and ISDN and IP Based
Videoconferencing. Distant parts of the site are connected by Ethernet or
802.11 wireless LAN. The expansion sites have slower asymmetric satellite
Internet connections (400kbs download speed, ~30kbs upload) provided by Telecom
Haiti and Skycaster inc. All sites have battery and generator power supplies
but outages due to loss of power or lightning strikes are common. The unstable
power and difficulty in providing technical support makes it problematic to
host servers in the clinics.
We have built a system with three components:
(1) A secure, central
web-based medical record system that records data on general clinical status,
laboratory results, current and previous medications, and followup visits. This is
based on the technology used for a web-based tuberculosis EMR in
We use an Oracle database with free software: Linux, Apache web server, and the
Tomcat Java Servlet engine, hosted in Boston.Figures 1 and 2 show part of the data entry
form and a report.
(2) An offline application
which allows the entry of clinical data from remote sites when the internet is
unavailable, and uploads the data when connectivity is restored. It is
configured by XML
descriptor files to replicate the web pages used online, based EMR
built using Java, and data is transmitted to the server as a secure web
connection (HTTP with SSL) simplifying the addition of extra forms as required.
(3) A drug inventory system modeled after traditional WHO stock cards, which records stock levels and transactions at different sites. It is accessible via the web, and is linked to patient regimens in the EMR. It displays current inventories in the warehouse and provides warnings if these drop below specified values, as well as analysis of predicted the usage and costs based on the drug regimens.
The EMR allows physicians to order medicines and laboratory tests, and provides alerts based on clinical status and test results. It is operational and patient records are currently being entered.
Figure 1. Part of the clinical data form
Over the next five years the project will be scaled up to treat several thousand patients. The offline application is being extended to store up-to-date patient summaries, to allow physicians to review cases when the network is down. Although the system has been developed for clinical care and program management, it is also useful for clinical and operational research. In addition the ability to track the patients in treatment and the resources they require is important in planning project expansion and advising other groups intending to treat HIV in similar areas. We plan to make the HIV-EMR available to other organizations once it is complete, using an open-source model for software distribution.
We thank Thomas J White, the
Bill and Melinda Gates Foundation, & the
F O KALOpen
1) Joint United Nations Programme on HIV/AIDS. Report on the global HIV/AIDS epidemic, June 2000. Geneva: Joint United Nations Programme on HIV/AIDS, 2000.
2) Farmer P, Leandre F, Mukherjee JS, Claude M, Nevil P, Smith-Fawzi MC, Koenig SP, Castro A, Becerra MC, Sachs J, Attaran A, Kim JY. Community-based approaches to HIV treatment in resource-poor settings. Lancet. 2002 Feb 16;359(9306):624.
2) Fraser HS,
Jazayeri D, Mitnick CD, Mukherjee JS, Bayona J. Informatics tools to monitor progress and outcomes of patients
with drug resistant tuberculosis in Peru.
Proc AMIA Symp. 2002:270-4.