Introduction and history
NepalEHR (an open-source software) is an integrated electronic medical record (EMR), built to keep patients’ organized medical history documents, patients’ complications, and the prescription to follow in the future. [1, 2] Integrated EMR differs from an ordinary EMR as it encompasses patients’ longitudinal care across outpatient, in-patient, emergency, laboratory, radiology, and pharmacy site of patient care. [2,3,4] It also has store management, an insurance support system, DHIS2 integrated module, which an ordinary EMR across the country fails to keep a record of. In addition, it can be generalized as a holistic patient health tracker software.
Looking behind using integrated EMR in Nepal, it was first used by an organization called Nyaya Health Nepal (NHN) as a pilot in Bayalpata hospital (residing in the hilly remote district, Achham) in 2015.  The integrated system included all the vertical programs of the government in its digital forms and provided electronic data to prepare monthly facility reports for the national Health Management Information System (HMIS). The hospital to national reporting platform integration can be tracked for the first time in the history of the country’s health system.
Currently, NepalEHR is being accepted and used at the provincial level. NepalEHR seems to be accepted and utilized in both low-resource settings as well as in district hospitals and other hospitals of Nepal. However, it can potentially incorporate and solve health information management and data-related issues nationwide.
Reporting structure and DHIS2
Current HMIS uses paper-based HMIS tools to record data, aggregate records on HMIS paper forms, and deliver them to the municipal office or District health/public health office. It is then put on district health information software (DHIS2). The DHIS2 is also open-source software, that is being used in more than 70 countries;  it is easy to use and needs 2-3 days of basic training to master it for recording, reporting and information sharing purposes. Its user interface, data entry, validation of data, and visualizers are built so conveniently that a computer literate can start using it with a short orientation. The government started using this software as a national reporting platform in 2017.
On average, the process of report preparation and submission from a district-level hospital into DHIS2 takes a week or more. This paper-based tool is serving national HMIS since 1993. These paper forms were designed to aggregate facility and community health data into national health reports. These paper records encounter human errors while recording, reading hand-written data, aggregating the data, and entering the report/data on a web-based platform. [5,7] The process is not error-free and tends to affect data analysis and national-level decision-making and policy implementation.
As defined by MoHP Nepal in “Hospital Management Strengthening Program (HMSP)”, a checklist to identify gaps in minimum service standards of district hospitals says, “Patient’s registration should be computerized using standard software.”  However, it still lacks reliable software, which can assure the standard of the national health record. The country seems to be waiting for reliable national software to onboard in the national health management information system. NepalEHR is built to satisfy the national requirement of keeping digital patient records and solves issues of human errors during report preparation. Facility level reporting continues from HMIS 9.3 and onwards. EHR’s observation forms are based on the national HMIS program forms and guidelines to fulfill the requirement of both clinical protocols to be followed and to prepare the HMIS report.
The integration module makes work easier in preparing the national HMIS report
The digital platform, NepalEHR is integrated with national HMIS’s reporting platform-DHIS2 through the “DHIS2 integration” module in EMR. It provides aggregated platform for entire hospital-based data for national HMIS reports, where data can be pushed directly from NepalEHR into the national DHIS2 platform. The full phased implementation of the data integration module in NepalEHR has been successfully used in several public-private, public, district, and province hospitals in provinces 3, 5,6, and 7 of Nepal.
NepalEHR has the entire data source to fulfill the required facility-based data to complete national HMIS reports from the health post level to the central-level hospitals. Aggregated facility-based data required for HMIS 9.3, 9.4, and 9.5 can be pushed from NepalEHR’s “DHIS2 integration” module to the government’s DHIS2 platform. The focal person for reporting or medical recorder then verifies the data in the DHIS2 platform and the dataset is clicked on “Complete” in DHIS2 to submit all the data available. The process takes less than 15 minutes with medium internet bandwidth.
Comparing the current time taken to prepare a monthly HMIS report to submission of it in DHIS2, it is much faster, and the data submitted are also error-free i.e. it exactly comes from original data recording forms. In addition, the data set can be reviewed in excel format before submission as well, which can be used for sharing aggregated monthly data with other stakeholders and can be used for program monitoring and improvement as well. It is useful for focal persons and team leaders to monitor the progress of the individual program.
The time has now come for the government’s assent in implementing national EMR software to prevent data errors and the use of information efficiently. It is easy to retrieve electronic data compared to a paper-based system. Due to the scarcity of space in keeping bulky Calculating the budget required to procure, use, and store the paper forms in a facility, the integrated EMR can be a substitute for paper-based records/reports from both space and financial perspectives. The integrated EMR is a one-time investment and the electronic medium can be friendlier to its implementers in many ways. In a nuts shell, implementing NepalEHR can be an opportunity in improving data management and information sharing by the nation in a holistic approach.
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7. Hospital Management Strengthening Program (HMSP) (2015). Checklist To Identify the Gaps in Minimum Service Standards (MSS) of District Hospitals. Retrieved from https://blog.apastyle.org/apastyle/2018/09/how-to-cite-a-government-report-in-apa-style.html
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