Tamanu

Tracking longitudinal patient data across multiple facilities and vertical programs is a challenge in remote settings. Approximately 80-90% of healthcare in the Pacific Islands is delivered outside of hospitals in local clinics. These clinics are predominantly staffed by time-poor nurses who must diagnose, treat, and record patient encounters. Patient records are typically handwritten in A3 general ledger books, so when a patient returns it is difficult to look at any previous visit, let alone build a holistic view of their history – and if they go to a different health facility, it is impossible.

There are digitised medical records systems on the market but none of them was fit for purpose across the five principles that we identified as necessary for the settings we work in.

As a result, people across the Pacific are not receiving consistent, long-term care that accounts for their medical history, risk factors, and long-term health needs. This has serious impacts on the region’s health; non-communicable diseases are the leading cause of death in Pacific Island countries and could be addressed with more consistent record keeping and consistent care across screening, prevention, and treatment.

In many places, each patient visit is hand-written but relevant data must be separately captured at month’s end for a variety of public health or vertical programs such as tracking diabetes and malaria. Electronic records eliminate two-step reporting, save time and are vital to consistent long-term management of patient care.

The Pacific presents additional, acute challenges; health service points are often in remote locations, there is poor digital infrastructure and internet connectivity throughout the region, and there is often low digital literacy amongst health clinic staff.

Our patient-level electronic medical record system, Tamanu, is specifically designed to address these problems. It is fully featured but simple to use, completely free, and open source. It is also a sync-first system across both mobile and desktop, allowing health workers to enter and access data when offline, enabling use in even the most remote settings. Tamanu has mobile and desktop versions that work out-of-the-box, removing the need for complicated integrations. It is interoperable with major existing systems, and it is highly secure. 

By using Tamanu, every professional in the person’s continuum of care is able to access their treatment plan and update it on mobile and desktop, making sure that treatment is consistent, comprehensive and coordinated.

Prior to commencing work on Tamanu in 2018, we conducted an extensive, six-month search for an electronic medical record that would overcome these challenges. We failed to find a software that was appropriate for the uniquely remote and under-resourced settings in which we work.

Tamanu is a free and open-source patient-level electronic medical record system for desktop and mobile. It allows health workers to track individual patients, providing clinical support and enabling consistent, long-term management of patient conditions in hospitals, health centres, clinics and even out in the field.

Tamanu is developed specifically for the Pacific context and meets the five principles of eHealth we consider to be fundamental to success:

1. Completely free and open-source, with no licensing costs.
2. Sync-enabled - able to work completely offline when the internet is slow or unavailable and syncing data when the internet is available.
3. Industry-standard data security, including encryption in transit and on the disk.
4. Desktop and mobile enabled, out-of-the-box, without requiring any third-party integrations.
5. Interoperable with existing systems (including mSupply, DHIS2 and Tupaia) and standards (including ICD-10, CPT etc which can be selected and configured within minutes).

Tamanu is currently used in six countries including Samoa, Fiji, Kiribati, and Nauru. It has modules for all inpatient and outpatient care, including vertical program data collection, emergency department and triage workflows, lab and imaging requests, immunisations, appointments, and scheduling.

In many countries, Tamanu has been critical in the national fight against COVID-19 and the vaccine rollout. Both in health facilities and out in the field, Tamanu is used to capture information for every individual receiving a vaccine, record COVID tests, manage active COVID patients and integrate with external data sources such as vaccination passport systems. The data is aggregated into Tupaia, our open-source data mapping and visualisation platform, allowing decision-makers to track the vaccine rollout in real-time and allocate remaining resources equitably.

One of our biggest aims is to move away from a model where every vertical program uses a different app to collect data or manage patients. To achieve this, Tamanu is designed with a highly configurable data collection module that can be used for all vertical programming. Data collection forms can be created and imported within minutes to enable data collection and decision support against individual patients for any vertical program. It is already being used for NCD screening, AEFI, disability programming and mobility equipment management. In Fiji, all COVID-19 tests are captured and displayed through Tamanu.

Tamanu is ONC certified and is included in the Digital Square Global Goods Guidebook Version 2 – it is one of only four EMRs in the Guidebook and the only one developed for, and based in, the Pacific.

Our innovation aims to improve health security in the Pacific region by providing a fit-for-purpose electronic medical record designed to work seamlessly in settings with poor infrastructure and low digital literacy. By improving the quality and continuity of care, Tamanu will help to strengthen healthcare systems and improve patient outcomes across the Pacific.

Tamanu improves patient outcomes for all those living in countries where it is implemented by creating a comprehensive medical record for each patient that can be shared across clinics. Non-communicable diseases are the leading cause of death in Pacific Island countries, accounting for 60-80% of mortalities. In countries such as Fiji and Samoa, diabetes is the leading cause of disability. Lower limb amputation for diabetic gangrene is the most common surgical operation in Fiji, which could be reduced by earlier detection and more consistent treatment plans.

Tamanu aims to improve the health security of all countries in the Pacific by providing a fit-for-purpose electronic medical record designed to work seamlessly in settings with poor infrastructure and low digital literacy. It benefits nurses and other healthcare professionals by streamlining the process of data collection and cleaning, saving time and resources that can instead be dedicated to patient care.

Tamanu’s data collection reflects the biological and gender-based differences between women and men that result in differences in health risk, disease incidence and health service needs. In this way, the information can be leveraged to improve decision making in low resource settings.

Through the use of role-based securities the system will ensure that users are only able to view patient information that is pertinent to their role and the healthcare they are providing. We believe that such securities will ensure that patients are protected from stigma and improve their trust in the healthcare system.

The introduction of Tamanu will help in overcoming existing gaps in healthcare capacity, such as through increasing the role of mobile technology and task-sharing. Overcoming these gaps and improving the accessibility of healthcare will help to ensure patient’s receive care and follow-up in a timely manner, and aid in the improvement of short and long-term outcomes, reducing the burden of disease.

Megan Lane (BComm, MBiomed, MPH) is an HIS specialist with more than five years’ experience implementing EMR systems in large hospitals and health networks in Australia and overseas. She is the Tamanu Program Manager for Beyond Essential Systems (BES), an Australian company that creates and implements innovative solutions for low-resource settings in the Indo-Pacific.

BES has developed a fit-for-purpose suite of eHealth solutions, including our flagship products Tupaia and Tamanu, that fit together to create a completely integrated software ecosystem. To date, BES has led the implementation of free and open-source eHealth systems in 20+ countries across the Asia-Pacific, including Tonga, Kiribati, Samoa, Solomon Islands and Vanuatu.

BES have demonstrated a continuing commitment to the Pacific and the ability to deliver high-quality implementations at low cost. Using innovative, collaborative solutions and working closely with local partners, we provide support in software development, procurement, supply-chain, fleet management, health financing, disease mapping, clinical pharmacy, quality assurance and data analysis.

We provide contextually appropriate solutions for remote and resource-limited settings, combining experience of cutting-edge technologies with an appreciation for the physical, financial and cultural challenges where we work. We are committed to ensuring that our products operate offline, with syncing capability, and are open source.

BES employs 40 full-time staff across offices in Melbourne and Auckland and employs locally engaged staff in project offices in several partner countries. Our staff include specialists in procurement, clinical services, project accounting, geospatial epidemiology and a full-time software development team of 22 staff. Each of BES’ key staff have over 10 years’ experience working in low-resource settings across Africa, Asia and particularly the Pacific, having completed work in nearly every Pacific Island Country.

We are applying to Solve to ensure that the impact that Tamanu can have on equitable health systems is not limited to a few countries, or even one region. By joining a network of peers that can provide inspiration and collaboration, we hope to improve the health outcomes of remote populations across the world.

BES has a history of deep connections and experience in the Pacific region; we have delivered projects in 12 countries in the region and each of our key staff have lived and worked in nearly every Pacific Island Country. Although Tamanu was designed specifically for the contextual challenges of the Pacific, the technology is well suited to tracking longitudinal patient data in remote settings across the world. We are keen to join an international network to collaborate with other innovators and build partnerships in other regions that would benefit from Tamanu’s offline-first and open-source technology, such as Asia, Africa, Caribbean islands and remote communities. We see synergies in closer adherence to OpenHIE principles, platform-wide adoption and optimisation of HL7 FHIR (which is now our standard for data exchange), stronger and more contextually appropriate data security, and more streamlined uptake of data standards.

We are also applying to Solve to access mentorship and strategic advice from experts in the areas in which operations are currently lacking. We believe that Tamanu would benefit from improved monitoring and evaluation support. Although we are able to gather data around the number of users and feedback, we would be able to better communicate our impact with an improved impact measurement practice. Through the MIT Solver network, we hope to learn from other innovators operating across the world and work to improve how we measure and report our success.

Tamanu is a free and open-source patient-level electronic medical record system for desktop and mobile. It allows health workers to track individual patients, providing clinical support and enabling consistent, long-term management of patient conditions.

We believe Tamanu is the only credible EMR on the market that meets the five principles of eHealth we consider to be fundamental to success:

1. Completely free and open-source, with no licensing costs.
2. Sync-enabled - able to work completely offline when the internet is slow or unavailable and syncing data when the internet is available.
3. Industry-standard data security, including encryption in transit and on the disk.
4. Desktop and mobile enabled, out-of-the-box, without requiring any third-party integrations.
5. Interoperable with existing systems (including mSupply, DHIS2 and Tupaia) and standards (including ICD-10, CPT etc).

Tamanu is innovative in the ways it is designed to address the specific challenges of healthcare in the Pacific. It is offline-first across both desktop and mobile, accounting for slow or intermittent internet connections by working offline and syncing when internet becomes available; it is also free and open-source, ensuring that countries are not burdened by high ongoing costs or tied to any single implementation vendor. Of course, with any software, there are naturally implementation and maintenance costs, but these do not need to be paid to us.

Tamanu works ‘out-of-the-box’ on desktops, tablets, or mobile phones, without requiring complicated third-party software integrations. This reduces the complexity of software support, speeds up implementations and allows software updates to be quickly disseminated. In Samoa, this allowed COVID-19 vaccination teams to record each vaccine administered directly into Tamanu while in the field. The record on the tablet then synchronised to the main servers with the update disseminated across all connected devices and the operations centre.

The integration of Tamanu with other software, such as our data visualisation tool Tupaia, allows for both user-friendly data collection on the ground and country-wide data mapping. In the Samoan COVID-19 vaccine rollout, this was vital in directing the next steps of the response.

The result is a seamless continuum of care that simply isn’t otherwise available in the Pacific or other remote settings; regardless of remoteness of health clinics, internet connectivity, or time-constraints, every professional in the person’s continuum of care will be able to access their treatment plan and update it, ensuring treatment is consistent, comprehensive, and coordinated.

Tamanu aims to improve the health security of all countries in the Pacific by providing a fit-for-purpose electronic medical record designed to work seamlessly in settings with poor infrastructure and low digital literacy. It aims to improve patient care and patient outcome by streamlining and standardising the recording of patient information and care, processing of data collection and cleaning, saving time, errors and resources that can instead be dedicated to patient care.

Our aim is that every single patient encounter with the health system across the Pacific will eventually be recorded in Tamanu, analysed and used to improve clinical care and regional health security.

The introduction of Tamanu will help in overcoming existing gaps in healthcare capacity, such as through increasing the role of mobile technology and task-sharing. Overcoming these gaps and improving the accessibility of healthcare will help to ensure patient’s receive care and follow-up in a timely manner, and aid in the improvement of short and long-term outcomes, reducing the burden of disease.

One of the biggest hurdles that Tamanu faces is medical staff improving their technologic literacy and preferencing using Tamanu over paperwork. BES works very closely with the in-country teams when first setting up and implementing Tamanu ensuring that Tamanu is customised to match medical workflows, terminology, and processes. BES also specifically employs staff with a high degree of ability to implement change management in a contextually appropriate way. Over the next 5 years there will be a concentrated effort to continue to train and support in-country staff using Tamanu, BES has the capacity to provide tailored training, and will provide face to face sessions where possible.

BES is also building a Tamanu Community of Practice across the Pacific for inter-country questions and user support.

Tamanu is a digital alternative to written patient records and manual data entry. It is an electronic medical record that tracks an individual’s clinical record from birth to death, across any health clinic that they may visit during that time.

The desktop app is a React frontend bundled into Electron app. Client machines connect to LAN servers running Postgres (or the LAN server can be run on the same machine). The LAN servers have two-way sync to a central server.

The mobile app is a React Native application running SQLite on the device with two-way syncing to a central server. The central server runs Postgres with NodeJS.

We can deploy servers locally (on bare metal) or in the cloud at massive scale. It is also possible to point desktop clients directly to a cloud environment, in a configuration we call ‘Tamanu Web’.

Within each country, our tech stack is designed to scale to handle millions of patients, with an initial target of 10 million patients on each central server and up to a million patients on a mobile device.

Importantly, Tamanu is developed specifically for the Pacific context and meets the five principles of eHealth we consider to be fundamental to success:

1. Completely free and open-source, with no licensing costs.
2. Sync-enabled - able to work completely offline when the internet is slow or unavailable and syncing data when the internet is available.
3. Industry-standard data security, including encryption in transit and on the disk.
4. Desktop and mobile enabled, out-of-the-box, without requiring any third-party integrations.
5. Interoperable with existing systems (including mSupply, DHIS2 and Tupaia) and standards (including ICD-10, CPT etc which can be selected and configured within minutes).

Tamanu has an existing secure REST API that is HL7 FHIR compliant, connecting with external services to share patient data. This allows Tamanu to act as a Patient Master Index.

The seamless integration of Tamanu with other software, such as our data visualisation tool Tupaia, allows for both user-friendly data collection on the ground and country-wide data mapping. Tamanu fits together with Tupaia, mSupply and DHIS2 to create a completely integrated eHealth ecosystem. In the Samoan COVID-19 vaccine rollout, this was vital in directing the next steps of the COVID-19 response.

Tamanu also helps with many aspects of data integrity. By inputting patient information directly into the app, which syncs the centralised patient registry across all devices, Tamanu greatly reduces the risk of data entry errors. Tamanu by default uses the internationally recognised ICD-10, International Statistical Classification of Disease and Related Problems (ICD), a medical classification list by the WHO, and CPT, Current Procedural Terminology, coding for diagnoses and procedures. For countries wishing to use alternative standards however (such as SNOMED or ICD-11), these can be changed within minutes prior to go-live.

Tamanu is currently used in six countries including Samoa, Fiji, Kiribati, and Nauru. In many countries, Tamanu has been critical in the national fight against COVID-19 and the vaccine rollout. The Director-General for the Samoan Ministry of Health has described Tamanu and Tupaia as “the most important digital tools we have used during the COVID pandemic. We are extremely grateful to DFAT and Beyond Essential Systems for the support they continue to provide to Samoa and the Pacific.”

During the national vaccine rollout in Samoa, over 200,000 entries were made in Tamanu. The software provides highly granular information to guide vaccination teams on where unvaccinated and partially vaccinated individuals are. On 23-24 September 2021, Tamanu and Tupaia supported the national two-day lockdown in which the COVID-19 vaccine was delivered door-to-door - all data was provided in real-time by the system. After this campaign, 94.4% of Samoa’s eligible population received their first dose and 52.4% their second dose, an addition of 12% and 10% respectively in just two days.

In Fiji,over 60,000 COVID-19 tests have been recorded through the system, supporting the Fiji MHMS through the toughest days of their COVID-19 outbreaks. Our analytics shows that there have been over 60,000 visits to our online results checking tool in Fiji alone, which has therefore saved over 60,000 calls to the national call centre from people trying to find their COVID-19 test result.

An instructional video on using Tamanu Mobile to collect COVID-19 swab samples in Fiji can be viewed here.

Feedback from nurses and other healthcare professionals utilising Tamanu in their everyday has been resoundingly positive; those using Tamanu for COVID-19 in Kiribati describe the software as “fantastic and resource-saving”, whilst public health physicians supporting NCD screening in Samoa affirm that “it’s a lot easier now, everything is computerized and saves us time from doing the data entry at the end of the day”.

We are committed to improving population health outcomes across the Pacific and, while our approach in Samoa and Fiji has focused on fighting COVID-19, our innovative technology have potential across other population health outcomes and SDGs. In Samoa, the immunisation module is used for typhoid vaccinations and in our collaboration with Motivation Australia, Tamanu supports the needs of people with disabilities in Papua New Guinea.

BES prides itself in its commitment to diversity, equity, and inclusion. Women make up approximately 50% of company employees, we are 50% female-owned and one of the company’s two Director roles is held by a female. Senior positions held by women include our COO, Product Owner and Data lead. 

Our entire ethos is focused on improving health services to the most marginalised populations and we are guided by these principles through the duration of our projects. We also are proud to be an inclusive workplace for multiple LGBT, non-binary, POC and ESL staff and strive to make the environment a safe space for these and all our staff.

As part of our project methodology, wherever possible, we engage local subject matter experts to assist with workflow and design sessions, and user-acceptance testing. We engage full-time local staff members in four countries, with a permanent presence in Fiji, where our support desk is based. 

Additionally, we use group training sessions and in-country visits to identify local ‘change champions’ for the software who can be used to more closely engage and train other users. Where budgets and roles allow, these users are invited to join closely in go-lives, receiving uniforms to identify and recognise them and providing peer-to-peer support on the wards and subsequent group training sessions to foster shared learning and positive adoption.

We anticipate that Tamanu itself will have a significant positive impact on the inclusiveness of Pacific healthcare systems. The introduction of Tamanu will help in overcoming existing gaps in healthcare capacity, such as through increasing the role of mobile technology and task-sharing. Overcoming these gaps and improving the accessibility of healthcare will help to ensure patient’s receive care and follow-up in a timely manner, and aid in the improvement of short and long-term outcomes, reducing the burden of disease.

Tamanu reflects the biological and gender-based differences between women and men that result in differences in health risk, disease incidence and health service needs. Throughout the consultation, training and deployment phases of the project, BES will consider the needs of all genders, abilities and social circumstances to ensure the design of an inclusive EMR.

We pride ourselves on maintaining a stable business model of profitable sustainability, where the only goal is to deliver outcomes and not simply to derive profits. BES is B-Corp certified and all our software is built on free and open-source platforms, meaning the software code is publicly accessible and can be managed or modified by adequately equipped local staff should they wish or need to do so.

Our revenue has been sustainable for 6 years and revenue streams include software customisations and implementations, consultancies, grants and support/maintenance contracts. We have grown every year for the last 6 years, we are profitable, we have not given up any equity and we have no debt.

Tamanu is funded through a combination of donor grants, implementations and customisations for individual countries and ongoing support and maintenance costs. BES also provides consulting services around health information systems and supply chains. BES has just entered its 7th year in business and for Tamanu, we are now in our 5th year of development and we remain financially sustainable - whilst still reliant on grants as a revenue stream, this mirrors the business model for several similar softwares (including DHIS2 and OpenMRS) and we believe that if usage of the platform continues across the region and we continue to demonstrate utility, it will continue to attract donor support.

Our revenue has been sustainable for 6 years and revenue streams include software customisations and implementations, consultancies, grants and support/maintenance contracts. We have grown every year for the last 6 years, we are profitable, we have not given up any equity and we have no debt.

We have ongoing partnerships with DFAT, MFAT, the mSupply Foundation, UNFPA, UNICEF and World Bank alongside partner countries and we are constantly looking to expand our partner base.