Technology Based on AHRQ-Funded Research Used to Track Tuberculosis in Homeless

A coalition of agencies and social service providers serving the Skid Row area of Los Angeles used an open-source electronic medical record (EMR) system, inspired by AHRQ-funded research, to track tuberculosis testing of the homeless for 2 years and make it easier for them to access social services.

Partners in Health, a nonprofit health organization that brings care to people in some of the poorest countries in the world, and Regenstrief Institute in Indianapolis conceived of the system, named OpenMRS, in 2004. It was devised as a flexible system capable of meeting the demand for high-quality health information in developing countries such as Rwanda and Kenya, where the two organizations were then working. The work was influenced by the AHRQ-funded research of William Tierney, MD, and his colleagues at the Regenstrief Institute. Tierney?s research, which identified factors that are important to the design and successful implementation of EMR systems, was a central element in the development of OpenMRS, which has since grown into a multi-institution, nonprofit software collaborative backed by a global software development community.

From 2009 to 2010, demographic and tuberculosis-related data for 3,000 of the 15,000 people who were homeless and living in Skid Row, a 50-block area in Los Angeles, were entered into the system. Paul Gregerson, MD, a key player in the OpenMRS project, calls it ?a good start.÷

The database came about after a 2003 study by Michael Cousineau, a professor and researcher with the University of Southern California Keck School of Medicine, found that health care for people who are homeless in Los Angeles was fragmented. ?There was really no formal program of health care for the homeless in Los Angeles at that time,÷ says Gregerson, Chief Medical Officer of the JWCH Institute, a private nonprofit health agency in Los Angeles that serves the homeless.

The finding led to the Skid Row Homeless Healthcare Initiative, a collaboration of 28 agencies and social service providers created in 2004, with Gregerson as Chair, to improve health outcomes and address deficiencies. One challenge in making improvements was communicating across social service providers and reaching the neediest people. This challenge was demonstrated in tracking tuberculosis testing. People who are homeless need to be tested for tuberculosis in order to receive vital social services such as housing and mental health care, but there was no system to track proof of testing, and the burden was on the patient to carry a yellow card indicating a negative result.

The OpenMRS tuberculosis registry was born after Gregerson and Lillian Gelberg, MD, MSPH, Professor of Medicine and Public Health at the University of California, Los Angeles (UCLA), and Joshua Newman, MD, MSHS, Assistant Professor of Medicine at UCLA, received a 2-year grant from LA Care Health Plan.

The Skid Row Homeless Healthcare Initiative maintained the OpenMRS system as a central registry that participating social service providers could consult to track a patient?s demographic information, such as where the patient had last lived and the various names used, tuberculosis status, and treatment status. The central registry improved communication among service providers and reduced duplicate testing that occurred after patients lost their yellow card, because they had no secure place to store it or because mental health or substance abuse problems made their lives unstable. The database did not track whether tuberculosis rates decreased.

Some challenges were encountered, including varying skill levels among collaborating agencies in using EMRs and computers, the capability to provide personnel to enter data, and agency funding levels, Gregerson says. Also, the project faced higher than expected costs from legal fees incurred in developing legal agreements for agencies and forms for patients.

No funding was available after the LA Care grant ran out in 2010, so the database has lost relevance because the information has become outdated. Patients have not been asked to give yearly consent to remain in the database as required by patient privacy laws, Gregerson says. Efforts to track tuberculosis are even more important now as Skid Row faces a resurgence of the disease. Ultimately, those involved in the registry hope that OpenMRS can be used to track other types of data to help improve the health of people who are homeless and living on Skid Row.