A peer-2-peer electronic health record system streamlining healthcare delivery during short-term medical mission clinics

Global health disparities, characterized by significant and avoidable differences in health outcomes and access to healthcare services across various populations and regions worldwide, represent a profound challenge to human well-being (1). For instance, child and maternal mortality rates remain disproportionately high in low- and middle-income countries (LMICs) (2). Billions of people globally lack full access to essential healthcare services, often facing catastrophic out-of-pocket expenses that push them further into poverty (3,4).

In the face of such challenges, short-term medical missions (STMMs) have emerged as a common approach to provide immediate healthcare in resource-limited settings. These missions typically involve healthcare professionals from high-income countries traveling to LMICs for periods ranging from days to a few weeks, offering direct clinical care, medical supplies, and sometimes educational support (5). When carefully planned and executed with a focus on local needs, collaboration, and sustainability, STMMs can play a valuable role in bridging critical gaps in healthcare access, providing essential services, and contributing to capacity building in underserved communities (6,7).

Nevertheless, STMM teams have the potential to cause harm. Unfamiliarity with the patient population, culture, and disease epidemiology as well as the short-term nature of the trip can lead to inappropriate and unsustainable treatments. Furthermore, the visiting provider is most likely unfamiliar with the practice standards in the host country while host country providers may be unfamiliar with medications and treatments provided by the mission teams (8). Specifically, mobile primary care clinics run by STMMs face several limitations that create room for potential medical errors. These clinics are run in isolation and are not linked with any existing electronic health records (EHRs) system. Clinic processes are also usually paper-based for cost efficiency reasons and compound the reasons for potential harm as first highlighted by Gorske listed below (9):

• Every patient is seen as a new patient so there is lack of background knowledge of past medical and medication history, drug allergies and past diagnoses;
• Lack of adequate time and translation support for obtaining adequate history, conducting physical examination, and counselling by doctors, pharmacists, and nurses;
• Disrupted continuity of care due to inability to retrieve and access past documentation done by the current or past STMM teams;
• Lack of follow-up for adverse effects to treatment after STMM team departure due to loss of documentation.

An EHR system is a potential solution to mitigate these risks. Moreover, it is in alignment with the World Health Organization’s vision for the global strategy on digital health “to improve health for everyone, everywhere by… developing infrastructure and applications that enable countries to use health data to promote health and wellbeing…” (10). However, implementing these technologies in global health missions is not without challenges. Issues such as limited internet connectivity, lack of technical expertise, and concerns about data security can pose significant obstacles.

A literature review by Dainton et al. in 2017 showed that there have been limited attempts to tailor EHRs to STMM mobile clinics and existing systems remain in early developmental stages (11). Subsequently, Maarsingh et al. reported in 2022 how the Gregory School of Pharmacy successfully improved patient-care processes during an annual STMM to rural Uganda through the implementation of an EHR system that functioned over a battery-operated local area network (LAN) (12). Alfille et al. reported in 2023 a novel, open-source smartphone-based EHR software that is usable in austere environments without internet access and is flexible to meet the needs of various types of projects, but its pilot implementation was focused specifically on surgical and perioperative care for short term surgical missions as opposed to medical missions (13).

HealthTouch is a faith-based organisation comprising volunteers from different healthcare professions who have been conducting STMMs to countries such as Nepal, Indonesia, Malaysia, Cambodia and Timor-Leste since 2003. In this brief report, we report the process of development of an EHR system that is not dependent on internet connectivity, the pilot implementation experience, its impact on clinic processes and patient safety, and its initial applications for a sustainable partnership between sender and host organizations.

A typical STMM by our organization would consist of the triage, the consultation and finally the dispensary. Pre-implementation, the process was as such—identifiable personal details, symptoms, and vital signs would be recorded onto a physical patient card at triage, patients would then bring this card to their consult where doctors/dentists would write their diagnosis as well as their prescriptions. They would finally proceed to the dispensary where the pharmacist would pack the medications accordingly and counsel the patients about its use.

However, there are limitations of this paper-based record system, the most important of which being the inability to access previous medical records for the same patient. Furthermore, the illegibility of handwritten data and high risk of data corruption led to the frequent need for different stations to clarify and validate the information on the card. Finally, during post-STMM action reviews, past teams found great difficulty in converting the manual data to digital data for analysis as the teams were composed of volunteers.

Several post-STMM debriefs had considered an electronic process to improve care delivery. In the brainstorming process among stakeholders, several desired features of the EHR system were raised. These included:

• The ability to use the EHR system in conditions without internet access;
• Ability to secure patient data;
• A simple digital flow of patients from one station to the next, directly reflective of patient’s journey (Figure 1);
• A simple way to export data and to reuse the data for future trips;
• Maintenance of data integrity;
• The ability to tag children to their parent at triage;
• A live inventory of medication supply;
• Templatized prescriptions to aid with the packing of medication in the pharmacy;
• Separate user interfaces for dentists, physicians, and surgeons with the ability to see each other’s prescriptions (Figures 2,3 ).

Figure 1 The homepage of our EHR system showing the roles available for users to select. EHR, electronic health record.

Figure 2 Input page for physicians. BMI, body mass index.

Figure 3 Tooth diagram for dentists to input notes. BMI, body mass index.

A solution was chosen which involved the decentralisation of data over a peer-2-peer network functioning over an LAN that does not need to be connected to the internet. Any portable router can be used to achieve this. Many database solutions were considered for the decentralisation of data, but existing solutions such as the InterPlanetary File System (IPFS) did not fit the scope of what we wanted to accomplish as using such solutions would make it harder for data to be shared for future STMMs. Assuming limited technical knowledge for future users, the best solution was decided to be a peer-2-peer network which synchronises data into an SQLite database. The single SQLite database file can then be shared with other users. The absence of a centralised server to manage concurrent updates to patient records poses the risk of data being lost or overridden. Therefore, a locking mechanism was implemented, ensuring that only one user can edit a patient’s record at any one time.

Our team conducted a pilot implementation of the EHR system in Timor-Leste due to our familiarity with the population and a longstanding relationship with the host partner. Furthermore, we had identified 3 different locations within Timor-Leste from more urban locations to more rural areas that allowed us to progressively roll out and test the EHR system over a span of 5 days.

Prior to the trip, a training session for team members as well as an initial trial run of the system was conducted using simulated patients with a similar STMM clinic setup. The trial run was successful in its intended aims while it highlighted important changes that had to be made to the system. For example, feedback from pharmacists enabled us to design the “runner” page such that packing of medication can be done before the patient arrives at the dispensary (Figure 4). This training and simulation session was a critical pre-implementation activity that contributed to the success of the pilot implementation.

Figure 4 The runner page where medication packing can be done before the patient arrives at the dispensary.

Experience from past STMMs by our group showed that the main bottleneck in the entire process is at the dispensary, where much time is spent packing the medications as well as counselling patients on medication use. Our EHR system overcame this issue by allowing team members (called “runner”) to view prescriptions as soon as patients finish their consult without them needing to be physically present at the station, saving and allowing more time for direct patient care.

Upon arrival in Timor-Leste, another system test was conducted on day 0. It was found that a single router was able to support more than 15 devices over an estimated radius of 100 m without any significant degradation in performance. On-the-ground troubleshooting for the first 2 days of clinics was mostly related to user-unfamiliarity with the system and data transmission issues which required on-the-spot updates to the EHR system. Once these minor issues were resolved, the entire process ran smoothly and a team of 6 doctors and 2 dentists were able to provide around 300–400 consultations over 6 hours per day.

One major issue quickly identified by the team was the reliance of the system on the router. Once the router failed, there were large-scale data synchronisation issues. Blackouts were common in the area our team operated in, and we faced multiple instances where the electrical supply to the router was cut without users noticing, leading to a great mismatch in the data. One potential solution to this problem is to use an uninterruptible power supply (UPS) for future STMMs. Issues with queue management also appeared when there were data syncing errors as queue number was assigned based on registration time. The solution was to have constant cross checks at the triage station to ensure data was being synced.

Feedback from the team was highly positive with frequent comments including that the EHR system helped streamline clinical processes and that the live inventory of medication supplies simplified prescribing decisions. The team also added that time was saved by not needing to frequently validate handwritten information on clinic cards, allowing for more time to be spent counselling patients. Furthermore, the EHR system allowed for easier editing of prescriptions leading to fewer medication errors. In addition, dentists and physicians were able to view each other’s documentation and prescriptions, thereby avoiding duplicate or conflicting prescriptions (Figure 5). This also saved time for pharmacists in performing medication reconciliation. Feedback from the host organisation was positive as our team was able to provide them with data in a timely fashion allowing them to shape their practices to better address the needs of their population.

Figure 5 Prescription page where users can see all prescriptions. BMI, body mass index.

At the end of the STMM assignment, there was no longer a need to manually count the hardcopy consultation cards and to find volunteers to interpret handwritten free-text documentation and perform manual data entry into a spreadsheet. Data was easily exported, and analysis could be done using Excel functions. In this trip, we had a total of 1,049 consultations and the age of the patients ranged from 0 to 84 years, with the median age being 34 years and the modal age being 27 years. More than half of the patients (60.6%) were aged 40 years and below, reflective of a relatively young population nationally. Aided by dropdown lists in the EHR for entry of patient diagnosis, analysis of exported data showed that the most common clinical problem for seeking consultation was musculoskeletal conditions (36.0%), followed by dental problems and headache (23.0% respectively), respiratory conditions (21.4%) and gastrointestinal conditions (15.3%).

Our EHR has shown the potential to transform healthcare delivery by STMMs by streamlining clinical processes as well as allowing continuity of care through data storage and access. Quick analysis of data from the STMM allowed for a better understanding of the population and therefore better planning and allocation of resources for subsequent STMMs to the same locations.

Due to the positive feedback we had received, our organisation has plans to continue using this EHR system for future STMMs. The main factor preventing a successful implementation of the system is the user’s unfamiliarity with the system. Hence, regular sessions to teach teams how to fully utilise the system is required. Required hardware resources are laptops (preferably 1 per team member), a router and an UPS in areas with unstable electrical supply. Since data processing and analysis can be done more quickly, we are able to share important data with partners and government organisations for capacity-building, public health education and policy-making.

However, there is an important limitation that limits the use of our EHR for continuity of care. Many residents of LMICs do not have any form of unique government identification. Consequently, the only available means of identifying them is through their names; however, this approach introduces complications related to transliteration, as foreign names may be rendered into English in multiple ways. A potential solution is the use of biometrics to uniquely identify patient records, which has been shown to have a high identification rate in rural environments (14,15).

Also, in situations where electrical power is unavailable, our EHR system will be reliant on how much power can be stored and delivered to the router. Additionally, if STMM locations are situated in areas inaccessible by road, trekking to the location may be challenging due to the need to transport all the equipment and hardware.

We have yet to quantify the effectiveness of our EHR system compared to our traditional pen-and-paper system, and we have only obtained qualitative feedback from team members and host organisation. A quantitative study is planned to compare the efficacy and patient safety outcomes of hardcopy medical records versus our EHR system. To evaluate these outcomes, a survey-based evaluation tool similar to that developed by Maki et al. will be employed (16). Such surveys quantify different factors such as cost, efficiency and impact, to evaluate STMMs through responses from the mission director, host, personnel and patients.

Nonetheless, the development of our EHR is an important step in the right direction and if the above-mentioned limitations can be overcome, it heralds potential future opportunities for remote telehealth follow-up for chronic diseases or treatment complications, and perhaps even synchronization with national EHR systems.

Acknowledgments

We would like to thank Dr. Alex Kuan, Dr. Andrew Chen and the team from HealthTouch and St. John’s-St. Margaret’s Church for their invaluable support and input.

Footnote

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-2026-0002/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-2026-0002/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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