Partners in Health Hôpital Universitaire de Mirebalais Partners In Health (PIH) was founded in 1987 to deliver quality health care to the poor residents of Haiti’s mountainous Central Plateau region. Since then, PIH has expanded in Haiti, and around the world, striving to achieve two overarching goals: to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair.
Highlights ThoughtWorks helped PIH build the new EMR system using the open source software, OpenMRS. ThoughtWorks got it done on time, within budget, with a concentration on the user experience that would otherwise have been difficult. Technology developed for the new system is being contributed back to the OpenMRS software project, which benefits numerous other organizations as well.
Shortly after Haiti’s devastating 2010 earthquake, PIH designed, constructed, and opened a major new medical center, University Hospital at Mirebalais, in Haiti. This 205,000 square-foot, 300-bed facility, opened in 2013, fills a huge void in the country for people who have until now had limited access to high quality health care. University Hospital functions both as a national referral hospital and as a national teaching hospital dedicated to training the next generations of Haitian health care providers. As part of the outfitting of the new hospital, PIH, together with ThoughtWorks, designed, developed and implemented a new electronic medical records system (EMR) using OpenMRS, the widely used open source medical records software.
The heart of patient service: Electronic Medical Records system The EMR performs key hospital functions, including patient registration, check-in, and reporting, and may also store and manage patient records including vitals, diagnoses, dispositions, notes and orders for radiology tests. It is used by nurses, doctors and many other staff. PIH has deployed OpenMRS EMR systems in four countries around the world and had piloted an early prototype of the University Hospital systems at a nearby hospital in Haiti, but a new version with improvements including an easier to use interface, and integration with a Picture Archive and Communication System (PACS), and real-time data entry had to be developed to support the new, much larger and state-of-the-art facility at University Hospital.
PIH developers gained experience in applying the latest agile methods, including Continuous Design, to their specific situation as the project went forward. PIH and the OpenMRS project will benefit from the new testing framework.
Technologies Coding: Java, Spring, Hibernate, Jquery, Knockout.js, Saas, Compass, Underscore.js, groovy, sinatra, slim Dev environment: IntelliJ, Github, Eclipse, Balsamiq, Bamboo. Testing: Selenium, Mockito, webdriver. Deployments: Puppet, capistrano, debian packaging, heroku, vagrant. Project Management: Mingle. Communication: Skype, Google Hangout, IRC, Evernote.
By the summer of 2012, PIH realized that it needed to accelerate the new EMR project. ThoughtWorks developers have been significant contributors to OpenMRS, and since PIH and ThoughtWorks had already worked together in various ways through smaller projects within the OpenMRS community, PIH contacted ThoughtWorks for help.
It all starts with a focus on the users At the very start, analysts from both PIH and ThoughtWorks met in Haiti for an initial week of meetings with experienced users and stakeholders, including the head of the new hospital, the head of nurse training, a doctor, and EMR users from Lacolline Hospital (the earlier pilot site). The time in Haiti was devoted to understand issues with the existing EMR, and learn as much as possible from people experienced with working in the environment—what their priorities and issues were.
The full ThoughtWorks team then traveled to Boston for a week of interactive workshops and exercises with PIH. This helped everyone agree on the set of user stories that would be targeted as the initial release, known as the MVP (minimum viable product). That initial release was scheduled for January 2013 (just four months away at the time), to allow for extensive usability testing onsite in Haiti with staff from the new hospital as well as Lacolline Hospital.
Working together, across continents During development, PIH staff worked primarily from their Boston office, while ThoughtWorkers were located in Porto Alegre, Brazil. They coordinated with the OpenMRS project as well, with developers as far away as Poland. Technology kept the analysts and developers (and later, users in Haiti) in close contact. To assure optimal communication and understanding, PIH’s senior OpenMRS leader collocated with ThoughtWorks developers for several weeks at the start. Others from PIH, including software developers and a business analyst with years of experience in Haiti, also worked onsite with ThoughtWorks for periods of time over the course of the effort. These exchanges provided valuable insights for both teams.
Techniques for fast, distributed development The joint PIH/ThoughtWorks team of more than a dozen people used advanced Agile methods including Continuous Design and Continuous Delivery. Use of test-driven development and early creation of a testing strategy for the project were key elements. Thinking about testing early and building good unit (and other) tests not only improved quality but accelerated progress. Creation of a “live style guide” web page also helped, by speeding development of new features and increasing UI consistency across the application. Developers could find color schemes, font styles, common fragments such as forms, buttons and see how and where to use icons, lists, and tables, as well as the relevant code snippets. Because of the live guide, front-end code and stylesheets were reused instead of reworked or duplicated. Developers were able to create new fragments without the need to worry about creating new styles or html structures. In the end, the style guide was also a testing tool. Since it was connected with the repository, the team could refer to it before each deployment to see that the styles were consistent across all the elements.
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Lessons from usability testing, and the impact of design The MVP release of the new system was ready as planned after four months for the first release in January 2013, to start tests onsite in Haiti. A ThoughtWorks business analyst and a UX designer/developer went onsite to the not-yet-open University Hospital, along with a PIH analyst, for four weeks of usability and functional testing with users. By this time the system was reasonably complete and users could perform most tasks. The onsite team ran tests and role-plays with the new system for four weeks, to address any issues and ensure that the new EMR was easy and intuitive to use. Users were given minimal instruction on tasks to perform, monitored while they used the system, and debriefed. Assumptions made back in the beginning were tested, but as the facility was still creating the final processes and hiring staff, some assumptions remained to be checked later when things were finalized.
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Working with ThoughtWorks has brought important resources onto our team (BA, PM, UX, DevOps) that we did not have, helped us improve our internal development processes, and created something much better, much faster than we could have done on our own. We have also helped teach ThoughtWorks more about OpenMRS and the requirements of working in a location such as Haiti.
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Among the findings was that the shift and caps lock keys as well as mouse navigation caused problems for users, some of whom had little or no computer literacy. Users were much more comfortable in general with keyboard navigation (everyone used at least a basic feature phone, with quite a bit of keypad navigation). ThoughtWorks UX designers took these factors into account, making the application largely keyboard driven and changing password requirements to eliminate use of caps/shift where possible. ThoughtWorks also helped with user flows outside the EMR system itself, such as developing a process for paper medical records to be retrieved, barcoded and scanned into the new system for tracking.
Localization: Haitian Creole and French Another facet of user interaction is language. Users at University Hospital work in both Haitian Creole and French. Haitian Creole translations were needed for the general navigation and administrative properties of the EMR, while French medical terminology was more appropriate for the clinical functions. Haitian Creole and French translations tend to be longer than their English counterparts—buttons, label fields and other UI fragments were made larger to account for this. Icons were chosen very carefully as a second and important reference to communicate function of each part of the system. Changes were made continuously once the application was implemented to best accommodate the various EMR users and their preferred language.
Evan Waters – Director of Informatics – Partners in Health
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Partners In Health and the OpenMRS community become more agile PIH developers and the OpenMRS development community are benefitting from experience in applying the latest Agile methods. Test-driven development and a test framework created for the Mirebalais EMR will help future projects. Continuous Delivery and other Agile techniques were also learned, including pair programming, the minimum viable product (MVP) approach, time-boxed development for iterations, and techniques for estimating and measuring true progress, among others.
Ready when planned University Hospital at Mirebalais opened in the spring of 2013, with the new EMR ready as planned. The first surgeries took place in May, and services continue to expand. More than 8,700 unique patients had been registered by the end of May 2013, of 3 million projected to be served within the next three years. Some 100 healthcare providers and ancillary staff use the new EMR. It is easy to use and presents an updated, modern look. Says Renee Orser, PIH business analyst, “The interface is so simple that you don’t really need to show people how to do things, only what’s available to do.” Whereas most implementations of OpenMRS support only retrospective data entry, at University Hospital the team made a great leap forward in real-time data entry. Enabling realtime data entry was a key reason to focus on efficiency and intuitiveness of user interactions, since medical staff can’t afford to let a system compromise patient care. Support for retrospective data entry capability remained necessary in case of network outages, where the EMR becomes inaccessible. PACS integration supports use with digital X-ray and other imaging systems to give doctors and patients instant reports. This completely removes the need for film development, and allows sharing with radiology experts across the world in real-time via the web.
Going forward Since University Hospital at Mirebalais opened, a PIH Informatics specialist who has been living in Haiti for years and speaks Creole serves as the eyes and ears on the ground for the EMR support team to ensure feedback from live use is heard and accounted for. Features are still being rolled out regularly, and although the initial contract ended in June, work on the project has continued.
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I’d like to give a big thanks to ThoughtWorks for helping us make this happen. It really sped up our development in the home stretch before Mirebalais Hospital opened, and let us concentrate on the user experience in a way we just wouldn’t have been able to do otherwise.
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Darius Jazayeri – Informatics Lead Developer – Partners in Health
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