E-Health Rwanda Case Study

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e-Health Rwanda Case StudyJuly 1, 2008

Hamish FrasierMaria A. MayRohit Wanchoo


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Table of ContentsExecutive Summary............................................................................................................ 2Introduction Country Overview and Demographics...................................................... 10Public Health Informatics ................................................................................................. 14Interoperability.................................................................................................................. 17Access to Information ....................................................................................................... 20eHealth Capacity Building................................................................................................ 23Electronic Health Records ................................................................................................ 26Mobile eHealth.................................................................................................................. 28Unlocking the Market for eHealth .................................................................................... 29National eHealth Policies.................................................................................................. 31Conclusion ........................................................................................................................ 32


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Executive Summary

Health information technology in Rwanda is a quickly growing industry with manycommitted stakeholders, including the Government of Rwanda (GoR), several non-governmental organizations (NGOs), and private sector partners. Particularly in the areasof electronic health records and national reporting system, Rwanda has been a pioneer innational initiatives to integrate technology into its expanding health care system. Wherethe private market has not emerged, the GoR has provided significant support to helpthese fledging industries. As a result, GoR is significantly involved in all majorinitiatives and emerging technologies.

There are six significant entities in health information technology in Rwanda to date.These programs are:

OpenMRS An open-source Medical Records System that tracks patient-leveldata

TracPlus and TRACnet Monthly monitoring of infectious diseases includingHIV/AIDS, TB, and Malaria

CAMERWA Drug and medical supply management system Telemedicine Information and communication technology (ICT) used to deliver

health and healthcare services, information and education to geographicallyseparate parties

Health Management Information Systems (HMIS) systems that integrate datacollection processing, reporting, and use of the information for programmaticdecision-making

E-Learning use of ICT in instruction of A2-level nurses for promotion to A1status.

In addition to GoR, Partners in Health and Voxiva, Inc. have played significant roles inleadership and implementation of HIT in Electronic Health Records and in inventorymanagement and pharmacy, respectively. The telemedicine, HMIS, and e-learningprograms are in nascent stages, but initial discussions or plans for their implementationhave already begun, often as collaborations between GoR, academic institutions andNGOs.

These programs will be discussed in additional detail in the following sections:

Introduction. The introduction will give a brief description of the demographics,politics, economic growth, and current governance of the country. Rwandas history isessential for contextualizing the governments priorities and attitude, as well as existinginfrastructural strengths and weaknesses that affect ease of implementing HIT.

Medical Overview. This section will provide a general overview of the current medicalstate of Rwanda, including human capacity statistics and health-related indicators. Thissection will also describe the various Government, Non-Governmental, and Private actors


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participating in the health and health-related spaces in Rwanda to illustrate the nature of relationships and organic collaborations.

Programs. TRACnet, OpenMRS, National Health Information System

Public Health Informatics. This section will describe GoR initiatives to evaluatepopulation health, monitor health trends, and create a responsive surveillance system. Inparticular this section will describe the TRACnet program, and the building of theNational Health Information System.

Electronic Health Records. This section will describe OpenMRS (Open MedicalRecords System), which is used by Partners in Health and Columbia UniversitysMillennium Village Project (MVP) and has been endorsed by GoR for national rollout.

Mobile e-Health. This section will explore how mobile technology is used to improvehealth delivery in Rwanda. Most of the work to date has focused on gathering clinic

level information on infectious diseases through mobile phones using Voxivas TRACnetsoftware.

Interoperability. This section will describe the degree to which the various programs(e.g. TRACnet, OpenMRS, and National Health Information System) integrate and/or cancommunicate with one another. Our initial findings are that the programs have beendeveloped in isolation from one another, and there is little current interoperability to date.Some initiatives are now in place to create such links.

Capacity. e-Learning,

Access to Information . This section will describe the ability of patients, providers andresearchers to readily access accurate healthcare information. Patients have almost noability to access health information, while providers have varying levels of ability.Partners-in-Health sites have the ability to access patient level information through theirelectronic medical record (EMR) system, OpenMRS. Other clinics have access to thehistory of the self-reported aggregated clinic level information as maintained byTRACnet.

e-Health Capacity Building . This section will describe the efforts underway to (a) usetechnology to train health providers in standard practice, and (b) to train medicalproviders in the various e-Health initiatives. Though to date, few formal trainingprograms have existed, a program to provide a rigorous 18-month practical program tonurses will be launched later this year.

Sectoral Responses.

National e-Health Policies . This section will describe the Governments role insupporting or creating the initiatives in e-Health to date. It will also suggest policies thatwill be required for future success in e-Health. The initiatives that are receiving the most


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attention from GoR are the electronic medical records initiative (EMR), the TRACnetprogram, and, HMIS, e-Learning. The Government has preliminary plans for work in theoverhaul of the Health Management Information System (HMIS).

Unlocking the Market for e-Health. This section will describe the private sectors role

in supporting or creating the initiatives in e-Health to date. To date, the largest privatesector partner is Voxiva, through the TRACnet development. Private sector partners,including MTN, Rwanda-Tel, and alfasoft , are helping to migrate the HMIS from anAccess database to a SQL server.

Conclusion This section will reiterate the current state of health information technologyin Rwanda and evaluate obstacles and remaining challenges. The governments role asthe main driver in HIT provides an opportunity to streamline efforts, though as yet therehas been little activity in the private sector. Continued economic growth and investmentin health systems may open new doors for the use of technology.

Profiles

OpenMRS . The most widely used patient-management system in Rwanda, this open-source medical record system has been endorsed by the government for national rollout.

TRACnet . The government collects monthly data from facilities providing ART to HIVpatients. This section describes the program, its use of mobile technology in collectingdata, and the partnerships involved in developing the system.


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Introduction Country Overview and Demographics

Overview

Rwanda is a country of approximately 9.5 million inhabitants and an annual populationgrowth rate of 2.8%. 1 The country is just over 26,000 square kilometers (about the sizeof Maryland) and has the highest population density in Africa 2. The country is one of thepoorest in the world, with a GDP per capita of approximately $202 ($1,600 adjusted forpurchasing power parity [PPP]), and nominal GDP is $2 billion ($13.7. billion adjustedfor PPP). 3

Rwandas poverty is also reflected in its social indicators. The country ranks 161 out of 177 countries on the United Nations Human Development Index 4 Sixty percent of thepopulation lives under $1 per day, sixty-six percent is under the age of twenty years, and83% is rural dwelling. 5 Most rural Rwandans are smallholder subsistence farmers,producing bananas, maize, beans, and sweet potatoes as staple crops; droughts arecommon and can greatly affect crops, as irrigation systems are limited. There are twomain ethnic groups in Rwanda. Hutus are the largest group and compose 84% of thepopulation. The Tutsis are the second group and compose 15% of the population. Theremaining Rwandans are Twa. 6

Government

Rwanda was colonized by Belgium in 1916 and remained under its rule until 1962. Inthe years before Rwandas independence , the Party of Hutu Emancipation Movementcame to power and thousands of Tutsis fled to neighboring countries. In 1973, under theleadership of Maj. Gen. Juvenal Habyarimana, the military took control of the countryand abolished all political activity. In 1990, after several rounds of single party elections,Tutsi exiles formed the Rwandan Patriotic Front and invaded from Uganda 7. While aceasefire was negotiated in 1992, the tension of the ethnic divide culminated in the

1 EIU Rwanda report, May 20082 https://www.cia.gov/library/publications/the-world-factbook/geos/rw.html3 Economist Intelligence Unit (2006) Rwanda: Country Profile 20064 UN Human Development Report Database accessed on June 13, 2008(http://hdrstats.undp.org/countries/country_fact_sheets/cty_fs_RWA.html)5 Food and Agriculture Organization (2006) The State of Food Insecurity in the World2006: Eradicating World Hunger -- Taking Stock Ten Years After the World FoodSummit.6 CIA. Rwanda . The World Factbook 2008 [Available from:https://www.cia.gov/library/publications/the-world-factbook/geos/rw.html]7 United States Department of State (2008), Background Note: Rwanda,http://www.state.gov/r/pa/ei/bgn/2861.htm


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genocide of 1994 after Habyarimanas plane was shot down. It is estimated that 800,000Rwandans were killed and millions fled to neighboring countries. 8

Current Government

Since the genocide, GoR has made remarkable steps to bring the country together. Underthe leadership of President Paul Kagame, who in 2003 became the first democraticallyelected President, Rwanda has become safer, and had more economic development thanany period since the countrys independence in 1962. 9 Addressing the harms caused bythe genocide, including the need for reconciliation within society, care for victims andorphans, rendering justice and promoting equality are also high priorities of thegovernment.

Governance indicators suggest vast improvement in Rwanda since 1996. According tothe World Bank report, Governance Matters 2007 , the most significant improvementshave been made in the categories of Political Stability, Government Effectiveness, Rule

of Law, and Control of Corruption. Moreover, the Government of RwandasEffectiveness is now ranked amongst the highest in sub-Saharan Africa and even aboveother large countries including Kenya and Uganda. 10 On Control of Corruption,Rwanda ranks behind only Botswana and South Africa.

Economy

By 1996, the vast majority of Rwandans who had previously fled the countryHutus andTutsis alikehad resettled in Rwanda. The economy has since recovered rapidly; from1995 to 2003, Rwanda was sub-Saharan Africas second fastest-growing economy. Sincethen, growth has been equally startling: the Gross Domestic Product (GDP) per capitagrew 76% from 2002 to 2007. 11

Services accounts for over 53% of GDP. Agriculture accounts for roughly 30%, andindustry/manufacturing provides the balance. The largest exports are coffee, cassiterite,tin, and coltan, a metallic ore.

Inbound Foreign Direct Investment (FDI) has expanded from USD 3 million in 2003 toUSD 8 million in 2005. 12 Official Development Assistance (ODA) has increased in

8 Rwanda: how the genocide happened. April 1, 2004. BBC News. http://news.bbc.co.uk/2/hi/africa/1288230.stm 9 IMF World Economic Outlook Database, April 2008http://www.imf.org/external/pubs/ft/weo/2008/01/weodata/index.aspx 10 http://info.worldbank.org/governance/wgi2007/mc_chart.asp , accessed on June 12,200811 Rwanda EIU Report, March 200812 OECD, African Economic Outlook 2007, Table 10


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dramatically, from USD 321 million to 576 million, since 2003 as the Government hasproven its capacity for governance and efficacy. 13

Health and Health Care Overview

Epidemiology

The health of Rwandas population reflects its high levels of poverty and still developinghealth care infrastructure. National statistics look similar to many other countries in theregion. Infant mortality currently is approximately 85 deaths per 1,000 lives births. 14 Forty-five percent of children under the age of five meet height-for-age criteria forchronic malnutrition. 15 HIV/AIDS prevalence reached 3% in 2005 and was considered ageneralized epidemic. 16 Malaria is the leading cause of morbidity and mortality for bothadults and children in Rwanda.

Health System

As of the end of 2005, Rwanda had about 366 health centers, 33 district hospitals, and 5referral hospitals. 17 Rwandas health system includes public, private and traditionalhealth systems, which are supported by GoR, non-governmental organizations (NGOs)and civil society.

Mutuelles de sant (mutual health insurance), a community-based health insuranceprogram, was launched by the GorR in 2006. Subscribers pay approximately USD 2 ayear, with GoR and Global Fund covering the enrollment fee for the poor. Over 83% of the population has enrolled in the program. Evaluation of the program is preliminary butdata from the past two years suggests that utilization rates of health services increaseswith enrollment. 18 Some have commented that the current structure leaves the mutuelle(community organization) with financial liability and involves burdensomeadministrative work. As the Mutuelles approach universal coverage, some issuesdiminish as the consequences of adverse selection become less pronounced.

Technical Overview

Government Leadership and ParticipationGoR participates in HIT initiatives in diverse ways. The major bodies that lead andpromote HIT are:

13 OECD, African Economic Outlook 2007, Table 1114 ORC Macro. Rwanda Demographic and Health Survey 2005 . July 2006.15 Ibid.16 Ibid.17 Rwanda Human Resources Assessment for HIV/AIDS Services Scale-Up (2005).Please see appendix for a more detailed explanation of each type of facility.18 Community-based Health Insurance in Rwanda: from Case Studies to National Policy.


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Ministry of Health . The Ministry of Health is the major Government body responsiblefor all health related activities. In particular, the Center for Treatment and Research onHIV/AIDS, Malaria, Tuberculosis, and other epidemics (TRACPlus) has been a promoterand user of e-health products, including TRACnet, a system that will be described in

detail in the Public Health Informatics section below.Ministry of Science, Technology, and Scientific Research. The Ministry of Science,Technology and Scientific Research sits within the Presidents Office and oversees the Information Communications Technology (ICT) Unit. The ICT Unit has direct influenceover the development of and the expansion of internet connectivity and therefore has themost direct influence over e-Health initiatives. It oversees the ICT initiatives taking placein other Ministries and Government related-bodies including the Rwanda InformationTechnology Authority, which is described below. 19

Rwanda Information Technology Authority (RITA). RITA is housed in the Presidents

Office that oversees science, technology and scientific research. Its charge is to designpolicies for technology used by GoR and create an IT governance framework andstandards for various ICT strategies. To accomplish these goals, RITA provides ICTsupport both in terms of training and consultancy services. It also is the body that isresponsible for standard setting and compatibility in ICT applications throughout thepublic sector, and for facilitating the private sector in the development of ICT in Rwanda.

Current State of Connectivity

GoR is known to be one of the governments most committed to ICT development in sub-Saharan Africa. That having been said, a lot of ICT work remains for e-Health to take off.Indeed, against all countries in Sub-Saharan Africa, Rwanda had fewer telephonesubscribers, fewer internet users, and fewer personal computers (per 100 people). 20

Rwandas connectivity fate is partially explained by the fact that it is not connected to theinternational fiber-optic backbone. This implies that Rwandas broadband efforts are allthrough satellite. Despite this limitation, there has been some initial success intelemedicine, which will be described below.

19 http://www.mininfra.gov.rw/docs/cadre_organique_du_MININFRA.pdf 20 World Bank, Rwanda ICT at a Glance, accessed atdevdata.worldbank.org/ict/rwa_ict.pdf on June 10, 2008


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Public Health Informatics

Introduction

There are two major programs attempting to document and track HIV/AIDS informationin Rwanda. The first, Open Medical Record System (OpenMRS), tracks patient-leveldata for clinics. * The second, TRACnet, is a software package used by TracPlus thoughwhich clinics report aggregate data on a monthly or biweekly basis into a repositorymanaged by the Central Government. Additionally, GoR has plans for an online bloodbank monitoring program.

Overview of Programs:

TRACnet . Please refer to the accompanying profile of TRACnet.

Health MIS

The TRACnet program informs a broader Health Management Information System(HMIS). Implemented by the MoH in 1997, HMIS has historically been largely paperbased at the health center levels, with a combination of paper and electronic reporting atthe district and central level. The broad goals of the information system are to integratedata collection, processing, reporting, and use of the information necessary for improvinghealth service effectiveness and efficiency through better management at all levels of health services 21 GoR is currently overhauling the HMIS to make it better-designed toassist in the management and planning of health programmes, as opposed to the deliveryof care. 22 A comprehensive HMIS will aggregate patient-level data into clinic anddistrict level information to enable it to inform drug and medical supplies procurement,disease surveillance, and programmatic funding.

Current Status of Programs

The Current Management Information System (Systme dInformations Sanitaires, SIS)is managed on a Microsoft Access database, separate from TRACnet, and has importantlimitations. Most significantly, it is not designed to easily pass information/data fromone program area to another or pass it from one system to another. This results in limiteddata entries, duplication, loss of critical information, higher costs, and missedopportunities for timely intervention and prevention. 23

* For more information on the OpenMRS section, please refer to the section on ElectronicHealth Records.21 WHO, Developing Health Management Information Systems: A Practical Guide for

Developing Countries, p322 ibid, p323 United States Agency for International Development, Rwanda HMIS Assessment

Report, p23-26; interview with Dr. Richard Gakuba


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Secondly, reports are currently not submitted from the district level to the central MoH. AUSAID Assessment Team in April 2006 found that as of the end of April only 37% of health centers and 34.3% of hospitals have submitted their SIS Monthly reports forMarch 2006. 24 As noted above, there is also insufficient capacity at the MoH to

aggregate, analyze, or report national level SIS data. Weekly epidemiological reports alsoceased to exist when the Epidemiological Unit at the MoH closed in January 2006.

A National Health Information System Project is currently in the planning phase, whichwill enhance the countrys ability to perform disease surveillance and enhance publichealth protection services. The first part of this transition is the migration of data to aStructured Query Language (SQL)-based relational database server by the end of summer. Such a migration should make room for a more sophisticated electronic systemto support HMIS efforts.

Planned Interventions

The National Health Information System Project will also include a revamping of indicators so that nursing staff enters data for only one set of forms, which thenelectronically inform the relevant databases. According to the GoR, by the end of 2008these systems should be coordinated. It intends to create a system that provides thefollowing capacity:

Service providers will be able to utilize the same data for the same cases, withouthaving to duplicate their collection work. Authorized service providers will be ableto share clinical information among themselves, about a patient. Public health issuesand communicable diseases will be quickly identified and managed to mitigate risk to the general public. A health surveillance system will provide information on risk factors, treatment, health service utilization and outcomes to assist in thedevelopment and evaluation of policies and programs aimed at the prevention andcontrol of infectious and communicable diseases. Aggregated data will be easilyaccessed by the Ministry of Health for reports on statistics and trends to supporthealth planning and decision making. 25

A simultaneous scale-up in the number of data managers is also planned. Currently, thehead of nursing completes most forms among their other duties. A data manager at eachhospital will not only ease the burden on the nursing staff, but will allow for fastertransitions between systems. Government of Rwanda estimates the costs for this humanresource expansion at USD 100,000 per month. In anticipation of the national roll out,the International Development Research Centre (IDRC) is funding a formal trainingprogram to be set up by PIH and the GoR for Java programming and medical informationsystems with a focus on OpenMRS. The training will create a cadre of Rwandan workers

24 ibid , p925 Government of Rwanda, Ministry of Health, National E-Health Strategic Plan 2007-2011


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who possess high level IT expertise to implement and extend OpenMRS in Rwanda. Thefirst students are expected to start training in fall of 2008.

Blood bank

The blood bank initiative would serve essentially the same function as TRACnet for theblood supply. This would allow central agencies to monitor the blood supply by type of blood and region. At the central level, the project is still in its design phases, but at thelocal level, three health centers are linking their blood inventories together. Theseactivities have no been followed by GoR and results of their efforts could not be located.

Conclusion

There are two major interventions currently underway in Rwanda that pertain to PublicHealth Informatics. The first is the use of TRACnet, and the second is the overhaul of the Health Management Information System. TRACnet currently interoperates with a

drug procurement system (Camerwa), which is in the midst of a significant overhaul, butnot with other MIS-related systems ( e.g. , medical records, surveillance, and laboratorytests). Although the drug procurement system provides critical support of the health caresystem, the government's limited ability to hold facilities accountable for theirdistribution of drugs reduces its effectiveness. Increasing integration of informationsystems and strengthening collection of patient-level data would increase the accuracyand resolution of the database; and could work in tandem with other efforts to reduceredundancy in forms and costs.


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Interoperability

Introduction:

This section will focus on interoperability the ability of the various Rwandan e-Healthsystems to communicate with one another. The major programs in Rwanda thatinteroperability applies to are: Open Medical Record System, a patient-level system usedin some clinics; TRACnet, the national aggregate facility-level reporting system for HIVtreatment; Camerwa, a surveillance program; and the Health Management InformationSystem (HMIS) broadly.. TRACnet interoperates with Camerwa, which is currentlyundergoing a significant overhaul, and serves as a proxy for a health surveillance systemHowever, the current form of the HMIS is not integrated with TRACnet, Camerwa, orOpenMRS. Another program that needs to interoperate with clinical level systems is theAccess database used in come facilities to support the Mutuelles insurance program.These programs are described in greater detail below.

Background on the Various Systems:

OpenMRS. Please see accompanying profile.

OpenMRS is currently being extended to interoperate with a variety of district andnational reporting systems. Rwandan programmers trained by PIH have created a modulethat allows data from OpenMRS to be automatically submitted to TRACnet. The systemshows the data to be submitted for the monthly report to the user, and then, with the click of a button, submits the information via the Internet or by mobile phone with guidancefrom an automated voice response to TRACnet. In addition, data can now be exportedfrom OpenMRS in a WHO-supported format called IXF. This format can then used bydistrict reporting systems and there is agreement to incorporate it in TracNET.

TRACnet. Please see the accompanying profile on TRACnet for more information.

GoR is currently modifying the TRACnet system to accept IXF.A public-private partnership between Voxiva, PEPFAR, Motorola, MTN, Accenture andGSM are in the planning process of integrating the existing systems using Tracnettechnology. GOR has approved the project and they have secured a planning grant fromthe Gates foundation.

Camerwa . Camerwa is a semi-independent non-profit organization administered by theGoR which manages the countrys drug inventory. TRACnet aggregates clinic-levelinformation on the number of HIV and TB patients seen in a given period. Camerwauses this information to manage the HIV/AIDS drug and medical supply purchases forthe country. Camerwa is also used to procure and distribute all other essential drugs andmedical consumables.


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Health Management Information System (HMIS) . Currently in implementation stages,the broad goals of the HMIS are to integrate data collection, processing, reporting, anduse of the information necessary for improving health service effectiveness andefficiency through better management at all levels of health services. 26 Themanagement information system will assist in the management and planning of health

programmes, as opposed to delivery of care. A full Management Information Systemwould aggregate patient-level data into clinic- and district-level information. This wouldinform drug and medical supplies procurement, disease surveillance, programmaticfunding, etc.

Rwanda Mutuelles . The Mutuelles program is a community-based health insuranceprogram coordinated by GoR. It currently utilizes a Microsoft Access database to storeinformation about patient health utilization for payment purposes in a central repository.Linking the system with a patient management system, such as OpenMRS, would enableGoR to evaluate how the insurance scheme improved health and identify remainingchallenges. Additionally, this linkage would also help improve the efficiency of clinics.

Additional improvements are intended to be made in the Mutuelles interface as well.Currently, clinics complete paper forms that are submitted for data entry at the centrallevel. While providers and patients have no electronic record of transactions, Mututelleshas created a database for their clients and plans to launch it in the fall of 2008. GoR, aspart of its broader movement towards electronic records, is trying to integrate ICT withits insurance programs.

Integration and Interoperability

Although there is progress on many e-Health fronts, one of the most important gaps hasbeen the integration of various systems (OpenMRS, TRACnet, Mutuelles, and HMIS) toconsolidate information. Currently, the various data are entered separately and exist invirtual silos. Nurses are required to fill out different and mutually exclusive forms,exacerbating strains on a system facing a scarcity of health professionals.

GoR plans to overhaul the HMIS. The system-level improvement is expected to resolvemany of these issues, but much more work is necessary for successful integration. TheGovernment has recently endorsed a roll-out of OpenMRS to all hospitals in Rwanda (itis currently only in use at all PIH and MVP sites). The OpenMRS program would thenfeed into the TRACnet system. That would also have the benefit of maintaining andimproving the data in the Camerwa drug procurement program. Drug procurementappears to be functioning well at a national level, but integration with patient- and clinic-level information should allow faster access from the drugs to the clinics and moreaccountability around their distribution. Moreover, the HMIS system will have thecapacity to gather data regularly for improved surveillance.

26 World Health Organisation, Developing Health Management Information Systems: APractical Guide for Developing Countries.


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GoR has two goals in attempting to overhaul the HMIS system and improveinteroperability. First, it believes that interoperability should create a large reduction inthe paperwork and administrative time spent by nurses. Nurses are the backbone of thehealth delivery system, and the current time they spend reporting to multiple sources iswidely considered burdensome. A well functioning system will draw information out of

patient-level records automatically, allowing nurses to spend more time with patients.Second, an integrated system can provide higher quality data as it is based on collectionat the patient level.

GoR has also implemented performance-based financing at the district level and collectsa set of clinical and managerial performance metrics that influence staff salary levels.Currently, it uses dedicated software to evaluate performance. Increased collection of clinical and operational data would allow GoR to identify drivers of performance, refineits incentive structure, and improve quality within and across sites.

There is little information on migration patterns of patients, but most information seems

to be communicated in English and/or French. Language translation did not surface as amajor issue during interviews.

Conclusion

There is limited interoperability between the various e-Health systems currently used inRwanda - OpenMRS, TRACnet, Camerwa, a surveillance program, the Mutuellesinsurance program and the HMIS broadly. TRACnet is integrated with Camerwa, andserves as a proxy for a health surveillance system.

However, the current form of the HMIS is not integrated with TRACnet, Camerwa, orOpenMRS. A planned HMIS overhaul is intended to fix many of these issues, but anabsence of funding has curbed efforts in this arena. Ideally, GoR would like the HMIS tobe universally interoperable with current systems and require interoperability with HMISas a criterion for future systems and modules.


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Access to Information

Introduction

This section will describe the ability of medical providers, government officials andresearchers to access necessary information in a timely manner. Many of the focus of Rwandan e-Health initiatives have been on increasing health system quality per se, andhave not yet focused on either provider or patient uptake of these services. Moreover,limitations to information access are due in part to the lack of Rwandas connectivity tofiber optic. Information access will likely follow general connectivity access.

Access by subpopulation

Medical Providers. Anecdotal evidence suggests that doctors are universally computerliterate but poor electricity supply and slow-at-best Internet connectivity limit the amountthat doctors can rely on ICT for clinical help. At the time of this writing, governmentofficials estimated that just over half of the district hospitals have Internet access, and allof the research hospitals have internet access. These access figures may be misleadinghowever, as computers are likely to be set up in management offices and clinicians andnurses may have limited-at-best access to this equipment.

Currently, even simple Google searches are not regularly used because of slowconnections and/or lack of regular access. Some providers use professional list-serves tocommunicate with each other, but again these appear to be of limited value in time-sensitive matters. GoR plans to have established LAN connectivity in all district-levelfacilities by 2010.

Clinics managed by Partners in Health (PIH) or Columbia Universitys MillenniumVillages Project (MVP) can individually access patient-level records using OpenMRSsoftware 27. At present, health facilities and hospitals managed by other groups are notusing the OpenMRS software. * For a more detailed discussion on OpenMRS, please seethe Section titled, Electronic Medical Records. The King Faisal hospital is alsoimplementing health information systems.

PIH recently developed modules to be used with OpenMRS to assist the providers. Oneis the patient dashboard, which provides key information on a patient to the provider inan easy-to-understand format. Particularly for patients that have coming to the facilityfor some time, navigating through paper charts can be challenging.

Health facilities. Health center information (at the clinic level) is available to respectivedistrict hospitals through the TRACnet program, which is the software used by the

27 Currently available at six out of the seven sites managed by PIH* For more information on OpenMRS, please refer to the section titled ElectronicMedical Records.


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Government of Rwanda to collect and store clinic-level HIV/AIDS information at thecentral level. These hospitals receive a copy of their own clinics statistics and data forhealth centers in their jurisdiction. The aggregated nature of the data also makes itimpossible for physicians to discern the quality of their performance relative to others.Though reporting rates for TRACnet are consistently high and data is collected at

frequent intervals, little research has been conducted verifying the accuracy of theinformation collected.

PIH has begun to collect clinical indicators across sites to compare outcomes anddistributes them among the sites. It also reviews longitudinal data aggregated from allthe sites to evaluate the programmatic performance over time. Their installation of OpenMRS also allows them to create alert lists; that is, lists of patients that have lowCD4 counts or other important markers and are not on ARV treatment. Such patients canthen be sought out and treated.

In addition, OpenMRS has enabled PIH to better understand its quality of care not only

clinically, but also programmatically. Recently they have begun to explore differentmeasures of quality, such as how long after a patient gets diagnosed with HIV they theirfirst appointment, and the percentage of patients missing follow-up appointments.

Government and researchers have access to information from the TRACnet application.Additionally both groups have information provided by the Health ManagementInformation System (HMIS), but this data is very limited and can be out of date. Theplanned HMIS overhaul may reduce duplicative data entry, and improve the quality andfrequency of the reported data.

Patients . Adult literacy rates are approximately at 65%, presenting an upper bound forthe medical literacy in the country and suggesting a need to communicate through non-written media. 28 According to first-hand accounts, radio has been used for this purpose,but GoR has largely centered its efforts in other areas.

Planned Programs

Government of Rwanda has other initiatives in the planning stages as well, includingsetting up and an electronic laboratory that will allow clinicians to access a patients labtest history electronically and to determine whether a patients lab test have already beenordered by another physician. No date has been set for when this system will be piloted.

The GoR sanctioned plan to roll out the OpenMRS EMR system will provide betteraccess to patient data in clinics. This should help to support monitoring of patient careand outcomes as well as better reporting.

Conclusion

28 World Bank EdStats April 2008


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Access to information at the clinic and national level exists though with little granularity.In some clinics, the implementation of electronic medical record systems enablesclinicians to access comprehensive patient data efficiently. The use of the EMR byphysicians is unclear. Little effort has been made to distribute information on HIV to thegeneral population, and the literacy rate indicates that in order to penetrate effectively,

visual or auditory media (including TV and radio spots) will be necessary. Whileresearchers are given access to high-level data, the lack of intra-clinical data collectionlimits its research potential, particularly around quality of care.


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E-Health Capacity Building

Introduction

This section will describe the telemedicine and e-Learning efforts in Rwanda. This report

will define telemedicine as the use of communications and information technology todeliver health and healthcare services, information and education, where the participantsare geographically separated." 29 In resource-poor environments, telemedicine can helpmitigate the absence of specialist doctors by connecting other health providers withspecialists located elsewhere, or be used to train future doctors in rural areas. In general,telemedicine facilitates clinical consultation, continuing professional education, healthpromotion, and healthcare management.

Current State of Telemedicine

There are two major telemedicine efforts already under way. The first of these efforts is

to connect district hospitals to referral hospitals to store and forward asynchronoustelemedicine; most immediately, teleradiology. X-rays taken in one facility, for example,the referral hospital, can be sent to anotherr facility, such as a district hospital, to be readby a radiologist. Importantly, computed radiography machines for this effort are alreadyinstalled in two clinics and the procurement process for an additional two machines hasalready begun, with funding from the World Bank.

The second effort is to create a universal platform for biomedical imaging using theDigital Imaging and Communications in Medicine (DiCom) platform in Rwanda. Theseefforts are being facilitated through the World Bank. As of the end of May, the tenderphase of the formal Request for Proposal had been completed.

Current State of e-Learning

Although a formal e-Learning program has yet to begin in Rwanda, there have beenisolated instances of e-Learning being used in limited settings. In the university setting,many medically relevant lectures have been broadcast over a local area network thatconnects all three referral hospitals. Moreover, there have been telecasts of open-heartsurgeries and various meetings. These efforts and others along the same vein areinstrumental in increasing learning in health practices.

GoR is also attempting to start a formal program in e-Learning for nurses. Rwanda,

along with many other countries, suffers from a shortage of A1-nurses, or nurses whohave completed secondary school and have two additional years of nurse training. A2nurses, who make up the bulk of the health work force, have two years of secondaryeducation and two years of nursing education. The e-Learning program is currentlyfocused on additional training for A2 nurses to graduate to A1 level. The training

29 Government of Rwanda, Ministry of Health, National E-Health Strategic Plan 2007-2011.


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program will be funded by the International Development Research Centre (IDRC) andwill use web-based training and exams. In its first stage, the program hopes to take 10nurses through a one-year, practical curriculum. The program is slated to start in late2008.

Telemedicine in Rwanda will be primarily provided through the use of communicationstechnologies alongside dedicated telemedicine software and diagnostic medicalequipments. The GoR hopes to connect the telemedicine efforts and the ElectronicHealth Records (EHR). For example, in the case of diagnostic imaging, GoR envisionsthe transmission of live echocardiogram and ultrasound images for interpretation, alongwith store-and-forward transfer of digital images for review and assessment.

Although there are health programs that use ICT, there are no formal training programs ine-Health technology per se. There are informal training programs that take place inspecific systems ( e.g. , TRACnet training), but there are few programs that focusexclusively on capacity building. The International Development Research Centre

(IDRC) have now funded a formal training program to be set up by PIH and the GoR forJava programming and medical information systems with a focus on OpenMRS. This willcreate the high level IT capacity to implement and extend OpenMRS in Rwanda. Thefirst students are expected to start training in fall of 2008.

Kigali Health Institute (KHI) the major teaching hospital in Rwanda has beenteaching basic computing skills as part of its nurse training. These training programs arefairly new, so only new graduates are likely to have acquired these skills.

Planned Activities

Government of Rwanda Goal for e-Learning

By 2009, GoR plans to for all 30 district hospitals will have Internet access, to improvecapacity for Telemedicine. 30 As part of infrastructure for e-health, VPNs will be set up inorder to allow high bandwidth interconnectivity. Its plan for rolling out this activity alsoinvolves procuring new equipment and coordinating the implementation efforts. KingFaisal Hospital will be the Telemedicine Hub, and all hospitals will have a functionaltelemedicine platform installed by 2011.

Conclusion

There are two initiatives to raise the capacity of health workers in Rwanda. The first istelemedicine, and the second is e-Learning. Telemedicine efforts have been growing atthe ground level, and the central government would like to build upon these efforts. GoRis also attempting to develop an e-Learning program that would facilitate nurse trainingand hopes to leverage its e-Health initiatives to build capacity broadly within its medicalprofessionals. Currently, capacity building in e-Health initiatives occurs primarily at an

30 http://allafrica.com/stories/200712310855.html


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application-specific level; that is to say that users are trained in TRACnet, OpenMRS,HMIS separately.

The IDRC have now funded a formal training program to be set up by PIH and the GoRfor Java programming and medical information systems with a focus on OpenMRS. This

will create the high level IT capacity to implement and extend OpenMRS in Rwanda. Thefirst students are expected to start training in fall of 2008.


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Electronic Medical Records

Electronic Medical Records (EMR) in Rwanda Overview

Electronic Medical Records allow clinics to collect, track, and analyze patient level dataover time and potentially across health facilities. There are currently two primarysystems in use - Open Medical Record System (OpenMRS), and Fuchia which aredetailed below.

OpenMRS . Please see accompanying profile.

Fuchia

Fuchia is a partially free software tool, originally developed by Medicines SansFrontieres (MSF) and Epicentre, based on Delphi and Microsoft Access. The product ispartially free because the software to run it is free and distributed by MSF, but in order touse it, you must have Microsoft Access, which in turn requires Microsoft Windows both of which incur cost. The installation of Fuchia at the TRAC clinic allows collectionof intake and follow-up data for HIV patients, but all changes to the code have to bemade by the original developers so the forms are fixed in the system and cannot be edited

Currently, the TRAC Clinic in Kigali has an installation of Fuchia with approximately6,000 patients registered. However, TRAC slowly suspended usage of the system in2007, due to lack of data accuracy and insufficient reporting and clinical tools. It wasdiscovered that the paper registers contained more accurate and up-to-date information onthe same set of patients.

Fuchia is also used by LUX Development at two locations Rwamagana Hospital andKimironko Health Center. Currently, it is estimated that the Fuchia database used byLUX contains data for 3,000 patients.

The installation of Fuchia at the TRAC clinic allows collection of intake and follow-updata for HIV patients, but the forms are fixed in the system and cannot be edited. Thesystem also can produce printed patient summaries for clinicians and has a few built-inreporting forms for monitoring enrollment over time and some other high-levelindicators. The system is not web-based nor is it built enterprise-style, so each computerutilized for data collection requires its own program installation and generates a separatedatabase.

Other EMR systems

Some sites are using homemade tools to generate a database of patient-level data, oftenbuilt in Microsoft Excel or Microsoft Access. It is likely that Excel and Access are usedoften because they are widely available, moderately priced and well known. While these


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forms provide clinics with basic information, these programs systems are hard to use forthe complex, longitudinal, and multi-domain information that clinics hope to include, andoften lack the security features necessary to protect patient confidentiality. They also donot readily facilitate data analysis from a quality or programmatic perspective and rarelystreamline reporting except for relatively simple data. Access has however been used in

many countries very successfully for smaller projects. The number of such systems andtheir capabilities is difficult to estimate and no formal research has been conducted byGoR.

Plans for EMR scale up In 2006, a letter from Dr. Innocent Nyaruhirira, the Minister of HIV/AIDS at the time,indicated that the Rwandan government had selected OpenMRS as the system that wouldbe used universally across Rwanda for patient-level collection and monitoring. Sincethen, the government has been working to secure funds and expertise for such a venture,and is beginning deployment at the TRAC Clinicthe main research clinic in the countryin central Kigali.

In anticipation of the national roll out, the International Development Research Centre(IDRC) is funding a formal training program to be set up by PIH and the GoR for Javaprogramming and medical information systems with a focus on OpenMRS. This willcreate the high level IT capacity to implement and extend OpenMRS in Rwanda. Aninitial round of students trained in the spring of 2008, and the first round of fundedstudents are expected to start training in fall of 2008.

Conclusion

TRAC has implemented a fairly robust aggregate-level data collection infrastructure forHIV services in Rwanda. Though TRACnets ability to allow its users access highquality patient-level data are limited, TRAC now can watch HIV trends over time.Patient-level data gives clinics and the government a much more granular view of trendsand activity, and the governments recent endorsement of OpenMRS demonstrates theirdesire to increase the quality of data collected in clinics nationwide. While OpenMRSprovides many useful features and flexibility for clinics to customize the software to theirneeds, in its current state it requires a considerable level of technical expertise to beinstalled and maintained so that it can be utilized in multiple sites with many users. Basicimplementations of OpenMRS on one Windows server for specific tasks requires a lotless support but requires all interactions with clinic staff to mediated by paper forms andreports. Creating efficient communication between TRACnet and OpenMRS will beessential for maximizing the value of both systems. In addition, creative thought abouthow to ensure quality of data collection and efficiency in entry will be importantcomponents of the rollouts success.


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Mobile eHealth

While mobile technology holds great potential for health care in Rwanda, at present,there is still little use of phones in Rwanda. Only 3% of the population had a mobilephone in 2006, though over 75% of the population lives in an area with cell phonecoverage. 31 It is worth noting that in 2000, only 0.5% of the population had a mobilephone, so the per capita phone rate grew seven-fold over, which may indicate that mobilephones will soon become more commonplace in Rwanda.

TRACnet

TRACnet has been able to utilize mobile phones as a tool for data submission quitesuccessfully; virtually all facilities providing ART to HIV patients submit monthlyreports using mobile phones. This process is outlined in detail in the accompanyingprofile on TRACnet.

OpenMRS

The Millennium Villages Project (MVP) has creating a program that allows communityhealth works to enter the vital statistics of patients into the medical record system(OpenMRS) using a mobile phone. MVP is currently piloting the program in its site inUganda and plans to roll it out in Rwanda in late 2008.

ConclusionMobile phone usage in health thus far has been limited thus far but may be an untappedresource. In Rwanda, where internet connectivity is extremely limited, mobile phoneshave served as a tool in aggregating facility-level data, in the case of TRACnet, and willsoon be used to enter patient-level data in the MVP sites.

31 World Bank, Rwanda ICT at a Glance. devdata.worldbank.org/ict/rwa_ict.pdf


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Unlocking the Market for eHealth

The private sector has played a partnering role in Rwandas eHealth initiatives. The maincoordinators of efforts appear to be the Ministry of Heath and the Rwanda InformationTechnology Authority, which then support ongoing private sector efforts. A foreignprivate player, Voxiva, Inc. has been awarded USAID funding contracts for thedevelopment of TRACnet, a system to track aggregate (clinic-level) information formonitoring purposes. 32 MTN Rwanda the largest local cellular provider has alsodonated airtime for this monitoring effort.

Background

Voxiva is the largest player in the e-Health space to date. GoR offers a tax holiday forprivate companies investing in e-Health and it is remains one of the best countries in Sub-Saharan Africa for setting up a business and enforcing contracts. However, Rwanda isaverage for the region in terms of dealing with licenses and registering property.According to the World Bank, the country requires substantial work in access to creditmarkets, protecting investors, trading across borders, and closing a business.

Related to these indicators is the small size of Rwanda. As a country of approximatelynine million people, any country-specific market opportunity would be small relative toother countries. 33

Telecommunications has had mixed results in Rwanda. In late 2007, the GoR privatizedits national telephone company and sold its 80% stake in Rwanda-Tel to Lap GreenNetworks, a Libyan Company. 34 MTN Rwanda the local branch of cellular providerMTN Group (a multi-national company), has had large success however.

In the e-Health sector particularly, the anecdotal evidence is mixed as well. The privatesector is involved in installing the information system, and a private local company isdesigning the new HMIS database. 35 However, the opportunities that would have beenthe most promising for the private sector are financed through public monies. VoxivasTRACnet was financed through USAID/PEPFAR and better fits the description of apublic-private partnership than a pure private sector opportunity.

At the time of this writing, the Rwanda Information Technology Authority (RITA) isunaware of other efforts to include the private sector per se. 36

32 TRACnet is referenced in detail in the accompanying profile.33 See appendixes for World Bank Doing Business ranking and summary of Doing

Business Profile for Rwanda.34 http://allafrica.com/stories/200710280052.html35 The HMIS database is described in detail in the Public Health Informatics section.36 Interview with Mr. Patrick Nyirishema


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Future possibilities

GoR has committed to a national rollout of OpenMRS. The implementation andmanagement of the system will require significant training and sustained investment.In anticipation of the national roll out, the IDRC are funding a formal training program to

be set up by Partners in Health and the GoR for Java programming and medicalinformation systems with a focus on OpenMRS. The training will create a cadre of Rwandan workers who possess high level IT expertise to implement and extendOpenMRS in Rwanda. Once trained, these individuals will possess valuableprogramming skills that could enable them to create private companies specializing inOpenMRS management, or apply their skills to other pieces of health informationtechnology.

Conclusion

The private sector has participated in some of the largest e-Health efforts in Rwanda

(TRACnet, HMIS overhaul). These efforts have largely been at the request of the mainplayer in the domain GoR. Private innovation in this space has been somewhat limiteddue to small potential returns. The countrys small size, and large amounts of povertycreate a difficult environment to create profits. Private efforts in the space are likely tobe dominated by private-public partnerships, or multilateral/bilateral governmentfinancing ( e.g. , PEPFAR, USAID).


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National e-Health Policies

Government of Rwanda (GoR) has made explicit, proactive effort in promoting both e-Health and Information and Communication Technology (ICT). The e-Health initiativesin large measure, began in 2007, and have multiple parts. In particular, GoR hasorganized around the following efforts:

OpenMRS An open-source medical record system that tracks patient-level data TracPlus and TRACnet Monthly monitoring of infectious diseases including

HIV/AIDS, TB, and Malaria CAMERWA A drug and medical supply management system Telemedicine ICT used to deliver health and healthcare services, information

and education to geographically separate parties

Health Management Information Systems

systems that integrate data collectionprocessing, reporting, and use of the information for programmatic decision-making

E-Learning use of ICT in instruction of A2-level nurses for promotion to A1status.

What is most striking about the evolution of the countrys e-Health program is the type of role that GoR plays. Rather than the simply regulating other participants efforts, GoRacts as an active facilitator it fundraises for new initiatives, it is active in programdesign, and it assists with implementation. This focus on active participation has perhapsallowed GoR to focus on programmatic policy (i.e., policies on which programs toimplement), rather than regulatory or standard setting policies. Indeed, even the nationale-Health documents do not bear the policy name, but rather are described as strategicplans.

The success of many of the e-Health initiatives will be on the back of increased Internetconnectivity. Although the Government has promoted ICT, in an absolute sense a lotmore work remains to be done. In particular, ICT indicators are still quite low for Sub-Sahara African countries (as of 2006). Only 3% of the population has a mobile phone,compared to 13% for the region. 37

Healthcare providers suggest that the two largest programs are TRACnet, a national dataaggregation system focused on ARV therapy enrollment and outcomes, and OpenMRS,an open source medical record system implemented in several sites that the governmentis planning to roll out nationally. 38 The decision facing GoR at the moment is how bestto use OpenMRS as the primary data collection mechanism for TRACnet. OpenMRS canprovide richer data for TRAC to analyze and to use to inform programmatic decisions,

37 World Bank, ICT at a Glance. 38 See accompanying profiles on OpenMRS and TRACnet for more information.


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but is logistically and technically much more demanding. GoR has in principle suggestedthat OpenMRS should inform the TRACnet program which can then be used for drug andsupply management (through Camerwa).

GoR has created an internal publication outlining its goals and activities through 2011.

Additionally, the GoR will need to work to develop appropriate patient confidentialitypolicies, as there appear to be none in place. Other government initiatives, such ascreating universal standards for patient forms, have great potential to streamline care, inthis case by reducing the number of forms that nurses are required to fill out on a regularbasis allowing them to focus on their clinical duties. These measures and others will go along way in creating a more efficient e-Health system. The Government is clearly awareof these needs, and is making inroads into creating a coordinated set of systems.

Conclusion

GoRs efforts in e-Health have been mostly strategic and programmatic rather thanregulatory. That is to say that the GoR has a vision of which segments ought to be builtup in the industry and partners with organizations that can effectively create the vision.Because the GoR is so active in the promotion of ICT and e-Health, its support acts as de

facto policy making. That having been said, some initiatives, such as medical recordssystems, are becoming increasingly complicated and require both support and regulation.To manage the growing systems, GoR will need to develop appropriate patientconfidentiality policies and universal standards for user forms.


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Conclusion

The implementation of health information technology faces great challenges in Rwanda.In the wake of a societal tragedy and in the midst of the realities of poverty and disease,GoR has many competing priorities and limited resources. Its embrace of information

technology, particularly in the health sector and HIV/AIDS treatment, and willingness topartner with organizations like Partners in Health, the Clinton Foundation and theMillenium Villages Project has been pivotal to creating the current landscape. Whilemany systems, such as TRACnet and OpenMRS, exhibit great shortcomings, they alsodemonstrate commitment to an HIT infrastructure and a chance to evaluate systems envivo to integrate into future systems and improvements in current ones. Rwandas HITcan simultaneously help it leapfrog into a relatively advanced health care system, but willalso be limited by the same factors that limit the health care system: lack of electricity,lack of good roads, and limited trained health professionals.

At this time, the government has created a virtual monopsony for health information

technology. Because a great deal of international aid is channeled through thegovernment and its partners, they control the incentives that exist for innovation andimplementation within Rwanda. Whether in the long run, this strategy is sustainable oroptimal is debatable, but at the moment, the size of the domestic market and the povertyof the population may deter private investors. For now, the power they weld gives themthe ability to create a unified and interoperable system that might not arise in freemarket. OpenMRS, TRACnet, Camerwa, and HMIS all represent necessary parts of managing a complex health system, but will require significant investment andrestructuring to be truly optimal. The value that they can add to the system as a sum, incomparison to discrete systems that don't communicate, is profound.

Currently, Rwanda lacks a surveillance system that can identify disease outbreaks andmonitor health trends at a population level. TRACnet, because it receives information onvirtually all ART patients, does provide a rough measure of HIV treatment and patternsin Rwanda. Unfortunately, it is difficult to validate the quality of the data collected fromthe facilities where there is no patient-level data maintained. OpenMRS, a patientmanagement system currently used mainly by Partners in Health and the MillenniumVillage Project, may give TRACnet legs once it is rolled out nationally if it improves thequality of data collection and maintenance. Furthermore, to maximize the benefit of these systems, it will be necessary to expand their use beyond HIV/AIDS. However,designing systems like TracNET in an open fashion facilitates ease of modifications,allowing the system to be customized for Rwandas needs and allow interoperability.

While work remains to be done, the Government has set an ambitious agenda. E-trainingprograms for nurses and technical training for the OpenMRS rollout will begin later thisyear. They are designing a new Health Management Information System that will link the variety of other systems and have improved capacity. Mutuelles is exploring ways tocreate a database with more capacities that could potentially link with patientmanagement information. With the economic growth trends in Rwanda, the healthinfrastructure should continue to strengthen, with new opportunities for mobile and


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Internet-based health services increasing as these technologies spread through thepopulation.


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Bibliography

BBC News. Rwanda: how the genocide happened. April 1, 2004.http://news.bbc.co.uk/2/hi/africa/1288230.stm

BBC News . Rwanda genocide failure berated. April 5, 2004.http://news.bbc.co.uk/2/hi/africa/3599493.stm

Boned-Ombuena (2007), Development Assistance to Health Information SystemsStrengthening, World Bank, Health, Nutrition and Population Unit.

CIA. Rwanda . The World Factbook 2008 [Available from:https://www.cia.gov/library/publications/the-world-factbook/geos/rw.html]

Economist Intelligence Unit (2006), Rwanda Country Report

Economist Intelligence Unit (2008), Rwanda Country Report , May 2008

Food and Agriculture Organization (2006) The State of Food Insecurity in the World 2006: Eradicating World Hunger -- Taking Stock Ten Years After the World Food Summit.

Gahigana, Innocent, Rwanda: Rwandatel Deal Sealed, The New Times, October 26,2007

Gahigana, Innocent, Rwanda: All District Hospitals to Be Connected in 2008, The NewTimes, December 31 2007

Government of Rwanda, Ministry of Infrastructure (2008),http://www.mininfra.gov.rw/page_en.php?subaction=showfull&id=1129416303&archive=1129472269&ucat=2&lang=en \

Government of Rwanda, Ministry of Infrastructure (2008), Network Organisational Chartof Ministry of Infrastructure,http://www.mininfra.gov.rw/docs/cadre_organique_du_MININFRA.pdf

Organisation for Economic Cooperation and Development (2007), African EconomicOutlook 2007

Shepard, Donald; Rwiyereka, Angelique K; Beaston-Blaakman Aaron, Community-basedHealth Insurance in Rwanda: from Case Studies to National Policy. Rwanda Medical

Journal . In press.

United States Agency for International Development (2005), Rwanda Human ResourcesAssessment for HIV/AIDS Services Scale-Up


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United Nations (2008), United Nations Human Development Report Database ,http://hdrstats.undp.org/countries/country_fact_sheets/cty_fs_RWA.html

United Nations Department of Education and Social Affairs, Division for Sustainable

Development (2008), TRACnet, Rwanda: Fighting Pandemics through InformationTechnology, www.un.org/esa/sustdev/publications/africa_casestudies/TRACnet.pdf

United States Agency for International Development (2006), Rwanda HMIS Assessment Report, May 9 2006.

Voxiva, Inc. website, http://www.voxiva.com/rwanda.asp , accessed June 12, 2008

World Bank (2008). Education Statistics, http://www.worldbank.org/education/edstats

World Bank (2008), Worldwide Governance Indicators (WGI) project,

http://info.worldbank.org/governance/wgi/index.asp ; accessed on June 12, 2008World Bank (2008), Rwanda: ICT at a Glance,www.devdata.worldbank.org/ict/rwa_ict.pdf

World Health Organisation, Developing Health Management Information Systems: APractical Guide for Developing Countries


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I. Interview List

Dr. Michael Kremer, Director General, TRACPlus- CIDC

Dr. Anita Asiiwame, Director of HIV/AIDS for the STI units, TRACPlus-CIDC Dr. Richard Gakuba, e-Health Coordinator for the Ministry of Health

Shabani Cishahayo, Interim Head of Surveillance of the Bioinformatics and IT Division,TRACplus

Jean Baptiste Koama, Voxiva

Patrick Nyirishema, http://inside.pih.org/node/754 Deputy Executive Director of theRwanda Information Technology Authority (RITA)

Christian Allen, Head of Technology for Partners in Health, Rwanda

Neal Lesh, Chief Technology Officer of D-tree International

Dr. Jean Kagubare, Senior Program Associate, Center for Health Outcomes, ManagementSciences for Health

Jonathan Jackson, Co-Founder and Chief Executive Officer of Dimagi

Linea Rowe, Director of Product Management of the Global Health Delivery Program,Harvard University

Dr. Andrew Kanter, Director of Health Information Systems/Medical Informatics of theMillennium Villages Project, Earth Institute at Columbia University

Darius Jazayeri, Lead Programmer for Partners in Health

Dr. Lisa Hirschhorn, Assistant Clinical Professor in the Department of Global Health andSocial Medicine, Harvard Medical School and Senior Clinical Advisor on HIV/AIDS atJohn Snow, Inc. Research and Training.


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II. Appendixes

Appendix 1: Map of Rwanda and ART health facilities

Graphic from Shabani Cishahayos presentation at Rwanda Health Education andInformation Network (RHEIN) Workshop. Kigali, May 29-30, 2008.

Appendix 2: Health Indicators for Rwanda and sub-Saharan Africa

Indicator RwandaRural

Sub Saharan Africa,all (2005) +++

A. Socio-Economic Characteristics % poor population 45% -- % of households with access to clean water 43% 56% Primary school attainment 54% 61% B. Mortality Rates Under-5 mortality rate 2000-2005 (per 1000)* 116 163


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Infant mortality rate 2000-2005 (per 1000)* 84 93 C. Reproductive Health Total fertility rate for 3 years prior to survey (all women 15-49) 6.1 5.2 Proportion of pregnant women who received any antenatal care at last pregnancy 93% 70% Proportion of assisted deliveries by trained personnel 35% 44% Proportion of deliveries taken place in health facility 24% -- D. Child Health Proportion of children WITHOUT full basic vaccine coverage 26% -- Proportion of children under 5 sleeping under a treated bednet 20% -- Prevalence of moderate and severely underweight children 24% 25% Prevalence of fever** 26% -- Prevalence of diarrhea** 15% -- E. Utilization of Health Services % of women who reported lack of money for treatment 74% -- % of women who reported distance to health service as a large barrier to accessing care 43% -- % of utilization of modern health services for diarrhea 14% -- % of utilization of modern health services for fever 23% -- F: Population Health Rwanda, All Sub-Saharan Africa,

all (2005) HIV prevalence (per 100,000) 3133 -- TB prevalence 2006 (per 100,000) + 562 348 (2005) Malaria cases 2000 (per 1000 population) ++ 120 -- *direct calculation used: (#died/#born alive 2000-2005)*1000.** of children who had had diarrhea or fever reported in the weeks prior to interview+TB prevalence taken from WHO Report 2008, Global Tuberculosis Control++ Malaria taken from most recent WHO Malaria Country Profile, Rwanda+++Sub-Saharan Africa data from Health Systems 2020 Country Brief and World Bank Development Indicators 2


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Appendix 3: Ease of Doing Business

Economy

Ease of Doing

BusinessRank

Startinga

Business

Dealingwith

Licenses

Employing

WorkersRegistering

PropertyGettingCredit

ProtectingInvestors

PayingTaxes

TradingAcross

BordersEnforcingContracts

Closing aBusiness

Mauritius 1 1 4 7 33 10 2 1 1 12 6

South Africa 2 3 6 14 8 2 1 13 20 13 7Namibia 3 13 3 4 21 4 9 8 26 1 2Botswana 4 12 21 10 3 2 16 2 27 17 1Kenya 5 17 1 8 15 1 12 38 30 19 11Ghana 6 24 29 27 1 15 3 15 3 4 17Seychelles 7 2 7 16 4 39 5 5 6 8 34Swaziland 8 27 2 5 27 4 46 6 28 25 4Ethiopia 9 15 9 12 29 10 16 3 31 11 8Nigeria 10 6 40 3 46 7 5 21 22 16 13Zambia 11 7 34 24 18 10 9 4 36 14 12Uganda 12 18 15 1 38 39 20 11 24 22 3Lesotho 13 21 32 9 22 15 30 9 16 18 5Malawi 14 16 20 13 11 7 9 16 37 27 27Tanzania 15 10 42 33 37 15 12 20 9 2 20Gambia 16 9 13 2 23 27 43 44 4 7 23Cape Verde 17 36 14 29 20 6 20 25 2 6 34

Mozambique 18 20 33 38 19 10 3 14 23 29 26Sudan 19 10 24 28 2 27 30 12 25 31 34Gabon 20 31 5 39 30 15 34 18 11 32 24Comoros 21 29 8 35 10 39 20 7 13 36 34Madagascar 22 4 28 32 40 46 5 17 15 35 34Rwanda 23 5 23 15 25 39 43 10 41 3 34Benin 24 23 22 21 14 15 34 39 14 41 18Zimbabwe 25 28 44 25 9 10 16 33 43 10 33Cameroon 26 38 36 23 24 15 16 42 18 44 16

Cte d'Ivoire 27 35 38 20 33 27 34 32 29 23 9Togo 28 44 31 30 31 27 27 31 5 37 14Mauritania 29 39 30 22 5 15 30 43 32 15 30Mali 30 32 17 11 12 27 34 36 38 39 19Sierra Leone 31 8 35 41 45 15 14 34 17 30 29

Burkina Faso 32 14 41 34 44 15 27 29 44 20 15Senegal 33 37 10 36 35 27 42 41 21 33 10So Tomand Principe 34 21 19 46 28 15 20 37 7 21 34EquatorialGuinea 35 41 16 45 6 27 30 30 19 9 34Guinea 36 40 39 17 32 27 43 40 10 24 22Angola 37 42 26 43 41 7 5 27 40 46 28Niger 38 33 37 37 7 27 34 24 39 26 25Liberia 39 26 45 19 42 27 27 26 8 40 31Eritrea 40 43 46 6 36 39 14 19 35 5 34Chad 41 45 12 26 17 27 20 28 34 42 34Burundi 42 19 43 17 16 45 34 22 42 33 34

Congo, Rep. 43 34 11 40 43 15 34 46 45 38 21Guinea-Bissau 44 46 17 44 39 27 20 23 12 28 34CentralAfricanRepublic 45 25 25 31 13 15 20 45 46 43 34Congo, Dem.Rep. 46 30 27 42 26 39 34 35 33 45 32


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Appendix 4: Ease of Doing Business

Business Procedures (number) 9Duration (days) 16Cost (% GNI per capita) 171.5

Starting a Business

Paid in Min. Capital (% of GNI

per capita)

0.0

Procedures (number) 16Duration (days) 227

Dealing with Licenses

Cost (% of income per capita) 822.1Difficulty of Hiring Index 56Rigidity of Hours Index 40Difficulty of Firing Index 30Rigidity of Employment Index 42Nonwage labor cost (% ofsalary)

5

Employing Workers

Firing costs (weeks of wages) 26Procedures (number) 5Duration (days) 371

Registering Property

Cost (% of property value) 9.4

Legal Rights Index 1Credit Information Index 2Public registry coverage (%

adults).2

Getting Credit

Private bureau coverage (%adults)

0.0

Disclosure Index 2Director Liability Index 5Shareholder Suits Index 1

Protecting Investors

Investor Protection Index 2.7Payments (number) 34Time (hours) 168Profit tax (%) 20.2Labor tax and contributions (%) 5.7Other taxes (%) 7.9

Paying Taxes

Total tax rate (% profit) 33.8Documents for export (number) 9Time for export (days) 47Cost to export (US$ percontainer)

2975

Documents for import (number) 9Time for import (days) 69

Trading Across Borders

Cost to import (US$ percontainer)

4970

Procedures (number) 24Duration (days) 30

Enforcing Contracts

Cost (% of claim) 78.7Time (years) No practiceCost (% of estate) No practice

Closing a Business

Recovery rate (cents on thedollar)

0.0

World Bank (2008), Doing Business Rwanda Case


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Profile: TRACnet

TRACnet is a software used by the GoR to collect and store clinic-level healthinformation at the central level since 2005. 1 The software was developed by Voxiva inc(a Washington D.C. based software and telecommunications company), but is managed

and used by the Treatment and Research AIDS Center (TRACplus) division of theMinistry of Health.

TracPlus

TRACplus is the new broader incarnation of the Treatment and Research AIDS Center(TRAC) division of the Ministry of Health. Originally, the group focused entirely onAIDS, but has expanded to encapsulate malaria and tuberculosis as part of its broadermandate, and plans to later include other conditions. It has changed its title to TRACplusto reflect these changes. Additionally TracPlus is the primary national agencyresponsible for Preventing Mother-to-Child Transmission (PMTCT) and Voluntary

Counseling and HIV testing (VCT), Epidemiology Surveillance, and Health ICT/ Information Management. As part of this mandate, TracPlus uses the TracNet softwaredeveloped by Voxiva to store facility-level data.

TracNet is a collaboration between both the private and public sectors. MTN andRwanda-Tel, the local cell phone carriers, donated network time for facilities to use whenreporting their data. Voxiva Inc., provided ICT support to the project. The United StatesCenters for Disease Control and Prevention (CDC) provided the financial andadministrative support through the President's Emergency Plan for AIDS Relief (PEPFAR).

The breadth of implementation to date is impressive. TRACnet has been deployed in all94 health facilities offering ART in Rwanda, thus capturing virtually all ART treatmentnationwide. 2 In addition, approximately 6,000 individual case records are monitoredusing the system. 3

According to the UN:

TracNet is a dynamic information technology system designed to collect, store,retrieve, display and disseminate critical program information, as well as tomanage drug distribution and patient information related to the care and treatment

of HIV/AIDS. This system enables practitioners involved in anti-retroviral (ARV)treatment programs to submit reports electronically and have timely access tovital information. By dialing 3456, a Rwanda toll free number, or logging onto a

1 http://www.voxiva.net/rwanda.asp2 From Voxiva website, with updated information from report, Development Assistanceto Health Information Systems Strengthening, World Bank September 2007.3 http://www.voxiva.com/rwanda.asp


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bilingual website (English and French), health centre staffers can submit orreceive program results on HIV/AIDS patients as soon as they are processed.TRACnet uses solar energy chargeable mobile phones, which can be used in themost remote parts of the country. 4

In essence, TracNet provides a direct electronic means of transmitting consolidated datafor programmatic decision making, including national level drug procurement. A processthat once only provided one-way information and took months, has been reduced tominutes, and can now provide two-way information.

The aggregated data guides healthcare delivery activities at the national level. Forexample, TracNet data informs drug procurement at a national level. The TracNet data istransferred to Camerwa, a Rwanda-based pharmaceutical company, that then keeps stock of the availability of ARV drugs. TRAC monitors and supervises health facilities thatprovide ARV treatment in the country. TRAC also has a team of IT personnel, who havetrained over 200 health care providers in health facilities on how to submit data to

TRACnet, and who also monitor reporting into TRACnet and publish monthly reports.Data is entered either on a biweekly or monthly basis (depending on the statistic) andthen collected in a national repository.

Data Quality

Some challenges remain in the implementation of TRACnet. Although TracNetscoverage is wide, the depth and accuracy of data remain unclear. One evaluationsuggested that there is wide variance in the completeness of data depending on the size of the facility. All ART sites had data for over 90% of patients at the time of abstraction.However, 6 month follow-up rates for patients who were alive on ART were 56%, 60%and 14% for small-, medium, and large-sized ART clinics. Moreover, 12-month CD4counts were only recorded for 35%, 30% and 25% of small-, medium-, and large- ARTcites respectively. 5

Additionally, because patient-level data is not maintained electronically at most facilities,cross-checking clinic-level data is difficult and does not appear to occur under normalcircumstances. There has been limited evaluation of data completeness to date but nocomparison of individual records at facilities with data in TracNET. The difficulty of verification may provide perverse incentives to clinics; since drug supply is based on thenumber of patients they report, over-reporting might be rewarded with excessmedications and supplies. Further evaluations of the system are planned.

While this type of surveillance is valuable for capturing a broad understanding of groupsof patients on ART, it does not identify the segment of the population whose HIV status

4 TracNet, Rwanda: Fighting Pandemics through Information Technology5 Government of Rwanda (2008) TRAC Report on the Evaluation of Clinical andImmunologic Outcomes from the National Antiretroviral Treatment Program in Rwanda,2004 2005, p47


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is unknown. These data collection efforts offer only a partial picture of the epidemicunless coupled with population-based survey efforts.

Exhibits

Screen Shot of TRACnet


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Architecture of the integration of information systems at TRACplus

Graphic from Shabani Cishahayos presentation at the Rwanda Health Education andInformation Network (RHEIN) Workshop. Kigali, May 29-30, 2008.


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Profile: OpenMRS

OpenMRS, developed by the OpenMRS collaborative, is a free and open source medicalrecord system that has been in development since 2004. In Rwanda, it is used by PartnersIn Health/Clinton Foundation (PIH) and the United Nations Millennium Village Project

(MVP). PIH currently operates in seven sites (as of May 2008) and their OpenMRSinstallation contains data for nearly 7,000 HIV patients, over 4,000 on HIV or TBtreatment.

Partners in Health

The OpenMRS installation that PIH-Rwanda uses includes many country-specificfeatures. Specifically, it can generate reports that meet Rwanda reporting requirements,including submissions to TRACnet, the national aggregation system. * It also containstemplates for quality monitoring and administrative overview reports. Patientinformation is available across sites, and the data synchronizes automatically when a

computer goes online (though information is available offline as well). OpenMRS usesSecure Socket Layer Protocol and role based authentication to ensure confidentiality of medical data the combination represents the same industry-grade security used bybanks and other highly-secure institutions around the world. There are data export, reportbuilding, and patient form building tools in the software package as well. It includespatient information lookup tools, and a variety of visualizations of patient data to helpclinicians quickly assess a patients progress over time.

As a result of the flexible nature of OpenMRS and the number of different functionsimplemented at PIH sites, installation and maintenance of the system requires substantialtechnical expertise. For example, PIH employs two full-time IT technicians to maintain

all harware system, and these technicians also have the part-time responsibility of troubleshooting EMR hardware issues across the seven sites. Particularly challengingissues have been stable power (now mainly addressed with solar systems), and lightening.

Use of electronic medical record (EMR) systems like OpenMRS can be very laborintensive. It allows clinics to collect a great deal of data about their patients, but the dataentry and quality control requires human attention. PIH collects five pages of information about HIV patients on an intake form and two pages in follow-up visits. Tocope with this inflow of data, PIH employs two data managers, four lab data officers, andeight patient data officers, for a total staff of 14 people responsible for the collection,cleaning, reporting, and analysis of data. If the database continues to grow, more staff

will be required to manage the data effectively. Many projects providing HIV treatmentand funded by the PEPFAR program or the Global Fund receive direct financial supportfor reporting. These funds usually support the salaries of data entry staff, data managersand also IT costs. Such funding will be important in speeding the rollout of the EMR inRwanda.

* For more information on TRACnet, please refer to TRACnet profile.


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The implementation of the EMR at PIH sites is one in which clinicians/providers consultwith patients and write down information on paper. This paper-based information is thengiven to the data team for entry. Later, the data team produces lists of patients, patientsummaries, reports, and alerts when appropriate. This information is usually printed onpaper and delivered back to a member of the clinical team. PIH has implemented patient

summaries and flow sheets within the software, and is now working to make themdirectly accessible during clinical visits by clinicians. They are also working to capturedata on patient follow-up and medication collection directly from clinic staff into theEMR.

Millennium Villages

The implementation of OpenMRS at MVP sites is more recent and contains a subset of functionality to the PIH installation. Neither organization is implementing real-time liveentry during clinical visit for the time being.

MVP uses OpenMRS as part of its health information system in the Bugesera District. Itruns on an Atheon server linking 6 Inveneo ION workstations within the clinic. TheOpenMRS system is being used to capture primary care data (e.g. adult and pediatric visitforms and pharmacy data) as well as vital statistics (new birth registrations). Unlike thePIH installation, the system uses a centralized data dictionary that is shared by otherMillennium Village clinics in multiple languages to ensure that the data will beinteroperable between the MV sites and will allow aggregation across linguistic andgeographic boundaries. In Rwanda, French is the most commonly used language, thoughMVP plans to translate the antenatal and community health workers forms intoKinyarwanda.

MVP hopes to expand its installation of OpenMRS to include other primary care clinicsin Rwanda through the Access Health Project in Kigali. In addition, MVP is workingwith other partners, such as ICAP at Columbia University and Loma Linda University toinclude geographical information systems into its data analysis.


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Exhibit 1: PIH Patient Dashboard


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Exhibit 2: Screenshot of patient information on PIH installation of OpenMRS


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Exhibit 3: List of patients and clinical summaries and alerts with scheduled appointments

E-Health Rwanda Case Study

Documents

Transcript of E-Health Rwanda Case Study