By: Jessica Wiken, Sanjaya Poudel, and Anant Raut

Background

Since signing the Alma Ata declaration in the 1970s, the government of Nepal has made significant improvements in health service delivery and population health outcomes. Primary health care (PHC) became a cornerstone of the country’s national health policy in 1991, aiming to expand affordable, reliable, and high-quality PHC services to rural and marginalized populations. 1 Nepal’s focus on community-based PHC as the foundation of universal health coverage (UHC) has remained a core theme of its national health sector strategies, 1 2 3 with the most current health sector strategy (2015 - 2020) built on four strategic principles: equitable access to health services, quality health services, health systems reform, and multi-sectoral approach. 4 While the country has made great progress in health in the past 20 years, including the passage of a National Health Insurance Act in 2017, 5 it continues to face many challenges to effective PHC delivery, especially in rural, disadvantaged areas. 2 4 6

The health system in Nepal, a low-income country with complex geography and a large multiethnic, multilingual, and multi-religious rural and remote population is characterized by a wide, decentralized network of public and private health facilities, community workers, and volunteers. 7 8  Poor or non-existent road infrastructure; limited administrative capacity; acute fiscal constraints; fragmented, verticalized health initiatives; and poor regulation and integration of the private sector into the broader health system have made it difficult for the government to deliver on its goals to provide high-quality, comprehensive, and coordinated PHC for all. 9 10 11 Effective delivery of high-quality PHC is particularly difficult in the rural and remote areas of Nepal with highly mobile populations. Consequently, issues of quality, affordability, accessibility, and fragmentation in both the private and public sectors have led to the erosion of public trust in health care institutions, leading people to bypass their nearest medical facilities for even the most basic health services, favouring hospital-level care over lower-level health clinics. 12 13 In efforts to strengthen the coordination of integrated, person-centred care across the public and private sectors and restore public trust in services, in 2009 the Ministry of Health and Population (MOHP) partnered with Possible, a US-based non-governmental organization. 14 15 The public-private partnership between the government of Nepal and Possible manages several programs. One of these programs is an innovative electronic health record program called NepalEHR, which is helping to strengthen the management and delivery of health services. 16 17 In particular, NepalEHR is supporting the delivery of continuous and coordinated PHC.

Possible's approach: Integrated information systems for high-quality PHC

An electronic health record (EHR) is an electronic information system used to manage patients’ clinical information and medical history to support their care over time. In addition to the personal care records for individual patients, a robust EHR often contains applications or decision support tools that providers can use to guide treatment planning and also supports the collection of data for uses other than clinical care, such as billing, quality management, surveillance, and outcome reporting. 18 19 EHRs have been widely adopted around the world as a tool to improve the quality, safety, and efficiency of patient care. 16 20 21 However, they are typically expensive and rely on advanced technologies that are difficult to implement and sustain in resource-constrained settings like rural Nepal. Consequently, many low-income countries that lack the infrastructure, resources, and skills to implement a large-scale EHR rely on paper-based record systems for managing patient care. 16 18 19 20 21 While much can be achieved with paper-based systems, they are typically time and resource-intensive and at risk of producing out-of-date and irrelevant data. 16 22 23 24 An effective EHR is considered to be an essential component of a strong, modern healthcare system that ensures the delivery of high-quality PHC for all. 22 25 26 Compared to paper-based care records, electronic systems are more comprehensive, reliable, scalable, accessible, interoperable, and interconnected and can support more effective planning and service delivery. 27 28

In 2014, Possible began to design and implement an integrated, holistic, and affordable health information system, NepalEHR, to better address the complex needs of the Nepali public sector health care system and deliver on the core functions of high-quality PHC. 16 17 21 29 The easy-to-use, the customizable interface can be used by a wide range of providers and planners across a network of government hospitals, clinics, and community health workers to improve the collection and use of patient information across diverse care settings and communities. 16 The EHR integrates three easy-to-use, low-cost information technology systems, and has adapted them for the local Nepali setting:

  • Bahmni - An open-source facility-based information system and electronic health record. 
  • Commcare - A community-based mobile data collection platform with offline functionality that is able to integrate with the hospital-based electronic health record. 
  • DHIS2 - A flexible, web-based open-source health management information system platform with supportive visualization and decision-making tools.

NepalEHR: Features and design

NepalEHR ensures informational continuity across Nepal’s health system to ensure that providers and administrators have access to the right information at the right place and right time. This includes information about facility-based care, community-based care, supply chain management, and administrative management. 17 It incorporates an array of features to capture comprehensive information on patient needs and the quality of services at the point of care, in both facilities and communities. These include: 16 17

  • Patient registration with unique identifiers for all patients
  • Patient medical records
  • Lab orders and results
  • Prescriptions and dispensing 
  • Inpatient bed management
  • Supply chain management
  • Radiology and imagery
  • Health Management Information System reporting
  • Mobile data collection with assisted decision making

At the patient level, these data are collected to help improve informational continuity between encounters at facilities with facility-based providers and encounters in the home provided by community health workers. At the facility and community level, providers use DHIS2 dashboards to aggregate these data for program improvement and population health monitoring to support the delivery of more responsive care. Taken together, these features allow providers to better identify threats to population health, such as disease outbreaks and longitudinally track patient outcomes to support the delivery of higher-quality, person-centred care. 9 

The design of NepalEHR embodies the five characteristics of strong information systems that support the delivery of high-quality PHC, including 9 16 17 30

  • Functional - To ensure that NepalEHR is consistently used to support effective decision-making for health, it integrates information technology platforms that are intuitively designed to be simple enough to be used by a range of different health workers at the point of care, with minimal training required; and feasible for use in low-resource settings, across multiple unique workflows and processes. 16
  • Well-defined - To ensure that the system captures data that is timely, reliable, comprehensive, and relevant to the needs of the population it serves, it undergoes monthly data system checks to ensure that the data collected are cleaned, summarized, and reviewed through regular data quality review sessions. 9
  • Comprehensive and coordinated - To ensure that the system captures and monitors a comprehensive range of health services and functions, holistic and communicated at the right place and time, it is equipped to capture and manage complex patient information across a wide network of care encounters and care settings. 
  • Resilient - To support the capacity of providers and planners to effectively adapt and respond to community needs, operationalize learnings, and coordinate with other health systems functions, NepalEHR harnesses the power of DHIS2 to allow for regulatory reporting and quality improvement. 32
  • Adaptable and scalable - While NepalEHR is not yet a nationalized system, it employs easy-to-use, open-source software that functions on a range of devices, including tablets and laptops. It is compatible with the national healthcare information system (DHIS2) and is scheduled to be made interoperable with openIMIS by the end of 2019. 16 31 This helps to support the adaptability and scalability of NepalEHR as a national tool for PHC planning and service delivery.

Relevance to PHC and progress to date 

To date, NepalEHR has made significant progress in refining its systems and has been successfully implemented across the facilities and communities of two districts in Nepal. Specifically, the roll-out of NepalEHR in the districts of Achham and Dolakha has helped to enable more effective PHC delivery in several ways. Prior to roll-out in Achham and Dolakha’s district-level hospitals and their surrounding communities, information was manually recorded and stored in a paper-based information management system, which compromised data quality, availability, and accessibility. 21 The intuitive design and interoperability of NepalEHR have made it possible for users to easily collect, access, and use patient information and decision-support tools regardless of their skill level or location. By coordinating the collection and use of data across facilities and communities, NepalEHR has helped PHC providers to better serve as the first point of contact in hard-to-access communities and improve the accessibility, quality, and use of data critical for continuity and coordination of care. 29 33 Specifically, shared access to electronic medical records between facilities and community health workers is helping to provide facility- and community-based providers with continuity of data that enables them to appropriately identify threats to population health and longitudinally track patient outcomes for more effective, person-centred service delivery and informational, managerial, and relational continuity of care. 9 29 34 While its implementation in additional districts throughout the country is ongoing, initial deployments have found NepalEHR to be technologically feasible, affordable, and acceptable to users. These early results from two districts and the robust, modular, design of the information system suggest that plans to implement at the national level have the potential to dramatically improve the delivery of PHC in Nepal. 9 16

In addition, to improve access to healthcare for the insured and reimbursement funds for providers, Possible has been working to develop an application that will make NepalEHR interoperable with openIMIS, Nepal’s open-source software for managing its national health insurance program. 32 Once complete, facilities will be able to use this application to efficiently process insurance claims and reimburse providers. If scaled effectively to the national level, this application will help to improve insurance uptake, and, ultimately, the use of interoperable information systems to support UHC. It is slated to be complete by the end of 2019. 31

Challenges and next steps

While the NepalEHR program shows promise for PHC strengthening, especially related to continuity and coordination of care, it is currently only operational for a small proportion of Nepal’s population. More work needs to be done to integrate and scale this program nationally in order to build a more coordinated, interoperable, and integrated electronic information system that can improve the health of all Nepalis, including those in hard-to-access rural and remote areas. In particular, issues related to privacy, data ownership, management and training, quality assurance, affordability, user-acceptability, and the sensitivity of patient information, especially among mobile and migrant populations, will need to be addressed. 9 16  Nonetheless, the early successes of NepalEHR provide important insights into how low-income countries with limited resources can harness the potential of digital, community-based technologies to better deliver high-quality PHC and support the path to UHC.

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