Smart phone based medical record software for short term surgical missions

Abstract

AbstractShort term medical/surgical missions (STMMs) are a common approach to address the limited access to surgical and anesthesia care in much of the under-resourced world. Documentation on surgical missions offers both a challenge and an opportunity to improve quality and safety of care provided. We describe a novel open-source electronic health record (EHR) software that addresses many of the limitations and safety concerns that currently exist in EHRs used for STMMs. It is usable in austere environments without internet access and is flexible to meet the needs of various types of projects. It contains unique safety features for patient identification with QR bar codes and clearly defined mechanisms for follow up and limitations of duplications of care. Documentation focuses specifically on surgical and perioperative care for short term surgical missions as opposed to medical missions. The software is smart phone-based without the requirement of tablets or laptop computers intended for use at point of care, but maintains the ability to complete post-mission quality and outcomes analysis through exporting data to spreadsheets. The scope of this software is focused specifically for surgical missions, but the open-source and collaborative nature allow for flexibility in specific requirements and details for different types of missions. This open source EHR software has unique accessibility and safety considerations, and facilitates both in-mission surgical care, ongoing follow up, and post hoc mission analysis.