Archive for the ‘eHealth’ Category

15 Apr

An Opinionated Approach to OpenMRS Concept Management

Posted by ssmusoke in eHealth, openmrs, opensource, software delivery, software development lifecycle, tips and tricks. Tagged: , , .

One of the key strengths of the OpenMRS platform is the concept dictionary, which allows for the mapping of real world health care data needs into concepts that provide the questions and answers.

The concept dictionary provides ability to map real life concepts to specializations across health care domains such as: SNOMED CT (clinical healthcare terminology), LOINC (laboratory observations), ICD-10/11 (disease classifications), RxNORM (normalized names for clinical drugs), CVX (vaccination codes) in addition to leaders in certain medical fields such as Partners In Health and AMPATH (HIV Care and treatment).

However with great power comes great responsibility, the concept dictionary coding can easily get out of hand, with duplicate concepts leading to inability to extract data for reporting and improving the efficiency clinical care that are key goals of health informatics activities.

This guide is based on my personal experience from working across multiple diverse implementations and the fact that Open Concept Lab (OCL) is not yet in widespread production usage which would alleviate most of the pains, which includes:

  1. Supporting the upgrade, evolution and rollout of UgandaEMR in Uganda from 350 sites in 2016 to over 1000 sites (December 2019) including implementation of 2 major revisions of national Health Management Information Systems tools
  2. Migration of 2 custom OpenMRS implementations in Uganda to align to and build on top of UgandaEMR
  3. Namibia PTracker PMTCT program
  4. Enhancements of the Reference Application

The key principles to this approach are as follows:

  1. CIEL dictionary is the official source of concepts, and first place to check for concepts
  2. Custom concepts must be setup in such a way that updates to CIEL or other custom modules used do not overwrite the customizations

Concept Server Setup

The setup involves using the following OpenMRS instances:

  1. CIEL dictionary server running the latest reference application version – contains the latest version of the CIEL dictionary and helps for data export when needed. The complete concept dictionary however is not recommended to be loaded for an implementation due to slowdowns in concept lookup, as sample concept numbers are:
    • Reference Application 2.9.0 – 446 concepts
    • UgandaEMR – 5,500 concepts
    • CIEL dictionary – 54,000 concepts
  2. Custom Concepts Server – this one contains the custom concepts and CIEL concepts that exist, is the single source of truth for the project concepts. This needs to run similar modules to what the implementation is running. I would recommend the following additional steps:
    • Set the autoincrement value of the concept table to 5,000,000. This ensure that the concepts created will never be overwritten by CIEL concepts, the last numeric ID as of April 2020 is 165900 due to retired concepts etc
    • Set the auto increment values of the rest of the concept* tables to 10,000,000 (there are usually more values than so these tables grow)
    • Create a custom mapping for your project or implementation, and use that to reference the custom and CIEL concepts that you use in your forms and reports. This adds a layer of redirection and consistency for access
  3. Implementation Development, Staging and Demo Servers – as needed

Moving Concepts Across Servers

There are multiple options for moving concepts from the CIEL to the Custom Concepts Server and finally to the implementation servers

Approach Description Notes
Use of Metadata sharing and metadata deploy modules to build of metadata packages (zip files)
  • Manually downloaded from the servers and uploaded where needed – faces the challenges of manual processes
  • Provide a dedicated url from source servers that clients can subscribe to get updates as the deploy packages are updated following the pub-sub model
  • The creation of the metadata packages is manual
  • The metadata packages are zip files which are difficult to debug
Download the concept data into CSV or DB Unit compliant XML The concept files are then loaded into the implementation using either Initializer or Data Exchange modules
  • This requires developers to extract the concept data from the different tables, without making mistakes.
  • This is still a manual and error prone process
Open Concept Lab (OCL) Allows creation of custom dictionaries and extraction of data through an online web interface This tool is not yet production ready but would provide the automation that solves all issues

Data Export Tools

The following additional tools can be leveraged for this purpose

  1. Dbunit XML data export plugin for Data Grip – https://ssmusoke.com/2017/04/17/techtip-dbunit-export-from-jetbrains-datagrip/

 

 

3 Sep

An Opinionated Approach to OpenMRS Customization

Posted by ssmusoke in eHealth, test driven development (TDD), tips and tricks. Tagged: .

This is my opinionated guide to OpenMRS (http://openmrs.org) customization for multiple sites, may work for a single site if developer resources are available. This guide is based on 3 years working with the UgandaEMR distribution (https://wiki.openmrs.org/display/docs/UgandaEMR+Distribution) for the Ministry of Health of Uganda, currently in 650 sites across the country (December 2017).

Background to OpenMRS 

OpenMRS is a electronic medical records solution, which runs on Java 8, Apache Tomcat 7 and MySQL 5.x (we are using 5.5 and 5.6). The solution is based on openmrs-core (the platform) and modules which extend the platform providing key functionality such as look and feel, REST API, data collection tools, dashboards, patient management workflows.

OpenMRS releases the Reference Application (RefApp) a collection of modules that showcases how the EMR can be setup for clinical workflows, and which is usually the starting point for implementations. The RefApp is released twice a year, April and October, with enhancements that are prioritized by the community and developed leveraging available resources.

I may be somwhat biased due to my role as Reference Application Lead from January 2017.

UgandaEMR

This is one of the nationally approved EMR solutions, which is being actively developed from August 2015, currently supporting HIV Treatment and Care including HIV Exposed Infants (babies born to HIV positive mothers), Safe Male Circumcision, Tuberculosis treatment, Maternal and Child Health (antenatal, maternity and post-natal care), Outpatient services among others.

Guiding Principles

This approach follows the list of principles below:

  1. Any distribution should only customize workflows, look and feel and provide metadata to the underlying EMR – any custom functionality belongs in the underlying core platform and modules. This rule means that the underlying code grows and evolves with time to meet needs of different implementations, may not be adhered to 100% but even 80% is sufficient
  2. “If you need to change the core, then you are probably doing something wrong” ~Daniel Kayiwa OpenMRS Core Contributor, which is probably true. There are multiple ways to skin a cat so skin it the “openmrs” way
  3. Use the OpenMRS SDK – this tool is what an SDK should be, allows you to create, run and test multiple variations and approaches using the openmrs-distro.properties file that allows the distribution to define and build its own war file and docker containers for shipping
  4. Leverage the new openweb apps (OWAs) approach to provide user interfaces with the REST APIs
  5. For concepts always refer to the CIEL dictionary (http://openconceptlab.org/) as your primary reference
  6. Contribute changes back to the platform and modules you are using rather than build your own – stand on the shoulders of giants, but feed them too so that they can grow stronger and carry others. This is a core opensource ethos
  7. Keep your distribution code public – share with others never know where the knowledge will come from. My personal technology experience has been that at some point in time, you will have to come out and find you missed alot of the magic
  8. Ask quesitons on design, approaches, best practices and collaborate with the community to grow your knowledge and others – Don’t build a wall fence around your house, raise your neighbors so that you do not need a wall fence

How to setup a Customization

  1. Setup OpenMRS SDK in your developer environment – by now you have figured that I love this tool
  2. Use the SDK to create a reference application module usually named openmrs-module-mydistribution using

    mvn openmrs-sdk:create-project -Dtype=referenceapplication-module

  3. Create a new OpenMRS SDK server following the steps at https://wiki.openmrs.org/display/docs/OpenMRS+SDK#OpenMRSSDK-Settingupservers
  4. Copy openmrs-distro.properties file from the server to api/src/resources for your module
  5. Add a build plugin in the omod/pom.xml folder such as below extracted from UgandaEMR

  6. <build>

    <finalName>${project.parent.artifactId}-${project.parent.version}</finalName>
    <plugins>
    <plugin>
    <groupId>org.openmrs.maven.plugins</groupId>
    <artifactId>maven-openmrs-plugin</artifactId>
    </plugin>
    <plugin>
    <groupId>org.apache.maven.plugins</groupId>
    <artifactId>maven-dependency-plugin</artifactId>
    </plugin>
    <plugin>
    <groupId>org.openmrs.maven.plugins</groupId>
    <artifactId>openmrs-sdk-maven-plugin</artifactId>
    <version>3.13.1</version>
    <executions>
    <execution>
    <id>build-distro</id>
    <phase>install</phase>
    <goals>
    <goal>build-distro</goal>
    </goals>
    <configuration>
    <dir>${project.build.directory}/docker</dir>
    <bundled>true</bundled>
    <distro>${project.build.directory}/classes/openmrs-distro.properties</distro>
    <batchAnswers>
    <param>n</param>
    </batchAnswers>
    </configuration>
    </execution>
    </executions>
    </plugin>
    </plugins>
    </build>
  7. Set your custom module to be watched by the server, so each time the server is started the latest version of the module is built and deployed also makes live reload of controllers and styling possible

  8. mvn openmrs-sdk:watch

  9. Add a .travis.yml file to provide integration to Travis CI a sample below
  10. language: java
jdk:
- oraclejdk8
  11. Traditional OpenMRS development approaches now follow 😉

More examples from UgandaEMR can be found at http://bit.ly/ugandaemr-technicalguide

In closing, these are my thoughts on how such customizations should be done, while they may need a developer available, they are bound to start the test of time.

Do share your thoughts and learnings from this and let me know how to improve, I may not be able to change though

1 Dec

UgandaEMR Bootcamp – Strengthening the Foundation for a National EMR

Posted by ssmusoke in eHealth, openmrs, opensource, software delivery, software development lifecycle, tips and tricks. Tagged: , , .

This article was originally published on the METS website at http://mets.or.ug/ugandaemr-bootcamp-2017/ with photos courtesy of Nancy Karunganwa (https://twitter.com/Kanandra26)

The week of November 20 – 24, 2017, was an exciting one for the EMR team at METS where we held the first UgandaEMR developer bootcamp, aimed at developing local capability to extend and build upon UgandaEMR. The end-goal was to have 4 new HMIS forms developed to be added to UgandaEMR by the participants, while building their understanding of the platform, how it works, and the software delivery process used by the METS team.

The blog post below is abridged in Twitter thread at https://twitter.com/ssmusoke/status/933970233261424641

Background

METS is the Monitoring and Evaluation Technical Support program a 5-year Centers for Disease Control (CDC) funded cooperative agreement, started in April 2015, led by Makerere University School of Public Health (MakSPH) as prime with University of California San Francisco (UCSF) as a sub-grantee. The aim of the program is to support Uganda Ministry of Health (MoH) with Strategic Information across multiple areas, one of which being the ability to leverage electronic medical records (EMRs) as the foundation for patient centered care starting with public health facilities.

From August 2015 to February 2016, the METS team embarked on updating an OpenMRS distribution, WHO Express, which was over 6 years old installed in about 350 public health facilities, to the latest released OpenMRS version as well as the the latest HMIS tools in ART care. In March 2016, the METS team started upgrades and training on how to use the new version of the EMR in Kabarole, a district in Western Uganda, with 20 sites. In May 2016, the first National Training of Trainers was held in Mbrarara with over 150 trainees, followed by an official rebranding of the OpenMRS distribution by MoH, to UgandaEMR.

Fast forward to September 2017, when METS released UgandaEMR 2.0.0 an upgrade from the 1.x series released in 2016, using the latest long term release OpenMRS platform (2.0.5) and Java 8, which is seen as the future foundation for the next 5 – 10 years.

The key challenge faced by the METS UgandaEMR team is that new features were not being added as fast as the implementing partners, MoH program areas and end-user facilities needed. This led to the concept of a bootcamp to seed the local tech scene with capacity to develop upon and extend UgandaEMR providing a key component of sustainability for the platform, through speeding up development of health tools needed by stakeholders.

The bootcamp with 20 participants, was split into 5 days, following the principles of agile software delivery, with focus on having usable forms by the end of the camp.

Day 1 – Problem definition and requirements gathering

To kick off the bootcamp was outlining of the expectations by the participants – most of which focused on learning about UgandaEMR, building on top of it and learning more about the software delivery process used to build the EMR.

The 4 HMIS tools to be developed in the week were introduced by a doctor from the METS team, building up an understanding of the purpose of the paper tools and how they are used within the context of a public health facility.

A parallel activity between the breaks of the tools discussion was setup of the development environment tools on participant laptops, which included MySQL/5.5, Java 8, git, maven, OpenMRS SDK, Intellij Community Edition & Visual Studio code that were to be used on preceeding days.

At the end of each day, the facilitators and participants had a “retrospective” looking at how the day went and what can be improved going forward.

UI Wireframe Showcase

Day 2 – Wireframing

The key challenge with digitizing paper records is how the paper tools are transformed to digital forms. The day kicked off with an overview and guidelines for UgandaEMR form design process at https://metsprogram.gitbooks.io/ugandaemr-technical-guide/content/form-management.html

The teams were handed pencils and paper, and with support from facilitators developed UI wireframes. After 3 hours of back-and-forth the teams were requested to show case their designs to provide feedback for each individual team but to also share learnings across all the teams.

Day 3 – Concept Management

OpenMRS Architecture Presentation

OpenMRS Architecture

This was the first day that the facilitators and participants delved into OpenMRS architecture and design, leveraging parts of a presentation “Health IT and OpenMRS: An Introduction”

The idea was to introduce concepts and how the medical data is coded using concepts. Once the introduction was complete, the teams re-assembled to identifying the concepts needed for their forms following searching the locations below:

  • UgandaEMR concept dictionary
  • CIEL – a local instannce using the latest released concept dictionary
  • Identifying new custom concepts to be created

The discussion and modeling of the required concepts led to interesting discussions on differing approaches to handling repeated data capture dependent on the context of usage of the concepts. In certain cases we agreed to disagree about the models which would be tackled in subsequent iterations.

Day 4 – Coding HTML Forms

This was the long awaited activity, to see the forms come to life. Based on prior experiences, all laptops had setup and configured development environments.

The process copied from OpenMRS development guide was as follows:

  • Each team picked a single machine to work on
  • The team created a branch which was the HMIS number for the form being worked on by the team
  • An OpenMRS SDK  server named ugandaemr was created
  • The server was configured to watch the developement folder such that any changes to the forms would be automatically viewed following steps at http://bit.ly/2hWyAun

Once the initial form metadata was entered, with a quick primer on using HTML form entry tags, the teams worked leaving gaps where concepts were not yet defined.

The presentations were electrifying as the work for the whole week could be visualised. The approach to the team was the non-developer was to do the actual coding of the form, with the support of the team so as to slow down the “coding speed” to ensure all team members were active.

At the end of the day a working version of each team’s form was committed to GitHub and a pull request issued for progress monitoring.

Day 5 – Presentation Day

This is usually the most stressful day, however to make it fun the teams took the opportunity to self-organize in order of presentation, with a . number of constraints, teams decided the order to present, with opportunities being given to team members who had not lead any presentations during the week.

Dr Eddie Mukooyo, Ms Evelyn Akello with the best performing team at the bootcamp

This was to give all the team members an opportunity and to force the teams to prepare for the presentations.

A winning team was selected based on their presentation style, understanding of the HTML form being delivered and progress within the constraints.

Key Learnings

  1. The bootcamp was for 20 participants of whom 6 were female with a range of background from students of software engineering and Masters, software developers, M& E and public health practitioners
  2. The 5 days were not sufficient to complete working on the forms so the teams will work on their own with a planned follow-on activity to finalize for inclusion in UgandaEMR
  3. The positive feedback from the participants was with regard to the practical, collaborative and hands-on nature of the bootcamp, the learning experience of having to work within their teams which were randomly selected, balance brought to the teams from both the technical and non-technical members.

The event as seen by a little eye

Interactive discussions

Smiles and laughter to lighten up the day

Random selection of teams using sticky notes

Dr Eddie Mukooyo making closing remarks at the bootcamp on opportunity and expectations from the cohort of participants

Part of the METS UgandaEMR team with CDC Program Manager just after the first round of final day presentations

Group Photo – The first UgandaEMR Bootcamp participants and facilitators

3 Jul

National Digital eHealth Systems Maturity Model

Posted by ssmusoke in eHealth.

My thoughts on this topic were fully crystallized at a WHO workshop to disseminate the Consolidated Guidelines on Person-Centered HIV Patient Monitoring and Case Surveillance, from June 18 to June 23, 2017, where one of the discussions centered on the state of national eHealth data collection and management systems.

My thoughts on this model, were firmed up by the discussion and sharing following the three-age system adopted by history, anthropology and archeology in organizing human events. The stages are:

  1. Stone Age – communities of 25 to 100 people surviving on hunting and gathering. Some communities evolved into having temporary settlements at opportune locations for economic activities
  2. Agricultural Age – permanent settlements varying in size from villages to walled cities. Increased scale of domestication of animals, planting of fields and use of tools for agriculture.
  3. Industrial Age – Replacement of hand tools by power driven-tools, communities coming together in governance, planning and resource mobilization. Learning and culture starting to blossom, and new knowledge being created

Now to map those models into national digital eHealth initiatives

  1. Stone age
    • Paper based tools for patient monitoring and reporting
    • Limited use of electronic medical records (EMR) coverage below 20% of sites
    • Where EMRs are available used as dumb data dumps to simplify mandatory reporting needs
    • Adhoc usage of data for facility care and program monitoring
    • Single disease support in EMR
  2. Agricultural age
    • Increased rollout and usage of EMR tools at patient service sites over 60% coverage
    • Disparate integration efforts and capabilities between different systems
    • Routine mandatory reporting well established
    • Routine data usage for patient care and treatment program monitoring
    • Initial efforts at system inter-operability over and above point-to-point system integration
    • Adhoc dashboards and data analysis outputs developed
    • Unique identification processes at initial state of establishment
  3. Industrial Age
    • At least 85% of sites have an EMR installed and routinely used
    • EMR systems cover at least 60% of clinical data available
    • Routine patient treatment and monitoring data generated, analyzed and summarized
    • Connections between systems done following documented best practices and protocols leading to development of health information exchanges
    • Dashboards and data analysis tools routinely used to display summaries at different levels
    • Well established, documented and routinely used unique identification
    • Data de-identification done regularly to provide data sets for analysis

Looking forward to hearing your thoughts … Where does your nation lie

29 Dec

OpenMRS Implementor Series 101 – Building a distribution package

Posted by ssmusoke in eHealth, openmrs, opensource, software development lifecycle, tips and tricks. Tagged: .

I am not sure where this will end, however it is my way of giving back to the OpenMRS community that has provided an excellent learning platform and great support to me over the last 6 months, I have been using the software tools.

My intention is to share what I know, as a way of organising my thoughts and sharing ideas as I figure out where to add this to the OpenMRS community documentation, where it surely belongs. The flow of each of these posts will usually be to answer a very specific question that I have asked in the past, and where I think I have figured out an approach that seems to work.

UPDATE December 31, 2015: The new home for this blog post is  on the OpenMRS Wiki at https://wiki.openmrs.org/pages/viewpage.action?pageId=93358939 all further updates will be placed there

Problem Statement: How can I get an OpenMRS distribution that has all the modules that I need?

New to OpenMRS – What is Possible?

If you are new to OpenMRS and would like to see what is possible, then download the OpenMRS X.X Standalone Edition from http://openmrs.org/download/ which contains a pre-configured reference application with sample data that is ready to run in a single command.  This is note meant for production use as the embedded components are not robust enough for the growth in data collected.

Enterprise Installation like Reference Application

If the reference application provides all the modules that you need, the next step is to set-up n enterprise ready installation using a dedicated application server & database in which the Platform x.xx WAR (for Enterprise) can be installed. The modules for the reference application above can be downloaded as a zip file from the standalone edition above.

Full Control of Enterprise Installation

The last option is the most complex, and is for those implementors who want to install the enterprise edition but have control over what modules are installed or even what versions. In this case the OpenMRS distro platform is your best choice (https://github.com/openmrs/openmrs-distro-platform) which allows the building of a custom WAR file that includes the modules that you need.

The modules are defined in the pom.xml file and are accessed from the OpenMRS Maven Nexus repository (http://mavenrepo.openmrs.org/nexus/index.html#view-repositories;modules~browsestorage).

An addition to this project is for modules (pending review) but currently available at https://github.com/ssmusoke/openmrs-distro-platform is the ability to include custom modules (*.omod files) by dropping them in a folder called modules.

Please do share your comments on this style and let me know where it would fit best in the OpenMRS community documentation

 

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