I want to design and pilot test EMR system for two areas (a rural and an urban Tuberculosis unit) in one of the States of India. If Annual TB case notification is about 123 per 100000 per year in one unit and another 90 per 100000, then what would be the estimated overall cost for developing and managing the EMR for these patients for 1 year? Can anybody advise on this with some breakup? Thanks

 
Dave Wyant
Replied at 1:45 PM, 18 Nov 2013

The cost of an EHR varies greatly depending on your starting point and the functionality you want. I can't give you an estimate, I don't know your local conditions. But as an example, in America when an EMR is purchased we might not need to add any hardware. Then, again, we might need significant new infrastructure and some kind of handheld devices. At one point , a few years back, everyone in the USA was worried about medical error, so they wanted EMR, CPOE and barcoding. Some providers already had one of these systems, so it changed their cost compared to other providers. You might think of the EHR as a hub. It provides data and receives data from many sources, and it is enhanced by and enhances those functions. As a starting point determine what functionality you want, and then determine what does that mean you will need to add in terms of software, hardware, and infrastructure.

dian marandola
Replied at 1:48 PM, 18 Nov 2013

I consider assessment and cost projections for E H R in three chuncks: pre implmentation, implementation and post implementation.
At Pre: consider your current costs of managing this patient population and how E H R may assist in meeting the management needs. I am inclined to see urban and rural important variables in this phase.
-consider what your current workflows are and how a given E H R would best support your process
-consider what kind of infrastructure your organization currently has in place.
Implementation: staff training needs: general and "superusers"
post implementation: ongoing hardward costs; ongoing software costs
-maximize the functionality of whatever product you invest in through staff training and report writing

Dr. Sachin Atre
Replied at 2:31 PM, 18 Nov 2013

Thanks to both of you for adding important points. Just to elaborate further, I am initially looking for a very basic EMR system for keeping track of the patients, their medications supply and want to see how it functions, whether this kind of system is acceptable to the health care providers as well as for patients. Currently no EMR system exists, and people are largely unaware about EMR system. In some areas internet access is poor or lacking. I hope once these issues are tackled, scale up can be thought of.

dian marandola
Replied at 2:45 PM, 18 Nov 2013

I think you may want to move over to the TB experts and see the kinds of tools that they recommend.

A/Prof. Terry HANNAN
Replied at 3:05 PM, 18 Nov 2013

Dian, good reply. Joaquin Blaya and Hamish Fraser would seem ideal resources to communicate with considering their work in South America. Terry

Ron Hebert
Replied at 6:24 PM, 18 Nov 2013

Dr, Atre, of India, raises the most fundamental issue associated with all eHealth initiatives in the developing countries. What is the COST of the implementation, including on-going support? This matter appears to be avoided by those with experience in the developed countries - who should know the costs - however, the costs in the developed countries of an EMR or EHR is extremely high (up to US$300 per capita per year in the UK) relative to the financial resources of any of the developing countries.

After 17 years of eHealth experience in developing countries, mainly in the Caribbean (Jamaica, Dominica and Montserrat), with two trips to India to discuss eHealth, I can provide some cost figures which are the crux of the question asked. In Jamaica, the cost of their national PAS (Patient Administration System) and e-Surveillance System (operational since 1997) is US$0.81 per capita per year. This is not for an EMR or for an EHR, for there are no such implementations in any developing country worldwide. I hope that this accurate field-proven cost information is of assistance to those developing countries contemplating eHealth initiatives.

A/Prof. Terry HANNAN
Replied at 6:50 PM, 18 Nov 2013

From my understanding A/Prof Andy Kanter of the Millennium Villages Project and developers of the AMPATH project in Kenya have costs details on e-health implementations.
This is some data I have from AMPATH: AMPATH maintenance cost only $175/patient/year in 2007 and is now less than $100/patient/year in 2009 [dividing all direct USAID/PEPFAR funding per year by the number of patients actively receiving treatment.] and the MVP (provided by Andy-Integrated development at $120 p child /y [schools,clinics,staffing,teachers,medicines,roads, water + administrators]. Writing to both project leaders may provide you with more accurate details.

Hamish Fraser, MBChB, MRCP, MSc
Replied at 11:20 PM, 18 Nov 2013

The question of the cost of EMR systems in low and middle income countries (LMICs) is clearly very important and is finally getting more attention. A number of LMICs including Kenya, Rwanda, Malawi, Tanzania the Philippines and Haiti are in the process of scaling up EMR systems to hundreds of clinics and hospitals. Evaluating the costs of implementing successful EMR systems and the ongoing yearly costs is crucial both to budgeting for a particular project and coming up with the most cost effective packages of hardware, power supply, networking, software, staffing and training.

We don't yet have all the numbers especially for running costs, but for an OpenMRS or similar EMR system the minimum cost is usually one laptop server (to ensure built in power back up and 4 - 6 hours use off the grid). Many sites will need a simple LAN with a router and 2 - 3 netbooks for clients. Physical security has to be budgeted for and possibly solar panels or fuel for a generator. Internet access through a cable or wireless such a 3G also needs to be included I many cases.

Software can vary from free to thousands of dollars. Even "free" systems can cost a significant amount in customization or configuration and there are potential technical support costs for bugs, upgrades and crashes due to power outages.

So these items can be matched to local prices and salaries to give broad estimates of cost. We are looking at the staffing costs of supporting different configurations of systems.

I am not sure where Ron is getting his numbers from. A primary care practice in the UK will have more than 1500 patients per doctor, so at $300 per capita that would be $450,000 per doctor which is more than 10 times the cost in the US even for first time implementation. The actual cost is likely under 10 USD equivalent per patient per year, I will find out accurate numbers and post to the list. As for there being no EMR implementations in any developing country, that this clearly incorrect as noted above. As to what these EMRs do however, some are fairly comprehensive point of care systems, others more basic and closer to PAS in functionality.

Steven Wanyee Macharia
Replied at 3:51 AM, 19 Nov 2013

Sachin, in Kenya, we at ITECH have scaled up implementation of OpenMRS customized for MOH and rebranded ad KenyaEMR (https://demo.kenyaemr.org username and password are demo), and now KenyaEMR is in active use at more than 100 health facilities. Implementation costs are generally broken down as follows;
Pre-implementation: mostly includes all the prep work necessary for a successful implementation/deployment and costs incurred here are mostly logistics, meetings with stakeholders (MOH, other partners, etc). Typical costs here for us are transportation, per diems, accommodation, meeting costs and on average this can rake up to KES: 200,000 depending on many factors of course like number if meetings, distances covered etc. additional costs include facility readiness assessment related activities which includes travel to sites identified for implementation, conducting assessment to determine facility's level of readiness to implement the EMR, then upgrade process based on assessment results. Key important factors that are minimum prerequisites for implementation and are addressed in assessment report are security, power and facility management support. Costs associated with this activity again vary, but for a single facility, can go up to KES: 50,000 again depending on several factors. Upgrade process again is variable and depends on findings from assessment report, but typical security upgrade depends on what is minimally required as adequate security and sometimes this can be as simple as installing grills on windows, locks on doors, etc. Simple security upgrades can cost on average KES: 20,000 or less. Power/electricity upgrades again depends on multiple factors. We don't invest in massive power solutions but instead purchase basic smart UPSes for our servers costing about KES:25,000 per unit and since we use thin clients, specifically N computing access terminals, we only need one UPS per facility. We also install LANs since our preferred implementation is Point of Care. LAbour for a typical LAN Costs about 30,000kes. Networking materials for one facility are about KES:150,000 for all basic networking materials for on average a 6-8 data points.

Implementation:
Typical costs here include:
Procurement of hardware server KES: 92,000, thin client KES: 40,000
Deployment related costs which are;
Travel logistics about KES:50,000

Post-implementation:
Mostly tech support here and on average per hour cost for technical staff is about KES2,000 per hour.

You also need to add software dev costs and other admin and ops overhead costs.

All these costs are very conservative estimates. I can probably work out a more accurate per facility total cost. We are working on better costings and we'll share that out ad well.

Hope this is useful.

Dr. Sachin Atre
Replied at 10:32 AM, 19 Nov 2013

Thanks to all of you for giving so many insights for me to think through about different aspects of EMR/EHR system. I look forward to hear from others about their experiences which will enrich this discussion and provide us more inputs for designing the EMR system for developing country settings.

Ron Hebert
Replied at 11:37 AM, 19 Nov 2013

This discussion is providing some interesting, and helpful, cost information for the many persons in the developing countries who are actively pursuing eHealth for their home country. It would be helpful if all cost figures could be standardized to one particular currency, whether the US$, or euro, or if in a national currency the ratio to US$ or euro would be provided. In Canada the cost per capita per year of eHealth is currently about US$80. However, as I have noted earlier, this cost is not for a national EHR or EMR, but refor even after 42 years Canada has yet to achieve a national EMR, which is projected to cost about US$300 per capita per year. To address Terry's point above, this cost in Canada will be in the same cost range as for the UK NHS - when either is ever completed, which remains several years out still.

Krishna Chintala
Replied at 8:19 AM, 28 Nov 2013

EMR costs can greatly vary depending on the features as others have mentioned.

We are based out of India and providing basic version of EMR free of cost to small practices and doctors from third world nations. You can check the attachement for more details.

Attached resources:

Dr. Sachin Atre
Replied at 10:29 AM, 3 Dec 2013

Hello Krishna, Thanks for this information. Worth sharing. I will come back to you soon with additional discussion points.

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