An information system and medical record to support HIV treatment in rural Haiti
http://www.100md.com
《英国医生杂志》
1 Brigham and Women's Hospital, Division of Social Medicine and Healthcare Inequalities,75 Francis Street, Boston, MA, 02115, USA, 2 Partners In Health, 641 Huntington Avenue, Boston, MA, 02115, USA, 3 Zanmi Lasante, Cange, Haiti, 4 Program in Infectious Disease and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
Correspondence to: H S F Fraser Hamish_fraser@hms.harvard.edu
Lack of infrastructure, including information and communication systems, is considered a barrier to successful HIV treatment programmes in resource poor areas. The authors describe how they set up a web based medical record system linking remote areas in rural Haiti and how it is used to track clinical outcomes, laboratory tests, and drug supplies and to create reports for funding agencies
Introduction
Haiti is the poorest country in the western hemisphere and, with about 6% of adults infected with HIV, is the most severely affected by HIV/AIDS.7 Six years ago the non-governmental organisations Partners In Health and Zanmi Lasante launched an innovative, community based HIV treatment programme in Haiti's impoverished central plateau.8 Zanmi Lasante currently monitors more than 7000 patients with HIV, of whom more than 1300 are currently receiving highly active antiretroviral therapy (HAART). In 2002, Zanmi Lasante was awarded part of Haiti's grant from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)4 to expand this successful programme to five more sites in the central plateau—Thomonde, Lascahobas, Boucan Carre, Belladere, and Hinche. Zanmi Lasante runs a central hospital housing the laboratory and main drug warehouse, with a second laboratory recently set up in Lascahobas and smaller pharmacies and laboratories in the other sites.
Highly active antiretroviral therapy requires daily administration of three antiretroviral drugs to maintain control of the disease and to minimise emergence of resistance.9 Scaling up care to thousands of patients requires good information management to ensure that each patient can be identified and traced, that his or her health status is monitored effectively, that results from critical laboratory tests are monitored and communicated to doctors, and that drug supplies are always available at each site. Implementing this rapid treatment expansion in a region with few doctors and virtually no roads, electricity, or communications is a major challenge. Zanmi Lasante's initial experience, in Cange, of access to the internet via a satellite link suggested that establishing communication with the new sites was feasible with new technologies to leapfrog the lack of infrastructure and that electronic record keeping was feasible and helpful in programme and patient management (fig 1).
Fig 1 Clinical staff in Belladere, rural Haiti, find their web based medical record system helpful for managing patients with AIDS
Information and communication
Medical information can be a critical lifesaving resource,10 but staff in remote hospitals often have to function almost entirely on their own, without access to up to date medical information or the support of more experienced colleagues. This situation is changing with increasing access to the internet, particularly with the expanded use of email.11 Consultation can include sending digital camera images, termed "store-and-forward" telemedicine.12 13 Our treatment sites in Haiti, Peru, and Russia have used email extensively over the past decade for clinical communication and logistics. Our experience in the original Haitian site, Cange, indicated that the cheapest and most flexible communication strategy was to establish a small satellite connection to the internet in each of the five new sites (box 1).
Box 1: Technical details of satellite systems
The main site (Cange) has a 256 kbs bidirectional link, using the USA Teleport Satellite signal, connected to a local area network (LAN) which provides broadband connection to the internet (256 kbs fractional-T1 line). The expansion sites have lower cost systems from Skycasters. Equipment includes a satellite dish and satellite modem that plugs into a standard PC server or a router. The asymmetric connection provides 400 kbs or better download speed but 30 kbs upload speed on the basic configuration, upgradeable to 64 kbs. The cost of basic hardware including the server PC is currently $6000 (￡3260; 4695), and monthly charges range from $130 to $260 depending on bandwidth. These specifications are similar to those for "Mini VSAT" satellite networks in west Africa and South Africa.
For connecting different buildings in a site, we use a standard Ethernet LAN or wireless LAN (802.11). Wireless technology allows low cost connection by avoiding additional wiring costs, and "in line of site" connections can be made up to 12 km at low cost ($1000).
Medical data management
Despite the value of email for supporting patient care, lack of structure and organisation limits its potential as the sole information management tool. Email also lacks good tools to ensure security and confidentiality of data. Creating a database of core information allows staff to track individual patients as well as to monitor the care of an entire group. For patients with HIV, this includes tracking critical laboratory results such as CD4 counts.
The traditional approach to electronic data management in a remote location is to place servers in the clinic sites,14 and in some systems data are periodically transmitted to a central server.15 In rural Haiti this is problematic because of unstable electrical power, humidity, dust, security concerns, and difficulty in providing technical support. Implementing a secure, web based electronic medical record allows data collection and review to occur from many remote sites. Using a shared server in a secure environment with stable power and good data backup (including a duplicate machine off site) has the additional advantage that the most recent data are available to all users. Scaling up treatment also calls for training new health workers; using decision support tools may assist them to become familiar with the management of HIV.
The HIV electronic medical record
Communications
Zanmi Lasante staff have fully adopted email to coordinate care between sites. This includes scheduling and obtaining the results of specialist investigations in the capital, Port au Prince, or the United States, organising patient transfers for surgery, and ensuring staff are ready for emergencies. Email consultation with doctors is done daily, especially by junior staff in remote clinics, who often require advice on treatment options. Patient names and addresses are excluded from non-secure email. Email also assists in ordering and monitoring shipments of drugs and equipment. Medical information websites are also used extensively.
Use of the HIV-EMR
The HIV-EMR has been operational for over nine months and is accessible at the six sites in the central plateau. Doctors and nurses enter all clinical and drug data using a standard patient registration form. To speed data entry, the form has a checklist to order patient management items, including investigations and standard sets of drugs (fig 2). Once this form has been submitted, the subsequent page displays any drugs that were selected. Doctors can check the drugs, their doses, and the times of day to be administered. Finally, when submitting this form, the user can print out an order for the pharmacy. As drugs are entered, they are cross checked for allergies, inappropriate doses, and incompatible drug combinations. The system displays warnings about any problems detected, such as prescribing zidovudine and stavudine together.
Fig 2 Part of the checklist of items in the patient registration form of the HIV-EMR electronic medical record (PPD=tuberculosis skin test, INH=isoniazid, HREZ=four standard antituberculous drugs, VCF=voluntary counselling and testing, PF=family planning, NRTI and NNRTI/PI=antiretroviral drug lists)
Decision support is also used for laboratory results. Technicians in two clinical sites, Cange and Lascahobas, enter CD4 cell counts. Each night, a program checks for patients with low CD4 counts who are not receiving the appropriate drug regimen. A warning email is sent to all 20 Zanmi Lasante clinicians and contains a link to the electronic medical records of patients who require additional treatment. Reminders can also be generated for patients who require extra drugs or investigations.
Currently more than 150 new cases are entered each month, mostly via the "Offline EMR" (see below). Of the 2500 cases that have been entered, more than 1300 have full registration data and vital signs, and 800 have full antiretroviral drug regimens recorded. Drug stocks in the warehouse are recorded regularly by the pharmacists using web based stock cards. Regular analyses monitor the expected drug use from the drug regimens entered.
Problems and challenges
Global experience in treating HIV in resource poor areas, including information management, is limited. Electronic medical record systems to support HIV treatment date back 10 years to Safran et al, who developed an ambulatory medical record component of the information system at Beth Israel hospital in Boston.22 Their system included email alerts for doctors about patients with low CD4 counts, and they showed it improved quality of care.22 Our HIV-EMR system shows that effective information management is also possible in a poor community with no modern infrastructure. The electronic medical record and communications systems continued to function even during the armed uprising in Haiti this year.
Box 4 describes existing systems for HIV information management in developing countries. The strategies for information management vary depending on the nature of a particular treatment programme, the number of sites where patients are treated, and the available infrastructure and human resources. Stand alone databases have the advantage of being easier to develop and maintain, but they typically lack valuable tools to coordinate data between sites. The use of guidelines and alerts to guide prescribing has been shown to improve the quality of treatment and reduce medical errors in developed countries.23 Given the limited experience in treating HIV in developing countries, decision support may have an important role, but this requires further evaluation.
Cost is a major concern with any technology intended to be used in very poor areas. Can the expenditure be justified with so many other pressing needs? The annual cost of internet access per site in Haiti is $1600, equivalent to about two years' highly active antiretroviral therapy and clinical care for one patient. Capital costs of $6000, along with staff training and assistance with data entry, increase the overall expense. This must be balanced against potential benefits including support for clinical care and research; our drug costs alone are currently more than $500 000 a year and rising. Strict reporting requirements by funders such as the Global Fund provide further incentives for effective monitoring.
Conclusions
Report on the global HIV/AIDS epidemic. Geneva: Joint United Nations Programme on HIV/AIDS, 2000.
Palella FJ Jr, Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med 1998;338: 853-60.
Marins JR, Jamal LF, Chen SY, Barros MB, Hudes ES, Barbosa AA, et al. Dramatic improvement in survival among adult Brazilian AIDS patients. AIDS 2003;17: 1675-82.
Richards T. New global health fund. BMJ 2001;322: 1321-2.
Betraying the sick in Africa. New York Times 2003 September 4: 22.
Loewenson R, McCoy D. Access to antiretroviral treatment in Africa. BMJ 2004;328: 241-2.
Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections. Geneva: WHO, UNAIDS, Unicef, PAHO, 2003: 2.
Farmer P, Leandre F, Mukherjee JS, Claude M, Nevil P, Smith-Fawzi MC, et al. Community-based approaches to HIV treatment in resource-poor settings. Lancet 2001;358: 404-9.
Harries A, Nyangulu D, Hargreaves N, Kaluwa O, Salaniponi F. Preventing antiretroviral anarchy in sub-Saharan Africa. Lancet 2001;358: 410-4.
Pakenham-Walsh N, Priestly C, Smith R. Meeting the information needs of health workers in developing countries. BMJ 1997;314: 90.
Fraser HS, McGrath SJ. Information technology and telemedicine in sub-Saharan Africa. BMJ 2000;321: 465-6.
Fraser HS, Jazayeri D, Bannach L, Szolovits P, McGrath D. TeleMedMail: free software to facilitate telemedicine in developing countries. Medinfo 2001;10(Pt 1): 815-9.
Della Mea V. Internet electronic mail: a tool for low-cost telemedicine. J Telemed Telecare 1999;5(2): 84-9.
Rotich JK, Hannan TJ, Smith FE, Bii J, Odero WW, Vu N, et al. Installing and implementing a computer-based patient record system in sub-Saharan Africa: the Mosoriot medical record system. J Am Med Inform Assoc 2003;10: 295-303.
Galvao J. Access to antiretroviral drugs in Brazil. Lancet 2002;360: 1862-5.
Fraser H, Jazayeri D, Mitnick C, Mukherjee J, Bayona J. Informatics tools to monitor progress and outcomes of patients with drug resistant tuberculosis in Peru. Proc AMIA Symp 2002: 270-4.
Olson C, Rankin J. Quantifying drug requirements. In: Quick J, Rankin J, Laing R, O'Connor R, Hogerzeil H, Dukes M, et al, eds. Managing drug supply. Hartford, CT: Kumarian Press, 1997: 184-206.
Milberg J. Adapting an HIV/AIDS clinical information system for use in Kampala, Uganda. Proceedings of Helina2003, Johannesburg. Johannesburg: International Medical Informatics Association, 2003: 44-5.
Rind DM, Kohane IS, Szolovits P, Safran C, Chueh HC, Barnett GO. Maintaining the confidentiality of medical records shared over the internet and the world wide web. Ann Intern Med 1997;127: 138-41.
Halamka JD, Szolovits P, Rind D, Safran C. A WWW implementation of national recommendations for protecting electronic health information. J Am Med Inform Assoc 1997;4: 458-64.
Douglas G. The Lilongwe Central Hospital patient management information system: a success in computer-based order entry where one might least expect. Proc AMIA Symp 2003: 833.
Safran C, Rind DM, Davis RB, Ives D, Sands DZ, Currier J, et al. Guidelines for management of HIV infection with computer-based patient's record. Lancet 1995;346: 341-6.
Bates DW, Cohen M, Leape LL, Overhage JM, Shabot MM, Sheridan T. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc 2001;8: 299-308.
Ministry of Health Brazil. National AIDS drug policy: June 2001. AIDS drugs logistic system. www.aids.gov.br/final/biblioteca/drug/drug4.htm (accessed 18 Oct 2004)..
Tassie J, Balandine S, Szumilin E, Andrieux-Meyer I, Biot M, Cavailler P, et al. FUCHIA: a free computer program for the monitoring of HIV/AIDS medical care at the population level. Int Conf AIDS 2002;14: C11029.
Geissbuhler A, Ly O, Lovis C, L'Haire J. Telemedicine in western Africa: lessons learned from a pilot project in Mali, perspectives and recommendations. Proc AMIA Symp 2003: 249-53.
Oberholzer M, Christen H, Haroske G, Helfrich M, Oberli H, Jundt G, et al. Modern telepathology: a distributed system with open standards. Curr Probl Dermatol 2003;32: 102-14.
Dolin RH, Alschuler L, Beebe C, Biron PV, Boyer SL, Essin D, et al. The HL7 clinical document architecture. J Am Med Inform Assoc 2001;8: 552-69.
Peleg M, Boxwala AA, Tu S, Zeng Q, Ogunyemi O, Wang D, et al. The InterMed approach to sharable computer-interpretable guidelines: a review. J Am Med Inform Assoc 2004;11: 1-10.
Carnall D. Medical software's free future. Open collaboration over the internet is changing development methods. BMJ 2000;321: 976.(Hamish S F Fraser, instru)
Correspondence to: H S F Fraser Hamish_fraser@hms.harvard.edu
Lack of infrastructure, including information and communication systems, is considered a barrier to successful HIV treatment programmes in resource poor areas. The authors describe how they set up a web based medical record system linking remote areas in rural Haiti and how it is used to track clinical outcomes, laboratory tests, and drug supplies and to create reports for funding agencies
Introduction
Haiti is the poorest country in the western hemisphere and, with about 6% of adults infected with HIV, is the most severely affected by HIV/AIDS.7 Six years ago the non-governmental organisations Partners In Health and Zanmi Lasante launched an innovative, community based HIV treatment programme in Haiti's impoverished central plateau.8 Zanmi Lasante currently monitors more than 7000 patients with HIV, of whom more than 1300 are currently receiving highly active antiretroviral therapy (HAART). In 2002, Zanmi Lasante was awarded part of Haiti's grant from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)4 to expand this successful programme to five more sites in the central plateau—Thomonde, Lascahobas, Boucan Carre, Belladere, and Hinche. Zanmi Lasante runs a central hospital housing the laboratory and main drug warehouse, with a second laboratory recently set up in Lascahobas and smaller pharmacies and laboratories in the other sites.
Highly active antiretroviral therapy requires daily administration of three antiretroviral drugs to maintain control of the disease and to minimise emergence of resistance.9 Scaling up care to thousands of patients requires good information management to ensure that each patient can be identified and traced, that his or her health status is monitored effectively, that results from critical laboratory tests are monitored and communicated to doctors, and that drug supplies are always available at each site. Implementing this rapid treatment expansion in a region with few doctors and virtually no roads, electricity, or communications is a major challenge. Zanmi Lasante's initial experience, in Cange, of access to the internet via a satellite link suggested that establishing communication with the new sites was feasible with new technologies to leapfrog the lack of infrastructure and that electronic record keeping was feasible and helpful in programme and patient management (fig 1).
Fig 1 Clinical staff in Belladere, rural Haiti, find their web based medical record system helpful for managing patients with AIDS
Information and communication
Medical information can be a critical lifesaving resource,10 but staff in remote hospitals often have to function almost entirely on their own, without access to up to date medical information or the support of more experienced colleagues. This situation is changing with increasing access to the internet, particularly with the expanded use of email.11 Consultation can include sending digital camera images, termed "store-and-forward" telemedicine.12 13 Our treatment sites in Haiti, Peru, and Russia have used email extensively over the past decade for clinical communication and logistics. Our experience in the original Haitian site, Cange, indicated that the cheapest and most flexible communication strategy was to establish a small satellite connection to the internet in each of the five new sites (box 1).
Box 1: Technical details of satellite systems
The main site (Cange) has a 256 kbs bidirectional link, using the USA Teleport Satellite signal, connected to a local area network (LAN) which provides broadband connection to the internet (256 kbs fractional-T1 line). The expansion sites have lower cost systems from Skycasters. Equipment includes a satellite dish and satellite modem that plugs into a standard PC server or a router. The asymmetric connection provides 400 kbs or better download speed but 30 kbs upload speed on the basic configuration, upgradeable to 64 kbs. The cost of basic hardware including the server PC is currently $6000 (￡3260; 4695), and monthly charges range from $130 to $260 depending on bandwidth. These specifications are similar to those for "Mini VSAT" satellite networks in west Africa and South Africa.
For connecting different buildings in a site, we use a standard Ethernet LAN or wireless LAN (802.11). Wireless technology allows low cost connection by avoiding additional wiring costs, and "in line of site" connections can be made up to 12 km at low cost ($1000).
Medical data management
Despite the value of email for supporting patient care, lack of structure and organisation limits its potential as the sole information management tool. Email also lacks good tools to ensure security and confidentiality of data. Creating a database of core information allows staff to track individual patients as well as to monitor the care of an entire group. For patients with HIV, this includes tracking critical laboratory results such as CD4 counts.
The traditional approach to electronic data management in a remote location is to place servers in the clinic sites,14 and in some systems data are periodically transmitted to a central server.15 In rural Haiti this is problematic because of unstable electrical power, humidity, dust, security concerns, and difficulty in providing technical support. Implementing a secure, web based electronic medical record allows data collection and review to occur from many remote sites. Using a shared server in a secure environment with stable power and good data backup (including a duplicate machine off site) has the additional advantage that the most recent data are available to all users. Scaling up treatment also calls for training new health workers; using decision support tools may assist them to become familiar with the management of HIV.
The HIV electronic medical record
Communications
Zanmi Lasante staff have fully adopted email to coordinate care between sites. This includes scheduling and obtaining the results of specialist investigations in the capital, Port au Prince, or the United States, organising patient transfers for surgery, and ensuring staff are ready for emergencies. Email consultation with doctors is done daily, especially by junior staff in remote clinics, who often require advice on treatment options. Patient names and addresses are excluded from non-secure email. Email also assists in ordering and monitoring shipments of drugs and equipment. Medical information websites are also used extensively.
Use of the HIV-EMR
The HIV-EMR has been operational for over nine months and is accessible at the six sites in the central plateau. Doctors and nurses enter all clinical and drug data using a standard patient registration form. To speed data entry, the form has a checklist to order patient management items, including investigations and standard sets of drugs (fig 2). Once this form has been submitted, the subsequent page displays any drugs that were selected. Doctors can check the drugs, their doses, and the times of day to be administered. Finally, when submitting this form, the user can print out an order for the pharmacy. As drugs are entered, they are cross checked for allergies, inappropriate doses, and incompatible drug combinations. The system displays warnings about any problems detected, such as prescribing zidovudine and stavudine together.
Fig 2 Part of the checklist of items in the patient registration form of the HIV-EMR electronic medical record (PPD=tuberculosis skin test, INH=isoniazid, HREZ=four standard antituberculous drugs, VCF=voluntary counselling and testing, PF=family planning, NRTI and NNRTI/PI=antiretroviral drug lists)
Decision support is also used for laboratory results. Technicians in two clinical sites, Cange and Lascahobas, enter CD4 cell counts. Each night, a program checks for patients with low CD4 counts who are not receiving the appropriate drug regimen. A warning email is sent to all 20 Zanmi Lasante clinicians and contains a link to the electronic medical records of patients who require additional treatment. Reminders can also be generated for patients who require extra drugs or investigations.
Currently more than 150 new cases are entered each month, mostly via the "Offline EMR" (see below). Of the 2500 cases that have been entered, more than 1300 have full registration data and vital signs, and 800 have full antiretroviral drug regimens recorded. Drug stocks in the warehouse are recorded regularly by the pharmacists using web based stock cards. Regular analyses monitor the expected drug use from the drug regimens entered.
Problems and challenges
Global experience in treating HIV in resource poor areas, including information management, is limited. Electronic medical record systems to support HIV treatment date back 10 years to Safran et al, who developed an ambulatory medical record component of the information system at Beth Israel hospital in Boston.22 Their system included email alerts for doctors about patients with low CD4 counts, and they showed it improved quality of care.22 Our HIV-EMR system shows that effective information management is also possible in a poor community with no modern infrastructure. The electronic medical record and communications systems continued to function even during the armed uprising in Haiti this year.
Box 4 describes existing systems for HIV information management in developing countries. The strategies for information management vary depending on the nature of a particular treatment programme, the number of sites where patients are treated, and the available infrastructure and human resources. Stand alone databases have the advantage of being easier to develop and maintain, but they typically lack valuable tools to coordinate data between sites. The use of guidelines and alerts to guide prescribing has been shown to improve the quality of treatment and reduce medical errors in developed countries.23 Given the limited experience in treating HIV in developing countries, decision support may have an important role, but this requires further evaluation.
Cost is a major concern with any technology intended to be used in very poor areas. Can the expenditure be justified with so many other pressing needs? The annual cost of internet access per site in Haiti is $1600, equivalent to about two years' highly active antiretroviral therapy and clinical care for one patient. Capital costs of $6000, along with staff training and assistance with data entry, increase the overall expense. This must be balanced against potential benefits including support for clinical care and research; our drug costs alone are currently more than $500 000 a year and rising. Strict reporting requirements by funders such as the Global Fund provide further incentives for effective monitoring.
Conclusions
Report on the global HIV/AIDS epidemic. Geneva: Joint United Nations Programme on HIV/AIDS, 2000.
Palella FJ Jr, Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med 1998;338: 853-60.
Marins JR, Jamal LF, Chen SY, Barros MB, Hudes ES, Barbosa AA, et al. Dramatic improvement in survival among adult Brazilian AIDS patients. AIDS 2003;17: 1675-82.
Richards T. New global health fund. BMJ 2001;322: 1321-2.
Betraying the sick in Africa. New York Times 2003 September 4: 22.
Loewenson R, McCoy D. Access to antiretroviral treatment in Africa. BMJ 2004;328: 241-2.
Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections. Geneva: WHO, UNAIDS, Unicef, PAHO, 2003: 2.
Farmer P, Leandre F, Mukherjee JS, Claude M, Nevil P, Smith-Fawzi MC, et al. Community-based approaches to HIV treatment in resource-poor settings. Lancet 2001;358: 404-9.
Harries A, Nyangulu D, Hargreaves N, Kaluwa O, Salaniponi F. Preventing antiretroviral anarchy in sub-Saharan Africa. Lancet 2001;358: 410-4.
Pakenham-Walsh N, Priestly C, Smith R. Meeting the information needs of health workers in developing countries. BMJ 1997;314: 90.
Fraser HS, McGrath SJ. Information technology and telemedicine in sub-Saharan Africa. BMJ 2000;321: 465-6.
Fraser HS, Jazayeri D, Bannach L, Szolovits P, McGrath D. TeleMedMail: free software to facilitate telemedicine in developing countries. Medinfo 2001;10(Pt 1): 815-9.
Della Mea V. Internet electronic mail: a tool for low-cost telemedicine. J Telemed Telecare 1999;5(2): 84-9.
Rotich JK, Hannan TJ, Smith FE, Bii J, Odero WW, Vu N, et al. Installing and implementing a computer-based patient record system in sub-Saharan Africa: the Mosoriot medical record system. J Am Med Inform Assoc 2003;10: 295-303.
Galvao J. Access to antiretroviral drugs in Brazil. Lancet 2002;360: 1862-5.
Fraser H, Jazayeri D, Mitnick C, Mukherjee J, Bayona J. Informatics tools to monitor progress and outcomes of patients with drug resistant tuberculosis in Peru. Proc AMIA Symp 2002: 270-4.
Olson C, Rankin J. Quantifying drug requirements. In: Quick J, Rankin J, Laing R, O'Connor R, Hogerzeil H, Dukes M, et al, eds. Managing drug supply. Hartford, CT: Kumarian Press, 1997: 184-206.
Milberg J. Adapting an HIV/AIDS clinical information system for use in Kampala, Uganda. Proceedings of Helina2003, Johannesburg. Johannesburg: International Medical Informatics Association, 2003: 44-5.
Rind DM, Kohane IS, Szolovits P, Safran C, Chueh HC, Barnett GO. Maintaining the confidentiality of medical records shared over the internet and the world wide web. Ann Intern Med 1997;127: 138-41.
Halamka JD, Szolovits P, Rind D, Safran C. A WWW implementation of national recommendations for protecting electronic health information. J Am Med Inform Assoc 1997;4: 458-64.
Douglas G. The Lilongwe Central Hospital patient management information system: a success in computer-based order entry where one might least expect. Proc AMIA Symp 2003: 833.
Safran C, Rind DM, Davis RB, Ives D, Sands DZ, Currier J, et al. Guidelines for management of HIV infection with computer-based patient's record. Lancet 1995;346: 341-6.
Bates DW, Cohen M, Leape LL, Overhage JM, Shabot MM, Sheridan T. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc 2001;8: 299-308.
Ministry of Health Brazil. National AIDS drug policy: June 2001. AIDS drugs logistic system. www.aids.gov.br/final/biblioteca/drug/drug4.htm (accessed 18 Oct 2004)..
Tassie J, Balandine S, Szumilin E, Andrieux-Meyer I, Biot M, Cavailler P, et al. FUCHIA: a free computer program for the monitoring of HIV/AIDS medical care at the population level. Int Conf AIDS 2002;14: C11029.
Geissbuhler A, Ly O, Lovis C, L'Haire J. Telemedicine in western Africa: lessons learned from a pilot project in Mali, perspectives and recommendations. Proc AMIA Symp 2003: 249-53.
Oberholzer M, Christen H, Haroske G, Helfrich M, Oberli H, Jundt G, et al. Modern telepathology: a distributed system with open standards. Curr Probl Dermatol 2003;32: 102-14.
Dolin RH, Alschuler L, Beebe C, Biron PV, Boyer SL, Essin D, et al. The HL7 clinical document architecture. J Am Med Inform Assoc 2001;8: 552-69.
Peleg M, Boxwala AA, Tu S, Zeng Q, Ogunyemi O, Wang D, et al. The InterMed approach to sharable computer-interpretable guidelines: a review. J Am Med Inform Assoc 2004;11: 1-10.
Carnall D. Medical software's free future. Open collaboration over the internet is changing development methods. BMJ 2000;321: 976.(Hamish S F Fraser, instru)