Digitizing public healthcare: Merits and potential

Sharmila Baral works as a statistical officer in a District Health Office, ensuring timely and accurate reporting for the country’s numerous health indicators. This includes tracking maternal mortality, infant mortality, adherence of antiretroviral drugs of HIV patients, vaccinations, and so on. Unfortunately, Sharmila still relies on a technology invented in the second century to do most of her reporting: paper.

The government provides Sharmila with large registers for national vertical health programs such as the program for the prevention of mother to child transmission of HIV. In this register, Sharmila writes clinical and demographic data, aggregates it every month, and then manually enters the data into a central digital reporting platform. There are numerous flaws in this system; it’s time consuming, inaccuracies are untraceable, feedback cycles are lengthy, and it’s expensive. The costs of continuing with paper systems are enormous. In the public health system of Nepal, costs for printing, storage and transportation of paper registries to every single public health facility in the country are very high - and this is excluding the opportunity cost of having healthcare workers manually crunch numbers for reporting purposes while they could be treating patients.

The dependence on paper still plagues most public institutions in most low and middle income countries. Walk into any public institution in South Asia, and it is likely that there shall be sacks upon sacks of paper registries, folders, and correspondences inconveniently occupying unnecessary space in an already cramped public office. In the age of big data, low and middle income countries such as Nepal have not been able to utilize existing technologies to harness the vast information collected by its bureaucracy.

In February of 2015, an open-source EMR platform named Bahmni, customized for Nepal’s healthcare system, was piloted at Bayalpata Hospital, a public-private partnership hospital in the hilly district of Achham in Far-Western Nepal. Such a point-of-care electronic medical record system had never been successfully implemented at a public healthcare facility in Nepal. The software now processes over 60,000 patients every year at this facility alone -  seamlessly integrating registration, clinical diagnosis and investigations, prescriptions, reporting, and stock management. Within one year of deployment in Achham, the EMR was successfully deployed at a second public facility in Dolakha, a district in eastern Nepal, that sees 200-400 patients daily.

Researchers at Possible, a non-profit that works in partnership with the Nepal government to run public healthcare systems, in collaboration with academic partners has recently published an academic article on the Bahmni EMR rollout in Nepal. The article highlights that Bahmni was designed in Nepal to integrate the EMR systems across in-patient, surgical, out-patient, emergency, laboratory, radiology and pharmacy sites of care, extract data for impact evaluation and government regulations, optimize the software for longitudinal care provision and patient tracking and advance quality improvement in care delivery.

A primary innovation of the Bahmni system is that it provides a user-friendly interface that helps healthcare workers working with EMRs for first time to easily adapt to a new system. In rural Nepal, most providers have had limited prior exposure to computers or EMR systems, and an intuitive and simple user-interface enables many healthcare workers to overcome the learning curve without feeling overwhelmed.

The use of an EMR also enables health service providers to track chronic conditions such as diabetes, mental illnesses, and chronic obstructive pulmonary disease. The system has further applications for coordination of longitudinal care, management of health research, and the analysis of data to understand the effects of such diseases on human populations.

The customized platform can be rolled out for as low as 30 lakhs at a district level facility in Nepal. However, there needs to be a fundamental shift in the management of health services in Nepal through a data driven lens. The government needs to promote integrated technology platforms as fundamental to healthcare service delivery, statistics as indispensable to public health, and transparency in expenditure as essential for democratically led health systems.

The government’s district health information system (DHIS) and health insurance platform (IMIS) are already being integrated with the EMR. Furthermore, the household-level service delivery provided by community health workers is being synced with the hospital-based care delivery system to address the much needed gap in public health of creating a system of care and data collection that links the household to the hospital.

The potential of EMRs in low-resource settings is remarkable. The development of such a platform in rural Nepal also serves as a testament that the technologies of the 21st century when used appropriately can be of service to some of the most marginalized people on the planet. Innovations developed in the Global South are valuable and informative to the need in global health to deliver better and accountable healthcare.

Raut is the healthcare systems engineer for Possible and Chand works for sickle cell disease advocacy in Nepal