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Objective: Little evidence exists on effective interventions to integrate HIV-care guidelines into practices within developing countries. This study tested the hypothesis that clinical summaries with computer-generated reminders could improve clinicians' compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa., Design: A prospective comparative study of two randomly selected outpatient adult HIV clinics in western Kenya. Printed summaries with reminders for overdue CD4 tests were made available to clinicians in the intervention clinic but not in the control clinic., Measurements: Changes in order rates for overdue CD4 tests were compared between and within the two clinics., Results: The computerized reminder system identified 717 encounters (21%) with overdue CD4 tests. Analysis by study assignment (regardless of summaries being printed or not) revealed that with computer-generated reminders, CD4 order rates were significantly higher in the intervention clinic compared to the control clinic (53% vs 38%, OR = 1.80, CI 1.34 to 2.42, p < 0.0001). When comparison was restricted to encounters where summaries with reminders were printed, order rates in intervention clinic were even higher (63%). The intervention clinic increased CD4 ordering from 42% before reminders to 63% with reminders (50% increase, OR = 2.32, CI 1.67 to 3.22, p < 0.0001), compared to control clinic with only 8% increase from prestudy baseline (CI 0.83 to 1.46, p = 0.51). Limitations Evaluation was conducted at two clinics in a single institution., Conclusions: Clinical summaries with computer-generated reminders significantly improved clinician compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa. This technology can have broad applicability to improve quality of HIV care in these settings.

Background: United states Agency for International development-Academic Model for Providing Accesses to Healthcare (USAID-AMPATH) cares for over 80,000 HIV-infected patients. Express care (EC) model addresses challenges of: clinically stable patient's adherent to combined-antiretroviral-therapy with minimal need for clinician intervention and high risk patients newly initiated on cART with CD4 counts < or = 100 cells/mm3 with frequent need for clinician intervention., Objective: To improve patient outcomes without increasing clinic resources., Design: A descriptive study of a clinician supervised shared nurse model., Setting: USAID-AMPATH clinics, Western Kenya., Results: Four thousand eight hundred and twenty four patients were seen during the pilot period, 90.4% were eligible for EC of whom 34.6% were enrolled. Nurses performed all traditional roles and attended to two thirds and three quarters of stable and high risk patient visits respectively. Clinicians attended to one third and one quarter of stable and high risk patient visits respectively and all visits ineligible for express care., Conclusion: The EC model is feasible. Task shifting allowed stable patients to receive visits with nurses, while clinicians had more time to concentrate on patients that were new as well as more acutely ill patients.

Objective: The AMPATH program is a leading initiative in rural Kenya providing healthcare services to combat HIV. Malnutrition and food insecurity are common among AMPATH patients and the Nutritional Information System (NIS) was designed, with cross-functional collaboration between engineering and medical communities, as a comprehensive electronic system to record and assist in effective food distribution in a region with poor infrastructure., Design: The NIS was designed modularly to support the urgent need of a system for the growing food distribution program. The system manages the ordering, storage, packing, shipping, and distribution of fresh produce from AMPATH farms and dry food supplements from the World Food Programme (WFP) and U.S. Agency for International Development (USAID) based on nutritionists' prescriptions for food supplements. Additionally, the system also records details of food distributed to support future studies., Measurements: Patients fed weekly, patient visits per month., Results: With inception of the NIS, the AMPATH food distribution program was able to support 30,000 persons fed weekly, up from 2,000 persons. Patient visits per month also saw a marked increase., Conclusion: The NIS' modular design and frequent, effective interactions between developers and users has positively affected the design, implementation, support, and modifications of the NIS. It demonstrates the success of collaboration between engineering and medical communities, and more importantly the feasibility for technology readily available in a modern country to contribute to healthcare delivery in developing countries like Kenya and other parts of sub-Saharan Africa.

We present the case of a 67-year-old woman with chronic cor pulmonale. She never smoked tobacco and had no other risk factors for pulmonary disease. In developed nations, chronic obstructive lung disease and cor pulmonale are overwhelmingly associated with tobacco use. However, indoor air pollution, most commonly due to burning of solid biomass fuel such as wood, can cause similar clinical syndromes. At our teaching hospital, there is an epidemic of chronic cor pulmonale among nonsmoking women. We attribute this sex predilection to women's greater exposure to wood smoke. Physicians must be cognizant of its risks and counsel patients on prevention strategies such as improved ventilation.

Background and Objective: The HIV/AIDS epidemic in sub-Saharan Africa is decimating populations, deteriorating economies, deepening poverty, and destabilizing traditional social orders. The advent of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) made significant supplemental resources available to sub-Saharan national programs for the prevention and treatment of HIV/AIDS, but few programs have demonstrated the capacity to use these resources to increase rapidly in size. In this context, AMPATH, a collaboration of Indiana University School of Medicine, the Moi University School of Medicine, and the Moi Teaching and Referral Hospital in Eldoret, Kenya, is a stunning exception. This report summarizes findings from an assessment of AMPATH staff perceptions of how and why this has happened. PARTICIPANTS AND APPROACH: Semistructured, in-depth, individual interviews of 26 AMPATH workers were conducted and recorded. Field notes from these interviews were generated by independent reviewers and subjected to close-reading qualitative analysis for themes., Results: The themes identified were as follows: creating effectively, connecting with others, making a difference, serving those in great need, providing comprehensive care to restore healthy lives, and growing as a person and a professional., Conclusion: Inspired personnel are among the critical assets of an effective program. Among the reasons for success of this HIV/AIDS program are a set of work values and motivations that would be helpful in any setting, but perhaps nowhere more critical than in the grueling work of making a complex program work spectacularly well in the challenging setting of a resource-poor country. Sometimes, even in the face of long odds, the human spirit prevails.

Partnerships between academic medical center (AMCs) in North America and the developing world are uniquely capable of fulfilling the tripartite needs of care, training, and research required to address health care crises in the developing world. Moreover, the institutional resources and credibility of AMCs can provide the foundation to build systems of care with long-term sustainability, even in resource-poor settings. The authors describe a partnership between Indiana University School of Medicine and Moi University and Moi Teaching and Referral Hospital in Kenya that demonstrates the power of an academic medical partnership in its response to the HIV/AIDS pandemic in sub-Saharan Africa. Through the Academic Model for the Prevention and Treatment of HIV/AIDS, the partnership currently treats over 40,000 HIV-positive patients at 19 urban and rural sites in western Kenya, now enrolls nearly 2,000 new HIV positive patients every month, feeds up to 30,000 people weekly, enables economic security, fosters HIV prevention, tests more than 25,000 pregnant women annually for HIV, engages communities, and is developing a robust electronic information system. The partnership evolved from a program of limited size and a focus on general internal medicine into one of the largest and most comprehensive HIV/AIDS-control systems in sub-Saharan Africa. The partnership's rapid increase in scale, combined with the comprehensive and long-term approach to the region's health care needs, provides a twinning model that can and should be replicated to address the shameful fact that millions are dying of preventable and treatable diseases in the developing world.

Providing high-quality HIV/AIDS care requires high-quality, accessible data on individual patients and visits. These data can also drive strategic decision-making by health systems, national programs, and funding agencies. One major obstacle to HIV/AIDS care in developing countries is lack of electronic medical record systems (EMRs) to collect, manage, and report clinical data. In 2001, we implemented a simple primary care EMR at a rural health centre in western Kenya. This EMR evolved into a comprehensive, scalable system serving 19 urban and rural health centres. To date, the AMPATH Medical Record System contains 10 million observations from 400,000 visit records on 45,000 patients. Critical components include paper encounter forms for adults and children, technicians entering/managing data, and modules for patient registration, scheduling, encounters, clinical observations, setting user privileges, and a concept dictionary. Key outputs include patient summaries, care reminders, and reports for program management, operating ancillary services (e.g., tracing patients who fail to return for appointments), strategic planning (e.g., hiring health care providers and staff), reports to national AIDS programs and funding agencies, and research.

The authors implemented an electronic medical record system in a rural Kenyan health center. Visit data are recorded on a paper encounter form, eliminating duplicate documentation in multiple clinic logbooks. Data are entered into an MS-Access database supported by redundant power systems. The system was initiated in February 2001, and 10,000 visit records were entered for 6,190 patients in six months. The authors present a summary of the clinics visited, diagnoses made, drugs prescribed, and tests performed. After system implementation, patient visits were 22% shorter. They spent 58% less time with providers (p < 0.001) and 38% less time waiting (p = 0.06). Clinic personnel spent 50% less time interacting with patients, two thirds less time interacting with each other, and more time in personal activities. This simple electronic medical record system has bridged the "digital divide." Financial and technical sustainability by Kenyans will be key to its future use and development.

Objective: To review the literature on coronary heart disease (CHD) and its electrocardiogram (ECG) manifestations in Eastern Africa and provide medical education by increasing awareness and strengthening recognition skills of myocardial infarction (MI) through discussion of key features from representative ECGs selected from the Moi Teaching and Referral Hospital (MTRH) ECG service in Eldoret, Kenya., Data Source: Peer reviewed published articles found using a Medline search. ECGs were reproduced with one complex from each of the 12 standard leads, without patient's name or other identifying information., Conclusion: CHD and its risk factors are increasing in prevalence in Eastern Africa over recent years. The ECG remains integral to the diagnosis of acute coronary syndromes, including MI. Representative ECGs from MTRH demonstrate the various features of the common anatomical distributions of MI, enabling medical education. Recognition of CHD and its ECG manifestations is one step on the path to decreasing resultant morbidity and mortality.

The authors of this paper describe the second phase of the implementation of the Mosoriot Medical Record System (MMRS) in a remote health care facility on the outskirts of Eldoret, Kenya, located in sub-Saharan Africa. We describe of the collaboration between Indiana University (IU) and the Moi University (MU), and the process that led to the development of the computer-based Mosoriot Medical Record System (MMRS) is provided. We then provide the conceptualization and initial implementation of this basic electronic medical record system. We also describe the different processes for assessing the MMRS' effects on health care, including time-motion studies and a strict implementation plan that is necessary for the successful implementation of the system. The MMRS project has many features that make it significant in the domain of CBPR systems. It may serve as a model for establishing similar, basic electronic record systems in the developed and developing world. In developing countries there are few (if any) projects that have attempted to implement such a system. This paper describes the planning, end-user education to new technologies, and time-motion studies necessary for the successful implementation of the MMRS. The system will be used to improve the quality of health data collection and subsequently patient care. It will also be used to link data from ongoing public health surveys and this can be used in public health research programs of the Moi University.

Faculty, postgraduate physicians, and students form Indiana and Kenya collaborate in areas of education, research, and clinical service. This article describes the activities of Indiana University in Kenya and encourages other American medical schools to join with them.

Objective: To assess the international health activities of departments of medicine, divisions of general medicine, and general medicine faculty and the interest among departments of medicine in joint international health ventures., Design: 15-item, mailed questionnaire., Participants: 100 chiefs of divisions of general medicine associated with training programs in internal medicine., Interventions: None., Measurements and Main Results: Completed questionnaires were returned by 87 division chiefs representing 1,355 general medicine faculty. 49% of division had faculty with six weeks' experience in less developed countries. 8.5% of general medicine faculty had six weeks' experience in less developed countries. 7.6% of general medicine faculty were interested in spending extended time in less developed countries. 19% of departments had formal collaborations with schools in less developed countries. 45% of departments were interested in affiliations with U.S. institutions for the purpose of joint international health ventures., Conclusions: The international health interests of current general medicine faculty may not be satisfied. Departmental and divisional encouragement of international interests would increase the number of U.S. general internists participating in less developed countries. The authors discuss the potential for greater involvement of general medicine faculty in international health.

Mathematical modeling was utilized in the planning and decision-making process involved in reorganizing a teaching clinic to effect continuity of care. The model interrelated physicians, time and space, facilitating value judgments and decisions. After examining multiple model runs, the authors finally selected a per-clinic-session doctor mix of 5 interns, 2.3 residents, and 1.6 fellows. Group productivity by model simulation was 14.6 pts/hour, utilizing 10.1 rooms. Subsequently, 90 house officers were each assigned to the clinic one-half day a week on a continuing basis. Time-motion data, from 10 sessions five months after the change, showed that during one week 353 patients were seen at a rate of 13.9 patients per hour in the rooms and time available. The fact that the reorganization was successful and the outcomes remarkably similar to model predictions has engendered confidence in the role of modeling in the planning process.

Before undertaking a hospital or clinic renovation project, "expert" opinions are usually gathered from architects, administrators, trustees, etc., but what about the opinions of those who will be most directly affected--the staff and the patients? This article talks about a study, funded by the Regenstrief Institute, which investigated the benefits to be gained by asking questions of that often-ignored group.

Smoking histories and beliefs about smoking were obtained on 120 ex- and current smokers. Ex-smokers view smoking as a serious health problem, did not report having a physician recommend they stop, and feel personally susceptible to its adverse effects. Moderate smokers (0-10/day) also view smoking as serious, but do not see themselves as vulnerable to its adverse effects. The data suggest that certain attitudes can discriminate between groups of current smokers, as well as smokers from ex-smokers.

Patient adherence to medication regimens in explored as a function of (1) patient beliefs, perceptions, and knowledge of the illness, (2) extent of social support for health actions, (3) complexity of and specific knowledge about the regimen, and (4) satisfaction with clinical encounters and the health care facility. One hundred and ninety patients receiving care on an outpatient basis at a municipal teaching hospital were interviewed. The patients' medical records provided an additional data source. Path analysis generally supported the stated hypotheses. The only variables that had a significant effect opposite to that hypothesized were perceived severity about and susceptibility to the illness. The factors with the greatest predictive power in regard to patient compliance were (1) patients' ability to state the names of or accurately describe their medicines, (2) patients' ability to state the functions of their drugs, and (3) the complexity of the medication regimen as measured by the number of drugs prescribed for the patient.

This study examines the hypothesis that increased physician contact with nurse practitioners (NPs) during residency training would ecourage positive house staff attitudes. House staff expectations of and attitudes toward NPs were assessed at three points during the residency. Data indicated a more positive evaluation of NPs by house staff later in the residency program, as shown by: 1) physician expectations and valuation of NPs, 2) attitudes concerning future employment of NPs, and 3) the extent and capacity of NP utilization by residents.