Public Health Informatics in Action in Malawi: Making life easier for healthcare workers and patients while improving quality through an innovative national Electronic Medical Record System

Keeping track of even one patient undergoing treatment for HIV/AIDS can be complicated enough.

Doing it for over 472,865 patients when you’re a low income country coping with high demand and a sputtering economy magnifies the complexity.

Which is why Malawi’s story – and its solution – is attracting attention and praise. It’s a story of how Electronic Medical Record System (EMRS) technology is being used and the foresight needed to bring it to reality.

You don’t have to look far to see the positive results.

Walking into one of the busiest HIV/AIDS clinics in the nation, with an annual facility volume of approximately 13,957 patients enrolled and receiving antiretroviral treatment (ART), clients seamlessly transition from point to point as clerks and clinicians use bar-code scanners and touch screen computers.

At every step health care workers query the EMRS to retrieve information from previous appointments and instantly record information from the current visit.

At the end of the visit, a label with printed information from the visit is affixed to the patient’s health passport, which acts as a vehicle for sharing information within or between health care facilities. More recently, health information exchanges are being expanded so if a patient seeks care in another health center with an EMRS, their information will be readily retrievable and in real time.

Looking back on how Malawi’s EMRS was established

Getting to this point wasn’t easy. The system’s origins date back to 2006 when Malawi’s Ministry of Health’s (MOH) Department of HIV/AIDS, CDC Malawi, and Baobab Health Trust first raised the possibility of electronic record keeping. The need was clear. Faced with the urgent need to respond to the HIV/AIDS epidemic and its supporting health care system, and the impracticality of managing high volumes of patients with paper-based systems, a hospital-based pilot was established to prove the ease and timeliness within which patients and health workers could conduct and document clinic visits, quality of care and the availability of data for clinical or public health decision making.

Since then, the Malawi national EMRS has evolved significantly along with the number of partners and participants. CDC Malawi, through funding from the President’s Emergency Plan for AIDS Relief (PEPFAR), and other donors, remains committed to its sustainability.

Baobab Health Trust is a Malawi organization and is CDC’s primary partner responsible for expanding the system nationwide. By 2012, Luke International joined its forces and is responsible for developing the EMRS in the Northern region of the country. Integral to the EMRS implementation are collaborative partnerships with the Malawi’s Ministry of Health and the National Registration Bureau. Informatics, epidemiology and surveillance technical assistance is through the University of Pittsburgh, Maikhanda Trust, and CDC’s Division of Reproductive Health and National Center for Health Statistics.

Since the original pilot demonstration in 2006, the EMRS has grown from 19 facilities in 2012 to 48 HIV/AIDS health care providers located in the Northern, Central, and Southern regions of the country.

This represents 40% of all HIV-infected persons receiving care or treatment in Malawi or approximately 189,146 individuals. By September 2014, the plan is to increase the number of EMRS sites to 53 health facilities out of a total of 71 HIV high burden sites. To date, more than 1,500 healthcare workers have been trained in using the national EMRS at the point of care.

Continued expansion is guided by MOH Department of HIV/AIDS protocols and its national M&E quarterly supervision system. Additional maternity modules have been added to the EMRS in support of Malawi’s Option B+ initiative, a national program for the lifelong treatment of HIV positive pregnant and breastfeeding women and prevention of transmission to their infants. The reuse of information from the maternity modules also benefit Malawi’s Safe Motherhood program which aims to improve the health of mothers and newborns and reduce mortality and illness.

Future directions for Malawi’s EMRS

As the EMRS expands across the nation, its functions are evolving in response to changing national information needs.

Currently, 39 health facilities are equipped to electronically capture patient information and report health indicators as part of Malawi’s Health Management Information System (HMIS).

More recently, the President’s Malaria Initiative is investing in the reuse of EMRS data for routine malaria surveillance at the facility level.

Developing laboratory information systems is another critical priority for the nation and the EMRS platform is again the opportunity for realizing a pilot demonstration at a Central and District hospital. Developing information systems for non-communicable diseases has resulted in hypertension and diabetes modules for improved clinical management and represent emerging surveillance systems for Malawi. Other evaluation and research projects benefit from the National EMRS with more recent protocols concerned with understanding hypertension management among HIV/AIDS patients and improving retention among people living with HIV.

With a strategic eye on the future, the National EMRS was recently evaluated according to sustainability principles. Findings suggest the national EMRS’ sustainability model is donor driven and this is typically characteristic of developing country programs. With a continued focus on capacity development, strengthening linkages with Ministerial programs, and optimizing EMRS use for public health research, learning and practice, remain strategic priorities. Further informing sustainability decision-making, research and evaluation seek to understand EMRS efficiencies, cost-effectiveness, and information and technology transfer for National ownership.

It may have been difficult to imagine 10 years ago how far a low income country like Malawi would come in planning, implementation and scale up towards a comprehensive national EMRS. This has been accomplished through a far-sighted and clear vision, the persistent hard work of a highly competent and innovative cadre of young Malawian informatics professionals, and an unwavering commitment to the health of Malawians and achieving an AIDS Free Generation. While the future challenges with scale and sustainability are clear, one can be confident that these same attributes will remain critical in successfully forging the way forward.

Did you enjoy this blog? Share it on Twitter!