Updating NepalEHR in response to COVID19

COVID19 is testing the world’s most advanced and resource-rich healthcare systems, and an uncontrolled outbreak in a resource-limited country like Nepal would most certainly be catastrophic. The government of Nepal has taken drastic steps to curb the spread like enforcing a national lockdown, but the healthcare system remains ill-prepared. The situation is compounded by misinformation propagated through social media that has managed to permeate urban and rural life alike.

In order to aid in the response, we have updated both the facility and community-based tools for our healthcare workers. This was done in coordination with Nyaya Health Nepal, using guidelines and protocols from the WHO and Ministry of Health, Nepal. These updated tools ensure dissemination of information through trusted local community healthcare workers who are available to answer specific queries, rapid clinical assessment at the facility by health workers, and data for immediate communication with the relevant bodies, which is so critical in an epidemic. These can very easily be adopted in other settings using Bahmni/OpenMRS and/or Community healthcare digital tools.

  1. Facility-based assessment

At the facility level, we have added a screening note that helps clinicians assess patients presenting with symptoms or exposure risk. The form was designed in consultation with official guidelines as well as physicians who already use NepalEHR. It was designed to be simple with a limited set of questions that do not require any free text input (notes can optionally be added to any response if needed). With the potential high flow of patients at the referral hospitals designated to screen patients, this helps the clinicians quickly assess a patient’s symptoms and risk factors, and guides them to concrete next steps.

COVID-19 has been added as a diagnosis to NepalEHR based on WHO’s ICD10 (https://icd.who.int/browse10/2019/en#/U07.1) classification. We are also looking to map all fields appropriately with the concepts in the CIEL concept dictionary from Open Concept Lab (OCL) for standardization across all systems using the terminology platform.

2. Community-based counseling

At the community level, we have added a counseling form that guides Community Health Workers in disseminating accurate information based on official guidelines, and referring suspected COVID-19 cases to the closest designated facility. Following is a screenshot from the COVID-19 counseling form which displays a one-pager from the government’s public awareness campaign.

The workflow of the COVID-19 Commcare counseling form is as follows:

COVID-19 Counseling Workflow

COVID-19 Counseling Workflow

Introduction and purpose of visit

Play 1-minute audio awareness message from the Government of Nepal regarding COVID-19

Walkthrough the infographic with symptoms and preventive measures (see screenshot above)

Counsel on the following preventive measures:

  1. Wash hands regularly with soap and water for at least 20 seconds

  2. Avoid touching your face

  3. Sneeze/cough into bent elbow

  4. Seek medical care immediately in case of fever, cough and breathing difficulty

  5. Avoid close contact with anyone showing symptoms mentioned above

  6. Avoid close contact with wild animals and livestock

  7. Ensure meat and eggs are properly cooked

  8. If possible, use a mask when leaving the house

  9. Wash hands before entering the house, and ask guests to do the same

  10. Avoid crowded areas

  11. Greet with “Namaste” instead of handshakes

Help set up a handwashing station at home

Counsel on precautions to take if you or your family members recently visited a foreign country

If you or a family member is showing ALL of the following symptoms, suggest visiting the nearest health facility for medical help:

  1. Dry cough and sneezing

  2. Fever of 100.4 degrees Fahrenheit or above

  3. Sore throat/ Headache

  4. Difficulty breathing