In the past many years, Ethiopia had made efforts to implement EMR systems at various public health facilities. However, the implementation efforts have been unsuccessful in all but a few health facilities. Training and follow-up, lack of management commitment, poor ICT infrastructure, and hardware and software-related issues were presumed to be the challenges that contributed to the EMR implementation failure. In addition, the absence of a national EMR implementation roadmap that guides the overall EMR implementation had contributed to the implementation failure of EMR systems.

In recent years, however, Ethiopia has made remarkable achievements in the implementation of health information systems including the District Health Information System (DHIS2), Electronic Community Health Information System (eCHIS), Electronic Logistics Management Information System (eLMIS), Electronic Public Health Emergency Management System (ePHEM), and Electronic Medical Record (EMR) system.

Currently, the Ministry of Health is facilitating and supporting the implementation of EMR systems that meet the Ethiopian Electronic Health Record (EHR) standard. One of the EMR systems that are being deployed in various public health facilities in Ethiopia including in the University of Gondar Comprehensive and Specialized Hospital, is the Bahmni system. The system is a global open EMR tool that meets the Ethiopian EHR standard and provides end-to-end automation of health facility services.

As part of the Ministry of Health initiative, we have proposed and implemented an open-source digital tool called Bahmni to the UoG Hospital. Bahmni is an easy-to-use, complete, open-source Hospital Information System and Electronic Medical Record under development since November 2012. It uses existing open-source products such as OpenMRS for medical record and patient management, OpenERP/ODOO for inventory, billing, and financial accounting, dcm4chee (DICOM and PACS) for radiology and image information management, and OpenELIS for laboratory management.

Objective

The primary goal of this project is to customize and implement the Bahmni system at the University of Gondar Specialized and Comprehensive Hospital

Approach

To implement the Bahmni system, the Chief Executive Director of the College of Medicine and Health Sciences, and Specialized Hospital, University of Gondar established a team of experts from the eHealth Lab, Department of Health Informatics, Department of Computer Science, Information System, and ICT Directorate of the University. The team officially approached Digital Health Activities (DHA), a partner of the Ministry of Health, for potential partnership and collaboration for Bahmni customization and implementation at the University of Gondar Hospital. We approached DHA because it has acquired experience in customizing Bahmni at Truneshi Bejing Hospital, Addis Ababa. Accordingly, an agreement between UoG and DHA was made to assist in implementing and customizing the Bahmni system.

Furthermore, the University has received a recommendation from the Ministry of Health to implement the Bahmni system. Following the recommendation from the Ministry and agreement with DHA, the University signed an official Memorandum of Understanding (MOU) with DHA to collaboratively customize and implement the Bahmni System.

After the MOU, the project team drafted a proposal and submitted it to UoG management for approval. The proposal was approved with the following main activities:

A.   Capacity building

B.   eHealth literacy and EMR readiness assessments

C.   Requirement Gathering and Analysis

D.   System Installation and Configuration

E.   System Customization and Implementation

F.   Monitoring and Evaluation

Activities

Based on the proposal, the technical team in collaboration with DHA performed the following key activities.

A.   Capacity Building

DHA organized and provided a one-week in-person training to the technical team of UoG on Bahmni system installation, configuration, and customization. During the training, not only the UoG technical team but also the health information technologist of the hospital was involved. The training helped the UoG team to be familiarized with the Bahmni system. It also helped to independently install, configure and customized the Bahmni system in the context of UoG.

B.   eHealth Literacy and EMR Readiness Assessments

Before the actual implementation of the Bahmni system at UoG Hospital, the project team conducted a cross-sectional research study aimed to assess the digital literacy and readiness of health professionals for the implementation of an EMR system. We also assessed the organizational readiness for EMR implementation. The research study was very crucial to identify implementation gaps both from the health professional as well as the hospital side.

C.   Requirement Gathering and Analysis

Along with the research, the team developed an interview guide questionnaire and an observational checklist to gather requirements for Bahmni customization and implementation. We visited each department of the hospital and interviewed the head of the department. In addition, we collected all clinical and administrative forms of each department. We have also interviewed the clinical director, ICT director, plan and budget director, and health information technologists to gather infrastructure and human resource requirements. Then, we developed use cases for different tasks in the hospital.

We found a significant difference between the requirements gathered by DHA from Tirunesh Bejing Hospital and the requirement we gathered from UoG Hospital. For example, in UoG hospital, as part of clinical medical training, medical students and junior doctors are endowed with the basic skills to interpret simple radiologic images. However, senior radiologists must review and approve the interpretations of medical students and junior doctors. Certain surgical procedures are carried out by residents under the close supervision of senior surgeons. The number of medical recording units, emergency units, inpatient and outpatient departments, diagnostic centers, drug and supply dispensaries, and specialties in UoG hospital are many as compared to Tirunesh Bejing Hospital. As a teaching hospital, there are well-equipped data centers, local area networks, computers, network switches and cables, and servers in UoG hospital.

D.    System Installation and Configuration

Following the requirement gathering and analysis, we identified the server specification and requested the ICT directorate to provide us with the required server. Then, we used the online Bahmni manual to install and configure the Bahmni system on the University’s local servers. We used training and production servers for end-user training and production, respectively.

E.     System Customization and Implementation

We followed a phase-by-phase approach to customize and install the Bahmni system. First, we customized the Medical Record Unit (MRU). There were data collected using a SmartCare system in the MRU. We took a backup and import the data to the Bahmni system. Then, we provided a two-round hands-on training to the MRU staff for four days. In the training, a presentation on the introduction to the Bahmni system, why the move from the SmartCare system to the Bahmni system is needed, and a demonstration of the software was made. Following the presentations and demonstrations, participants had practical exercises on the Bahmni system focusing on the MRU. On-the-job training was also given to the participants on the actual patient registration. After the training, we implemented the Bahmni system in the MRU. We provided on-the-job support to the MRU staff while registering patients.

After the MRU customization and implementation, we then customized and implemented the Bahmni system in the following other departments in a similar fashion: Central triage, emergency triage, OPD, IPD, laboratory, radiology, and pathology departments.

To fully implement the OPD, laboratory, and radiology departments, we requested and got support from DHA to assist us in Bahmni – Machine integrations. First, the type of machines, their specifications, license requirements, and network configuration requirements were identified. Then, the Bahmni system was fully integrated with different laboratory (CBC) and Radiology (X-Ray, MRI, and CT scan) machines.

For example, to integrate EMR with radiology machines, we first made an image-acquiring device (computer) and the PACS server on the EMR system to be in the same network. Then, we configured the IP, port, and title of DCM4CHEE (EMR PACS server) on the image-acquiring computer. When a doctor orders a radiology investigation, a radiographer can see the order using either DCM4CHEE. Then, the radiographer enters the patient’s medical record number and order ID into the image-acquiring device and acquires the image from the machine (X-ray, MRI, CT). The radiographer can then send the image directly from the acquiring computer to DCM4CHEE (EMR PACS server). There is an Oviyam2 image viewer linked with DCM4CHEE, so the radiologist can view (read) the image and give interpretation notes using the orders module in the Bahmni system. The image is not sent directly from DCM4CHEE to OpenMRS; rather the image link is available on the patient dashboard, so the physician (doctor) can see both interpretations note and images for the perspective order and patient.

To date, the following EMR modules are active and currently running on the Bahmni system:

• Central Triage
• Emergency Triage
• Patient Registration Unit
• Clinical Module
• Order Fulfillment
• PACS Integration
• Radiology Upload
• Patient Documents Module
• Laboratory Module
• Appointments Module
• Appointments Scheduling Module
• Programs (e.g., ART) Module
• Operation Theatre Scheduling Module
• Bed Management Module
• Report Module
• Integrate the remaining machines (Mobile X-ray, Hormone, and Chemistry Chemistry) into the system.