the role of the electronic medical

8/10/2019 The Role of the Electronic Medical

1/7

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


2/7

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


3/7

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


4/7


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


5/7


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.


6/7


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

REFERENCES

1 Godal T. Do we have the architecture for health aid

right? Increasing global aid effectiveness. Nature Reviews

Microbiology2005;3:899903.2 Tolmie CJ and Plessis JP. The use of knowledge-based

systems in medicine in developing countries: a luxury or

a necessity? Methods of Information in Medicine1997;

36:1549.

3 United Nations ICT Task Force.Tools for Development:

using information and communications technology to

achieve the Millennium Development Goals. 2003.

4 Socialist International. Declaration on the Millennium

Development Goals. 2005. www.socialistinternational.

org

5 Shortliffe EH and Perreault LE (eds). Medical Informatics:computer applications in health care and biomedicine(2e).

New York: Springer, 2001.

6 Simba DO. Application of ICT in strengthening health

information systems in developing countries in the wake

of globalization.African Health Sciences2004;4:1959.

7 Fraser HSF, Biodich P, Moodley D, Choi S, Mamlin BW

and Szolovits P. Implementing electronic medical rec-

ord systems in developing countries. Informatics in

Primary Care2005;14:8395.

8 Levesque Y.Going Paperless with Minimal Pain. 2001.

www.chmonline.ca/issue/article.jsp?content=20010201_270128_9928

9 Powsner SM, Wyatt JC and Wright P. Opportunities for

and challenges of computerization. The Lancet 1998;

352:161722.

10 Tomasi E, Facchini LA and Maia MFS. Health infor-

mation technology in primary health care in developing

countries: a literature review. Bulletin of the WorldHealth Organization2004;82:86774.

11 McDonald CJ. The barriers to electronic medical record

systems and how to overcome them. Journal of the

American Medical Informatics Association 1997;4:213

21.

12 Bates DW, Ebell M, Gotlieb E, Zapp J and Mullins HC. A

proposal for electronic medical records in the US pri-

mary care.Journal of the American Medical Informatics

Association2003;10:110.

13 DickRS and Steen EB(eds). The Computer-based Patient

Record: an essential technology for health care. Washington,DC: National Academy Press, 1991.

14 Miller RH and Sim I. Physicians use of electronic

medical records: barriers and solutions. Health Affairs

2004;23:11626.

15 College of Physicians and Surgeons of Alberta Guideline.

Transition to electronic medical records. 2005. www.

cpsa.ab.ca.publicationsresources/attachements_policies/

Transition%20t0%20Electronic%20Medical%20Records.

pdf

16 Ginneken AM. The computerized patient record: bal-

ancing effort and benefit.International Journal of MedicalInformatics2002;65:97119.

17 Jayasuriya R. Health information from theory to prac-

tice: lessons from a case study in a developing country.

Medinfo Proceedings1995;8:16037.

18 Osunlaja AA and Olabode JA. Role of an effective

Hospital Information System in a depressed economy.

Methods of Information in Medicine1997;36:1413.

19 Azubuike MC and Ehiri JE. Health information systems

in developing countries: benefits, problems, and pros-

pects. TheJournal of the Royal Society for the Promotion of

Health1999;9:1804.20 Kamadjeu R, Tapang EM and Moluh RN. Designing and

implementing an electronic health record system in

primary care practice in sub-Saharan Africa: a case study

from Cameroon. Informatics in Primary Care2005;13:

17986.

21 Fraser HSF, Jazayeri D, Nevil P et al. An information

system and medical record to support HIV treatment in

rural Haiti.British Medical Journal2004;329:11426.

22 Tierney WM, Rotich JK, Smith FE, Nii J, Einterz RM and

Hannan TJ. Crossing the digital divide: implementing

an electronic medical record system in a rural Kenyanhealth center to support clinical and research.Proceed-

ings of the AMIA Annual Symposium2002;7925.

23 Rotich JK, Hannan TJ, Smith FE et al. Installing and

implementing a computer-based patient record system

in sub-Saharan Africa: the Mosoriot Medical Record

System. Journal of the American Medical Informatics

Association2003;10:295303.

24 Tierney WM, Rotich JK, Hannan TJ etal. The AMPATH

medical record system: creating, implementing, and

sustaining an electronic medical record system to sup-

port HIV/AIDS care in western Kenya. Medinfo2007;12:3726.
http://www.ingentaconnect.com/content/external-references?article=1740-1526(2005)3L.899[aid=8393345]http://www.ingentaconnect.com/content/external-references?article=1740-1526(2005)3L.899[aid=8393345]http://www.ingentaconnect.com/content/external-references?article=1740-1526(2005)3L.899[aid=8393345]http://www.ingentaconnect.com/content/external-references?article=0026-1270(1997)36L.154[aid=8393344]http://www.ingentaconnect.com/content/external-references?article=0026-1270(1997)36L.154[aid=8393344]http://www.ingentaconnect.com/content/external-references?article=0026-1270(1997)36L.154[aid=8393344]http://www.socialistinternational.org/http://www.socialistinternational.org/http://www.chmonline.ca/issue/article.jsp?content=20010201_270128_9928http://www.chmonline.ca/issue/article.jsp?content=20010201_270128_9928http://www.ingentaconnect.com/content/external-references?article=0140-6736(1998)352L.1617[aid=8393341]http://www.ingentaconnect.com/content/external-references?article=0140-6736(1998)352L.1617[aid=8393341]http://www.ingentaconnect.com/content/external-references?article=0140-6736(1998)352L.1617[aid=8393341]http://www.ingentaconnect.com/content/external-references?article=0042-9686(2004)82L.867[aid=6696633]http://www.ingentaconnect.com/content/external-references?article=0042-9686(2004)82L.867[aid=6696633]http://www.ingentaconnect.com/content/external-references?article=0042-9686(2004)82L.867[aid=6696633]http://www.ingentaconnect.com/content/external-references?article=1067-5027(1997)4L.213[aid=1536364]http://www.ingentaconnect.com/content/external-references?article=1067-5027(1997)4L.213[aid=1536364]http://www.ingentaconnect.com/content/external-references?article=1067-5027(1997)4L.213[aid=1536364]http://www.ingentaconnect.com/content/external-references?article=1067-5027(2003)10L.1[aid=6367861]http://www.ingentaconnect.com/content/external-references?article=1067-5027(2003)10L.1[aid=6367861]http://www.ingentaconnect.com/content/external-references?article=1067-5027(2003)10L.1[aid=6367861]http://www.ingentaconnect.com/content/external-references?article=0278-2715(2004)23L.116[aid=6936864]http://www.ingentaconnect.com/content/external-references?article=0278-2715(2004)23L.116[aid=6936864]http://www.cpsa.ab.ca.publicationsresources/attachements_policies/Transition%20t0%20Electronic%20Medical%20Records.pdfhttp://www.cpsa.ab.ca.publicationsresources/attachements_policies/Transition%20t0%20Electronic%20Medical%20Records.pdfhttp://www.cpsa.ab.ca.publicationsresources/attachements_policies/Transition%20t0%20Electronic%20Medical%20Records.pdfhttp://www.cpsa.ab.ca.publicationsresources/attachements_policies/Transition%20t0%20Electronic%20Medical%20Records.pdfhttp://www.ingentaconnect.com/content/external-references?article=1386-5056(2002)65L.97[aid=8393340]http://www.ingentaconnect.com/content/external-references?article=1386-5056(2002)65L.97[aid=8393340]http://www.ingentaconnect.com/content/external-references?article=1386-5056(2002)65L.97[aid=8393340]http://www.ingentaconnect.com/content/external-references?article=0026-1270(1997)36L.141[aid=8393339]http://www.ingentaconnect.com/content/external-references?article=0026-1270(1997)36L.141[aid=8393339]http://www.ingentaconnect.com/content/external-references?article=1476-0320(2005)13L.179[aid=8393337]http://www.ingentaconnect.com/content/external-references?article=1476-0320(2005)13L.179[aid=8393337]http://www.ingentaconnect.com/content/external-references?article=1476-0320(2005)13L.179[aid=8393337]http://www.ingentaconnect.com/content/external-references?article=1067-5027(2003)10L.295[aid=6696631]http://www.ingentaconnect.com/content/external-references?article=1067-5027(2003)10L.295[aid=6696631]http://www.ingentaconnect.com/content/external-references?article=1067-5027(2003)10L.295[aid=6696631]http://www.cpsa.ab.ca.publicationsresources/attachements_policies/Transition%20t0%20Electronic%20Medical%20Records.pdfhttp://www.cpsa.ab.ca.publicationsresources/attachements_policies/Transition%20t0%20Electronic%20Medical%20Records.pdfhttp://www.cpsa.ab.ca.publicationsresources/attachements_policies/Transition%20t0%20Electronic%20Medical%20Records.pdfhttp://www.cpsa.ab.ca.publicationsresources/attachements_policies/Transition%20t0%20Electronic%20Medical%20Records.pdfhttp://www.chmonline.ca/issue/article.jsp?content=20010201_270128_9928http://www.chmonline.ca/issue/article.jsp?content=20010201_270128_9928http://www.socialistinternational.org/http://www.socialistinternational.org/http://www.ingentaconnect.com/content/external-references?article=1740-1526(2005)3L.899[aid=8393345]http://www.ingentaconnect.com/content/external-references?article=1740-1526(2005)3L.899[aid=8393345]http://www.ingentaconnect.com/content/external-references?article=0026-1270(1997)36L.154[aid=8393344]http://www.ingentaconnect.com/content/external-references?article=0026-1270(1997)36L.154[aid=8393344]http://www.ingentaconnect.com/content/external-references?article=0140-6736(1998)352L.1617[aid=8393341]http://www.ingentaconnect.com/content/external-references?article=0140-6736(1998)352L.1617[aid=8393341]http://www.ingentaconnect.com/content/external-references?article=0042-9686(2004)82L.867[aid=6696633]http://www.ingentaconnect.com/content/external-references?article=0042-9686(2004)82L.867[aid=6696633]http://www.ingentaconnect.com/content/external-references?article=1067-5027(1997)4L.213[aid=1536364]http://www.ingentaconnect.com/content/external-references?article=1067-5027(1997)4L.213[aid=1536364]http://www.ingentaconnect.com/content/external-references?article=1067-5027(2003)10L.1[aid=6367861]http://www.ingentaconnect.com/content/external-references?article=1067-5027(2003)10L.1[aid=6367861]http://www.ingentaconnect.com/content/external-references?article=0278-2715(2004)23L.116[aid=6936864]http://www.ingentaconnect.com/content/external-references?article=0278-2715(2004)23L.116[aid=6936864]http://www.ingentaconnect.com/content/external-references?article=1386-5056(2002)65L.97[aid=8393340]http://www.ingentaconnect.com/content/external-references?article=1386-5056(2002)65L.97[aid=8393340]http://www.ingentaconnect.com/content/external-references?article=0026-1270(1997)36L.141[aid=8393339]http://www.ingentaconnect.com/content/external-references?article=1476-0320(2005)13L.179[aid=8393337]http://www.ingentaconnect.com/content/external-references?article=1476-0320(2005)13L.179[aid=8393337]http://www.ingentaconnect.com/content/external-references?article=1067-5027(2003)10L.295[aid=6696631]http://www.ingentaconnect.com/content/external-references?article=1067-5027(2003)10L.295[aid=6696631]


7/7


25 Allen C, Jazayeri D and Miranda J. Experience in

implementing the OpenMRS medical record system to

support HIV treatment in Rwanda. Medinfo 2007;12:

3826.

26 Bergsj P, Mlay J, Lie RT, Lie-Nielsen E and Shao JF. A

medical birth registry at Kilimanjaro Christian MedicalCentre.East African Journal of Public Health2007;4:14.

27 Goedert J. Finding the HIPAA mix.Health Data Man-

agement2005;12:48.

28 Leonard KJ. The role of patients in designing health

information systems: the case of applying simulation

techniques to design an electronic patient record inter-

face.Health Care Management Science2004;7:27584.

29 Davidson O, Kitiyi E, Nkomo J, Turner C and Sebitosi B.

Sustainable energy in sub-Saharan Africa. 2007. www.

icsu-africa.org/sustainable_energy_rep_2007.pdf

30 Jayasuriya R. Managing information systems for healthservices in a developing country: a case study using a

contextualist framework.International Journal of Infor-

mation Management1999;19:33549.

31 Noronha F. Developing Countries from Free/Open Source

Software. 2003.www.linusjournal.com/article/6884

CONFLICTS OF INTEREST

None.

ADDRESS FOR CORRESPONDENCE

Faustine Williams

School of MedicineUniversity of MissouriColumbiaMO 65211USATel: +1 (573) 7710 346Email: [email protected]

Accepted April 2008
http://www.ingentaconnect.com/content/external-references?article=1386-9620(2004)7L.275[aid=8393347]http://www.ingentaconnect.com/content/external-references?article=1386-9620(2004)7L.275[aid=8393347]http://www.icsu-africa.org/sustainable_energy_rep_2007.pdfhttp://www.icsu-africa.org/sustainable_energy_rep_2007.pdfhttp://www.ingentaconnect.com/content/external-references?article=0268-4012(1999)19L.335[aid=8393346]http://www.ingentaconnect.com/content/external-references?article=0268-4012(1999)19L.335[aid=8393346]http://www.ingentaconnect.com/content/external-references?article=0268-4012(1999)19L.335[aid=8393346]http://www.linusjournal.com/article/6884http://www.icsu-africa.org/sustainable_energy_rep_2007.pdfhttp://www.icsu-africa.org/sustainable_energy_rep_2007.pdfhttp://www.linusjournal.com/article/6884http://www.ingentaconnect.com/content/external-references?article=1386-9620(2004)7L.275[aid=8393347]http://www.ingentaconnect.com/content/external-references?article=0268-4012(1999)19L.335[aid=8393346]http://www.ingentaconnect.com/content/external-references?article=0268-4012(1999)19L.335[aid=8393346]

the role of the electronic medical

Documents