CERHIS has been developed to address the issue of non-existing suitable IT solution to facilitate information management in small hospitals and health centers confronted to difficult environmental conditions (poor power supply , poor internet connection, low computer skills, distant IT competences, low financial resources) in low and middle income countries. CERHIS is a facility health information system using Android tablets in replacement of the paper registers. The tablets are synchronized using a Wi-Fi local area network. It is an integrated solution, with software and hardware components, including a specifically designed protection and charging cabinet with alimentation by solar panels and/or grid electricity and/or generators, when available. It produces a simplified EMR, information for the facility management, and aggregated information for the National HMIS (through interoperability with DHIS2).
Connecting CERHIS with OpenIMIS will thus allow to consolidate the OpenIMIS coverage in reaching healthcare users who would otherwise be excluded because they are attending facilities that cannot use more demanding hospital information systems like OpenMRS or Bahmni.
For that purpose some work is still needed to fully comply with open source requirements, to adhere to interoperable standards and to connect the CERHIS billing module (under development) to the OpenIMIS platform.
The project consists in providing additional resources mainly in terms of labor costs to:
- Support the transition of CERHIS towards an open source system, with an ultimate goal of reaching a global good status;
- Implement adherence to the HL7 FHIR standards and OpenHIE framework, particularly concerning FHIR standards for claims & reimbursement;
- Adapt the billing module to integrate health insurance management functionalities, working in interoperability with OpenIMIS.
Consortium includes the following organizations:
AEDES - the European Agency for Development and Health, is a private consulting company specialized in public health in low and middle-income countries. AEDES is very much involved in supporting Health information system with a focus on challenging operating environment. AEDES has started supporting the development of CERHIS in 2014 in collaboration with students of the computer and engineering departments of the Université libre de Bruxelles who help design CERHIS full solution package including the cabinet to store tablets, power supply, server and router. AEDES also works with the cooperation agency of the university (ULB-Coopération) that is active in DRC where the first pilot took place.
Since then, AEDES has hired developers to continue the development of the solution, and AEDES as a health organization provides health professionals to advise the developers. The combination of these two competences (IT and health) guarantees the relevance of the developed solution.
The pilot has been extended with the support of the Global Fund in Kinshasa in close collaboration with the HIS department of the Ministry of Health, an installation took place in Burundi with the Belgian Technical Cooperation agency (Enabel), a new installation is starting in partnership with ULB-Coopération and the Provincial Hospital of North Kivu (HPNK) funded by the European cooperation. Other installations are planned among others with NGOs such as MEMISA.
AEDES is responsible for technical project management, software development, training of local trainers, helping local implementers, contact with partners, coordinating volunteer effort, and public relations.
In countries AEDES builds partnerships with local organizations that AEDES trains so that they have the capacity to provide close technical support to implementers. The local ULB-Coopération bureau in Goma, DRC, and the North Kivu Provincial Hospital (Hôpital Provincial du Nord-Kivu) will participate in the testing process.
In low and middle income countries, well established digital solutions exist to help manage health information at National level (DHIS2), at the level of rather large health facilities (OpenMRS, Bahmni...) as well as for frontline health workers (OpenSRP). But at the level of small health facilities in difficult environmental conditions (poor (or no) power supply, poor (or no) internet connection, scarcity of IT competences...) where OpenMRS or Bahmni could not operate there was no solution answering all the needs of the health facility Information management. The patients of such facilities would therefore be excluded from an Insurance scheme managed with a system like OpenIMIS.
CERHIS has been developed to address this issue. CERHIS is a facility health information system using Android tablets in replacement of the paper registers. The tablets are synchronized using a Wi-Fi local area network. It produces a simplified EMR, information for the facility management (without requiring Internet connection) and aggregated information for the National HMIS (interoperable with DHIS2 via only intermittent internet connection if available or via any other means including USB drive). CERHIS is highly configurable and adaptable, and is meant to address, amongst others, the needs of the National Health Information Systems.
A billing module has been designed and is in its pilot phase but it doesn’t integrate yet health insurance management functionalities.
CERHIS is an integrated solution, with software and hardware components, including a specifically designed protection and charging cabinet with alimentation by solar panels and/or grid electricity and/or generators, when available. The software is free to use but the code is not yet published as open source, and it will require some refactoring, improvement and commenting before being ready to efficiently accept input from independent developers and to be easily reviewed by third parties, as part of a wider open source community. Some documentation is available on a private wiki, but it needs to be to be further elaborated and opened to the public to allow the community to independently install and configure the system.
Facilitating the process for CERHIS to conform to open source requirements, facilitating meeting the interoperability standards, and providing support to finalizing the billing module with a connector to OpenIMIS will allow OpenIMIS to consolidate its coverage in conformity with its priorities and roadmap: open source, scalability, interoperability and modularity, adherence to standards, build on existing software, handling IMIS facility-level functionalities (registration and pre-authorization, claiming), approach on micro-services and standardization).
The project consists in:
- Supporting the transition of CERHIS towards an open source system, with an ultimate goal of reaching a global good status;
- Implementing adherence to the HL7 FHIR standards and OpenHIE framework, particularly concerning FHIR standards for claims & reimbursement;
- Adapting the billing module to integrate health insurance management functionalities, working in interoperability with OpenIMIS.
The technical approach follows steps as described below:
- Analysis of i) the existing code and data model, ii) relevant FHIR standards (particularly the Claim & Reimbursement and Accounting and Billing standards) and iii) the OpenIMIS API;
- Adaptation of the design of CERHIS to adhere to those standards (this is already done with dxf2 for DHIS2, and ready for ADX), to optimize the data model, and to improve implementation of the microservices architecture;
- Review of some elements by an independent eHealth security specialist, including existing encryption, authentication and role-based access control;
- Further development of the billing module that includes functionalities required by insurance management and a connector to OpenIMIS (a medical doctor and a health economist from AEDES, who are both specialized in health facility management will be associated in the process to better conform to real needs);
- Iterative development in order to insure both quality improvement and compliance with open source standards and communication standards (FHIR, OpenHIE): code review, refactoring, unit testing creation, and documentation;
- Migration of the code of this new version of CERHIS from the current private GitLab repository to a public GitHub repository;
- Testing in an existing implementation site in the DRC, with iterative development, adaptation and maintenance.
At this point, a production-ready, open source new version of CERHIS will be available to the wider community. Since CERHIS is already highly configurable, it is expected that independent implementations of the core system will then be possible without requiring modification of the code, thanks to the provided software in a ready state and the sufficient documentation. The project will also be in a state making it possible to start forming an open source community for interested contributors.
Development of a new billing / insurance management module will take place on a public branch of CERHIS 2.0, using agile methodology, with testing on the same site in DRC and progressive adaptation under the supervision of a local team of hospital personnel comprising a medical doctor, the administrative agent, and a technician who will participate to the deployment and ensure that remarks, requests and bug reporting is facilitated between field testers and the development team.
Anticipated timeline: the process is expected to be finalized within a 12 month periods including iterative testing and adaptations.
- Open source code of CERHIS core available online;
- Open source code of the billing and insurance management module available online;
- Documentation for CERHIS implementation and use available in a public wiki;
- Beta-testing reports shared with the community.
Internal monitoring will be facilitated by the use of the JIRA project management system. A steering committee will also gather periodically to review progress and validate results. Reports presenting progresses and results will be produced. The QA procedures includes as well public bug tracking; public issue tracking, code published on a public GitHub repository; public wiki with documentation for use and installation.
The main risk is to miss the deadlines, but the use of JIRA project management tool and close follow up by the steering committee must mitigate that risk.
For this proposal, the following team composition is proposed:
Within AEDES, in Belgium:
- The current CERHIS project manager (part time)
- The current CERHIS developer (part time)
- A new developer funded through this Digital Square request for application (full time)
- A medical doctor (part time, specific activities)
- A health economist (part time, specific activities)
- eHealth security specialist (consultancy)
To pilot the tests, in the Democratic Republic of Congo (Goma):
- A local medical doctor from ULB-Coopération (part time)
- A local computer technician from the hospital (part time)
- A contact person from the hospital staff (part time)
Roles and responsibilities of the actors are as follows:
- Facility management information system
- Health finance and insurance information system
- Electronic medical record
- Low-resource settings
- Open source