Correction: [On Becoming a Global Citizen: Transformative Learning Through Global Health Experiences].

[This corrects the article DOI: 10.1016/j.aogh.2017.07.005.].

On Becoming a Global Citizen: Transformative Learning Through Global Health Experiences.

BACKGROUND: Globalization has increased the demand for international experiences in medical education. International experiences improve medical knowledge, clinical skills, and self-development; influence career objectives; and provide insights on ethical and societal issues. However, global health rotations can end up being no more than tourism if not structured to foster personal transformation and global citizenship. OBJECTIVE: We conducted a qualitative assessment of trainee-reported critical incidents to more deeply understand the impact of our global health experience on trainees. METHODS: A cross-sectional survey was administered to trainees who had participated in a 2-month elective in Kenya from January 1989 to May 2013. We report the results of a qualitative assessment of the critical incident reflections participants (n = 137) entered in response to the prompt, "Write about one of your most memorable experiences and explain why you chose to describe this particular one." Qualitative analyses were conducted using thematic analysis and crystallization immersion analytic methods based on the principles of grounded theory, employing a constructivists' research paradigm. FINDINGS: Four major themes emerged. These themes were Opening Oneself to a Broader World View; Impact of Suffering and Death; Life-Changing Experiences; and Commitment to Care for the Medically Underserved. CONCLUSIONS: Circumstances that learners encounter in the resource-scarce environment in Kenya are eye-opening and life-changing. When exposed to these frame-shifting circumstances, students elaborate on or transform existing points of view. These emotionally disruptive experiences in an international health setting allowed students to enter a transformational learning process with a global mind. Students can see the world as an interdependent society and develop the capacity to advance both their enlightened self-interest and the interest of people elsewhere in the world as they mature as global citizens. Medical schools are encouraged to foster these experiences by finding ways to integrate them into curriculum.

Fostering reciprocity in global health partnerships through a structured, hands-on experience for visiting postgraduate medical trainees.

BACKGROUND: Global health programs that allow international experiences for US learners should also enable reciprocal learning experiences for international learners, particularly if that is a need identified by the partner institution. METHODS: A partnership between Indiana University and Moi University, Kenya, has successfully hosted 41 visiting Kenyan internal medicine and pediatrics registrars at Indiana University since 2006. The program's logistics, curriculum, and evaluation are described. RESULTS: The registrars rotated through nephrology, cardiology, hematology and oncology, infectious diseases, and intensive care, as well as related ambulatory experiences, functioning on a level comparable to fourth-year medical students. They showed significant improvement in pretest and posttest scores on a standardized National Board of Medical Examiners examination (P  =  .048). International learners experienced culture shock, yet they felt the Indiana University elective was helpful and would recommend it to future participants. CONCLUSIONS: Global health programs can reciprocate the benefits derived for US students and residents by offering learning experiences to international learners if that is an expressed need from the international partner. Barriers to those experiences can be overcome, and the hands-on, elective experience has the potential to positively affect the knowledge and attitudes of participants as well as the home nation.

Chronic noncommunicable cardiovascular and pulmonary disease in sub-Saharan Africa: an academic model for countering the epidemic.

Noncommunicable diseases are rapidly overtaking infectious, perinatal, nutritional, and maternal diseases as the major causes of worldwide death and disability. It is estimated that, within the next 10 to 15 years, the increasing burden of chronic diseases and the aging of the population will expose the world to an unprecedented burden of chronic diseases. Preventing the potential ramifications of a worldwide epidemic of chronic noncommunicable diseases in a sustainable manner requires coordinated, collaborative efforts. Herein, we present our collaboration's strategic plan to understand, treat, and prevent chronic cardiovascular and pulmonary disease (CVPD) in western Kenya, which builds on a 2-decade partnership between academic universities in North America and Kenya, the Academic Model Providing Access to Healthcare. We emphasize the importance of training Kenyan clinician-investigators who will ultimately lead efforts in CVPD care, education, and research. This penultimate aim will be achieved by our 5 main goals. Our goals include creating an administrative core capable of managing operations, develop clinical and clinical research training curricula, enhancing existing technology infrastructure, and implementing relevant research programs. Leveraging a strong international academic partnership with respective expertise in cardiovascular medicine, pulmonary medicine, and medical informatics, we have undertaken to understand and counter CVPD in Kenya by addressing patient care, teaching, and clinical research.

"Talkin' about a revolution": How electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings.

Health care for patients with HIV infection in developing countries has increased substantially in response to major international funding. Scaling up treatment programs requires timely data on the type, quantity, and quality of care being provided. Increasingly, such programs are turning to electronic health records (EHRs) to provide these data. We describe how a medical school in the United States and another in Kenya collaborated to develop and implement an EHR in a large HIV/AIDS care program in western Kenya. These data were used to manage patients, providers, and the program itself as it grew to encompass 18 sites serving more than 90,000 patients. Lessons learned have been applicable beyond HIV/AIDS to include primary care, chronic disease management, and community-based health screening and disease prevention programs. EHRs will be key to providing the highest possible quality of care for the funds developing countries can commit to health care. Public, private, and academic partnerships can facilitate the development and implementation of EHRs in resource-constrained settings.

AMPATH: living proof that no one has to die from HIV.

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.

The AMPATH medical record system: creating, implementing, and sustaining an electronic medical record system to support HIV/AIDS care in western Kenya.

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.

Responding to the HIV pandemic: the power of an academic medical partnership.

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.

A computer-based medical record system and personal digital assistants to assess and follow patients with respiratory tract infections visiting a rural Kenyan health centre.

BACKGROUND: Clinical research can be facilitated by the use of informatics tools. We used an existing electronic medical record (EMR) system and personal data assistants (PDAs) to assess the characteristics and outcomes of patients with acute respiratory illnesses (ARIs) visiting a Kenyan rural health center. METHODS: We modified the existing EMR to include details on patients with ARIs. The EMR database was then used to identify patients with ARIs who were prospectively followed up by a research assistant who rode a bicycle to patients' homes and entered data into a PDA. RESULTS: A total of 2986 clinic visits for 2009 adult patients with respiratory infections were registered in the database between August 2002 and January 2005; 433 patients were selected for outcome assessments. These patients were followed up in the villages and assessed at 7 and 30 days later. Complete follow-up data were obtained on 381 patients (88%) and merged with data from the enrollment visit's electronic medical records and subsequent health center visits to assess duration of illness and complications. Symptoms improved at 7 and 30 days, but a substantial minority of patients had persistent symptoms. Eleven percent of patients sought additional care for their respiratory infection. CONCLUSION: EMRs and PDA are useful tools for performing prospective clinical research in resource constrained developing countries.

Can data from an electronic medical record identify which patients with pneumonia have Pneumocystis carinii Infection?

BACKGROUND: Pneumocystis carinii is the leading opportunistic pulmonary infection in HIV-infected patients. Invasive diagnostic procedures might be avoided if available electronic data can accurately identify patients with Pneumocystis pneumonia (PCP). METHODS: We extracted data from electronic hospital records, emergency department records, and a pathology database for 299 HIV-infected patients with pneumonia who underwent bronchoscopy. We identified independent indicators of confirmed PCP using logistic regression analysis on a random half of the patients and validated the predictive power of the resulting model on the other half. RESULTS: Bronchoscopy confirmed pneumocystis carinii in 111 patients (37%). Five of the seven significant independent predictors of PCP came from patients' electronic medical records: infiltrate on chest radiograph, male gender, lower red cell distribution width, lower serum creatinine, and a prior positive HIV test. The other two (duration of illness and presence of dyspnea) came from the emergency department record. A simple index found 43% of patients at low risk (18% with pneumocystis), 37% at moderate risk (36% with pneumocystis), and 20% at high risk (74% with pneumocystis). CONCLUSIONS: Data from electronic medical records can help quantify the risk of PCP among HIV-infected patients. However, the model failed to identify 18% of patients with PCP in the low risk group, and empiric therapy would erroneously treat 26% of patients classified as high risk. Bronchoscopy is needed to accurately diagnose PCP among HIV-infected patients with pneumonia. However, if bronchoscopy is not available, the model can help with initial decisions about antibiotic therapy.

Using an electronic medical record system to describe injury epidemiology and health care utilization at an inner-city hospital in Indiana.

Injuries are a major public health problem worldwide. In the USA, injuries cause 146, 400 deaths annually, with 31 million non-fatal injury visits to emergency departments (EDs). EDs thus represent an important source of injury data. The primary objective of the current study was to describe the epidemiology of injury-related ED visits and assess injury-related utilization of health care resources in an inner-city hospital in Indiana, using data stored in a computerized medical record system. It involved a retrospective review of the records for injury visits to EDs and injury admissions over a 3-year period. The variables extracted and analysed included patients' demographics, external cause of injury, diagnosis, length of stay, ED and hospital charges. A total of 60,470 injury-related ED visits were made, the majority of patients were male (61.6%), uninsured (63.1%), treated in ED and discharged (98.4%). The leading causes of injury were falls (18.8%), motor vehicle crashes (18.4%), assaults (17.6%), being struck (11.2%) and overexertion (10.6). Firearms caused most injury deaths (32.4%; n = 314); motor vehicle crashes were the leading cause of hospitalization (26.6%; n = 642) and also the most expensive to treat as inpatients (mean charge $19,190). The mean charge per patient treated and discharged was $150 compared to $11,116 for patients admitted. These findings demonstrate the value of computerized medical records in capturing and storing E-coded injury data. The system generates data that can be used for epidemiological surveillance and injury prevention at the local level, and for assessment of impact of specific injuries on health care resources.

Installing and implementing a computer-based patient record system in sub-Saharan Africa: the Mosoriot Medical Record System.

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.

Crossing the "digital divide:" implementing an electronic medical record system in a rural Kenyan health center to support clinical care and research.

To improve care, one must measure it. In the US, electronic medical record systems have been installed in many institutions to support health care management, quality improvement, and research. Developing countries lack such systems and thus have difficulties managing scarce resources and investigating means of improving health care delivery and outcomes. We describe the implementation and use of the first documented electronic medical record system in ambulatory care in sub-Saharan Africa. After one year, it has captured data for more than 13,000 patients making more than 26,000 visits. We present lessons learned and modifications made to this system to improve its capture of data and ability to support a comprehensive clinical care and research agenda.