This application addresses the urgent need for more and better evidence on the appropriate selection, implementation and use of electronic health (eHealth) systems to support the care of HIV patients in developing countries. eHealth system including electronic medical records (EMRs) are potentially powerful instruments to strengthen health systems, to improve access to and quality of care, and reduce costs. While these technologies show great promise in countries whose health systems face severe financial, infrastructural, technical and human resource constraints, key questions remain for decision makers: (1) How can eHealth facilitate scale up of health initiatives in resource poor environments? (2) How can such systems be more effectively developed, and implemented to ensure high quality information for clinical and programmatic use? (3) Have the large investments in eHealth in resource-poor environments demonstrated clinical impacts such as improving HIV patient outcomes? (4) What are the short term and long term costs of implementing such systems and how can their sustainability be improved? While eHealth is proliferating in resource poor environments, often for HIV care supported by large investments from agencies including PEPFAR, data on their implementation, clinical impact and costs is very sparse. Countries like Rwanda and Kenya whose eHealth plans call for national rollouts of EMRs critically need evidence from rigorous, and generalizable studies. The core issue being addressed in this study is: What is the benefit of using an eHealth system to collect and manage clinical data at clinics that are often in remote sites with limited staff, and infrastructure? It builds on a critical opportunity to assess an open source EMR system, OpenMRS, that is being adapted by a technical team from the Rwandan MOH, and rolled out to several hundred clinics. With 11 sites implemented to date, this is the ideal time to perform a randomized controlled trial with 50 or more sites randomized to receive the system early or late. We will address three related questions: how to optimize systems and ensure they are stable, usable and used, what are the impacts on clinical processes and outcomes, and what are the costs of deploying and sustaining such systems? Clinical indicators will include mean CD4 count and viral load, activities such as ordering of laboratory tests, and rate of loss to follow up of pre-ART patients. The results should inform policy and care in many countries for HIV and other diseases. We will also create a training course in eHealth evaluation at the National University of Rwanda School of Public Health, training evaluators to take a lead in designing and carrying out studies.

Public Health Relevance

This project addresses a key question in the scale up of HIV treatment in resources poor environments: what is the role of Electronic Health (eHealth) systems in improving quality and access to care. While large investments have been made in such systems by PEPFAR, governments and other agencies very little evidence exists to inform policy makers. We propose to carry out a randomized, controlled trial of the rollout by the Rwandan MOH of the OpenMRS open source EMR system to several hundred clinics. We will randomize 50 or more clinics to early and late implementation and measure three key aspects: how to optimize and maintain the systems, what the clinical impact is, and the short and long term costs. We will also create a training program in eHealth evaluation at the National University of Rwanda School of Public Health.

National Institute of Health (NIH)
Coordinating Office of Global Health (COGH)
Research Project--Cooperative Agreements (U01)
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Special Emphasis Panel (ZGH1)
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National University of Rwanda
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