designing an electronic health information system integrating mobile phone technology suitable for a...

Designing an Electronic Health Information System Integrating Mobile Phone

Technology Suitable for a Low and Middle-Income Country

CASE STUDY: Curative Care Services in Kenyan Level 5 Hospitals

Paul MACHARIA1, Maureen INIMAH1, Davies KIMANGA 2

1Ministry of Health, National AIDS & STIs Control Programme

2 Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya

Mailing Address: P.O Box 3966 00100 Nairobi

E-mail: [email protected], [email protected], [email protected]

ABSTRACT

Shortage of healthcare workers (HCWs) hampers

treatment outcomes in Sub-Sahara Africa (SSA),

there is also a great need for scalable, cost-effective

and long-term strategies in curative care services.

The benefits of e-Government, the integration of

innovative Information and Communication

Technologies (ICTs) to conveniently provide access

to services are yet to be realized. m-Health is an

emerging concept with potential to revolutionize

delivery of healthcare, mobile phone technologies

potential to change healthcare for the better when

used as an enabler to immediate and secure access

to critical clinical information when needed in the

provision of patient care has not been fully

exploited. The study an exploratory research design

aims to discover ideas and insights on the use of

Electronic Medical Records integrating mobile

phone technologies. The research hopes to identify

potential problems of EMR system setup and

available opportunities for integrating mobile phone

technologies relevant to the provision of quality

healthcare and treatment outcomes.

KEYWORDS

e-Health, m-Health, Quality Healthcare, EMRs,

Mobile Phone Technologies

1. INTRODUCTION

To efficiently provide services, Countries are

embracing e-Government, the integration of

innovative Information and Communication

Technologies (ICTs) in a way that conveniently

provides access to services & up-to-date

information to its citizens [1]. In leading

economies, e-Government has had great success.

However, more efforts are needed to realize

similar success in developing Countries [2].

Scalable, cost-effective and long-term strategies

in preventive and curative care services are

greatly needed. Information and Communication

Technologies (ICTs), when used in a health

system setup, could greatly improve how

healthcare is administered in a health facility [3].

e-Health is the enhancement of clinical care

through use ICTs in the delivery of treatment,

diagnosis and disease management [4]. e-Health

could also provide an opportunity to extend

healthcare ability to meet patient needs in a

manner that supplements traditional delivery of

healthcare [5].

The capacity to improve health outcomes Sub-

Saharan Africa is greatly hampered by shortage

of health workers [6], exchange of clinical data

Proceedings of the Third International Conference on Digital Information Processing, E-Business and Cloud Computing, Reduit, Mauritius 2015

ISBN: 978-1-941968-14-7 2015 SDIWC 95

can be bridged by the use of ICTs bringing great

benefit to healthcare systems and medical

information sharing [7]. An increase in cheaper,

efficient and reliable mobile phones avails

technological opportunities to offer m-Health

solutions for preventive and curative care

services in low and middle-income countries [8].

1.1 Rationale

The Government of Kenya (GoK) lays a

strong emphasis on strengthening prevention,

eradication and control of diseases by

endeavoring to provide quality healthcare

services to the whole population [9]. A number

of policy documents have been formulated to

operationalize and support implementation of

quality healthcare through the Ministry of

Health (MoH) and other relevant Government

Agencies.

To improve service delivery in healthcare,

GoK through the Ministry of Health (MoH) and

other stakeholders reviewed the First National

Health Sector Strategic Plan (NHSSP-I) service

delivery system devising a new strategy that

makes healthcare effective and accessible to all.

This new strategy is part of the second National

Health Sector Strategic Plan (NHSSP-II) that

proposed different levels of healthcare delivery

[10].

The 6 healthcare delivery levels in the Kenyan

health system are; level 1 a community level

service delivery point targeting a population of

up to 5,000 people. Level 2 and level 3

predominantly handling promotive and

preventive care in a population of up to 40,000.

Level 4 service delivery points handles in and outpatient services and is the first level of

curative care services to a population of up to

200,000. Level 5 facilities have a broader

spectrum of curative care services to a

population of 1,000,000. Level 6 facilities are

national hospitals providing referrals for all

specialized services of healthcare [11].

The service delivery levels integrating all

health programmes into a single package are

represented by the Kenya Essential Package for

Health (KEPH). These levels aim to provide

interventions that will improve peoples health at every stage of human development [11].

KEPH defines the six levels of service delivery.

The levels of care are as shown in figure 1.

Patient.about.com states that Curative care refers to treatment and therapies provided to a

patient with the intent to improve symptoms and

cure the patient's medical problem. Examples of

curative care include antibiotics, chemotherapy

or a cast for a broken limb. Level 5 hospitals now referred to as County hospitals are handling

curative and preventive care in the 47 Counties

of Kenya. The Level 5 hospitals form part of the

County level referral services of comprehensive

healthcare services [12].

2. RESEARCH DESIGN

This research applied an exploratory research

design with a goal to discover ideas and insights

on the use of Electronic Medical Records

(EMRs) integrating mobile phone technologies.

The research would identify potential problems

Figure 1: Levels of health care delivery in

the Kenya Package of Health (MoH, 2004)


ISBN: 978-1-941968-14-7 2015 SDIWC 96

of EMR system setup and available

opportunities for integrating mobile phone

technologies relevant to quality healthcare and

health outcomes. The exploratory research was

conducted to provide a better understanding of a

patients access to curative care services, document patient flow and map service delivery

points. Through the research, a conceptual

model of integrating mobile phone technologies

on EMRs was developed.

3. LITERATURE REVIEW

The use of ICTs in healthcare including

mobile technologies to provide services could

transform service delivery. Mobile technologies

are experiencing rapid advancements, this opens

up opportunities to integrate the technology to

existing e-Health services and catalyze the use

of m-Health in provision of healthcare [13],

[14].

In sub-Saharan Africa, communicable,

maternal, nutritional, and newborn diseases are

still a leading cause of injuries and premature

deaths. Although there has been considerable

decline in communicable diseases in childhood,

these diseases still account for a large part of

health losses and public health concerns despite

the efforts. Malaria and HIV/AIDS still account

for many losses in this part of Africa, however

non-communicable diseases including diabetes,

heart conditions and Cancer have been on the

increase in the recent past [15].

In Kenya, HIV/AIDS, lower respiratory

infections, and malaria contributed highest to

disease burden in 2010. Underweight in children

is the leading risk factor in Kenya; other factors

include non-communicable and nutritional

causes of death. [16].

The GoK e-Health strategy is greatly

dependent on the success of Kenyas Vision 2030, the visions key achievement related to health is to catalyze equitable and affordable

healthcare at the highest achievable standard. This aligns well with radical changes in clinical

care which is defined as a comprehensive, ongoing approach to care delivery excellence

that measurably improves quality, enhances

service, and reduces costs through the effective

alignment of people, process, and technology [17]. The use of ICTs in healthcare makes a key

technology component that will enable clinical transformation.

e-Health can be defined as a new field in

healthcare where ICTs are taking a greater role,

it is the putting to good use the Internet and

related technologies to connect and facilitate

provider-to-provider communication and

provider-to-patient communication in the

provision of healthcare services. It involves the

use ICTs to store and manage a patients data and their relevant clinical information [18].

An EMR system is a computer application

supporting digitalization of a patients medical history by electronically documenting all

relevant information to this patients healthcare. EMR systems store and provide for retrieval of

information on a patients diagnosis, care and treatment [19].

EMRs have been identified to make relevant

clinical data available to the providers with

minimal effort. A patients safety is assured to due to safe storage of their confidential

information; providers have been noted to be

efficient and learning on their jobs when

working in a well setup health information

system [20]. EMRs should increase a health

providers ability to access patient data and share confidential records among authorized

persons [21].

The EMR can track patients stored data over time, scheduled visits and monitor all relevant

patient health information which could

potentially improve the quality of healthcare

[22]. An EMR captures information in a

structured way enabling continuous


ISBN: 978-1-941968-14-7 2015 SDIWC 97

improvement in healthcare delivery. System

interoperability, which is the ability to share data

with other EMRs is a key component in

providing quality healthcare. Standards of EMR

systems setup that include HL7 standard which

regulates interoperability standards of EMRs

should be strictly adhered to thus enhancing

sharing of patient data across systems and

quality of services [23]. Interoperability among

EMR systems enables healthcare providers to

actively interrogate healthcare procedures and

decisions from shared data thus ensuring quality

healthcare [24].

Although EMRs have great potential, there is

very little literature or studies specifically

designed to evaluate what already setup systems

have had to the quality of healthcare, making the

services affordable and accessible in LMICs.

Customizing the EMR to meet a communitys culture and health expectations is still in great

need [25].

In the recent past mobile phone technologies

have experienced rapid growth, major

developments on both hardware and applications

is creating more opportunities to integrate

mobile phone technologies into existing e-

Health services, this is catalyzing the use of m-

Health in the provision of healthcare [26]. The

world has over 5 billion mobile phone

subscribers with over 70% of these residing in

LMICs making mobile technology a very ideal

platform in provision of quality healthcare in

these countries [27].

As an innovative way to face the challenges in

health systems in LMICs, m-Health offers an

opportunity to bridge the gap to barriers

including shortage of infrastructure, patient data

being accessible and enough healthcare workers

to deliver affordable high quality healthcare

[27]. Bastawrous states that The evolution of mobile phone technology has introduced new

possibilities to the field of medicine. Combining

technological advances with medical expertise

has led to the use of mobile phones in all

healthcare areas including diagnostics,

telemedicine and research.

A number of efforts are already in place to

harness the many health benefits that could be

derived from the use of mobile technologies in

public health in Kenya. In 2011, leading

research institutes met to deliberate on the

potential of sharing and using m-Health

solutions to provide healthcare. The meeting

also provided an opportunity for successful

research on the use of technology in healthcare

to showcase their successes, it was agreed that

efforts would be made to spearhead turning that

meeting recommendations to policy [28].

Bring your own device (BYOD) can be

described as the trend by employees to use their own devices on the job disrupting the traditional model in which IT had full control

over corporate productivity tools but also

driving greater employee productivity through

increased workplace flexibility [29]. To maximize on the potential benefits of BYOD,

policy to regulate the use of employee-owned

mobile devices and how the facility ICT staff

can support need to be formulated [30].

An acute shortage of Human Resource for

Health (HRH) in Kenya like many other LMICs

significantly hampers GoKs capacity to improve health outcomes and achieve the health

related MDGs [31]. Although health expenditure

has improved, there is minimal increase in

health system resources [32]. The BYOD

concept could benefit GoKs effort to meet the

health needs of its population. BYOD can

reduce the health facility investment costs of

hardware, this could increase and HCW

productivity by allowing staff to access a health

facilitys EMR system remotely and provided needed care.

To secure EMRs supporting the BYOD

concept, device provisioning for devices allowed

to access the system is paramount. The mobile

devices should be well documented and


ISBN: 978-1-941968-14-7 2015 SDIWC 98

managed by the systems administrators. Policies on data security and privacy should be

enforced to keep patient data uncompromised

[33].

4. RESULTS

An electronic interview guide was sent to 20

healthcare providers in March 2014, 16

providers responded. The participants included 7

nurses, 5 doctors, 3 clinical officers and 1 social

worker. Three in every five study participants

were working or had ever worked in a health

facility using paper-based health information

system to record, store and retrieve patient data.

The study respondents outlined a number of

issues that would inform the conceptual model

of the EMR integrating mobile phone

technologies. 40% of the respondents proposed

that the EMR system could be used for patient

diagnosis; 30% of the participants identified data

storage and the remaining 30% patient records

retrieval.

Quality of healthcare could be improved by

the use of EMRs, the system could enhance

service delivery efficiency, reduce patient

waiting time and prevent data loss. One in every

two participants indicated less time would be

spent by patients waiting for a service

encouraging more and more patients to access

care, healthcare providers will also be able to

provide care to a larger population.

On mobile phone integration, study

respondents identified on-demand availability of

patient records as very important. Mobile phone

technologies would address this need. 90% of

identified access to patient records as the

greatest advantage. The issue of misplaced

patient records, a patients laboratory results being mixed up, loss or any other issue that

makes patient records not to be available will be

reduced by an reliable EMR system.

Other benefits of integrating mobile phone

technologies with the EMRs were noted; over

40% of participants felt healthcare could be

scaled up with lean healthcare providers by

technology enabling remote access of patient

records from different locations. Patient data

confidentiality was a big concern among the

study participants, 60% of respondents feared breach of patient confidentiality if the electronic

data was accessed by unauthorized persons. To

secure patient data security features including

firewall, data encryption and secure wireless

connection need to be implemented. Challenges

envisioned by participants in the use of EMRs

integrating mobile phone technologies included

health provider skills, power failure, financing

and related infrastructural needs.

Computer Server

Scanner

Printer

Firewall

Phone

Local Access

PhoneNetwork Switch

Remote Access

Healthcare Provider

Personal Computer

Figure 2 above demonstrates a conceptual

model illustrating the EMR system setup taking

into consideration health providers needs, concerns and suggestions.

5. CONCLUSION

The continuum of healthcare can be well

supported by an EMR that has interoperability

capacities allowing multiple health facilities to

share patients data; this would make it possible for the clinical staff to access a comprehensive

medical history of their patients. In LMICs,

healthcare providers are not enough, EMRs

Figure 2: Conceptual model of an EMR System

Integrating Mobile Phone Technologies


ISBN: 978-1-941968-14-7 2015 SDIWC 99

integrating mobile phone technologies could

support the scale up services by available lean

clinical staff remotely accessing a patients investigation, current medical condition,

exhibiting symptoms and the healthcare

providers at the remote locations will be able to

arrive at diagnosis and relay their results back

increasing healthcare access and reach to

patients even in remote parts of Kenya.

The research has identified considerable

benefits of using EMRs integrating mobile

phone technologies in curative care services. A

larger study needs to be done to include

healthcare providers in urban, rural and semi

urban settings; this will help to evaluate the

system usability and the cost benefit analysis of

the system.

REFERENCES

[1] Fang, Z. (2002). E-government in digital era: concept, practice, and development. International

journal of the Computer, the Internet and

management, 10(2), 1-22.

[2] Schuppan, T. (2009). E-Government in developing countries: Experiences from sub-Saharan

Africa. Government Information Quarterly, 26(1),

118-127.

[3] Lucas, H. (2008). Information and communications technology for future health systems in developing

countries. Social Science & Medicine, 66(10), 2122-

2132.

[4] Eysenbach, G. (2001). What is e-Health?. J Med Internet Res, 3(2), e20.

[5] Juma, K., Nahason, M., Apollo, W., Gregory, W., & Patrick, O. (2012). Current Status of E-Health in

Kenya and Emerging Global Research Trends 1.

[6] World Health Organization. (2007). Global atlas of the health workforce. Geneva: WHO.

[7] Ojo, T. (2006). Communication networking: ICTs and health information in Africa. Information

Development, 22(2), 94-101.

[8] Tamrat, T., & Kachnowski, S. (2012). Special delivery: an analysis of m-Health in maternal and

newborn health programs and their outcomes around

the world. Maternal and child health journal, 16(5),

1092-1101.

[9] Oyaya, C. O., & Rifkin, S. B. (2003). Health sector reforms in Kenya: an examination of district level

planning. Health Policy, 64(1), 113-127.

[10] Muga, R., Kizito, P., Mbayah, M., & Gakuruh, T. (2005). Overview of the health system in Kenya.

Demographic and Health Surveys.

http://www.measuredhs.com/pubs/pdf/SPA8/02Chap

ter2. pdf (accessed June 16, 2011)

[11] Ministry of Health, Kenya (2004) Second National Health Sector Strategic Plan 2004 2010

[12] Ministry of Health, Kenya (2012) Kenya Health Policy 2012 2030

[13] Bukachi, F., & Pakenham-Walsh, N. (2007). Information technology for health in developing

countries. CHEST Journal, 132(5), 1624-1630.

[14] Patrick, K., Griswold, W. G., Raab, F., & Intille, S. S. (2008). Health and the mobile phone. American

journal of preventive medicine, 35(2), 177.

[15] The Global Burden of Disease: Generating Evidence, Guiding PolicySub-Saharan Africa Regional Edition [online]

http://www.healthmetricsandevaluation.org/sites/def

ault/files/policy_report/2013/world_bank/GBD_SSA

_Parts/1_GBD_SSA_Report_overview.pdf

[accessed 8 April 2014]

[16] GBD Profile: Kenya [online] https://www.google.com/url?sa=t&rct=j&q=&esrc=s

&source=web&cd=9&cad=rja&uact=8&ved=0CIEB

EBYwCA&url=http%3A%2F%2Feahforum.files.wo

rdpress.com%2F2013%2F03%2Fgbd-country-

report-kenya.pdf&ei=OApFU_DaE6-

X0AWnyIDIDA&usg=AFQjCNHK3nKS3zR8Tsjq

O6PNBOzvhMIyEA&sig2=VUutS5XDjSp2Y1OEl

CeFDw&bvm=bv.64507335,d.d2k [accessed 8

April 2014]

[17] Novins, D. K., Aarons, G. A., Conti, S. G., Dahlke, D., Daw, R., Fickenscher, A., ... & Spicer, P. (2011).

Use of the evidence base in substance abuse

treatment programs for American Indians and Alaska

natives: pursuing quality in the crucible of practice

and policy. Implementation Science, 6(1), 63.

[18] Grayson, L The History of Electronic Medical Records, 2014

[online]http://www.ehow.com/about_5042653_histo

ry-electronic-medical-records.html[accessed on 10th

January 2014]

[19] Eysenbach, G. (2001). What is e-Health?. J Med Internet Res, 3(2), e20.

[20] Bates, D. W., Ebell, M., Gotlieb, E., Zapp, J., & Mullins, H. C. (2003). A proposal for electronic

medical records in US primary care. Journal of the

American Medical Informatics Association, 10(1), 1-

10.

[21] Barrows, R. C., & Clayton, P. D. (1996). Privacy, confidentiality, and electronic medical records.

Journal of the American Medical Informatics

Association, 3(2), 139-148.


ISBN: 978-1-941968-14-7 2015 SDIWC 100

[22] Hanna, K. E. (2008). Think research: Using electronic medical records to bridge patient care and

research. 2005.

[23] Lucas, H. (2008). Information and communications technology for future health systems in developing

countries. Social Science & Medicine, 66(10), 2122-

2132

[24] Sheikh, A., McLean, S., Cresswell, K., Pagliari, C., Pappas, Y., Car, J., ... & Majeed, A. (2011). The

Impact of eHealth on the Quality and Safety of

Healthcare. An updated systematic overview and

synthesis of the literature. Edinburgh: The

University of Edinburgh.

[25] Aspden, P., Corrigan, J. M., Wolcott, J., & Erickson, S. M. (Eds.). (2004).Patient safety: achieving a new

standard for care. National Academies Press.

[26] Kay, M., Santos, J., & Takane, M. (2011). m-Health: New horizons for health through mobile

technologies. World Health Organization.

[27] Bastawrous, A., & Armstrong, M. J. (2013). Mobile health use in low-and high-income countries: an

overview of the peer-reviewed literature. Journal of

the Royal Society of Medicine, 106(4), 130-142.

[28] Karanja, S., Mbuagbaw, L., Ritvo, P., Law, J., Kyobutungi, C., Reid, G., ... & Lester, R. (2011). A

workshop report on HIV m-Health synergy and

strategy meeting to review emerging evidence-based

m-Health interventions and develop a framework for

scale-up of these interventions. Pan African Medical

Journal, 10.

[29] Dell What Is BYOD? [online]http://www.dell.com/learn/us/en/555/solutio

ns/byod[accessed on 13th November 2013]

[30] Techtarget (2011) BYOD policy [online]http://searchconsumerization.techtarget.com/

definition/BYOD-policy[accessed on 10th January

2014]

[31] Ministry of Health, Kenya (2010,b) National Human Resources for Health Annual Report.

[32] Ministry of Health, Kenya (2012) Kenya Health Policy 2012 - 2030

[33] Meru Networks (2013) BYOD in Healthcare Improving Clinician Productivity and Patient

Satisfaction


ISBN: 978-1-941968-14-7 2015 SDIWC 101

designing an electronic health information system integrating mobile phone technology suitable for a...

Documents