Julie Rosenberg Talbot discusses the Global Heath Delivery Project case, Electronic Medical Records at the ISS Clinic in Mbarara, Uganda. The case was co-authored by Rebecca Weintraub and Amy Madore.
This case documents the evolution of medical records at an HIV/AIDS clinic in a resource-limited setting. The Immune Suppression Syndrome (ISS) Clinic in Mbarara, Uganda had used paper records to manage care, treatment, and reporting needs until it partnered with the University of California, San Francisco on research initiatives. In 2004 ISS Clinic became a global health initiative beneficiary and the outpatient antiretroviral therapy center of Mbarara Regional Hospital. Offering free treatment, patient enrollment jumped dramatically and the clinic's electronic Access database was unable to keep up. The clinic secured a grant to implement a new medical record system, and leaders struggled to convince the physicians and other stakeholders of its value. The most clinically-relevant pieces were slow to be put in place, and new Ministry of Health regulations posed minor setbacks. At the end of 2010, the clinic had seen nearly 21,000 patients. Clinic research had contributed to more than 20 peer-reviewed articles, but the long-term prospects for the database were unknown.
Why ISS Clinic in Mbarara?
The ISS Clinic in Mbarara works closely with David Bangsberg, the case protagonist, at Massachusetts General Hospital in Boston. As part of the relatively small global health circle in Boston, we knew Bangsberg and contacted him about the potential for writing a case. This was an important case to write as it provides a clear example of why the field of health care delivery is so important. It illustrates that we must not only create medical technologies, but we must be able to meaningfully implement them and integrate them into care delivery systems so that they add value.
When writing the case we found that there was relatively limited data evaluating the efficacy or value of the ISS Clinic’s medical record systems. Because this challenge was similar to the challenges implementers in the field face every day, we decided to include in the case only the information that was readily available to us, allowing students to truly assess the situation in the shoes of the case protagonists. This decision allowed us to keep moving forward without too much concern.
Another challenge was that people working in global health are incredibly busy, flying around the globe and working from various offices in multiple time zones. We found that persistence and flexibility were essential in finding time to talk with them, and that those going to the field should co-ordinate their travel with local protagonists to ensure they’ll be in country.
We wanted the case to show what it takes to implement an electronic medical records (EMR) system in a resource-limited setting. We met this goal and learned in writing that the implementation is not the only challenge for global health programs. Even with an EMR system in place, programs must work hard to collect accurate health data and systemize it for patient care and research.
A productive class discussion will allow students to appreciate what it takes to collect and systemize accurate health data for patient care and research, what it takes to implement an electronic medical system in a resource-limited setting, and the relationship between a health record system, clinical care, and public health.
Teaching the case
This case could fit into various types of modules, including those looking at health care systems, at implementing information technology, health economics, HIV/AIDS, or general lessons in public health.
Though there is a lot of interest in the potential for information technology to drive innovation and improve the efficiency and quality of health care, implementing new systems is challenging and the impact of such systems is not always clear. Presenting issues such as these without a clear answer engages students to think about the answer for themselves and learn to analyze the situation critically.
When teaching the case a useful supporting article is Health technologies and innovation in the global health arena1 by Sidhartha Sinha and Michele Barry. This may help students think about EMR systems as health technology and in broader terms, to apply some of the lessons from the case to other products. As the article says, “Creating appropriate products for low-resource settings requires not only a rethinking of what is considered a health technology, but also cross-disciplinary innovation and in-depth understanding of the particular needs of each country.”
1 Sidhartha Sinha and Michele Barry. 2011. Health technologies and innovation in the global health arena. New England Journal of Medicine. 365 (9): 779–782.