Volunteers Pilot EMR Use in Haiti using iPhones

Steven Lane, M.D., FAAFP, MPH

In this post, Dr. Steven Lane describes ongoing volunteer medical relief efforts in Haiti following the earthquake in January 2010. He is part of a volunteer group of doctors, nurses and medical staff who are caring for patients and helping to establish an international standard for health IT in disaster situations by piloting the iChart mobile EHR program on the iPhone. The group sends a new team of volunteers to Haiti every month for a week of service. The fifth group returned to Haiti in May 2010. More than 82 team members have traveled so far. The volunteer teams are organized by Dr. Enoch Choi, of the Palo Alto Medical Foundation’s Urgent Care Department, and  include members from other medical organizations.

Dr. Lane is a Family Medicine Physician at the Palo Alto Medical Foundation, EHR Ambulatory Physician Director at Sutter Health, Clinical Associate Professor of Medicine at Stanford University School of Medicine, and Associate Clinical Professor of Family & Community Medicine at the University of California, San Francisco.

Piloting Mobile EMRs for use in Disaster Situations

In planning for our initial trip to Haiti to provide post-earthquake disaster medical relief we felt that some sort of electronic medical record (EMR) capability would be beneficial to support our team of doctors and nurses. An EMR would provide a simple record keeping system regarding the patients seen and the care provided and could potentially allow us to make this information available to other providers who might assume ongoing responsibility for follow-up care of the same population.

We reached out to friends and colleagues who worked in medical informatics and received a number of offers of help including donated hardware, software and custom development to provide an application that would meet our needs. At the same time we learned of the work of the Harvard Operational Medicine Institute (OMI) that was working with the United Nations to pilot a number of mobile EMR applications in hopes of establishing an international standard for the use of health information technology in disaster relief situations. The Harvard group had determined that the most ubiquitous technology amongst health care workers providing disaster relief in Haiti was the Apple iPhone and that standard mobile phone technology would provide the most reliable connectivity between providers. They quickly reviewed the available applications and decided to try to use one called iChart,  developed initially by an internist in Los Angeles. The volunteer medical team working at an impromptu field hospital near the Haiti-Dominican Republic border had begun using the iChart application with some success. Due to the nature of disaster relief they were not using the EMR application in the way it had been designed, but rather were redefining existing data fields to allow for the rapid entry of key demographic and clinical information.

The Harvard team was also in discussion with the developers of Open MRS, an open source EMR that has been used extensively in the third world, particularly to support HIV care. As we made contact with Harvard they were hoping to finalize a handheld front end for the Open MRS application that our team might be able to pilot to provide a comparison with the early field experience with iChart. As our departure date approached we did not know which application or what sort of mobile devices we would be using in Haiti. Four days before our departure we learned that the Open MRS application would not be ready in time and we were invited to join the iChart pilot. As our team would be working in tent cities providing primary and urgent care this would provide a very different use case than the experience thus far in the field hospital where they were caring for post-op patients and managing children who had lost their families.

iPhones Loaded with iChart Software  for EMR Application

In the days before our departure for Haiti we needed to obtain iPhones, load them with the iChart software, arrange for cellular connectivity in Haiti and learn how to use the EMR application. We were lucky enough to get 10 iPhones on indefinite loan through a friend at Apple and to hook them up with AT&T mobile service which was being offered for free to disaster relief workers in Haiti. While it was possible to learn the basic functionality of the iChart EMR application, it was not until we arrived in Haiti and could visit the field hospital where the application was being used that we received the specific instructions on how the Harvard team had decided to enter clinical data.

Our initial goal in using the EMR was to support our clinical workflows, having the triage staff enter basic demographic data, synchronize with the server over the cellular connection, and then have the physician providing definitive care access the patient record and document the diagnosis, treatment, etc. As we began to see patients we realized that this was not going to be possible. There was no reliable cellular service where we were working and the volume of patients that needed to be seen did not allow for the extra time required to enter even minimal demographic and clinical data into a hand-held device in real time. We came to Haiti prepared with half page paper forms that we had designed to facilitate rapid clinical documentation in case the EMR didn’t work out. We found that even these simple documentation tools were more than we were able to utilize in the rush to care for the hundreds of patients who presented themselves at our clinics each day.

As our team was committed to contributing to the effort to pilot health information technology to support disaster medical relief, each night, after clinic, we entered data from our paper records into the EMR application. By walking out into the front yard of the house where we were staying we were able to catch a sufficiently strong mobile signal to upload our data to the server maintained by the iChart vendor.

After our first team returned from Haiti, we had a series of calls with the Harvard team to provide feedback regarding the iChart application itself, as well as the challenges of utilizing a hand-held EMR in the context of disaster relief field medicine.

Before our second medical team departed for Haiti, we had a chance to upgrade the iChart software on the iPhones with a version that had been modified in response to initial feedback from pilot use. Our second team was prepared with full instructions on how to use the application and had every intention to use it in real time patient care. Team Two’s experience was similar to that of Team One, finding it impossible to use the EMR application in the process of care. They again, documented care on paper, entering data after the fact into our growing database of patient information.

Challenges and Limitations of a Volunteer Project

One of the goals of the EMR pilot in Haiti is to build a database of clinical information that can be handed over to the Haitian government, the UN or some other NGO to serve as the foundation of a national EMR database. After each of our trips we discussed with the Harvard team and the iChart vendor the possibility of merging our databases. While this has still not been accomplished everyone agrees that this is desirable, doable and should be accomplished in time. As with many of the challenges we have faced with this project, we are limited by the fact that the software vendor and all of the pilot participants are volunteering their time and energies, so turn around times are limited by people’s ability to work after hours on this project. As the situation in Haiti has evolved after the earthquake there have also been changes at the UN. The UN mission in the Dominican Republic, which initially supported this work, is no longer primarily responsible for medical disaster relief efforts in Haiti, so connections are being made with the re-established UN mission in Haiti. Also it is not clear whether or when a local entity will be established in Haiti that will be able to take ownership of a national health information database.

As fifth team starts works in Haiti this week, they are again prepared with an updated version of the EMR application. This time, multiple changes have been made based on our feedback and we are again hoping to be successful in using the application in real time.

Promise of Disaster Relief EMR and an International Standard

The promise of a disaster relief EMR is compelling. If we are able to collect and manage clinical data in real time it would support continuity of care for individual patients, provide critical data to direct the distribution of scarce human and material resources, and allow for the early identification of disease trends. The ideal disaster relief EMR would also provide real time decision support, which is sorely needed by clinicians working in a foreign country, with unfamiliar diseases and severely limited access to diagnostic testing, medications, supplies and other therapies. An international standard, specifying a minimum data set, decision support functionality and back end database characteristics would allow developers to provide various hardware and software solutions that might be deployed immediately after a disaster as well as a community of relief organizations and individuals prepared to operationalize these tools quickly and effectively when the need arises.

Print PDF