A Free, Open-Source, Offline Digital Health System for Refugee Care

Abstract

Background Rise of conflict, extreme weather events, and pandemics have led to larger displaced populations worldwide. Displaced populations have unique acute and chronic health needs that must be met by low-resource health systems. Electronic health records (EHRs) have been shown to improve health outcomes in displaced populations, but need to be adapted to meet the constraints of these health systems. Objective The aim of this viewpoint is to describe the development and deployment of an EHR designed to care for displaced populations in low-resource settings. Methods Using a human-centered design approach, we conducted in-depth interviews and focus groups with patients, health care providers, and administrators in Lebanon and Jordan to identify the essential EHR features. These features, including modular workflows, multilingual interfaces, and offline-first capabilities, led to the development of the Hikma Health EHR, which has been deployed in Lebanon and Nicaragua. Results We report the successes and challenges from 12 months of Hikma Health EHR deployment in a mobile clinic providing care to Syrian refugees in Bekaa Valley, Lebanon. Successes include the EHR’s ability to (1) increase clinical efficacy by providing detailed patient records, (2) be adaptable to the threats of COVID-19, and (3) improve organizational planning. Lessons learned include technical fixes to methods of identifying patients through name or their medical record ID. Conclusions As the number of displaced people continues to rise globally, it is imperative that solutions are created to help maximize the health care they receive. Free, open-sourced, and adaptable EHRs can enable organizations to better provide for displaced populations.

Development of an Offline, Open-Source, Electronic Health Record System for Refugee Care

“…Responses to interview questions were audio recorded by the interviewers with consent of the providers with notes recorded simultaneously by the interviewers. The design process involved a framework analysis to synthesize provider input as previously described by the authors ( 15 ).…”

Adapting and Implementing Apps for Mental Healthcare

“…A project developing and adapting an app for displaced persons was the Hikma Health Electronic Health Record, initiated by a non-profit organization [37]. The authors stress the importance of three aspects as success factors for implementation: provider-tailored modular workflows, multilinguality of the app (English, Spanish, Arabic), and an offline-first capability.…”

“…Comprehensive language, cultural and contextual adaptation of cognitive behavioural therapy for Arabic and Farsi speaking refugees [35 •• ] Language and content adaptation for an app supporting self-management of somatic and mental disorders in Norway [36] Development of an offline digital health system for refugee care [37] Co-design process to adapt a smoking cessation app for people with severe mental illness [38 • ] Agile project management principles to adapt an app for cognitive stimulation for people with dementia and their relatives [40,41] Co-design process to develop an app for patients with opioid use disorders [42] App implementation Establishing an ecosystem of digital mental healthcare in existing routine clinical workflows [46, 47 •• , 48, 49 •• ] Establishing "blended" mental healthcare by combining face-to-face and online therapies [51 • ] of implementing this adapted version of the toolbox were not reported, the methods of adapting the toolbox may be used as a guideline for the process of optimizing the potential of digital technologies in blended mental healthcare.…”

Crossing the digital divide: The workload of manual data entry for integration between mobile health applications and eHealth infrastructure

“…The implementation of both DHIs and EMRS brings benefits to clients, providers, and programs. Yet, many DHIs, including mHealth, largely operate without links to MoH supervision, routine data aggregation pipelines, or national M&E reporting systems 2,3,8 . Operating outside of national eHealth infrastructure may reduce potential impact, replication and scale while also undermining MoH authority.…”

“…mHealth tools are recognized by the World Health Organization (WHO) for their potential to improve the quality of client care across diverse health sectors and healthcare contexts 1 . Digital health interventions (DHIs), like mobile health (mHealth) apps, may require less consistent electricity or connectivity; be faster to design; and lower costs over traditional electronic health (eHealth) systems [2][3][4] . mHealth also holds promise to extend the reach of traditional electronic medical record systems (EMRS) that typically operate in static hospitals and health facilities.…”