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Refereed papers
The role of the electronic medical record(EMR) in care delivery development indeveloping countries: a systematic review
Faustine Williams MSResearcher, Health Management and Informatics
Suzanne Austin Boren PhD MHAAssistant Professor, Health Management and Informatics
School of Medicine, University of Missouri, Columbia, USA
Introduction
Most countries in Europe and the USA are increasingly
using an electronic medical record (EMR) due to thebelief that it can help improve healthcare quality.Especially after Hurricane Katrina in 2005 theimportance
of EMRs has been re-emphasised, since the hurricane
destroyed or left inaccessible the medical records of anuntold number of people. This focused new attentionon the need for computerised medical records health
ABSTRACT
Objective Most countries in Europe and the USAare increasingly using an electronic medical record
(EMR) to help improve healthcare quality.Unfortunately, most developing countries facemany challenges ranging from epidemics and civil
wars to disasters: they also lack a robust healthcareinfrastructure in the form of information and com-munications technology (ICT) to ensure continuityof patient health which many research studies con-sider a lifesaving resource. The aim of this system-atic review is to examine the benefits of an EMR and
its contribution to the development of healthcare
delivery in developing countries.Methods We searched MEDLINE, PubMed,CINAHL, COMPENDEX and Academic SearchPremier as well as systematically searching thereference lists of included studies and relevantreviews. Inclusion criteria were that studies should
relate to the importance and challenges of an EMRsystem, paper-based medical records, developmentand implementation of an EMR system in devel-oping countries or EMR impact on care delivery in
developing countries.
Results A total of 23 articles were identified thatmet the eligibility criteria. Articles identified were
grouped into five non-exclusive areas: EMR benefits(n=4), challenges (n=6), transition from paper-based to EMR (n=5), EMR in developing countries
(n=8) and pilot projects (n=5). Nine articles wereexcluded because three were not published in Englishand six were studies on EMR in developed countries.Conclusions The potential of EMR systems totransform medical care practice has been recognisedover the past decades, including the enhancement
of healthcare delivery and facilitation of decision-
making processes. Some benefits of an EMR systeminclude accurate medication lists, legible notes andprescriptions and immediately available charts. Inspite of challenges facing the developing world suchas lack of human expertise and financial resource,most studies have shown how feasible it could be with
support from developed nations to design andimplement an EMR system that fits into this en-vironment.
Keywords: computerised medical records systems,developing countries, information systems
Informatics in Primary Care2008;16:13945 # 2008 PHCSG, British Computer Society
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F Williams and SA Boren140
records that follow patients, even if their doctorsoffices no longer exist. A disaster does not mean re-
starting care from scratch. Unfortunately, mostdeveloping countries faced with challenges such asepidemics, civil wars and disasters, also lack robusthealthcare infrastructure in the form of informationand communications technology (ICT) to ensure thecontinuity of patient health which many researchstudies consider a lifesaving resource.
Good health is not only important for individuals,but also for governments because it plays a central rolein achieving sustainable economic development andgrowth as well as effective use of resources.1 Un-
fortunately, we live in a world where two thirds ofthe population lives in so-called developing coun-
tries under conditions grossly different from those inthericher industrialisedcountries.2The Okinawa Charteron the Global Information Society, adopted by leadersof the G8 countries at their summit in 2000, re-
emphasised the importance of ICTs in the globaldevelopment agenda.3 To ensure the MillenniumDevelopment Goals (MDGs) are achieved by 2015,the Socialist International has challenged the Organ-ization for Economic Cooperation and Development(OECD) countries to focus first on delivering Goal 8
i.e. with additional and more effective aid, directedmainly to poor countries, and also more sustainabledebt relief and more trade and technology oppor-tunities for these countries.The Socialist Internationalhas pointed out that for poor countries to realise theMDGs, an additional US$50 billion is needed in aidfrom OECD countries. Further urgent measures must
be taken to fix the problems in the international tradesystems that continue to prevent the worlds poorcountries from trading themselves out of poverty.4
In spite of the importance of ICT and EMR systemsin developing clinical care and policy in developed
countries, there are still some problems or challengesthat must be overcome. Among them are hardware
and software compatibility, training, lack of qualitycontroland antiquated infrastructure.5Some researchersalso believe data collected in developing countries areincomplete, inaccurate, unreliable and not timely,
therefore the potentials of EMRs may not be realised.6
There is the fear that the use of an EMR system might
expedite the dissemination of wrong or poor datawhich does not represent the truth, hence the slowpace of development.6 Irrespective of these challengesthe aim of this study is to examine EMR benefits to the
patients, physicians and other care providers as well asits ultimate contribution to development of health-care delivery in developing countries.
Methods
Data sources
Medline (19662007), CINAHL (19822007),COMPENDEX (19802007) and Academic SearchPremier (19842007) were searched using combin-ations of the following search terms: electronic medicalrecords OR informatics computerised OR informa-
tion storage and retrieval OR medical informatics ORcomputer-assisted decision making OR information
systems OR hospital information systems AND devel-oping countries. We also systematically searched thereference lists of articles retrieved. There was no limit-
ation of publication date in the search; however, theearliest eligible article was published in 1995.
Inclusion and exclusion criteria
Our inclusion criteria were studies relating to theimportance and challenges of an EMR system, medical
records, development and implementation of an EMRsystem in developing countries, and EMR impact on
care delivery in developing countries. We excludedstudies that were not published in English as well asthose that were not on developing countries.
Results
While there have been many papers on EMRs or
computer-based patient records, there exists only afew articles significant to this research area in devel-oping countries. In all, 32 articles were identified, butbased on the aforementioned selection criteria 23articles were considered eligible.2,526
Benefits of EMR systems
As already noted, EMRs and other decision supporttools like computerised physician order entry (CPOE)
help to reduce medical errors.7 For example, someclinical information systems (CIS) are able to checkfor drug allergies, drug doses and appropriateness ofmedication, thereby eliminating the need for phys-icians to write orders by hand in the patients chart.According to Levesque every time someone in a practiceor hospital touches a chart, it costs the organisation
nearly $3.8 Therefore one main advantage of an EMR
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The role of EMR in care delivery development in developing countries 141
is that care givers never have to worry about findinga chart, since information concerning the patient is
already input into the computer.Another important element of an EMR is legibility
of clinical notes.79 An EMR provides documentationin a computerised format that allows for data orrecords to be printed in text form rather than handwritten. Also the computer makes spelling, validityand range checks which prompt users when data entry
error is detected. An EMR also increases efficiency ofhealthcare providers workflow. Thus, data entered intothe hospital information system (HIS) can be used torefer a patient to a specialist. Also, epidemiologists,
researchers, physicians and other clinicians canextractinformation from HISs to protect and promote the
health of the population through efficient surveil-lance, investigation, prevention and control of com-municable diseases of public health importance. Further,an EMR allows care providers an opportunity to be
abreast of patient health status. For instance, by creatingshortcuts to documents warning about abnormallaboratory examination results, prescriptions and drugadministration, physicians are able to quickly providefeedback to patients without any difficulties. Otherbenefits of EMRs include data accessibility by multiple
users and continuous data processing as well as auto-matic data back up and stored at different locationsoutside the hospital or clinics so that in case of disasteraccess to the record will not be denied.7,9
Challenges of EMR systems
Despite EMRs importance there are some challengesthat must be considered when designing and imple-
menting EMR systems. One limitation is lack of hard-ware and software standardisation. Although standardsreduce development costs, increase integration andfacilitate the collection of meaningful aggregate datafor quality improvement and health policy develop-ment,5 due to the complexity and different needs ofeach of the units/departments within the healthcare
industry, maintaining technological standards is alwaysdifficult. As a result, each department usually imple-ments its own technology pertaining to the needs of
that unit, which makes it impossible for all systemswithin the hospital system to communicate. Further,lack of such standardisation makes it harder to auto-matically generate the alerts which are necessary for
decision making.10 Similarly, a survey of US primarycare physicians identified 264 different EMRs in use.7
Consequently, EMR systems development has hadproblems of proprietary and incompatibility.
Other limitations include too many data sources,privacy, confidentiality and security issues and
cost.5,1014,27
Security is a very important issue, butit is essential that the appropriate users are not denied
access when the information is needed. It is true thathospitals need robust ICT infrastructures, particularly
in terms of hardware and software, but the cost of suchtechnology is highly capital intensive, therefore smallhospitals and developing countries especially find itdifficult to embark on. Also, due to the heavy costinvolved, any decision to implement an EMR shouldbe a strategic one involving all leaders from everysegment of the healthcare institution to facilitate the
design, implementation and maintenance of the sys-tem. Further, due to fear, change is often considered athreat. Yet without adequate involvement of the usersof the system, the project can never be developed,
implemented and maintained successfully.28
Transition from paper-based to EMRsystems
Converting from a paper-based to an EMR system iscomplex and difficult because it represents a paradigmshift for the work of physicians and other staff. Thetransition requires a systematic activity and must bemanaged from many aspects clinically, administrat-
ively, culturally, and organisationally. The transitionmust include not only the process changes inherent inthe use of a new tool, but also the technical andprocedural training, and the resultant changes to
physician and staff roles within the office.15 Subse-quently, it requires a strong management commit-ment and motivation.16 Secondly, involvement of allstakeholders, care providers and other users of thesystem right from the beginning is necessary forsurvival and sustenance of the project. Involving the
stakeholders will help them to have a clear understand-ing of why the organisation is making the change.Involvement and understanding also helps users (careproviders) to identify themselves with activities thatwill make the transition very smooth to achieve desir-able outcomes.
During this process, care must be taken not to
impact the patientphysician relationship or the in-tegrity of the clinical processes covered. Some factorsto be considered during the process include: (i) cost oftraining, hardware and software; (ii) type of hardware
and software; (iii) security of patient information;(iv) maintenance of patient privacy and confidentiality;(v) maintenance and integrity of medical record con-
tent and (vi) continuity and quality of care must bemaintained through the transition period.15
EMR systems in developing countries
Although the need for EMR systems is felt in mostthird world countries, they lack financial and human
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F Williams and SA Boren142
resources vital for strategic policy making to eitheracquire, train, or accommodate informatics profes-
sionals to handle the design and implementation ofsystems to meet their needs.1719 Again due to lack offunds and high costs of repair, developing countriesare not able to draw up maintenance plans to sustainthe few computers and other equipment donated byphilanthropists.
Some researchers believe data collected in devel-
oping countries are incomplete, inaccurate, unreliableand not timely, therefore the potential of EMR systemsmay not be realised.6 It is also suggested that the use ofan EMR might expedite the dissemination of wrong or
poor data which does not represent the truth, hencethe slow pace of development.6 Further, it is assumed
that technology architectures designed for developedcountries are appropriate and can easily fit into devel-oping countries environments. However, consideringthe differing cultural, organisational and environmental
factors, it is essential for systems analysts and designersto research into these areas to design equipment per-taining to the needs of these countries. Finally, EMRimplementation in developing countries requireshuman resources, funds, systematic collection of dataand effective monitoring of the existing system. Gov-
ernments, health managers and administrators haveto exercise strong commitment, and invest in HISs toimprove the health delivery status of their citizens. Tobridge the digital divide between the north and south,it is essential for international agencies and corpor-ations to assist developing countries in the areas oftechnology and manpower developments in order to
meet the demand of 21st century healthcare delivery.
Implementation of EMR systems indeveloping countries
Availability of good quality data for continuity of care,decision making and allocation of limited resources inmost developing countries, and especially sub-Saharan
Africa, remains a mirage. Table 1 provides an overviewof thedesign and implementation of three EMRprojects.
These projects illustrated the potentials of imple-menting EMR systems in developing countries despite
the challenges. To facilitate effective and efficient datacollection for policy making, evaluation, disease man-
agement and quality care delivery, collaboration andinvolvement between developing countries and thedeveloped world is required.
EMR impact on care delivery indeveloping countries
EMR systems have been shown to be feasible andimportant in developing countries in spite of some
challenges. Some immediate benefits on care deliverydevelopment are as follows:
Patient care An EMR promotes effective and ap-propriate management of cases leading to quickerrecovery without undue hospitalisation. The econ-omic impact can be seen in terms of speedy storageand retrieval of patient records thus reducing un-necessary costs of repeating diagnostic examinationsover and over.14,18
Planning and managementIncomplete and incor-rect information is leading to defective health plan-ning and management in most developing countries.Healthcare programs are failing because inaccurate
data is used for planning. Access to accurate, correctand timely information could be a good source of data
to plan and prepare for epidemics or disasters toprevent undue loss of life.7,18
Research An effective HIS is indispensable infurthering medical research.16 Availability of quality
data enhances identification of problems in treatmentand finds solutions to prevent extra costs due to ineffec-tive treatment, thus making care delivery less expensive.
Discussion and conclusion
The potential of EMR systems to transform medical
care practice has been recognised over the past decadesincluding their ability to enhance healthcare deliveryand facilitate decision-making processes. Consequently,
EMR systems and other clinical decision support toolsare currently used in both primary and secondaryhealthcare facilities in most developed nations. How-
ever, implementing an EMR system or any HIS in aclinical practice is a daunting task. It requires goodplanning, strong management, clinical leadership andsupportive staff. The most immediate benefits of EMRsystems include accurate medication lists, legible notesand prescriptions, immediately available charts, de-creased chart pulls, lower transcription costs, medical
errors reduction and improvement in quality care andstandards in patient safety. Unfortunately, most devel-oping nations lack the experts, funds and ICT infra-
structure necessary for the implementation of suchmodern healthcare technology to ensure continuity ofcare.
Another challenge facing the developing world relates
to sustainableenergy, a key indicator for socio-economicdevelopment. Availability of and reliable access toelectricity is essential in healthcare delivery develop-ment. Despite this, most countries in sub-Saharan
Africa and other countries in the developing worlddepend on hydroelectric dams as their main source of
electricity. This usually becomes a problem during dryseasons when the water level drops, therefore leading
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The role of EMR in care delivery development in developing countries 143
Table 1 EMR pilot projects
Cameroon20 Haiti22,24,25 Kenya2225
Background MEDCAB is a locally designed
electronic health record (EHR)
system for primary healthcare
(PHC) practitioners in
Cameroon. It was released at
the beginning of 2003. It is
important to note that as with
any other place in sub-Saharan
Africa, the public sector is the
principal healthcare provider.
Non-governmental
organisations, Partners In
Health (PIH) and Zanmi
Lasante, have collaborated to
launch a community-based
HIV treatment programme in
Haitis impoverished area.
The Mosoriot Rural Health
Center comprises six separate
clinics; adult medicine,
pediatrics, well children (infants
and children < 5 years of age),
antenatal care, family planning
and sexually transmitted
infection (STI) clinics.
Collaboration between Indiana
University School of Medicine
and the Moi University School
of Medicine led to Mosoriot
Medical Record Systems
(MMRS) in 2001.
Design MEDCAB was designed after
in-depth observations and
interviews, and modeling of the
providerpatient encounters
(PPE). Using the International
Classification for Primary Care
(ICPC-2) disease classification,
and Visual Basic 6 (VB)programming language, the
system development platform
was Microsoft Windows, i.e.
MS-Access and MySQL as the
systems databases.
It is a web-based system using
satellite internet connectivity,
hosted on a server in Boston,
USA. It is bilingual (English and
French) with an open source
system backed by an Oracle
database. Categories of data
collected in the HIV-EMR arepatient demographics, previous
treatment and any adverse
effects, symptoms, physical
examination, laboratory
investigations, drugs etc.
The MMRS consists of a paper
encounter form, based on an
IBM-compatible
microcomputer powered by a
UPS with solar battery back-up
and programmed in Microsoft
Access using the following
modules; registration,encounter data, reports and
data dictionary.
Functions The system consists of many
user interfaces with multiple
functionalities including; users
administration, medical
encounter, patient registration,
appointment management,
report generation, patient card
generator, diagnosis, etc.
Healthcare professionals enter
all clinical and drug
information using a standard
patient registration form. The
system checks for drugs and
their doses, administration
procedures, allergies. It also has
an inbuilt mechanism to detect
errors such as prescribing
zidovudine and stavudine
together.
The MMRS assign a unique
registration number to patients.
The report module generates
monthly reports required by
the Kenyan Ministry of Health.
The data dictionary provides
information on all diagnoses
necessary for treatments.
Implication/
significance
After four months of
implementation, there was a
significant decrease in coding
time and consultation and
better management of patients.Also there was a significant
increase in best practices, i.e.
system prompting for
measurement of parameters and
checking for unusual values
(temperatures, blood pressures
etc.), reminders for conditions
requiring special attention and
making data from previous
contacts readily available.
Successful implementation and
use of the system has proved
the importance of EMR in rural
impoverished areas.
Despite the digital divide,
logistical and cultural problems,
this simple inexpensive system
is serving the needs of the
Kenyan rural population byimproving on the quality of
care, research and training for
the local medical school.
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F Williams and SA Boren144
to power rationing.2325,29 Meanwhile, without reli-able and relevant HIS, healthcare providers cannot
effectively plan, assess health needs of populations andgroups, make decisions to allocate scarce resources toimplement programmes, improve the quality of health,or address the numerous health issues facing themespecially HIVAIDS, tuberculosis, malaria and civilwars.
In spite of these challenges, implementation of
computer-based medical record systems in Haiti, Kenya,Rwanda and Cameroon, using web-based systemswith satellite internet connectivity and IBM compat-ible microcomputers powered by an uninterrupted
power supply with solar battery back up, have shownhow feasible it could be with support from developed
nations to design and implement systems that fit intothe developing world environment.20,2225 Finally, toavoid problems with inefficiencies and tie-in to ex-pensive software vendors regarding intellectual property
rights and maintenance, developing countries can takeadvantage of various open source software (OSS)solutions that are available. Free and open-sourcesoftware is not only a useful and significant tool forthe developing countries, but clearly has the potentialto help reduce the costs associated with IT investment
because these codes are freely available for public use.They can easily be modified and tailored towards theneeds of less developed countries, hence helping findsolutions to the most pressing problems faced by thepopulations in these countries.2426,30,31
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CONFLICTS OF INTEREST
None.
ADDRESS FOR CORRESPONDENCE
Faustine Williams
School of MedicineUniversity of MissouriColumbiaMO 65211USATel: +1 (573) 7710 346Email: [email protected]
Accepted April 2008
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