The financial implications are equally significant. Duplicate records inflate administrative costs, create billing complications, and reduce operational efficiency across healthcare organizations. Staff spend valuable time reconciling conflicting information, while the integrity of health data analytics and population health initiatives suffers from inaccurate patient counts and scattered clinical data.

Recognizing these challenges, the Tamanu EMR has developed a comprehensive, multi-layered approach to patient deduplication that addresses both prevention and remediation. This systematic strategy ensures that healthcare providers can maintain clean, accurate patient databases while delivering safe, coordinated care.

At the centre of any patient management strategy of course, are good processes and procedures, implemented by diligent staff. Tamanu can only help – we recognise though that it is the people at the heart of the system who determine its success.

The five Tamanu strategies for de-duplication

Strategy 1: Patient Master Index Integration

The foundation of effective duplicate prevention lies in establishing a unified patient identity management system through a Patient Master Index (PMI) integration. A PMI serves as the authoritative source for patient identities across an entire healthcare network, maintaining a single, comprehensive registry of all patients served by the organization.

Tamanu’s PMI integration offers remarkable flexibility to accommodate diverse healthcare environments. In small to medium sized healthcare systems or those starting fresh, Tamanu can function as the primary PMI, becoming the central repository for patient identities across all connected systems and departments. This approach ensures seamless coordination between different clinical areas, from emergency departments to specialty clinics or allied health, with each patient maintaining a single, consistent identity throughout their care journey.

For larger healthcare networks or those with existing infrastructure investments, Tamanu can consume data from external PMI systems already in operation. This integration capability means organizations don’t need to abandon their current patient identity management investments. Instead, Tamanu synchronizes with these existing systems, ensuring consistency while leveraging established workflows and data governance practices.

Whether consuming data or making it available to other systems, Tamanu achieves this through an HL7 FHIR compliant API, which defines the resources and the business rules around which the data is exchanged.

The PMI approach creates a robust foundation for preventing duplicates at the source. By establishing unique patient identifiers that persist across all systems and encounters, healthcare organizations can eliminate the confusion that arises when patients are known by different identifiers in different departments or facilities.

Strategy 2: ID Card System

Physical patient identification represents a practical, user-friendly solution to many duplicate creation scenarios. Tamanu’s ID card system addresses the common registration challenges that lead to duplicate records—misspelled names, forgotten dates of birth, or variations in how patients provide their personal information.

The system supports both basic ID cards containing essential patient identifiers and more sophisticated photo ID cards that provide visual verification. When patients present their ID cards during registration or subsequent visits, healthcare staff can quickly and accurately retrieve their existing records without relying on potentially inconsistent verbal information. Each ID card contains a barcode, which is scanned in seconds across any part of the health system and all points of care.

This approach proves particularly valuable in busy clinical environments where registration staff may be working under time pressure or dealing with patients who may be distressed, confused, or unable to clearly communicate their details. The ID card system also benefits patients who frequently interact with the healthcare system, creating a streamlined experience that reduces wait times and administrative friction.

Furthermore, the physical ID card serves as a tangible connection between patients and their healthcare records, encouraging patients to maintain and present their identification consistently across different healthcare encounters and providers within the network.

ID cards can be configured for local context and printed directly from Tamanu

Strategy 3: Real-Time Duplicate Detection

Tamanu’s newly released real-time duplicate detection represents a significant advancement in proactive duplicate prevention. This intelligent system operates at the point of patient registration, analyzing incoming patient data against existing records using sophisticated matching algorithms that consider multiple data points simultaneously.

The system evaluates various criteria including name similarities (accounting for common spelling variations and phonetic matches), birth dates, contact information, and other identifying characteristics. This multi-factor analysis helps identify potential duplicates even when exact matches aren’t present, recognizing that patient information may be provided differently across various encounters.

One of the system’s most significant advantages is its offline capability. Many healthcare facilities, particularly in rural or resource-limited settings, face connectivity challenges that can interrupt their workflows. Tamanu’s offline duplicate detection ensures that patient safety measures remain active regardless of internet availability, making it an ideal solution for diverse healthcare environments.

When potential duplicates are identified, the system presents them to registration staff for review, enabling informed decisions about whether to link to an existing record or proceed with creating a new patient entry. This human-in-the-loop approach combines the efficiency of automated detection with the nuanced judgment that healthcare professionals bring to patient identity verification.

Strategy 4: Patient Merge Tool

Despite the best prevention efforts, duplicate records sometimes occur, particularly when integrating legacy data or managing complex patient populations. Tamanu’s patient merge tool provides a secure, comprehensive solution for consolidating duplicate records while preserving the integrity of all associated clinical data.

The merge process is designed with both safety and usability in mind. Authorized administrators can access the merge functionality easily through Tamanu’s admin panel, using a simple user interface. Here they can review duplicate records and complete the consolidation process. The system preserves all medical history, appointment records, clinical notes, laboratory results, and other patient data, ensuring that no information is lost during the merge operation.

This comprehensive data preservation is crucial for maintaining clinical continuity and meeting regulatory requirements for medical record retention. The merged record provides clinicians with a complete, unified view of the patient’s healthcare history, enabling more informed clinical decision-making and better care coordination.

The merge tool also maintains an audit trail of the consolidation process, documenting which records were merged and when, supporting quality assurance efforts and regulatory compliance requirements.

Strategy 5: Database-Wide Reporting

Maintaining long-term database integrity requires periodic assessment and cleanup of existing patient data. Tamanu’s comprehensive reporting tool addresses this need by analyzing entire patient databases to identify potential duplicates that may exist within legacy data or have been missed by real-time detection systems.

The reporting system employs advanced pattern recognition algorithms to examine patient data across multiple dimensions, identifying subtle similarities that might indicate duplicate records. Like the real-time duplicate detection, this analysis goes beyond simple name matching to consider combinations of demographic information, contact details, and other identifying characteristics that could suggest the same individual is represented multiple times in the database. The system is also designed to improve as it goes. We leverage machine learning to enhance the identification of potential duplicate patient records. Our models are trained to account for regional naming variations and cultural nuances—for instance, recognizing that “Jenny” and “Jennifer” may refer to the same individual. This is done by labelling pairs of potential matches as duplicate, different or unsure. This approach improves accuracy across diverse datasets and geographies.

The reports provide actionable insights, presenting suspected duplicates in a format that enables efficient review and decision-making by administrative staff. This systematic approach to database maintenance helps healthcare organizations conduct regular data hygiene audits, ensuring ongoing database quality and supporting accurate healthcare analytics and reporting.

These periodic cleanups are particularly valuable for organizations transitioning from paper-based systems or consolidating data from multiple legacy electronicsystems, where duplicate creation may have occurred during data migration processes.

The Importance of Integrated Systems and Processes

While Tamanu’s built-in deduplication strategies provide robust protection against patient duplicates, the most effective approach to patient identity management can involve integration with complementary systems and processes that strengthen identification accuracy from multiple angles.

Biometric Identification Systems

Biometric identification represents a powerful complement to traditional patient identification methods, offering unique advantages in accurately distinguishing between individuals. Simprints, an open-source biometric identification platform, is one such example which exemplifies how these technologies can enhance patient identity management in healthcare settings.

Biometric systems capture unique physiological characteristics—such as fingerprints, iris patterns, or facial features—that remain consistent throughout an individual’s lifetime. When integrated with EMR systems like Tamanu, biometric identification can provide definitive patient verification that transcends the limitations of traditional identifiers like names, addresses, or even identity documents, which can be forgotten, lost, or shared between family members.

Simprints has demonstrated particular effectiveness in challenging healthcare environments, including refugee settings, rural communities, and populations with limited documentation. The system’s open-source nature makes it accessible to healthcare organizations with varying resource levels, while its offline capabilities ensure functionality in areas with limited connectivity—a critical consideration for many healthcare deployments.

Biometric identification is not a panacea – in larger populations across broad age and ethnic spectrums, biometrics can help to massively reduce patient duplication and improve patient identification, but the systems still need to be backed by strong patient management systems and high quality policies and procedures.

Civil Registration and Vital Statistics (CRVS) Integration

Civil Registration and Vital Statistics systems provide another crucial layer of patient identity verification and lifecycle management. These systems maintain authoritative records of births, deaths, marriages, and other vital life events that establish and track individual identities throughout their lives. EMRs should interact with CRVS systems at moments including birth and death to ensure that people have official identities that benefit them throughout all facets of their lives, not just healthcare. The integration of CRVS systems with EMRs like Tamanu creates a comprehensive identity ecosystem where healthcare records are anchored to officially recognized vital events.

Birth registration data helps establish definitive patient identities from the earliest stages of life, providing healthcare systems with authoritative information about patient demographics and family relationships. Death registration integration ensures that deceased patients are appropriately flagged in healthcare systems, preventing inappropriate record creation and supporting accurate population health statistics

OpenCRVS represents a leading example of modern CRVS implementation, working globally to improve the management of vital events and strengthen the foundation of identity management systems. Also a free and open-source platform, OpenCRVS are working in the Indo-Pacific region with partners including BES and agencies such as SPC. When integrated with healthcare systems, CRVS data provides several critical benefits for patient identity management.

Conclusion

Effective patient duplicate management requires a comprehensive, multi-layered approach that addresses both prevention and remediation while integrating with broader identity management ecosystems. Tamanu EMR’s five-strategy framework—PMI integration, ID card systems, real-time detection, merge tools, and database-wide reporting—provides healthcare organizations with robust tools for maintaining clean, accurate patient databases.

By combining Tamanu’s built-in deduplication strategies with thoughtful integration of complementary identification systems, healthcare organizations can achieve the highest levels of patient data integrity. This comprehensive approach ensures that every patient record is unique, accurate, and complete—supporting the delivery of safe, coordinated, and effective healthcare services.

Tamanu EMR’s comprehensive approach to duplicate management provides healthcare organizations with the tools and strategies needed to achieve and maintain this essential data quality standard. Come and chat with us about how our Project Management and Data teams can help your health ecosystem achieve its goals.

Watch our video on the five Tamanu deduplication strategies here:

We’re excited to announce the Spring 2025 super release of Tamanu, our Electronic Medical Record. Officially launching August 14^th, this release represents our most significant leap forward in clinical efficiency, data integrity, and user experience since the release of Tamanu 2.0. Built on extensive feedback from our healthcare partners, these six major enhancements address real-world challenges that clinicians and administrators face daily in our partner countries while maintaining the robust, reliable foundation that Tamanu users have come to trust.

Our latest super release – the first in 18 months – contains six major new features (as well as dozens of minor features and optimisations):

Enhanced medication module

Patient charting

Intelligent duplicate patient detection

Floating encounter notes

Enhanced auditability

Enhanced program registries

1.     Enhanced Medication Module: Comprehensive medication management

Medication management is a cornerstone of patient safety and clinical care, and our enhanced medication module delivers significant improvements to how healthcare teams track, administer, and monitor patient medications.

Medication Administration Record (MAR)

The introduction of the Medication Administration Record represents a major advancement in medication safety and documentation. This feature provides a centralized system for tracking when medications are administered, by whom, and under what circumstances. Healthcare providers can now maintain accurate, real-time records of medication administration, reducing the risk of medication errors and improving compliance with safety protocols.

The MAR system supports complex medication regimens, including scheduled medications, PRN (as-needed) administrations, and one-time doses. This comprehensive approach ensures that all members of the healthcare team have immediate access to current medication status, supporting seamless care transitions and reducing the potential for adverse drug events.

Patient-level ongoing medication tracking

Beyond individual administrations, the enhanced module now provides robust tracking of ongoing medications at the patient level. This longitudinal view allows clinicians to monitor medication histories, and make informed decisions about new prescriptions or medication changes. Ongoing medications can be brought into each encounter with a single click, saving huge amounts of time, and reducing transcription errors.

The system maintains a complete record of current and historical medications, including dosage changes, discontinuations, and the clinical reasoning behind medication decisions – it also supports pharmacy notes, allowing the pharmacy team to undertake medication reviews from their desks.

This comprehensive medication profile supports continuity of care and enables more informed clinical decision-making across all patient encounters.

2.     Patient Charting: Longitudinal data capture within and between encounters

Longitudinal clinical care often requires tracking multiple, complex data points over time, and our new Patient Charting feature transforms how clinicians document, monitor, and use this critical patient information.

Comprehensive charting capabilities

The Patient Charting module enables better tracking of longitudinal data both within individual encounters and across multiple patient visits. This capability is particularly valuable for managing complex conditions that require ongoing monitoring and trending of clinical parameters.

Clinicians can now easily chart critical areas including fluid management, pain assessment and management, wound care progression, maternal health monitoring, and partograph documentation. Each of these specialized charting areas is designed to support the specific workflows and documentation requirements that clinicians encounter in their daily practice – and deployments are able to configure their own charts using easy reference data imports – no coding is required.

Strengthening clinical decision support

By providing clear visualization of trends and patterns in patient data, the charting system supports more informed clinical decisions. Healthcare providers can quickly identify concerning trends, evaluate the effectiveness of interventions, and adjust care plans based on comprehensive longitudinal data. It also allows clinicians to more easily track metrics across multiple encounters.

This last feature – the system’s ability to track data across encounters – is particularly valuable for chronic disease management (e.g. diabetes or hypertension), post-operative care, and other situations where long-term monitoring is essential for optimal patient outcomes.

3.     Intelligent duplicate patient detection

Patient misidentification remains a persistent challenge in healthcare, potentially leading to fragmented medical records, medication errors, and compromised patient safety. Our new duplicate patient alert system addresses this challenge with sophisticated detection capabilities.

Advanced fuzzy matching technology

When creating new patient records, Tamanu now automatically checks for existing patients using PostgreSQL’s fuzzy string matching capabilities – and the system can check in real-time, alerting admin users before the record is created. This technology goes beyond simple exact matches to identify potential duplicates even when there are common data entry variations.

The system is designed to catch duplicates despite spelling errors (Jon vs John), phonetic variations (Smith vs Smyth), minor typing mistakes, and even common date formatting errors like swapped days and months in birth dates. This comprehensive approach significantly reduces the risk of creating duplicate records while maintaining system performance.

Flexible and Updatable Detection Logic

The duplicate detection system is built using a PostgreSQL function that can be updated as organizational needs evolve. The function applies a principle called ‘Levenshtein distance’ to determine the likelihood that a newly created record is a duplicate of an existing record.

Intelligently and flexibly, countries can tweak the existing algorithm to suit their needs or use entirely new functions in the future. This flexibility ensures that the system can be fine-tuned based on the specific patient populations and naming conventions relevant to each healthcare organization – and also that the system can evolve as more modern tooling emerges.

While the system is highly effective, we’ve been transparent about current limitations, such as when there are significant phonetic differences in last names and substantial variations in name length. This transparency allows users to understand the system’s capabilities and implement appropriate additional verification procedures where needed. Users retain the ability to produce near-duplicate patients and can be simply prompted to choose the patient record they would like to work with.

4.     Floating encounter notes: A game-changer for clinical documentation

Clinical documentation has always required a delicate balance between thorough record-keeping and efficient patient care. Our new floating encounter notes feature addresses a longstanding user request and represents a significant improvement in clinical workflow design.

“Can we enter patient notes whilst we navigate throughout the rest of patient’s record?” – yes, now you can.

Seamless chart navigation while documenting

The enhanced notes modal now allows users to navigate a patient’s chart while simultaneously recording encounter notes. This seemingly simple improvement addresses a major frustration point for clinicians who previously had to choose between completing their documentation and reviewing relevant patient information.

Clinicians can now reference previous visits, review medication lists, check lab results, and examine imaging reports without interrupting their documentation process. This capability is particularly valuable during complex patient encounters where multiple systems and historical data points need to be considered.

Improved clinical decision-making

By enabling simultaneous chart review and documentation, this feature supports more comprehensive and accurate clinical notes. Clinicians can incorporate relevant historical information, identify patterns across visits, and make more informed decisions about patient care—all while maintaining their documentation workflow.

The reduction in navigation burden translates to decreased frustration and improved job satisfaction for healthcare providers, while also supporting more thorough and accurate patient records.

5.     Enhanced auditability: meeting international standards

Recognizing the critical importance of audit trails in healthcare systems, we’ve significantly enhanced Tamanu’s auditability features. These improvements align with ISO27789: Health informatics – Audit trails for electronic health records, ensuring that our audit capabilities meet international standards for healthcare information systems.

Comprehensive audit trail architecture

Our enhanced audit system tracks two distinct types of activities, providing comprehensive visibility into all system interactions:

Access Tracking monitors when logged-in users view patient personal and clinical data. The system intelligently differentiates between different types of access patterns. For instance, when a user searches for a patient by name, this generates a “query access” log entry for the list of results returned. When they subsequently open a specific patient record to view complete information, this creates a “single access” log entry. This granular approach ensures that audit trails capture the full context of how patient information is accessed and used.

Change Tracking captures all modifications made to data within Tamanu, including creates, updates, and deletes. This encompasses both user-initiated changes made as part of clinical workflows and system-generated actions such as automatic patient discharges. The comprehensive nature of this tracking ensures that every data modification has a clear audit trail, supporting accountability and compliance requirements.

Of course, we retain all of our existing front-end edit logs, including for notes, vitals, lab results and more. The enhanced auditability functions are a step up from these tools though to allow fare more comprehensive audit trails.

Supporting healthcare governance

These audit enhancements provide healthcare organizations with the detailed information needed to address various circumstances, from routine quality assurance to regulatory compliance and security investigations. The alignment with ISO27789 standards ensures that Tamanu’s audit capabilities meet the rigorous requirements expected in healthcare environments.

The enhanced audit trails support healthcare organizations in demonstrating compliance with privacy regulations, tracking user activities for security purposes, and maintaining the data integrity that is essential for quality patient care.

6.     Revolutionizing program registry management

The final pillar of this release is our comprehensive enhancement to the Patient Program Registry Module. Healthcare organizations managing cohorts for disease surveillance, chronic condition tracking, and population health programs will find these improvements transformative for their daily operations.

Advanced condition category tracking

One of the most significant improvements is the introduction of condition category tracking with configurable statuses. Clinicians can now track the natural progression of conditions through customizable stages such as “suspected,” “under investigation,” and “confirmed.” This granular approach reflects the reality of clinical practice, where diagnoses often evolve as more information becomes available.

The system maintains a complete audit trail of these status changes, providing healthcare teams with unprecedented visibility into how conditions develop over time. This transparency is crucial for quality assurance, clinical decision-making, and regulatory compliance. Users can see exactly when a condition status changed, who made the change, and what information was available at each stage of the diagnostic process.

Streamlined registry management workflows

We’ve consolidated registry management into a unified interface that allows clinicians to update both registry status and multiple related conditions simultaneously. This workflow optimization eliminates the need to navigate between different screens and reduces the time required to maintain accurate patient records. For busy healthcare environments, this efficiency gain translates to more time available for direct patient care.

Enhanced data model architecture

Behind the scenes, we’ve restructured the program registry data model to support improved auditing and condition tracking. A critical improvement is that conditions are now directly linked to specific registrations rather than patients. This architectural change prevents conditions from automatically carrying over between registry enrolments and allows the same condition to be recorded multiple times when clinically appropriate (for example, across multiple diagnoses of dengue or malaria).

This enhancement ensures data integrity while providing accurate historical tracking. Healthcare organizations can now maintain precise records of when patients were enrolled in specific programs, what conditions were relevant during each enrolment period, and how those conditions evolved over time.

The updated patient-level dashboard now displays condition categories clearly, giving clinicians immediate insight into a patient’s current status across all relevant programs. The improved registry activation process preserves condition history, ensuring that valuable clinical information is never lost during transitions between programs.

Looking forward

The Spring 2025 super release represents our commitment to continuous improvement based on real-world healthcare needs. These six major enhancements—from sophisticated program registry management and intelligent duplicate detection to seamless clinical documentation, comprehensive medication management, advanced patient charting, and robust audit trails—work together to create a more efficient, accurate, and compliant healthcare information system.

As healthcare continues to evolve, Tamanu remains dedicated to providing the tools and capabilities that enable healthcare organizations to deliver exceptional patient care while maintaining the highest standards of data integrity, clinical efficiency, and regulatory compliance.

Later in 2025? Look out for our new patient portal, launching in Q4, 2025. The patienr portal will give patients greater access to their healthcare record as they move throughout the systems and across their lives. We will also be introducing our new AI tool, ‘Atamai’, which will allow users to query data using plain language requests. Keep your eyes out – it’s going to be incredible.

We encourage all users to explore these new features and provide feedback as we continue to refine and enhance the Tamanu platform. Your insights and experiences are invaluable in shaping the future of healthcare information management in our region.

The BES Support Centre in Suva, Fiji, is rapidly becoming a cornerstone of technical capacity building for digital health in the Pacific. Since its opening in late 2023, it has welcomed teams from across the region, providing hands-on training in IT, data management, and digital health. Recently, with the support of DFAT’s Global Health Division through the Partnerships for a Healthy Region initiative, teams from Tonga and Timor-Leste visited the centre to expand their expertise in server management, health information systems, and supply chain logistics.

Strengthening Technical Capacity: Linux and other IT Training for Tonga’s Ministry of Health

In March 2025, the BES Support Centre hosted a specialized Server Linux Training course for two IT staff from Tonga’s Ministry of Health, with virtual participation from Kiribati. Led by Ashnil Kumar, with support from Anil Karan and Monika Lal, the training aimed to enhance technical proficiency in Linux server management.
Key topics covered included:

• Linux & Server Basics – Fundamentals of Linux, virtualization using VirtualBox/VMware, and WSL setup for SSH access
• Linux Administration & Networking – Package management, user administration, firewall setup, and SSH security best practices.
• Server Configuration & Security – Securing SSH, implementing fail2ban, and system hardening techniques.
• Advanced Topics & SENAITE – Hands-on installation of SENAITE, server monitoring, log management, and automated backups.
• Tamanu Deployment & Upgrade – Practical experience in installing, verifying, and upgrading Tamanu.
• Support Centre Overview – Insights into support functions, issue assessment, and the Zendesk ticketing system.

Participants engaged in practical exercises such as setting up Linux virtual machines, deploying security tools, and troubleshooting real-world scenarios. The training concluded with an interactive Q&A session, fostering peer-to-peer learning and collaboration.

Learning from Experience: Timor-Leste Delegation Visits Fiji’s Supply Chain Systems

Also in March 2025, a four-member delegation from Timor-Leste’s Ministerio de Saude visited the BES Fiji office to gain insights into Fiji’s health supply chain. The visit allowed them to explore the similarities and differences between their systems and Fiji’s implementation of mSupply as a Logistics Management Information System (LMIS).
Throughout the week, the delegation:

• Examined mSupply’s role in improving Fiji’s supply chain management.
• Discussed key topics such as procurement, dispensing, and laboratory integration.
• Visited FPBS, CWM Hospital, and remote health facilities to observe operations firsthand.
• Learned about BES’s contributions to health information systems, including Tamanu, Tupaia, and SENAITE.
• Participated in a live demonstration by the BES Support Centre, showcasing how each product is actively supported.

This visit reinforced the importance of knowledge-sharing across Pacific nations and highlighted how digital solutions can be leveraged to improve healthcare supply chains.

Digital Health Capacity Building: Nauru Digital Health Officer Training

Nauru Digital Health Project Officer Templa Tau spent a week at the BES Support Centre in Suva for an intensive training program in September 2024. He worked closely with the deployment and support teams to deepen his understanding of Tamanu EMR, Tupaia, mSupply, and mSupply Cold Chain.
Templa also traveled to various health facilities to observe Tupaia facility assessment surveys in action. As a key player in Nauru’s health system digitization, his time in Suva provided invaluable insights into IT support, data configuration, and user training. The opportunity allowed him to see ‘behind the curtain’ of BES’s IT and software solutions while also sharing firsthand field experiences with the support team.
This exchange not only strengthened Templa’s technical expertise but also reinforced BES’s commitment to building local capacity, ensuring sustainability and long-term project success.

Building a Stronger Digital Health Community

Through initiatives like these, the BES Support Centre is becoming a vital hub for collaboration, ensuring that Pacific health professionals have access to high-quality technical training. By fostering regional connections and providing hands-on experience, the centre is empowering teams to strengthen digital health infrastructure across the region.
We look forward to hosting more teams in the future and continuing our mission to support technical capacity building in the Pacific.

#CapacityBuilding #HealthTech #LinuxTraining #DigitalHealth #Collaboration

It’s the Holy Grail for EMR implementations across multiple sites. How do you get true data mobility – the full patient record available to all users in all places – whilst supporting offline use with 100% functionality, from outreach teams to large tertiary hospitals?

This is why Tamanu is unique – it has universal sync.

If you’ve ever used Tamanu, you might have noticed that it looks fantastic, has great functionality, and is super intuitive to pick up (heh – well that’s what we think anyway!). But what our engineers are most proud of is something that you probably haven’t noticed at all – the sync engine. In this case, not being noticed is actually what we’re aiming for! Like a cricket umpire or football referee, a bad job will be really obvious, but good sync should fade into the background and “just work”, without the user having to think about it.

It’s not so easy to make that happen though. When we first built Tamanu, our prototype sync engine was honestly pretty unreliable. Users noticed it all the time, in a bad way. It ran too slowly and would sometimes silently fail – we never lost data and the system stayed up for users but data was not moving around as smoothly or quickly as we’d hoped. So, over the last two years, we’ve dedicated almost a quarter of our engineering time to focus solely on sync. Fortunately, as well as being challenging, it’s also really interesting and a source of endless fascination for our engineers at BES. The result of this work is a super-robust, super-fast sync engine for Tamanu, which we released in v2.0 at the start of 2024.

Why put in so much effort? Because a strong, stable sync engine is foundational to working offline. The ability to work offline is absolutely critical in the places Tamanu is used, and so is the ability for health workers to access up-to-date patient records, wherever that patient presents. This is not just about supporting outreach teams looking at individual patients – hospitals and health centres need a system where all users across a large facility can be accessing the same record, looking at the same version of the data, even when the facility goes offline (whether that is for minutes or for weeks). Back in 2018, when we looked around for a software that would achieve this, we came up short. No existing open-source EMR could work at a national scale, while allowing users to use the full set of functionality, offline, for as long as the internet might be down.

To this day, that’s still true. While other open-source options have some offline capabilities, they’re generally limited to specific workflows, and often just go in one direction. 

For example, something that’s easy to do offline is submitting forms. You can download the form to the user’s device, and then cache their answer until the internet is available. This is the way Tupaia DataTrak works, and there’s nothing wrong with it at all for that use case! However, it doesn’t get you to the point that health workers can see all of a patient’s medical history, and continue to interact with that history without the internet. 

For true offline capabilities, you need what we call “Universal Sync”. Universal because it covers 100% of functionality, across all locations and devices, for any amount of time. That means that information can travel in all directions across the health system, and be kept coherent and up-to-date, while also dealing with extended periods of internet downtime. The table below shows the differences between the basic sync systems that are most common, and Tamanu’s Universal Sync model.

Basic vs. Universal Sync: Side by side, the differences are stark

Case Studies

But hang on… the software we’re using says that it works ‘offline’? What’s the difference? It turns out there’s a lot of difference and ‘offline use’ can refer to a spectrum of functionality ranging from submitting a single form response on a mobile device, all the way up to hundreds of simultaneous desktop users with a fully functional EMR in a tertiary hospital.

Case Study 1: Tupaia DataTrak

DataTrak is designed to collect data at health facilities and other locations via offline forms. It implements a form of Basic Sync, downloading all surveys and questions ahead of time so they can be filled out without an internet connection. It caches them using very modern technology, with a full database embedded in the database, able to run fast and store large amounts of data by combining WASM and OPFS (don’t worry if you haven’t heard of them!).

When the internet is available, Tupaia DataTrak will sync all answers back up to a central server. It is limited by all the constraints of Basic Sync listed above, though with a very high maximum db size and length of time offline. Those constraints are completely acceptable when the use case is focused solely on collecting survey data, as opposed to providing full health system functionality.

Case Study 2: KoboToolbox WebForms

KoboToolbox uses Enketo WebForms to provide Basic Sync in a very similar way to Tupaia DataTrak, just with older technology used to cache data in the browser. As such it is limited by the same set of Basic Sync constraints, but additionally has lower limits on the amount of data and length of offline support. Again, this is generally not an issue in real world scenarios, as it is specifically designed for collecting information through surveys and forms rather than managing patient data or health system workflows.

Case Study 3: KoboCollect

KoboCollect uses SQLite natively in an Android app, so extends upon the WebForms option in terms of the scale and longevity of data it can cache. However, it is only available on Android devices, and also requires more user intervention to send data to the central server, rather than automatically syncing in the background. 

As with the previous two case studies, the limitations of Basic Sync are not hugely detrimental in the context of collecting data that is generally aggregate, and only used for reporting rather than operational or clinical workflows.

Case Study 4: Bahmni Connect

Bahmni Connect is a heavily stripped back version of the Bahmni port of OpenMRS. It provides offline support for a few basic workflows, including viewing a subset of patient data, registration of new patients, and recording observations against patients. 

The web app stores data offline using a browser cache, but because it was built before most databases supported browser builds via WASM, this cache is limited in performance and scale. Bahmni provides an estimated maximum of 2GB, and while that is smaller than a large facility might require, it is plenty for the limited data types and workflows supported. 

In terms of longevity of data, the browser technology used comes with a disclaimer that data may be purged at any time, losing it from offline access. However, this right-to-purge is seldom enacted by browsers, so it is unlikely to be an issue in most cases. 

While Bahmni Connect has much more of a clinical focus than the previous three case studies, it is only designed for use in outreach settings, as the per-device cache and limited workflow support would not be ideal in a medium to large health facility. 

It is worth noting that Bahmni Connect is now marked as deprecated in some documentation, though it is likely still to be in use for some time as projects migrate to other options.

Case Study 5: Bahmni Outreach App for Community Health 

The Bahmni Outreach App is built to support community health workers (CHWs) in offline environments. It allows health workers to register patients, record basic observations, and track health programs like immunizations or antenatal care. It uses more modern technology than earlier Bahmni solutions, leveraging the third-party open source project Avni.

Avni stores data locally on a mobile device, using a database called Realm. To limit the database size growing too large, each device will only store predefined subsets of patient data based on catchment area. This is helpful in allowing the app to operate at scale, but may create difficulties when interacting with patients from outside of the predefined list.

The app does support bidirectional sync of some data types, allowing registration and editing of basic patient details, as well as recording vitals, entering lab results, and making referrals. This data will sync to Avni when the app is online and open, and from there an integration service transmits it back into Bahmni.

Outsourcing the sync engine to a pre-existing project brings some benefits for Bahmni, including being able to launch a new offline app quickly. There are also some downsides, including the overhead of installing an additional server, app, and integration engine, as well as the need to keep metadata updated in concert across both systems. Because Avni was not designed for clinical workflows, all concepts in Bahmni need to be mapped to entities and form fields that are otherwise used for reporting-oriented data collection. Some of this is done automatically, and Bahmni have also written an upgrade guide detailing how to set up the initial mapping.

The Bahmni Outreach App for Community Health is designed for small-scale, community-based health initiatives, and the limitations of Basic Sync are likely to be acceptable in these contexts. However, because it is only available on Android mobile devices, and the workflows are limited, it is unlikely to be useful for larger clinical settings.

Case Study 6: OpenMRS Offline Community Outreach

While it is no longer maintained, a notable mention is OpenMRS 3 Offline Community Outreach, which introduced the ability to interact with some features of OpenMRS offline. Like the Bahmni offline offerings, the system is focused on community health workers, so only supports basic patient details, and submitting forms. 

One downside of the OpenMRS system compared to Bahmni is that it requires a lot of hands-on interaction from users. They need to make sure to manually add patients to the offline list before they go offline. Sync is also quite manual, requiring the user to click the download button to get the latest data, and staying on that page while the data syncs. This works really well for community outreach, where you might know the set of patients who you are visiting that day, and can download them in advance. However, it is more risky when dealing with unexpected internet outages, as patient data may or may not be available.

Both the manual steps required, and the range of functionality that is available, are areas of active work for OpenMRS, so we can expect to see some improvements in future. 

As with Bahmni Connect and Tupaia DataTrak, because the offline cache is based on browser technologies, the size is limited and potentially subject to purge or accidental deletion if the user clears the cache. This decision is another one that is really focused on their core use case of community health workers. In a hospital, as well as the larger data size, the browser based data storage mechanisms don’t generally work as it requires every individual user to independently sync, constantly. 

Case Study 7: EMR4All (OpenMRS 3 on Raspberry Pi)

The EMR4All project aims to have OpenMRS 3 run on a local Raspberry Pi, and synchronise with a cloud server. This is a really fantastic step, and if successful, will bring OpenMRS closer to that Universal Sync holy grail, at least for smaller facilities. The project is still in the proof of concept phase, with sync set up just for a set of 5 core tables, as of October 2024. There is also still some friction in the sync system, for example needing to manually rebuild search indexes after each sync.

If taken to production at scale, the syncing Raspberry Pi approach will be analogous to the Tamanu Iti mini-servers that BES provides. In fact, they contain pretty much the exact same set of components, with the only major difference that the Tamanu Iti includes an inbuilt battery to handle temporary power outages without any peripherals. With several of these Iti’s hosting Tamanu in production across the Pacific, we can attest to it being a successful model in situations where internet and power connectivity is an issue. 

The first target of the synchronising Raspberry Pi will naturally be smaller, more remote facilities with correspondingly lower data throughput. Of course, larger hospitals require significantly more data to flow through the system, but if OpenMRS is able to build upon the same sync engine to handle the breadth and volume of data required, it’s possible that the EMR4All project could be the first building block for those contexts as well. Polishing and battle-testing the system will likely take some time, as will adding support for all tables needed in full-service facilities, but it is well worth keeping an eye on progress over the coming years.

Case Study 8: Tamanu

As you’re aware by now, Tamanu implements Universal Sync, meaning all functionality and all data is available offline, in every situation you might want to use Tamanu. 

Tamanu Desktop achieves this using a distributed server architecture, where each facility has a local server with full enterprise-grade support for all operational and clinical workflows. This local server stores all required data for that facility, and automatically syncs with other facilities every minute. Tamanu servers use PostgreSQL as the back end database, which is proven to work at the huge scale of systems like Netflix. The huge benefit of using a per-facility local server, rather than a per-device cache, is that all users in the facility are using a common source of data. This means that if a nurse takes vitals for a patient, the results are visible for all other users instantaneously, without the lag of a sync cycle.

Tamanu also has a mobile application, which uses an SQLite database to store full records for any patient that has previously been seen in that facility. Tamanu Mobile also syncs automatically, on a 5 minute schedule. Currently Tamanu Mobile is only available on Android, like other mobile apps covered earlier. 

Just like the Tamanu Desktop application, the Tamanu Mobile can be used offline for any amount of time. Unlike the desktop application, it does not require connection to a local network. This makes it great for outreach into rural communities, or running small facilities with little to no network connectivity.

All facility servers and mobile devices sync via a central server. The central server manages conflict resolution of concurrent edits via record- and field-wise comparisons of when the last update happened. Updates are tracked on a globally coherent timeline using a “logical clock”, which gets around issues with inconsistencies across clock time on each device. This architecture allows bidirectional sync, so that any record (patient) in the system can be edited on all devices by any user at any time without fear of conflicts.

Bonus benefits of Universal Sync

Other than offline access, there are some other benefits of a universal sync system. One is disaster recovery – in the technical sense of a server failing, but often caused by a real-world disaster! For example, in a cyclone, a server room may become flooded. Because all patient interactions are already synced to the central server, the IT team can set up a “failover” server that syncs that information down, and is quickly available to work from. 

The same attribute of real-time data replication also prevents a very real security vulnerability. Hospitals around the world have had their server taken over by hackers, who will stop people using it until a ransom is paid. With a live backup of data on multiple servers across the distributed system, it becomes nearly impossible for them to take hold of everything. The Universal Sync model allows failover servers that can be started and synced, removing any disruption or need to negotiate with bad actors.

Finally, having data synced down means that things work really fast. When a user pulls up a patient’s medical history, Tamanu doesn’t have to fetch that over the internet, the data is right there on the local database. 

BES are currently working with several countries on the implementation of disease surveillance and screening tools across the Pacific. One upcoming example is the implementation of the Fiji National Notifiable Disease Surveillance System in collaboration with the Fiji MHMS, Fiji CDC, and WHO.

Disease surveillance can take many forms – from syndromic surveillance, passive notifiable disease surveillance, active case finding during outbreaks, and disease-specific community-based screening. Another novel surveillance tool being rolled out in the Pacific is crowd-based surveillance – FluTracking is soon to be introduced into Fiji for example, expanding one of the world’s most successful crowd-sourced disease surveillance system in the world. Already implemented in Australia and New Zealand (as well as Hong Kong and Argentina), FluTracking asks volunteers to complete a short weekly survey on flu-like symptoms, which helps public health agencies to augment other sources of surveillance data, such as laboratories and emergency department presentations.

Across all spheres, nothing replaces ‘human intelligence’ in the form of highly skilled public health experts and epidemiologists – including field epidemiologists – who detect, investigate and stop disease outbreaks on a near-daily basis. These skilled health professionals spend their days conducting contact tracing, testing water sources, and analysing data sets to make sure that the public is protected from the spread of harmful diseases – and multiple investments across the Pacific are increasing the size and skill of these health workforces.

Digital technologies however can augment disease surveillance in a way that analogue systems never can. Our aim – in our partner countries – is to eventually have truly real-time surveillance across all encounters occurring within a health system, being detected and properly investigated within tight, agreed, auditable deadlines. If a patient presents to a facility with suspected TB, health authorities should know about this within minutes and hours, not days and weeks. If a cluster of diarrhoea patients emerges in a village, field epis should be arriving within 24 hours, not within 7 days. We think that tools like Tamanu, SENAITE and Tupaia can help to drive these targets, as can global initiatives such as 7-1-7  which we learnt more about recently at the Global Health Security Conference in Sydney this year.

Here, we highlight some other brief case studies of disease surveillance work taking place across the Pacific, harnessing digital tools to augment the work of the amazing humans protecting all of us.

GIS-based disease surveillance in Kiribati

The GIS Disease Surveillance Project in Kiribati recently went live, with the dual implementation of the Tamanu EMR and Tupaia software platforms. These two solutions – and necessary IT infrastructure – were rolled out at health clinics in the South Tarawa region with the support of UNDP.

A collaboration between the Kiribati Ministry of Health and Medical Services, BES, and the UNDP, the project aims to inform health responses in Kiribati by digitally mapping disease outbreaks as they are reported. Each day, disease case data collected by health workers using Tamanu flow through automatically to map overlays and data visualizations in Tupaia that show the type, size, location and patient demographics of disease outbreaks in near real-time. The diseases of interest include acute fever and rash, diarrhoea, dysentery, influenza-like illness, pneumonia, and prolonged fever.

Since late April, Kiribati health workers have reported 288 cases of interest from nine clinics, with further expansion expected in the near future. BES looks forward to helping Kiribati further digitize its health system for improved patient outcomes, including with the implementation of Tamanu at TCH (Kiribati’s national hospital), with the support of DFAT.

Samoa dengue outbreak

Recently BES were able to support the Samoa MOH in their response to the 2024 dengue outbreak. Using the positive case data they had available to them, we worked with the MOH to put together a dashboard and map overlays to show disaggregated case information at a highly granular level. This has enabled the MOH surveillance team to see where potential dengue hotspots are and prioritise their response. Dashboards and map overlays were updated hourly to ensure they had up to date information to act on.

In addition to reporting on lab confirmed cases, syndromes such as dengue-like illness, are expected to be reported at the point of care through Tamanu which feeds through to syndromic surveillance dashboards on Tupaia. Whilst the implementation of Tamanu has not been completed yet, the data that is available helped authorities to locate the epicenter of the outbreak and to identify the population groups most affected (including by age and sex). Whilst the outbreak seems to currently be under control, dengue remains endemic in Samoa and the system remains in use for ongoing surveillance and investigation – since November last year, nearly 600 cases have been detected in the country.

This work is part of an eHealth strengthening project being undertaken with the Samoa MOH to help improve patient outcomes and give individuals accurate and reliable data for decision making.

Nauru

In response to the detection of Rotavirus cases in Nauru in April 2023, BES staff worked with the Nauru Ministry of Health and Medical Services to develop a digital rotavirus screening tool. In the space of just a day, the Rotavirus Community Screening Form was developed in Tamanu and was in use by the Community Outbreak Investigation Team. The team used this form to collect information on close contacts, vaccination status, symptoms and potential exposure routes.

Tupaia dashboards and map overlays were used to map screening progress and track case numbers and potential sources of infection such as food. The outbreak was quickly controlled and active case detection was able to quickly cease, saving money and time otherwise needing to be spent on a larger event.

Since the outbreak, BES have continued to work with Nauru MHMS to strengthen digital health capabilities across the nation, including further digitisation of the Notifiable Diseases system.

Sample data only shown

Through our digital health systems – Tupaia and Tamanu – as well as SENAITE and mSupply, BES supports data collection against more than 10,000 clinical events every day across the Pacific. Each clinical event generates multiple data points on patient demographics, time/place, epidemiology and treatment – some clinical events might generate dozens of useful data points on their own. In addition to this, we help partner countries to gather data on non-clinical health information, such as environmental health, infrastructure and equipment, assets, weather, supply chain, and animal health.

This means that today, our systems have collected >200 million data points about healthcare in the Pacific!

Data is not information however – and turning data points into useful information is far more important than gathering the data in the first place. Unless countries are able to make clinical, public health, and administrative decisions with their data, improve safety, or save time – what we call evidence based data for decision making – then they may as well still be collecting information on paper, in dusty red ledger books that nobody will ever read. In short, the digitisation of health systems is only useful if it leads to improved clinical and public health outcomes.

For this reason, every day, our project managers liaise with countries and then work with the BES data team to extract useful stories from this enormous dataset and provide it back to countries in meaningful, purposeful ways. In turn, they then strengthen the capacity of local data analysts and HIS officers to become better stewards of their own data, building and interpreting their own reports to tease out the stories useful to them. Together, we are helping to drive improvements across the region, led by amazing, dedicated Pacific Islands health professionals from all backgrounds.

In this piece, we have gathered together just a tiny handful of these stories to highlight the difference that digital health systems can make every day. We’re going to continue to try and gather these short stories and publish them regularly – if you know of an interesting use case for digital health records in the Pacific (using any system!), then feel free to reach out and share them with us.

Palau

Data-driven environmental health: Sylvia Tmodrang using her data to better target interventions

Sylvia Tmodrang is not just an Environmental Health Specialist and Health Inspector at Belau National Hospital; she’s an advocate for the impact of Tupaia on her work and community. Since its introduction in 2022, Sylvia has been at the forefront, leading her team in mapping over 1,300 households across Palau and conducting more than 1,000 environmental health inspections.

For Sylvia, the difference isn’t just in the numbers—it’s in the tangible changes she’s witnessing. During follow-up inspections, she’s noticed a shift in behaviour among residents. Sylvia has commented that “People are considering [how] it effects their community. I can’t change it over night, but it’s working”.

Using Tupaia’s dashboards, Sylvia tracks everything from overall household health scores to fine grained details like mosquito breeding sites in specific homes. This level of granularity empowers her to monitor changes not just at an individual level, but also at a village-wide scale. This information guides Sylvia in making informed decisions about where her team should focus their interventions, ensuring resources are targeted where they’re needed most.

Beyond her role, Sylvia’s commitment to leveraging technology for public health underscores her dedication to improving the well-being of Palau’s communities. Her story is not just about data and inspections; it’s about driving meaningful change, one household and one village at a time.

Kiribati

Hepatitis B care

A partnership between Kiribati’s Ministry of Health and Medical Services (MHMS) and Hepatitis B Free has significantly improved Hepatitis B management using the Tamanu Electronic Medical Record (EMR) system. Led by Dr Thomas Russell, the digitisation of this initiative has helped to improve the longitudinal care of Hep B patients in Kiribati and reduce the number of patients list to follow-up.

Tamanu’s Program Registry went live at the Hepatitis Overview Programme to trEat (HOPE) Clinic on March 13th 2024, and allows for efficient patient tracking and data collection. In the first three days, 75 patients were registered, showcasing the demand for the system and the enthusiastic uptake. Since then, over 450 patients have been registered in the system – along with their clinical status, associated conditions, home village and other information.

Kiribati faces a high Hepatitis B prevalence, with a national rate of approximately 15% and some areas exceeding 20%. Despite >30,000 HBsAg tests being performed – with >5000 positive cases identified – only 30% of these patients (around 2000) have been linked to care. 730 patients have been started on tenofovir but only 200 patients are currently continuing treatment (though some have finished treatment).

The introduction of Tamanu’s new Program Registry module aims to enhance patient care and disease surveillance, addressing the challenge of managing long-term, complex care across dispersed islands. The system is already showing promise, with staff positively responding to the new technology and improvements in patient follow-up on South Tarawa. Excitingly, the initiative also allows Dr Russell and colleagues to provide remote care to patients from outside Kiribati, letting them review patient records in real-time, securely and highly accurately.

Samoa

Transforming NCD data into a useful report for tracking patient cohorts

In Samoa, in 2023 it was identified that individuals who were being screened for NCDs in the community were not being followed up at rural health facilities as expected. In collaboration with the Samoa Ministry of Health, BES built a report that helped to identify individuals who were expected to visit a rural health facility after screening but had not shown up.

The nurse manager at Safotu district hospital noted that she found it an easy to use this tool to identify these individuals who required follow up. This helped to facilitate more timely follow up and diagnosis of patients, specifically with hypertension and diabetes. She said that the report also helped to ensure patients were followed up within 60 days, which is a target for rural health facilities.

The report included the patient details (name, sex, date of birth etc), the primary screening site, their home village, the date of screening, reason for referral, screening results, blood pressure, blood sugar level, and the number of days since the screening took place.

With the new Program registry feature now also available (since early 2024), health staff in each facility are even better equipped to use Tamanu to filter all patients with a single click, to show those from their area suffering certain conditions (or screened as high-risk) who have not presented for diagnosis or follow-up.

3621 adults were screened using the system in 2023, with 60% of these being women.

Supporting medication forecasting

In September 2023 the Samoan Ministry of Health carried out a Mass Drug Administration (MDA) for lymphatic filariasis and scabies. The MDA involved treating individuals with albendazole, ivermectin and diethylcarbamazine medication to interrupt the infection cycle and prevent the ongoing illness associated with these infections affecting much of the Samoan population. Each individual’s dose was calculated based on their weight. These treatments were recorded on Tamanu at the end of each day and data was aggregated and visualised on Tupaia in real time.

After a few days, stocks of these medications were lower than anticipated. Lenara Tupai (ACEO HITC, 2023) noted, using Tupaia, that because individuals were dosed based on their weight, this was resulting in higher-than-expected medication consumption and that if the MDA were to continue in this trend stocks would deplete before the target population could be dosed.

This information helped to facilitate and justify an emergency drug order to replenish stock, so the team could successfully continue the MDA which then occurred, achieving high coverage.

Dashboards to monitor outpatient workload

In December 2023, Tamanu was implemented at the Acute Primary Care Clinic (APCC) at TTM Hospital. Working collaboratively with the Head of Department and Nurse Manager BES built a dashboard on Tupaia to visualise aggregated data from the clinic. The dashboard showed wait times, diagnoses, patient demographics, procedures carried out and referrals. This gave the clinic oversight of their patient cohort they had not before had in real time.

BES additionally built visuals to be used for performance management, which identified the number of key activities performed by each staff member within Tamanu. This has proved to be a valuable tool for the nurse manager who is more easily able to identify problem areas and individuals who may need upskilling in their understanding of Tamanu. Using these dashboards, they have been able to ensure that information is entered correctly by staff and that it accurately reflects the work being performed which they hope will be justification for additional resources.

Nauru

CVD Screening Data

In 2023 the Health Promotion team continued to use the Cardiovascular Risk Screening form in Tamanu to capture data during their workplace screening programs. The NCD dashboard in Tupaia was created to display aggregate data including number of participants, abnormal vitals results, existing diagnoses, cardiovascular disease risk and referrals made for further care. Data is available at both a national and a district level. This data is reviewed by the Health Promotion team leads and influences decisions on where to hold education and awareness programs and where to distribute Information and Education Communication (IEC) materials. In 2023, 299 people were screened for CVD risk by the Health Promotion team.

COVID-19 Vaccination Mop-up Campaign

In the second half of 2023 Nauru received a donation of COVID-19 vaccines, including paediatric vaccines. In order to maximise vaccine uptake, the Public Health division decided to use data captured through Tamanu to identify how many children were eligible, which children should be prioritised for vaccination and how this compared to number of vaccine doses were received.

The registered patient line list report can be exported from Tamanu to identify patients within a defined cohort. In this instance the list was used to identify all registered children aged zero to 17 years.

The Ministry of Health decided to prioritise children with certain underlying conditions for vaccination. The Tamanu recent diagnosis line list was used to identify those children who had a relevant diagnosis entered into Tamanu. 29 children with asthma were identified as priority for vaccination. These data sets were combined with data provided by the education department as well as older paper records kept by MHMS.

The Vaccine line list in Tamanu was used to identify those children in the selected age groups who were fully vaccinated, those who had started, but not completed the initial course of COVID-19 vaccinations, and those who had not received any previous COVID-19 vaccination. This data was cross referenced against the registered patients list and allowed the Health Promotion and clinical teams at Naoero Public Health Centre to adopt a targeted approach to their vaccination efforts.

In total, 62 children aged 0-17 were vaccinated for COVID in September and October 2023. This includes 44 first doses, 14 second doses, and four third dose vaccinations.

Minister’s Weekly SitRep and COVID-19 Cases and Vaccinations Dashboards

The Minister’s weekly SitRep dashboard (MWSD) and the COVID-19 Cases and COVID-19 Vaccinations Dashboards have been in use in Nauru since 2022.
The MWSD provides high level data on COVID-19 cases as well as summary data on Outpatient diagnoses. These dashboards are used regularly by the Director of Medical Services and the Director of Public Health to provide weekly updates to the Minister of Health in Nauru.

As part of the SitRep, data is provided on top diagnoses in the Republic of Nauru Hospital Outpatients Department, Emergency Room and for Admitted Cases. This information is used to identify any conditions which may present a public health risk (eg. Increasing numbers of respiratory infections).

1. Free and open-source
2. Desktop and mobile enabled out-of-the-box
3. Seamless data exchange via HL7 FHIR compliant API, as well as interoperability with all major clinical data standards
4. 100% offline functionality across desktop and mobile, with powerful syncing. Run offline for unlimited periods, with all data syncing in two directions when you come back online
5. Highly secure to global standards

We also wanted Tamanu to have a modern, clean interface; to be intuitive for first-time users; and to meet nearly all clinical and public health use cases so that users didn’t need a different app for every single different clinical workflow.

Today, Tamanu is used in 6 countries around the world and tracks >10,000 clinical events every day.

Since we first went live with Tamanu in 2020 though, there had been 38 minor version upgrades and we’d reached Tamanu 1.38. Over that time, Tamanu changed completely – the big changes since our release included:

• Dozens of new features and improvements, supporting use from outreach clinics to tertiary hospitals
• Newer, more modern user interfaces
• Much greater stability
• A completely new sync engine, changing the way that data moves around and supporting use at scale
• Hugely improved (and much more granular) permissions model and a raft of security features
• Smarter data exchange using HL7 FHIR
• Report-builder

By the time we reached version 1.38, Tamanu was a completely different software to where we started – and then we introduced one of the biggest updates of all, releasing Tamanu as a web application in Chrome. This meant that Tamanu would be usable across Mac, PC and Linux machines (as well as on Android in a mobile version).

We therefore decided that it was time for Tamanu 2.0.

Our technical description of these changes is here: https://beyond-essential.slab.com/posts/tamanu-2-0-mchlk33i

Most importantly, Tamanu Desktop is now usable across any platform – Mac, PC and Linux – with no local software required except Chrome. It is more stable, more scalable, and has more features than ever before. Recent new features include:

• Program registries module
• Translation tool to seamlessly switch between languages
• FHIR-compliant International Patient Summary
• Improved Electronic Immunisation Register module
• Front-end report builder

For many people who haven’t seen Tamanu in a while, we invite you back to see it again. For new users, we invite you to get in touch and experience the best open-source EMR in the world.

An Electronic Medical Record like nothing you’ve seen before.

Nauru has become the first country in the world where every single clinical encounter in the public system is being recorded in a single, national Electronic Medical Record, with point-of-care access for all clinicians.

Nauru’s two dental clinics, based at the Anibare and Yaren Wellness Centres went live with Tamanu on 12 February this year. The three dentists, assisted by their dental nurses, picked up Tamanu quickly and though a BES staff member was at the clinics to provide support, after the first two days the dental staff were comfortably using Tamanu on their own.

In just the first month after Go-Live, there were 354 dental encounters recorded in Tamanu.

The launch of Tamanu at the dental clinics was the final piece in the puzzle that has seen Tamanu implemented across all health facilities in Nauru. Now, every encounter, for every patient, at every health care facility in the country is recorded in Tamanu, and staff across the system have access to a complete patient history, allowing for continuous, longitudinal care no matter where the patient is being seen.

This is a crucial point in a long program of work, which saw the launch of Tamanu at OPD at Republic of Nauru Hospital in early 2023, followed by the roll out of Tamanu across the rest of the hospital, Naoero Public Health Centre, the two Wellness Centre nursing clinics and finally at the dental clinics.

“Tamanu is unique. It is not a central national health records database that pulls basic encounter data from multiple different systems like Australia’s My Health Record. It is a point-of-care Electronic Medical Record with a distributed data model allowing simultaneous offline use across hundreds of facilities at a time. This means that you can run it in multiple facilities with local hardware (or via the cloud) and experience 100% offline functionality indefinitely when you lose connectivity to the central server. Tamanu will then sync in two directions whenever it has a connection to the central server – it is the only free and open-source EMR in the world that can do this across both desktop and mobile. The result is that all clinicians, in all settings, can access the entirety of a patient’s medical record whenever the patient is sitting in front of them”.

Emily Porrello, BES Head of Programs

BES Project Manager Regina Akacich leads training for Naoero Public Health staff in 2023

The implementation of a point-of-care EMR is of course only the first step towards a digital future in which patient outcomes are improved and public health decision making is guided by a true, data-driven evidence base. BES staff continue to work closely with the Nauru Ministry of Health to refine the use of the system, improve reporting, data quality and completeness, and to drive data for decision-making. Despite BES’ support however, this has been a truly locally-driven initiative, with a Ministry Steering Committee overseeing all aspects of the project.

Since the launch of Tamanu in Nauru in January 2023 there have been:

• 42,310 Outpatient  encounters across all facilities
• 1,578 Hospital admissions
• 4,450 Emergency encounters

recorded in Tamanu.

This remarkable achievement not only improves clinical care for patients, it saves clinicians time during clinical encounters, whilst eliminating the need to ever need to find old paper record in order to provide care for long-term, chronic conditions. This means that clinicians can spend more time with patients and HIU staff can spend their time analysing and using data, instead of entering data or endlessly searching for manila folders.

In addition to the implementation of Tamanu, the Nauru Ministry of Health have also simultaneously implemented mSupply (a Logistics Management Information System for health systems) and Tupaia (data aggregation and reporting). Later in 2024, they will go live with Voyager (a PACS for the national imaging department) and SENAITE (a Laboratory Information Management System). These systems will all integrate with each other in a completely holistic eHealth data ecosystem.

Importantly for health planners, the implementation of an end-to-end electronic medical record system automates the vast majority of public health reporting. Health planners can now spend their time considering “what is the best question to ask of our data” instead of “how can we go out and get some data”. Moreover, the ability to now aggregate and report all clinical data in near real-time allows public health teams to respond far more rapidly to disease outbreaks or issues of concern.

It is an enormous achievement – particularly given the infrastructure and environmental restraints on digital initiatives in the isolated country.

Back in the dental department, the staff are enjoying this at a local level:

“Tamanu is proving great for us in managing individual patients who are returning for treatment. It will also help us a LOT with our quarterly and annual reporting requirements, so we’re very excited!”

Dental staff member in Nauru

BES’ work in Nauru is led by Corinna Minko, Templa Tau and Amanda Lipinski