Journal:Development and national scale implementation of an open-source electronic laboratory information system (OpenELIS) in Côte d’Ivoire: Sustainability lessons from the first 13 years

Full article title	Development and national scale implementation of an open-source electronic laboratory information system (OpenELIS) in Côte d’Ivoire: Sustainability lessons from the first 13 years
Journal	International Journal of Medical Informatics
Author(s)	He, Yao; Liams-Hauser, Casey; Assoa, Paul H.; Kouabenan, Yves-Rolland; Komena, Pascal; Pongathie, Adama; Kouakou, Alain; Kirn, Mary; Antilla, Jennifer; Rogosin, Carli; Ngatchou, Patricia S.; Kohemun, Natacha; Koffi, Jean B.; Flowers, Jan; Abiola, Nadine; Adjé-Touré, Christiane; Puttkammer, Nancy; Perrone, Luca A.
Author affiliation(s)	University of Washington, I-TECH Côte d’Ivoire, Ministry of Health and Public Hygiene, U.S. Centers for Disease Control and Prevention
Primary contact	lucy dot perrone at ubc dot ca
Year published	2023
Volume and issue	170
Article #	104977
DOI	10.1016/j.ijmedinf.2022.104977
ISSN	1872-8243
Distribution license	Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
Website	https://www.sciencedirect.com/science/article/pii/S138650562200291X
Download	https://www.sciencedirect.com/science/article/pii/S138650562200291X/pdfft

Abstract

Purpose: Côte d'Ivoire has a tiered public health laboratory system of nine reference laboratories, 77 laboratories at regional and general hospitals, and 100 laboratories among 1,486 district health centers. Prior to 2009, nearly all of these laboratories used paper registers and reports to collect and report laboratory data to clinicians and national disease monitoring programs.

Project: Since 2009 the Ministry of Health (MOH) in Côte d'Ivoire has sought to implement a comprehensive set of activities aimed at strengthening the laboratory system. One of these activities is the sustainable development, expansion, and technical support of an open-source electronic laboratory information system (LIS) called OpenELIS, with the long-term goal of Ivorian technical support and managerial sustainment of the system. This project has addressed the need for a comprehensive, customizable, low- to no-cost, open-source LIS to serve the public health systems, with initial attention to HIV clients and later expansion to cover the general population. This descriptive case study presents the first published summary of original work which has been ongoing since 2009 in Côte d’Ivoire to transform the information management systems and processes in laboratories nationally.

Impact: OpenELIS is now in use at 106 laboratories across Côte d’Ivoire. This article describes the iterative planning, design, and implementation process of OpenELIS in Côte d'Ivoire, and the evolving leadership, ownership, and capacity of the Ivorian MOH in sustaining the system. This original work synthesizes lessons learned from this 13-year experience towards strengthening LISs in other low-resource settings.

Highlights of this work:

• Factors for scaling and sustaining an electronic LIS (eLIS) in low- and middle-income countries (LMICs) have not been previously described in the literature.
• Successful adoption, scaling, and sustainment of OpenELIS in Côte d'Ivoire relied on early collaboration with partners, regulatory agencies, and technical experts into every step of the design, implementation, and evaluation phases.
• Entities planning to nationally scale an eLIS should plan for 1) workforce development in both end users and system administrators; 2) financial sustainability; and 3) institutionalization of government ownership and technical leadership.
• An open-source eLIS can increase accuracy and timeliness of clinical laboratory data, supporting diagnostic testing and monitoring in a resource-limited setting such as Cote d’Ivoire.

Keywords: electronic information systems, laboratory information systems, quality, low-resource country

Introduction

In low- and middle-income countries (LMICs), inadequate infrastructure—including limited availability and use of electronic laboratory information systems (LISs)—has hindered quality laboratory service delivery for communities. [1] International development efforts such as the U.S. President's Emergency Fund for AIDS Relief (PEPFAR) have aimed to strengthen national laboratory systems by modernizing infrastructure and diagnostic testing methods, including automated analyzers that require computer connectivity for data management. The increase in the quantity and complexity of data generated from high-throughput analyzers and sophisticated diagnostics necessitates the transition from paper records to LIS.

Compared to paper-based systems, LIS are more efficient and enable better quality control (QC) in collecting, processing, managing, synthesizing, and reporting large amounts of data (Table 1). [1–2] The COVID-19 pandemic has highlighted the acute importance of digital health, including LIS, in providing data and enabling rapid data exchange and sharing to facilitate public health surveillance and data-driven decision-making. [3]

Table 1. Strengths of laboratory information systems (LISs) compared to paper-based processes. Lab aspect LIS feature(s) Actions Impact Reception Batch entry; referral workflows Accelerate the processing and recording of incoming work Reduce turnaround time (TAT) Results generation Work plans Help managers monitor workload and supply management Ensure efficient operation of laboratories Analyzer interfaces Relay results quickly and accurately Reduce TAT Reporting Interface with electronic medical record (EMR) Communicate client laboratory history rapidly to clinicians in referral networks Enable faster clinical decision-making regarding diagnosis, treatment, and prognosis; reduce TAT Interface with client notification systems via Short Message Service (SMS) or email Communicate test results to clients rapidly Prompt immediate behavior augmentation and achieve better health outcomes (e.g., initiate self-quarantine in the case of COVID-19). Interface with routine health information systems at the district, regional, and national levels Enable faster aggregate data reporting Facilitate data-driven policy making; reduce TAT Reports of quality indicators such as turnaround time Help managers monitor quality performance Facilitate continuous quality improvement; increase testing quality Overarching Graphic widgets (e.g., drop-down menus, checkboxes), active logic and value checks, flags and reminders for potential issues, and automation Reduce errors Facilitate quality control; increase testing quality Data storage and data query tools Allow secure, long-term data retainment and easy data retrieval based on specific needs Improve client privacy, long-term data availability, and data usage

However, LIS uptake and routine usage in LMICs remains low due to several barriers. LIS ownership, development, and maintenance can be perceived as bearing high costs of financial and human resources. Numerous proprietary LIS exist but may not be ideally suited for LMICs, where financial resources are limited and, most often, ongoing software support relies on long-term service contracts with private companies. Although some LMICs have implemented proprietary systems [4–6], these systems are vulnerable to market changes and can leave users unsupported if a company suspends its operations or modifies its service terms. Health information systems (HIS), including LIS, that use open-source code and are supported by communities of practice (CoPs) offer an attractive alternative in LMICs. Open-source CoPs have a vested interest in capacity building of software developers and users, including those from LMICs. [7] Implementation time and effort aside, there are no licensing fees, and all software code created is in public ownership, which enables others to customize and improve functionality. [8] Several open-source LISs are currently in use in LMICs in Africa and Asia, with varied scale. [9]

Another barrier to sustained, wide-scale usage of LIS is that LIS initiatives are often international-donor-driven and may lack close collaborations with ministries of health (MOHs) in LMICs. Engaging the MOH in the initial design and feature prioritization stage, building local capacity to own and maintain the software, and securing resource commitment after phaseout of donor support are time- and labor-intensive. [10] Additionally, power asymmetries between donors and LMIC stakeholders may discount local priorities, requirements, and innovations. [11] However, successful experiences of implementing an LIS in LMICs at the national scale have shown that strengthening MOH leadership and cultivating mutually beneficial partnerships are essential to impactful and sustainable laboratory system strengthening. [4][12]

Since 2009, the University of Washington’s (UW) International Training and Education Center for Health (I-TECH) has worked in partnership with the Côte d'Ivoire Ministry of Health and Public Hygiene (Ministère de la Santé et de l’Hygiène Publique, or MSHP) to implement a comprehensive set of activities aimed at strengthening the laboratory system. PEPFAR and the U.S. Centers for Disease Control and Prevention (CDC) have funded the partnership. One of the key activities is the sustainable development, expansion, and technical support of an open-source enterprise-level LIS, the OpenELIS system, with the long-term goal of Ivorian technical support and managerial sustainment of the system. The software serves as both an effective laboratory information management solution and a business operations framework for the laboratory service units (Fig. 1). The collaboration has addressed the need for a comprehensive, customizable, low- to no-cost, open-source LIS to serve the public health systems, with initial attention to HIV clients and later expansion to cover the general population.

Figure 1. OpenELIS laboratory software solution and business process framework. (Color should be used in print).

Côte d'Ivoire has a tiered public health laboratory system of nine reference laboratories, 77 laboratories at regional and general hospitals, and 100 laboratories among 1,486 district health centers. Prior to 2009, most laboratories used paper registers and reports to collect and report laboratory data to clinicians and national disease monitoring programs. The only LIS was a bespoke database located at the national HIV reference laboratory (called rETRO-CI), and this system was paired with commercial software.

The objectives of this case study are to: 1) present the iterative implementation process of OpenELIS in Côte d'Ivoire; 2) describe the evolving leadership, ownership, and capacity of the Côte d'Ivoire MSHP in sustaining routine use of OpenELIS; and 3) synthesize lessons learned for strengthening LIS in other LMICs.

Notes

This presentation is faithful to the original, with only a few minor changes to presentation. Grammar was cleaned up for smoother reading. In some cases important information was missing from the references, and that information was added. No other changes were made in accordance with the "NoDerivatives" portion of the content license.