Electronic Medical Records System

The problem is that currently, over 50% of health facilities in rural Uganda are reliant on paper record systems. Paper record systems are time-consuming to maintain, take up a lot of space, are highly prone to error and are at risk of records being lost or destroyed (by fire, damp, flooding, insects/rodents). Additionally they are inflexible as they are often stored at the facility and not available if the patient has travelled and needs to access care in another part of the country. Such records are often inaccurate or unavailable leading to patients receiving sub-optimal and uninformed care, with poor health outcomes. Paper records limit capacity to use available health data to monitor patient health and to spot trends in the health of the population, such as the spread of disease.

Uganda is on a path to establish access to rural health provision in all its 2,184 sub counties. If implemented, Uganda will have over 4,300 government facilities and 2,044 that are privately owned in the next 5 - 10 years.  At least 50% of these facilities are located in the hardest to reach, rural areas of Uganda, that do not have access to a digital health information management system like the one Nyaka has designed which is used to improve health in rural southwestern Uganda. They submit hard copy reports generated through tally paper sheets, to the district every month. These facilities don't have capacity to auto aggregate data, monitor historical data through various parameters and do not have the capacity to share health analytics in real time or virtually. Over 3,100 health care centres serve close to 12,000,000 people in Uganda alone. The situation is very similar across countries in the global south, especially in sub Saharan Africa,  especially in rural areas. A significant proportion of the global population, living in low income contexts suffer poor health outcomes as a result.

To address the issues mentioned above, we have designed and set-up  an automated Electronic Medical Records (EMR) System, in house, for www.nyakaglobal.org (Nyaka AIDs Orphans Project). Streaming patient data from across three clinics located in the rural districts of Kanungu and Rukungiri, southwest Uganda.  The clinics offer services including OPD, dental, immunization, family planning, antenatal, health education, health outreach and self test kit laboratory services.

What does it do?

The EMR helps health workers, monitoring and evaluation staff and program management teams at Nyaka to efficiently monitor large streams of patient data and information, boosting our capacity to make high impact decisions in real time and initiate interventions that continue to trigger improved health service delivery amongst children, students, grandmothers and the wider community that Nyaka supports. 

 Our EMR system captures patient data, on and offline, transmitting from multiple entry points and sources, to a central server for storage. The system also auto analyses data into precise visualization insights and graphics that align with the KPIs of our health program. Auto generated summary reports are sent via scheduled email notifications to inform relevant staff. The system is also configured to facilitate tailored data harvesting through real time downloads, in the formats of excel, csv, google sheets and PDF - allowing for additional data synthesis, parsing and health analytics. Data is available in real time and is sharable as and when needed. 

Our EMR is the integration of www.surveycto.com data collect, monitoring and storage technology, and Google’s Open Source Data Studio Visualization Dashboards. The platform has a back end user interface that makes it easy for anyone to design a data collect, analysis,  storage, visualization and data harvest system tailored to their own needs, using an online or offline design interface. 

 The SurveyCTO platform is built in a way that allows all its users to innovate systems based on need. Creativity and innovation is key. Creative and experienced users are more advantaged to design better systems than their peers who may be not as creative or innovative. Nyaka has designed a 360 degrees data management and visualization system that is fully automated. Our pilot cost us $2,800 in annual subscription for SurveyCTO license, Google data studio is open source. Nyaka’s EMR is tailored to our service area, beneficiary grouping and programmatic needs. We are managing a database for our staff and beneficiaries, both new and old. 

 Data capture starts at the point when a patient reports to the clinic. We use smartphones to capture patient data in offline mode regardless of where we are. Working in a rural setting means that we have limited access to the comfort of electricity, computers and other related technologies, but we are able to capture patient data even from the deepest and hardest to reach areas of rural, southwestern Uganda. Data collection and management during home based health care and community outreach is made possible through our EMR system. Uploading data onto our server, and visualizing the graphics and analysis via dashboards, requires access to an internet supply. One could use a smartphone, tablet or laptop to view data. Internet supply in rural Uganda is generally poor with limited and unreliable bandwidth, however, our data teams are able to upload their data and also interact with the dashboard via smart phones. The key underlying setback is the cost of the internet. 

How does it include human centred design?

Our EMR system is tailored to meet the health needs and complement the services offered by Nyaka to the vulnerable, rural communities that we serve.  We planned, designed and developed the EMR based on the need to provide free and low cost quality health care to children, grandmothers and the wider community in rural southwestern Uganda. Our system design is flexible and is very easy to customize. It takes about 30 minutes to implement an update into the EMR system. The platform is user friendly and does not require one to reinvent the wheel. SurveyCTO and Google have already done the back-end coding and programming. Routine maintenance is done by one staff member who specializes in database design, data management and Monitoring and Evaluations systems design - it's all user friendly and scalable. 

Our solution serves impoverished communities living in southwest Uganda. However, it  can easily be extended across rural Uganda and indeed rural Africa. We have already successfully piloted over 4,000 people in 2 rural districts of Kanungu and Rukungiri, training 7 Nyaka healthcare workers, 4 members of the village health teams (VHTs) and 2 data clerks.  The communities we work with live within the extreme poverty quadrant (typically surviving on $1.65 or less a day, ( The World Bank benchmarks extreme poverty at $1.9 or less a day). Our solution will improve the care of all community members, but especially the most vulnerable and those with more complex medical needs: older people, children aged 0-5 years, and pregnant mothers (postpartum haemorrhage in Uganda causes 25% of maternal deaths). Improved health care for rural communities means that people are more productive and are able to continue working towards lifting themselves out of extreme poverty. Nyaka works to transform household income to over $2.38 USD a day in a period of 24 - 60 months, giving the community and specifically grandmothers who are the main caregivers of over 87,000 children, opportunities to break the cycle of poverty, give children an education and have an improved quality of life.. 

Our solution will mean, that upon presenting at a healthcare facility, anywhere in the region (and eventually the country), healthcare professionals will be able to quickly and easily access their full health history and treatment plan to ensure that they receive appropriate and well informed care. Collecting and analysing data in this way will allow healthcare professionals not only to provide high quality care, but also to track health issues, monitor trends and help develop preventative interventions. Interventions might include targeted malaria education / distribution of nets and antenatal malaria treatment (fansidar), focused COVID-19 education, vaccination and treatment, or HIV/AIDS testing, education and stigma reduction work. 

 Our solution also means that primary health care data is tailored to specific communities and needs, and is fully utilized to improve care services and policy.  Data from the hardest to reach areas (last mile communities) is collected and submitted for auto-analysis enabling quick decision making and tracking in real time. It also means that field health workers like VHTs and community health teams contribute to the mainstream even when they do not have computers and offices. Health workers learn how to read and interpret health data and deal with patient needs and emerging risks as and when detected. 

This innovation is being spearheaded and coordinated by Nyaka’s monitoring and evaluation team which is based in Kanungu . The team of 4 specialists operates within the rural community where the innovation is being implemented. Working with 7 health workers and 4 members of the village health teams (VHTs), they ensure patients get quality health services, but are also monitored through the EMR system. The 3 teams are supported and supervised by the Nyaka Programs Manager. 

 Our beneficiaries are key stakeholders, and are always consulted through needs assessments and baseline surveys to incorporate their ideas and feedback on program / project planning and design. Progressive program monitoring and evaluation activities are also used to gather feedback for continuous refinement and improvement. 

Nyaka is deeply embedded within the local community and has been since its inception in 2001. Nyaka founder Twesigye Jackson Kaguri, was born and raised in the village of Nyakagezi, which gives Nyaka its name. Jackson’s family, classmates and friends continue to live there and Jackson visits for extended periods 3-4 times each year. Nyaka engages and involves the local community every step of the way - the organization provides holistic solutions to poverty, enabling grandmothers and children to access education, microfinance loans, healthcare, clean water and other essentials so that they can lift themselves out of poverty and access a brighter future. 

Following a successful pilot that ended in June 2022, we have embarked on the growth phase with a plan to achieve the following;

• To secure, sustain and improve the innovation as a long term strategy to improve health in rural south western Uganda. 

• To build capacity for Nyaka staff to adapt and utilize the system functionalities with ease. This means we will provide them the much needed equipment especially smart tablets and laptops to support data analysis. 

• To scale up capacity for Nyaka staff  and management teams to use the available healthcare data and information to better inform their decision making process and the efficiency to deliver health services. 

• To continue using the available resources to further design and plan health initiatives that aim to improve and redefine access to quality health care for the rural poor, especially children, women and the elderly. 

• To secure more storage, but with capacity to transmit and retrieve in real time.  Acknowledging that our data will continue to increase and will require an on-premises data storage space, away from the SurveyCTO server. 

• To add an offline integration for data storage and visitation.

• To start thinking about scaling the initiative program to other health centres in the area, and to advocate for adoption by the government and other NGOs, as well as private sector health care providers. 

 Where is the help much needed from the challenge?

• Financial barriers. We look to the challenge for financial support to help Nyaka;

  • Settle operational costs comprising procurement of hand held smart tablets and laptops for our 15 staff across 3 clinics 

  • Purchase of license keys for SurveyCTO and a suitable visualization tool (preferably Microsoft Power BI)

  • Support staff training and capacity building costs

  • Set up an on-premise server for offline and online access through laptops, phones and tablets. 

  • Secure a long term license key for SurveyCTO and Power BI

  • Settle mid term staff stipend, wages and alliances as we create a path away to secure long term and sustainable revenue streams for the innovation. 

  • Establish a free toll hotline for clients to seek guidance on health related issues through Nyaka clinic. 

• Financial support to plan, design and implement initiatives aimed at addressing some of the health risks and issues identified through Nyaka EMR system. Examples include a centurion program to address diet among grandmothers and children at a household, mobilization campaign through our hubs and adolescent clubs, etc. 

• Technical support. If Nyaka secures an on premise or customized server for data storage through this challenge, we shall then require technical expertise from a programmer or software developer at installation and database mapping. 

• Our health workers, data clerks and village health teams will require handheld smart tablets that we have not yet secured. They have been using their personal smartphones with low battery life challenges, limited capacity to take clear photos or capture GPS accurately.  We need equipment to grow this initiative to the next level.

No other organization or entity that is operating in rural Uganda has designed and created an integrated health information management system similar to Nyaka’s. No one has leveraged SurveyCTO to innovate an automated EMR tool like ours, with capabilities to deliver analysis and information in real time and at such a low cost. 

 It's only in the urban health facilities and at major hospitals that systems like https://dhis2.org/  have been installed by the government to manage specific patient data. DHIS2 has not yet scaled down to the over 50% health providers that exist and work amongst rural vulnerable communities. Our innovation is tailor made to prioritize our organization’s goals and community needs. Our solution requires only 7 - 10 days of design, set up and launching across clinics (it's efficient and scalable in record time). Our solution is low cost, does not require heavy onsite systems and complex servers to set up, maintain and manage. Our solution is a perfect problem solver for all organizations and entities offering health services in the hardest to reach areas, leveraging offline data collection capabilities. It is automated and streams data in real time upon submission, but is also flexible to work in the absence of front desk computers for data collectors and health workers. Data visualization happens in real time, and one can use their phone or tablet to view and interact with the dashboards. This means that health needs are immediately visible which ensure that necessary health interventions can be delivered quickly and efficiently to areas / people most in need. Data harvest and extraction is through a simple click and download process. Automated emails and auto-generated reports are an efficient way to schedule and disseminate information, so one is not worried about sharing reports and information manually. It is tailored to collect data for impact surveys, evaluations and other health related surveys with both small and larger communities (multipurpose). We save up to 100% the cost on paper and up to 100% the cost of hiring data entrants. We save up 80% on the time taken to clean, organize and analyse data for quick decision making. 

Uganda's health care system is ranked 149th out of 191 countries by the WHO. In addition, the lack of capital and access to technology has put pressure on an already broken health care system for many rural Ugandans. To address this, Nyaka will offer the Electronic Medical Records System (EMRS) to all rural clinics in the Kanungu district over the next 1-2 years. The EMRS will empower medical professionals to make accurate diagnostics, record treatments, securely store all records, and facilitate communication between attending physicians.

 Over the next five years, Nyaka's mission is to transform the healthcare system by utilizing analytics, machine learning and improving healthcare delivery. The EMRS database will empower Nyaka to dynamically empower staff at each clinic based on forecasted demand, justify the need for additional doctors/clinics, and accurately track healthcare trends in the community. As a result, Nyaka can uniquely foster better patient outcomes at lower costs for all stakeholders. Data real time visualization is the fastest way to red flag emerging community health risks. We look to use the EMRS to plan, design and implement initiatives that promote good living. Our goal is  to reduce malnutrition to its lowest rates ever, support communities in fighting against epidemics, communicable and non communicable diseases including malaria, dysentery COVID-19 and measles , and other conditions that are detrimental to health, especially among children and women. Our health interventions are part of the bigger solution to reduce poverty. Nyaka will continue to indirectly return time and income to our beneficiaries through free and quality health service and less days will be lost to sickness. This will continuously trigger an increase in income to above $1.95 daily for the majority of the poor households so they are able to educate their children and provide for their basic needs. Our physicians are well positioned to offer the right medication and treatment, and make referrals when required. We will use our EMR to enhance capacity to achieve these commitments.   

Impact outcomes (1 - 5 years)

• Change in disease incidence at households level - measured through household health surveys and patient records

• Change in disease incidence among school going children and women - measured through household health surveys and patient records

• Number of community initiatives planned, designed and implemented out of EMR data insights - measured by tracking all health initiatives implemented. . 

• Number of rural health facilities/clinics connected to the system - so far they are three (within Nyaka).    

• Reduced mortality among children and women - patient follow-ups are made using patient data to confirm recoveries. 

• Change in household Income and earnings per day - measure through annual income surveys

 Intermediate Outcomes will include increased numbers of:

• Staff attaining skills in use of EMR technology and data interpretation for dat to day decisions

• Consultations conducted and diagnoses reported

• Medication administered

• Patient recoveries reported

• Adoption rates to best WASH practices at household and schools

Outputs will include the increased number of:

• Field surveillance reports submitted by VHTs members

• Patient records submitted to the EMR system on a daily basis

• Children receiving consultation and treatment, broken down by age, gender, level of education and other parameters like weight and height

• Specific groups of people accessing consultation services and treatment, including Nyaka-led students, elderly women, People living withHIV and other community members

• People receiving health education and awareness

Rural Health Improvements through Nyaka’s EMRS (Electronic Medical Records System)

Existing Challenge: Substandard healthcare due to paper records system; Limited ability to monitor & track trends, resulting in lack of analysis/preventative activities. 

Theory of change

Nyaka’s EMRS is built and anchored on the SurveyCTO technology. SurveyCTO is a powerful, scalable, and flexible platform that researchers and organizations use to create forms and modular workflows with complex branching logic, non-linear navigation, randomized elements, multimedia and GIS capabilities, linkages to previous data collection rounds, and form version control. If you can imagine it, the surveyCTO platform can do it. It allows for the enhancement of the survey with audio, photos, videos, signatures, device sensor data, and GPS positions, boundaries, and paths. It performs random field audio audits, watches for outliers and suspicious distributions, reviews and corrects raw data before publishing, and receives nightly reports. 

Allows routing data to hundreds of external systems thanks to integrations with Google Sheets, Zapier, and OpenFN, plus RESTful and webhook APIs. You can also download your data in multiple formats to use with other tools, deploy new or revised forms to mobile devices and the web. Can be used to collect data on any Android or iOS mobile device. SurveyCTO is built on fixed, stable Linux servers that are maintained and won’t change over time. 

SurveyCTO always encrypts Internet communications with SSL technology that secures data in transit. Encrypts data at the point of collection, using its own 2048-bit encryption keys. Allows you to control which fields to share or publish—and which to keep safely encrypted with your own private encryption key. SurveyCTO is designed with multiple layers of data redundancy in mind, ensuring that data is recoverable from your server (and from SurveyCTO’s desktop application). All servers are mirrored 24×7 across multiple Amazon Web Services (AWS) locations and backed up every minute.

Our primary data collectors are a team of 9 people - comprising 3 full time health workers, 2 dedicated data clerking volunteers, and 4 members from the village health teams who undertake outreach visits and surveillance work.  Our staff and volunteers are from Kanungu and are committed to helping and supporting the communities in which they live.  The data collection methods are detailed above.

Nyaka values diversity, equity and inclusivity and these values are embedded in all areas of our work.  Our staff in Kampala and in the field are all Ugandan with the greater percentage coming from southwest Uganda where our work is focused.  We work across whole communities regardless of faith, culture, sexuality, physical/ mental health or ethnicity.

Nyaka programs also have a strong focus on gender and overcoming the many barriers women and girls in southwestern Uganda face. We believe that increasing education and access to opportunities for girls and young women has the most significant and positive impact on alleviating extreme poverty for them, their future children and the community at large.  Some of the steps taken by Nyaka to support girls include: 

• Girls make up 55% of Nyaka school pupils.  

• Sanitary towels are distributed to girls and young women to ensure that menstruation is not a barrier to education or employment. 

• Nyaka schools are also unusual in the Ugandan context in that girls who become pregnant are encouraged to complete their education. 

Electronic Medical Records System - Business Plan

Many of Nyaka’s donors have supported our work from the very beginning- more than 20 years. All of our current trusts and foundations have long term relationships with Nyaka, many of them stretching back more than 10 years. Being non-profit, Nyaka works to expand its donor list from around the globe every year, while continuing to build strong relationships with existing donors and allowing them to feel part of the solution. Nyaka has a funding strategy which is agreed by the Management Board.  The strategy is designed to ensure that key services, including this one, continue.  Funding is sought in a timely fashion to ensure that there is no disruption to provision and this project will be included in this.  In the event that other healthcare providers wish to purchase our expertise / EMR system, then, as a non-profit organization, any income will be reinvested into the service.

Nyaka has a very successful fundraising track record, growing year on year for the last 20 years.  Our full budget (including capital campaigns) for 2022 is $3.2 million. We have developed long term relationships with about 1000 individual donors (including some major donors) who support us with regular financial donations; this represents about two thirds of our annual income. We also have long term relationships with a number of trusts and foundations, who provide the remaining one third of our annual income. These include Imago Dei Foundation, Segal Family Foundation, Women’s Empowerment, Stephen Lewis Foundation, Beautiful World Canada. We have partnered with grant giving bodies for particular time limited pieces of work- in recent years these have included PEPFAR and CFLI. Additionally we work long term with a number of partners who support us with in-kind donations. These relationships include Bombas socks and Nakasero hospital. We have reserves in the bank which equate to 7 months operating costs. Nyaka also owns substantial tracts of land, planted with trees , in southwest Uganda which forms part of our sustainability plan (as well as having positive environmental implications).