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NB I would be grateful for any inputs you may have on this first draft of a scenario of establishing a pilot  PIRS and HIS in a developing country. It  is a fictitious country and put together from a mixture of my experiences and those of   colleagues on the littlefish project.

Annie, an  experienced RN with an International Aid Agency has just arrived at a remote district township of @ 10,000 in a developing country that has had a history of civil unrest and the breakdown of essential services. Stability has gradually returned to the country and more aid is becoming available.

A single telephone line into the township has recently been re-established. The Health Department wants to utilise e-mail as the most cost effective means of communication.   It wishes to gain an overall idea of the health status of the population in the provinces. It is establishing a number of pilot projects to overcome the lack of telephony infrastructure and is looking at utilising the satellite networks to the fullest extent.

RN Annie has brought with her a Pentium 200MMX  with two four GB harddrives, a power stabiliser, a modem and a laptop for field visits. An email account has been set up by the aid agency and Annie has received basic training in the use of e-mail and the patient information system. Part of her role will be to train the medical officers, health workers laboratory and pharmacy staff in its use. The hospital staff consists of two doctors I male I female, 3 female healthworkers, one male health worker, a Pharmacy Trainee, a laboratory technician and one assistant. Three cleaners, a groundsman, a mechanic /
driver and two guards.

On her first visit to the local health centre she is shown the facilities by the senior doctor.There is a generator in good working order so that power supplies to the hospital are consistent. There are no airconditioners. Cooling is by fan.  The Library consists of one copy of the British Medical Journal which is 8 years old, 4 paperback novels and an airline magazine.
The operating room has a working steriliser. The operating table has seen better days and is fixed in one position due to  lack of maintenance and missing parts. only minor surgery is carried out. Patients traditionally have been sent to the regional or central hospital. This has been problematic as the overworked staff in these establishments cannot always see new arrivals and some patients have had to wait up to two weeks before being seen. Many arrive with no referral letters or histories. Many have
returned home as their money has become exhausted. The health department is keen to set up a referral and scheduling system to alleviate these problems. The laboratory has recently been supplied with a centrifuge, microscope,water baths, Westergren ESR rack, primus stove,   reagents, a fridge. Other equipment is still needed to become fully functional
The basic tests that they can carry out are:
Blood tests Haemoglobin,WCC,ESR, and examination of stained slides, wet
slides for examination of parasites such as microfilariae, trypanasomes &
malaria. Formol gel tests for leishmaniasis. Sickle cell tests.
Urine tests  for nitrates , protein, ketones, glucose, bilirubin, blood.
Stool Tests for direct examination of parasites & occult blood.
Exudate tests  for trichomonas  & yeast. For gram stained urethral smears
and gram negative diplococci.
Skin Tests for M Leprae. Skin snips for onchocera volvulus.
Sputum Tests  for acid fast bacilli.
Cerebrospinal fluid -  total proteins & test for globulin, cell counts.
Examination for sediments for cells bacteria, & trypanasomes.
Blood grouping and cross matching for emergency situations.

The Pharmacy has a working fridge and three large bottles of aspirin. There are no other supplies. Patients have to purchase medications from Pharmacies in the township.The trainee has a 1987 copy of Mims. Intravenous Fluids are sold at the gates of the hospital compound by traders. A 1 litre bag of normal saline  can cost the equivalent of a months income.

Medical Records are kept by the patients themselves on A4 cards. They are purchased from the hospital to help provide  some income to help pay the wages of staff. (Most   have not been paid in months.) The information usually consists of date, diagnosis & treatment given.

There are three health outposts within a 50 Kilometre radius. They have no power or telephone communications.The Senior Healthworker visits each centre once a month to consult with the local Health worker. Any seriously ill persons are usually brought back to the hospital by the Senior health worker. Cases that are beyond the capabilities of the district hospital (usually surgery) are sent to the State General Hospital or the Mission hospital 100km away. Patients have to pay for their drugs and whatever may be required for their surgery. The Mission hospital is better staffed and equipped but costs more so most people will go to the state hospital where there are no lights and patients sometime have to provide their own beddings

After discussions with the staff they decide that what they require is
1. Access to quality information useful and applicable to their reality.ie current medical pharmaceutical, nursing & laboratory information.
2. A means of storing and accessing the information offline
3. A means of ordering supplies in good time.
4. Establishing a good medical record system but one which supports their present efforts- which whilst very problematic -works.
5. A means of scheduling  hospital appointments
6. Establishing levels of access to the patient record
7. Ensuring that confidential information can only be read by the intended person
8. Establishing Health care priorities for the district- eg  a) Antenatal care b) under 5 care c) Immunisations d) Malaria Control
9. Establishing which illnesses in the locality can be prevented and what health education materials can be utilised