This episode features a conversation with Kelly Kuru, SNOMED International Chief Communications and Collaborations Officer; Nick Egarhos, SNOMED International Global Vendor Engagement Lead and Customer Relations Executive, Middle East and Africa; and Satish Viswanathan, Head, Social Change & Sustainability, Thoughtworks India & the Middle East. It focuses on the Bahmni electronic medical record developed for low-resource, digitally maturing regions, the work SNOMED International has done with the Bahmni Coalition to date, SNOMED's recent decision to join the Coalition more formally, and the opportunities to collectively further enable digital health around the globe.
SNOMED CT + the Bahmni Coalition: Open-source electronic medical record makes digital health tech available in low-resource settings globally
Episode 04: Show Notes
The mission of SNOMED International, the not-for-profit organization that owns, administers and develops SNOMED CT, the world’s most comprehensive clinical terminology, is to develop a global language for health -- uniting health systems from around the world and enabling them to communicate with and understand one another. As part of that goal, the organization also has a humanitarian mandate to develop tools and advance capabilities in digitally maturing countries with the goal of enabling more people around the globe to benefit from the use of SNOMED CT. To that end, in 2023 SNOMED International began a collaboration with the Bahmni Coalition, a group of organizations that have come together to steward the future of Bahmni, an open-source EMR specifically designed for use in low-resource healthcare settings. In 2024, SNOMED International official joined the Coalition.
In this episode, SNOMED International Chief Communications and Collaborations Officer Kelly Kuru is joined by Nick Egharos, SNOMED International's Global Vendor Engagement Lead and Customer Relations Executive for the Middle East and Africa; and Satish Viswanathan, Head of Social Change and Sustainability for ThoughtworksIndia & Middle East, and a member of the governing committee of the Bahmni Coalition.
They discuss how SNOMED CT has been integrated into the Bahmni EMR, and what this means for the low-resource countries where it is being used. Through the Coalition, the ecosystem using Bahmni has grown, leading to its adoption in more than 50 countries around the world. Tune in to hear about the evolution of this partnership and the plans for it going forward.
Key points from this episode:
Quotes:
“By providing SNOMED for free in an open source EMR product, I think we're really trying to show that we're committed to the broad distribution of SNOMED globally, and super keen to find ways to distribute it in ways that allow us to maintain our ability to support SNOMED and yet give that broad access.” — Nick Egharos [0:05:48]
“The credibility that having an organization like SNOMED as part of the Bahmni Coalition offers to countries and ministries of health worldwide can prove a real shot in the arm for adoption of open source technologies like Bahmni in digital healthcare settings worldwide.” — Satish Viswanathan [0:18:57]
“We've already benefited from collaborating with the SNOMED team to enhance our understanding of terminology, but we also hope that with SNOMED’s deep clinical and terminology expertise, we'll also be able to get more feedback about the product itself and help shape the future of the product as we go forward.” — Satish Viswanathan [0:19:24]
“In terms of additional enhancements, I think there's nothing but opportunity and there's a wide array of things we could do, but we want to make sure that as we move forward, we're building things that add value to the customers and to the Bahmni Coalition as a whole.” — Nick Egharos [0:22:51]
Links mentioned in today’s episode:
TRANSCRIPT FOR MAY 10, 2024 PODCAST WITH SNOMED INTERNATIONAL AND THE BAHMNI Coalition
This transcript has been lightly edited for clarity.
Kelly Kuru: Hi there and welcome to SNOMED International Coded Conversations podcast. Today we're excited to have with us Nick Egerhos, SNOMED International's Global Vendor Engagement Lead and Customer Relations Executive for the Middle East and African Regions. And we're also joined today by Satish Viswanathan, Head of Social Change and Sustainability for ThoughtWorks India and the Middle East and a member of the governing committee of the Bahmni Coalition. Hey, welcome to both of you guys. Thanks for joining us.
Nick Egarhos: Thanks for having us.
Satish Viswanathan: Thank you for having us, Kelly.
Kelly: Great, I think we're going to have a good discussion today. The conversation that we're going to go through today is really focusing on how SNOMED International is working to advance capabilities and also develop tools in digitally maturing countries with the goal of enabling more people around the globe to benefit from the use of SNOMED CT. Specifically, we're going to focus on SNOMED's work with the Bahmni Coalition, which is a group of organizations that have come together to make open source digital health tools available to desired areas where needed. And by way of a little bit of context, last year SNOMED struck a project with the Bahmni Coalition to create an openly accessible SNOMED CT module that can be used in conjunction with the Bahmni EMR (Electronic Medical Record). So today we're going to explore how SNOMED is working with the Coalition, what it signifies for low resource and digitally maturing countries and where the Bahmni EMR is already used. So enough of me, let's get to it. Satish, we're going to start with you. Could you give us a bit of background on the Bahmni Coalition, why it was formed and what it aims to do?
Satish: Yeah, sure thing. The Bahmni Coalition is essentially a group of organizations that came together to steward the future of Bahmni, which as you've already introduced is an open source EMR. They're specifically designed for use in low resource healthcare settings. Bahmni was actually created as part of a social impact program at ThoughtWorks in 2012. And in 2017, ThoughtWorks realized that Bahmni's impact could be much greater with a broader group of organizations steering the future of the project so we formed the Bahmni Coalition. This includes, of course, ThoughtWorks, large organizations that use Bahmni, like Médicin Sans Frontières, or Doctors Without Borders, implementation partners in various countries, such as India, Kenya, and South Africa, and of course, the OpenMRS Foundation, which actually provides legal and fiscal sponsorship for the Bahmni project. Through the Coalition, what we've been able to do is create a much wider community and ecosystem around Bahmni, which has led to its adoption in more than 50 countries around the world today. So when SNOMED International approached the Bahmni Coalition in 2022 to explore the possibility of building a closer integration between Bahmni and SNOMED CT, the Coalition was of course very excited at the prospect of collaborating with SNOMED International, the leading terminology service in the world. Bahmni already supported SNOMED through the Columbia International eHealth Laboratory (CIEL) Open Concept Lab (OCL) project, but given the opportunity to enhance the Bahmni product with a tighter integration with SNOMED CT, we really jumped at the opportunity and we thought that it was a very interesting one. ThoughtWorks actually led a Coalition team of developers to work closely with the SNOMED team to implement the work.
Kelly: Yeah, that's great, Satish. Thanks so much. Nick, from the SNOMED side of things, can you tell us a little bit about our engagement with Bahmni, with the module itself? What did the project involve and what were the overall objectives that brought the two organizations together?
Nick: Sure. First I'd like to say that working with the Bahmni Coalition and Satish and his team was actually a real pleasure. They're a highly skilled group and they really bought into the benefits that SNOMED CT could bring to the Bahmni product and the user community. So that was great. We had weekly touch points on the tech side and other regular meetings that also included the broader teams from both sides so it was a very tight collaboration and the result sort of speaks for itself.
In terms of our goals, we had three goals that we were looking to achieve. We wanted to provide a best practice example of how SNOMED can be used natively within the EMR. That means including it in the user interface, using a terminology server, et cetera, beyond just coding clinical terms in the back end. So many vendors over the years have told me that it's really difficult to implement SNOMED CT, especially in a mature product. So we really set out to prove that not only can it be done, but it can be done relatively easily without a massive investment. We also wanted to show some of the higher value operations that are available within an EMR if you're coding your data at the UI (user interface) using SNOMED CT – not just the coding of data, but using it for things like analytics and clinical decision support. That was really important for us to be able to demonstrate given the ontological structure of the SNOMED CT product. And the third is really, SNOMED International has a humanitarian mandate as well to provide SNOMED CT to countries with emerging digital capabilities for the benefit of a greater portion of the population, the global population. So by providing SNOMED for free in an open source EMR product, I think we're really trying to show that we're committed to the broad distribution of SNOMED CT globally and super keen to find ways to distribute it in ways that allow us to maintain our ability to support SNOMED and yet give that broad access. So it's a bit of a fine line, but this is helping us to explore those ways that we can do that.
Satish: Thank you.
Kelly: That's fair. A couple points from that is that SNOMED International generally is a membership-based organization, so being able to do this is a really excellent way to get the terminology out there where we can. Also, it comes back to the question of, so we came together, what did we actually deliver then at the outcome of the project?
Nick: Right. So we had broken the project into two phases in order to keep it manageable as the team was ramping up and learning about SNOMED CT and we figured out our ways of working together through the first phase. The first phase was really focusing on diagnosis – recording patient diagnoses in Bahmni using SNOMED CT right through the user interface. That was a key part of Phase 1, starting with the clinical decision support piece based on recorded diagnosis and potential drug interactions. That was important to kick off because we built on that in the second phase. Reports were important to use SNOMED for – gathering reports and aggregating data using SNOMED CT as the foundation for that. There was a form builder that we created, so [we were] customizing the form designer using SNOMED terminologies and to generate forms having SNOMED value sets. That was key in terms of being able to use the OpenMRS framework and building that into Bahmni so that it was sustainable going forward for folks to use. And then the procedures piece – so the ability to set up and order procedures using SNOMED. That was Phase 1. We got through that in the first four or five months and we were able to demonstrate, hey, this is really working. This is high-value stuff, best practice implementation. Phase 2 then kicked off and we really built on the Phase 1 piece. The data analytics integration tools – we integrated them and we were able to export the data such that the SNOMED analytics tool could utilize the data coming out of Bahmni, so [we were] demonstrating how you can actually use the way SNOMED is structured to create interesting and deep analytics opportunities. There was a goal of also including other standards in the project. We certainly know that many countries report back to the World Health Organization using ICD-10 coding, so we wanted to be able to leverage the SNOMED to ICD -10 map to be able to drive that reporting requirement from out of Bahmni. That was really important to show that SNOMED CT does integrate well with other standards and we're certainly collaborating with other standards continually. We did some clinical decision support enhancements. Building on the Phase 1 piece, we created some additional features on top of that, especially around the drug-to-drug interaction component. Prior to that, it was drug and diagnosis interactions. This is now drug-to-drug interaction, so it’s taking it to another level. Part of the project was to build a micro or light version of the SNOMED Snowstorm FHIR Terminology Server, which is also part of a best practice implementation. Our implementation team built that light product so that in low resource settings, you could still utilize the benefits of a terminology server.
Then we synced procedures with the SNOMED terminology server. So we actually synced that component and we were managing the terminology through the terminology server as well.
Kelly: Wow, that is a tremendous amount of work and for a relatively short period of time. I think as you look at the clinical requirements that were satisfied with that, the technical requirements, it's a significant amount of work, especially as it's something that is actively out there that can be used at the point of care. So that's fantastic.
Satish, do you have anything that you wanted to add to Nick's story in terms of how the project rolled out and what it delivered?
Satish: I would say that Nick is very kind. When we talked about the working experience, I'd really like to say that we had an equally fantastic experience working with Nick and the rest of the SNOMED team, Kai and others. It was truly collaborative. We're not clinical experts in Bahmni. I mean, we do software well. But this is a really good opportunity for us to understand the terminology side of things quite a bit. And of course, in the process, we also learned a lot more about standards such as FHIR and so on and so forth. There is a good amount of FHIR support. I think this is an opportunity for us to extend the FHIR support provided within the product itself, so that was a fantastic experience too.
Kelly: Yeah, definitely. And as this is a project that we initiated and worked with you on, as this project is something that leverages the Bahmni EMR and works in an integrated way with the Bahmni EMR, maybe you can tell us a little bit about the Bahmni EMR itself.
Satish: Yeah, how much time have we got? I can talk all day about Bahmni! As I mentioned before, Bahmnii was started as a social impact project by ThoughtWorks in 2012. Back then, it was a project. So we just started working with this hospital called Jan Swasthya Sahyog or JSS.
Kelly: Well, maybe we'll take the high-level version.
Satish: It (JSS) stands for People's Health Cooperative. They run a hospital in this place called Bilaspur in central India. It's a flight and then probably a three-hour trip by road to get to the hospital, so it's fairly interior. This hospital actually serves as the main healthcare center for villages in a 30- to 40-kilometer radius around the hospital.
Back when we first started working with JSS, people would come to camp at the hospital because it would sometimes take three or four days for them to get an appointment to see a doctor. So it played a very important role in the area. Their records office and all of their medical records were paper-based, [leading to] issues such as duplicate patient records and taking a really long time to retrieve a patient's file, even if it did exist in the record room. Essentially, providers did not have the full history of the patient when they actually did a consult. I think these are the main problems that JSS was facing when we first started talking to them. We essentially built Bahmni as a way of solving some of these issues, really guided by feedback from doctors on the ground, working in these low-resource settings.
In keeping with our philosophy of being strong supporters of open source software, we didn't want to build anything from scratch, but we thought that we should look at the best of open source that's already out there and build on top of it, thus contributing to the project itself. We started with OpenMRS, one of the most popular and probably the oldest open source EMR. Once we built the clinical pieces that solved the providers’ issues, then we found that the rest of the hospital wasn't yet wired up; you still had to order lab tests physically and then somebody had to get it back from the lab and show it to the doctor. X -rays needed to be printed out. Then we figured out, OK, what can we do to address this main point? So we added in a lab system called OpenLS, which allowed doctors to both order lab tests as well as retrieve and see the results as part of the patient record in context. Same with X-rays; we introduced dcm4dhc, which is another open-source radiology system. And then lastly, to kind of tie everything neatly together, we also integrated an open source ERP (enterprise resource planning) [tool] called Odoo that allowed the hospital to do things like manage the inventory in the in-house pharmacy, as well as complete the billing of the patients. In short, it was like a readily usable hospital management information system that we ended up building, purely driven by needs from JSS and using the best of breed open source systems that just got them talking to each other. That's the power of open source that we were able to leverage. And over the years, though, we haven't done a whole lot of marketing, it's found great organic adoption.
It's used nationwide in the Kingdom of Lesotho to run their entire public healthcare system and in countries like Bangladesh. Nepal also uses Bahmni across many of their public health care systems in many different districts. It has strong footprints on the African continent, in Ethiopia, Cameroon, Mozambique. Overall, like I said, more than 50 countries around the world use Bahmni.
In some of the use cases, Bahmni is used in a fairly diverse [way]. For example, MSF and a group of other organizations came together to start the End Tuberculosis project. Part of that was a clinical trial to test a few new drugs for multidrug-resistant tuberculosis.
Bahmni was used across 17 countries to manage the clinical trial data from that experiment. It has also been used across many, many different countries – to manage children's surgery hospitals across Africa, and many, many outpatient settings for the most part. It's been used in daycare settings in India.
More recently, we've made inroads into the Indian public health care system by piloting it in some primary health care centers for an Indian state government. We're really proud to have received an award for the best open source creation fairly recently, actually, in February 2024, as part of the Future of Government Awards. That was a really proud moment for all of us, for all the work that we have done over the last decade or so.
Kelly: Wonderful. It has only been about 12 years from starting to where you are now, so to have that kind of software development, build testing, QA, et cetera, in addition to the uptake that you've seen, is really quite encouraging, I would say. It shows that there's been a real need for something like the Bahmni EMR to be available in certain markets. Nick, maybe I'll just ask you. We got ourselves involved in this project. We started working together. Bahmni is a Coalition. Bahmni is a group of organizations that come together with a common purpose. After we had the great opportunity and experience of being exposed to this world a little bit, tell me a little bit about SNOMED's role now with Bahmni and any kind of recent developments that have taken place.
Nick: Sure. We're doing a few things with the Coalition. It has only been a short while since we've been officially named a member of the Bahmni Coalition.
Kelly: Which is huge and we were really excited to have that come through.
Nick: It's not easy, right? This is a group of folks who have been working together for a long time. They needed to really see some value in terms of allowing us to actually be part of this group. I think we can do a lot of things for the Bahmni Coalition. We represent the leading clinical terminology globally so it's a clinically assured set of data that we're providing, as well as that global thought leadership and relationships across the health data standards ecosystem, of which there are many, as we all know. We can also be technical advisors. Our implementation team was key to building some of this functionality. We can continue to play that role and even [provide] marketing assistance and marketing the Bahmni product and the Coalition partners to our membership where there's necessity. And frankly, the Coalition ticks a lot of boxes for us. It gives us access to the broader Bahmni community of users and implementers and gives us the ability to build those relationships and help drive the awareness of SNOMED. So hopefully that results in some pilot opportunities over the next few months. It gives us a platform for demonstrating our functionality, which is awesome when you're trying to get a point across. It gives us that demonstrator to actually show a native implementation, a best practice implementation. And it shows our ability to work with other healthcare standards. Obviously, we're using FHIR as our messaging protocols, which is certainly a global messaging standard, as well as ICD-10, which is really, really important. Everybody uses ICD in some way, shape or form for the most part. Being able to show that we can integrate and be kind of a hub terminology with ICD-10 and provide value through that relationship and those maps, I think, was also super important for us. And that's all aside from our humanitarian mandate.
Satish: Thank you.
Kelly: Satish, does any of that echo with you on being a member of the governing committee of the Bahmni Coalition? Does any of what Nick said kind of echo with you in terms of the Coalition's goals now that you have SNOMED?
Satish: Nick covered a lot of important points, which I think really points to the great mutual benefit of this partnership. But I think it's worth saying again that, you know, SNOMED joining the Bahmni Coalition is a really big deal for us – [it’s] the leading terminology, or dictionary, and it’s the credibility. Having an organization like SNOMED International as part of the Bahmni Coalition offers to countries and ministries of health worldwide a real shot in the arm for adoption of open source technologies like Bahmni in digital healthcare settings worldwide. So I think that's a really, really important benefit that we hope that this partnership will bring. The other thing that we are hoping – like I said, we've already benefited from collaborating with the SNOMED team to enhance our understanding of terminology – is that with SNOMED's deep clinical and terminology expertise, that we'll also be able to get more feedback about the product itself and help us shape the future of the product as we go. One thing I would say is the implementation that we built is already gaining interest from a lot of people. In fact, there was a short demonstration of this at the last [2023] SNOMED CT conference in Atlanta and then recently we had somebody from the Ministry of Health in Jamaica reach out to us because they saw this demo and they're more interested in finding out more. So we're hoping that a lot more of that happens.
Kelly: Yep, that's right.
Satish: In fact, we're hoping to have a small Bahmni booth at the upcoming 2024 SNOMED CT Expo conference later this year as well. So I hope to meet a lot more people and talk about SNOMED and Bahmni there.
Kelly: Yeah, exactly. I think that's great. It's important to note that in addition to the build of the module and SNOMED and ThoughtWorks and Bahmni all working together, there have been a host of technical clinical implementation tools and resources that have also been developed. While we probably won't go into those today, we will provide in the show notes to our podcast the links to where we can find those. Maybe it's an opportunity as well for us to have a follow up and we can go through the resources that help implementers because in so many cases you're just given something and have to figure it out; a developer has to figure out what to do with it. In this case, a lot of useful resources have been created so I think that's something we definitely want to call out. Now, looking forward, I understand, Satish, that the Coalition right now is seeking input to develop a new roadmap. Can you tell us a bit about what the Coalition is looking for in terms of feedback?
Satish: Yeah, glad to. The Bahmni Coalition is very much community run. In addition to the set of Coalition members, there's a wider ecosystem around Bahmni where we have members give us feedback on all kinds of things, ask questions and help shape the product itself. So we're constantly driven by feedback from our members. We have a broad set of priorities that we've identified as goals for 2024 and 2025 and we can probably share a link to that where people can add more info. But we're looking for inputs from different types of people in the ecosystem – implementers, organizations that are actively using Bahmni, developers, terminology experts to help us shape what we need to prioritize and build. We're always looking for feedback around that through our discussion forums through our Slack channels and so on.
Kelly: That's great. We can definitely put that link up with the show notes as well so that anyone who stumbles upon this podcast or is actively seeking it out can be part of that consultation process. We're getting to the end of our conversation today, but Nick, I want to start with you and ask, what's next? Where do you hope to take this over the next year, 18 months, or two years?
Nick: Thanks. I think that we see 2024 as a year to establish some learnings within the community. To that end, we're trying to get at least one pilot off the ground and gain some lessons learned and take it from there in terms of additional enhancements. I think there's nothing but opportunity and there's a wide array of things we could do, but we want to make sure that as we move forward, we're building things that add value to the customers and to the Bahmni Coalition as a whole, reaching back into some other experience with a project that was focusing on low and middle income countries. We also know that the community health workers on the ground, particularly in Africa, are really critical in terms of gathering health information in rural and remote areas, so it would be great to find a project that could actually connect those community health workers with tools that could actually feed (potentially) a Bahmni + SNOMED implementation so that the data can be aggregated in one spot and you get that reach into the rural communities. For me, that's kind of a personal goal and I think it could add just a ton of value to any implementation.
Kelly: Yeah, I know. That's great insight, Nick. I think it comes back as well to making a real world difference and a lot of what our organizations have collaborated to accomplish is really making that possible and enhancing the excellent tools that have already been created to the best extent possible. Satish, over to you. What do you hope to see happen with this collaboration and just generally with Bahmni over the next little while?
Satish: Yeah, I probably agree with Nick. I think we've done a lot of work and it's really important for us to get real-world feedback about how this is used in practical care settings – so that's a priority for us as well. We've also been trying to find settings where we can pilot this and get feedback from people. We hope to do that pretty soon. That said, I think some of the things that we're thinking about are how we leverage the drug model more extensively. Other improvements that we're looking at are, say, encoding body sites, specimens, stagings, and so on. One other area that we have been talking about is how we could use country-specific extensions. So these are, broadly, the laundry list of things. I found what Nick said really interesting about community healthcare workers being able to use this in remote settings because over the last year or so in parallel to the work on SNOMED, we've done a fair amount of work beefing up the offline version of Bahmni that allows healthcare workers in rural areas with poor internet connectivity to gather data. I think it'll be an interesting thing to explore to see how we can integrate SNOMED in these settings so that the data quality captured in field settings is also of very high quality.
Kelly: Yeah, that's fantastic. I think what we've been able to see is even just with our brief conversation today that there has been a tremendous amount of work done, but there still is a lot of opportunity left to take advantage of. So with that, I'm going to draw us to a close today. We really thank you, Nick and Satish, for joining, for sharing your expertise and insights over the work that you've done over the past couple of years together.
We look forward to definitely having a follow-up and seeing where we've gone maybe in the next year or so with the Coded Conversations podcast and all of the links and resources that we've referred to today are included in the show notes so people can refer to them there. Thanks very much and we'll close this one off and we'll talk to you guys later!
Nick: Thanks, Kelly.
Satish: Thank you, Kelly. It was a pleasure. Thank you, Nick.