Martin Msukwa Approved

UNIVERSITY OF MALAWI College of Medicine
User Perceptions on Electronic Medical Record System (EMR) in Malawi

Submitted by Martin K.B. Msukwa BSc.N
A dissertation submitted in partial fulfillment for the award of a Master in Public Health (Informatics)
August 2011
Evaluation study on implementation of electronic medical record system (EMR) in Malawi
CERTIFICATE OF APPROVAL
The Thesis of Martin K.B. Msukwa is approved by the Thesis Examination Committee:
_______________________________________________ (Chairman, Postgraduate Committee)
________________________________________________ (Supervisor)
_________________________________________________ (Internal Examiner)
___________________________________________________ (Head of Department)
MPH Dissertation. University of Malawi-College of Medicine
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DECLARATION
I, Martin K.B. Msukwa, hereby declare that this thesis is my original work and has not been presented for any other awards at the University of Malawi or any other university.
Name of Candidate: Martin K.B. Msukwa
Signature:
Date:
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ACKNOWLEDGEMENTS
I wish to thank Dr Maureen Leah Chirwa, my academic supervisor and mentor, for the support, guidance and most of all for believing in me and giving me a chance to enroll for this program. Mr. Benjamin Kumwenda, my research supervisor, for his input during the preparation and writing of this dissertation. I also want to thank Dr. Gerry Douglas, the founder of Baobab Health Trust; Sabine Joukes, my service supervisor, and Country Director of Baobab Health Trust in Malawi and all Baobab Health Trust team for their untiring support, guidance during the whole process of coming up with this document. I am also very grateful to all Department of Community Health Staff especially Regina, all friends (especially Alice Chikhoswe, Monipher Musasa, Edgar Lungu, Aulive Gift Msoma, Paul Kawale, Bern-Thomas Nyangwa, Paras Valeh, Abilasha Karkey) that I continuously consulted for guidance and input. I would also like to thank all Antiretroviral Therapy (ART) Clinic staff in Ntcheu, Salima and Dedza for their time and participation in this study. My acknowledgements would be incomplete without the mention of my mum, Eunice Namwayi, for what she has been and continue to be to me, I LOVE YOU so much.
Last but not least; I would like to acknowledge the Norwegian Government through its NORAD program for Masters Studies (NOMA) for availing the scholarships that enabled me pursue MPH specializing in Health Informatics. May I also acknowledge Health Management Unit, Community Health Department at College of Medicine who through their collaboration with University Oslo I was able to access this scholarship.
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In an attempt to arrive at the truth I have applied everywhere for information but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison. If they could be obtained they would enable us to answer many questions. They would show subscribers how their money was being spent, what amount of good was really being done with it or whether the money was not doing mischief rather than good.
Florence Nightingale, 1863
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TABLE OF CONTENTS
CERTIFICATE OF APPROVAL ..................................................................................... II DECLARATION ............................................................................................................ III ACKNOWLEDGEMENTS ............................................................................................. IV TABLE OF CONTENTS ................................................................................................. VI LIST OF TABLES .......................................................................................................... IX LIST OF FIGURES ......................................................................................................... X ACRONYMS .................................................................................................................. XI ABSTRACT .................................................................................................................. XIII CHAPTER 1: BACKGROUND AND JUSTIFICATION .................................................. 1
1.2 1.3 1.4 1.5 1.6 Study Background .........................................................................................................................................1 Problem Statement ........................................................................................................................................2 Purpose of the Study .....................................................................................................................................2 Specific Objectives ........................................................................................................................................3 Significance of the Study ...............................................................................................................................3
CHAPTER 2: LITERATURE REVIEW .......................................................................... 4

2.1 2.2 2.3 2.4 2.5 2.6 Introduction ...................................................................................................................................................4 Benefits of the Electronic Medical Record (EMR) .....................................................................................6 Challenges of Electronic Medical Records ..................................................................................................7 Use of EMR in Developed Countries ......................................................................................................... 10 Use of EMR in Developing Countries and Sub Saharan Africa .............................................................. 13 Introduction and Use of EMR in Malawi .................................................................................................. 15
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CHAPTER 3: METHODOLOGY .................................................................................. 17

3.1 3.2 3.3 3.4 Type of Research Study .............................................................................................................................. 17 Study Place, Population and Sampling ...................................................................................................... 17 Data Collection Tools .................................................................................................................................. 18 Data Collection ............................................................................................................................................ 18
3.5 Data Management Analysis ........................................................................................................................ 19 3.5.1 Qualitative Data Analysis ......................................................................................................................... 19 3.5.2 Quantitative Data Analysis ....................................................................................................................... 20 3.6 3.7 Study Limitations ........................................................................................................................................ 20 Ethical Considerations ................................................................................................................................ 21
CHAPTER 4: RESULTS ................................................................................................ 22

4.1 4.2 Description of Participants ......................................................................................................................... 22 Experience of Users ..................................................................................................................................... 23
4.3 Effectiveness and Efficiency of EMR ......................................................................................................... 24 4.3.1 System Perceived as Faster and Easy to Use .......................................................................................... 25 4.3.2 Effect of EMR on the Quality of Care ....................................................................................................... 26 4.3.3 Report Generation .................................................................................................................................... 28 4.4 User Satisfaction and Challenges of Using EMR ...................................................................................... 29 4.4.1 User Satisfaction with EMR ...................................................................................................................... 30 4.4.2 Challenges Users Face while Using the EMR .......................................................................................... 31 4.6 4.7 User Training ............................................................................................................................................... 32 Summary of the Results .............................................................................................................................. 35
CHAPTER 5: DISCUSSION .......................................................................................... 37

5.1 5.2 5.3 5.4 Introduction ................................................................................................................................................. 37 Effectiveness and Efficiency of EMR ......................................................................................................... 38 User Satisfaction with EMR ....................................................................................................................... 41 User Training ............................................................................................................................................... 43
CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS ...................................... 49

6.1 6.2 Conclusion .................................................................................................................................................... 49 Recommendations ....................................................................................................................................... 50
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REFERENCES .............................................................................................................. 52 APPENDICES ............................................................................................................... 58

Appendix 1: QUESTIONNAIRE FOR IN-DEPTH INTERVIEWS ..................................................................... 58 Appendix 2: FOCUS GROUP DISCUSSION GUIDE ........................................................................................... 68 Appendix 3: EMR USE OBSERVATION GUIDE ................................................................................................. 70 Appendix 4: REQUEST FOR PERMISSION FROM THE INSTITUTION ....................................................... 74
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LIST OF TABLES
Table 1: Age of users of Electronic Medical Records .................................................................. 22 Table 2: Experience of Users ........................................................................................................ 24 Table 3: Frequency of user satisfaction on the performance of EMR .......................................... 30
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LIST OF FIGURES
Figure 1: Participants' profession .................................................................................................. 23 Figure 2: System perceived as faster and easy to use (efficient and effective) ............................ 26 Figure 3: Reported effect of EMR on quality of care ................................................................... 27 Figure 4: Overall satisfaction with EMR amongst professionals ................................................. 31 Figure 5: Preparation of users before EMR use ............................................................................ 33
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ACRONYMS
AIDS AMPATH AMRS ART ARV BMI COMREC CPOE DHO EHR EMR FGD HAART HIT HIV HSAs ICTs IDI IS IT KCH MDG Acquired Immunodeficiency Syndrome Academic Model for the Prevention and Treatment of HIV/AIDS AMPATH Medical Record System Antiretroviral Therapy Antiretroviral Body Mass Index College of Medicine Research and Ethics Committee Computerized Physician Order Entry District Health Officer Electronic Health Records Electronic Medical Records Focus Group Discussion Highly Active Antiretroviral Therapy Health Information Technology Human Immune Deficiency Virus Health Surveillance Assistants Information and Communication Technologies In-depth Interviews Information Systems Information Technology Kamuzu Central Hospital Millennium Development Goals Page XI
MMJ MMRS MOH MRHC NLP OI PIH SPSS UK UMLS UN USA WHO
Malawi Medical Journal Mosoriot Medical Record System Ministry of Health Mosoriot Rural Health Centre Natural Language Processing Opportunistic Infection Partners in Health Statistical Package for Social Sciences United Kingdom Unified Medical Language System United Nations United States of America World Health Organization
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ABSTRACT
INTRODUCTION: Baobab Health Trust with the Malawi Ministry of Health has developed and operationalized a point of care electronic medical data system for managing the care and treatment of patients receiving antiretroviral therapy in selected high burden HIV clinics. OBJECTIVE: The main objective of this study was to evaluate user perception on the effectiveness, efficiency, satisfaction, challenges and training of electronic data system in Malawi. METHODOLOGY: This was an evaluation study that used both quantitative and qualitative study methods. Data were collected from three purposively selected districts out of five districts using Electronic Medical Records (EMR) in the central region. Quantitative data were analyzed using the Statistical Package for Social Sciences version 16.0 (SPSS version 16.0) while qualitative data analysis was interpretive (explain meaning of words said and actions) and iterative (repetition of uttered words). RESULTS: The study findings showed that users preferred using the EMR than paper based records and that overall, found it more effective and efficient. The study results also indicated that the training conducted to prepare potential users of EMR was not well structured and the support given after the training was not uniform and not enough. The study also showed that there were a number of activities that users expected Baobab Health Trust to consider, make sure the EMR is more user friendly and able to capture more information. CONCLUSION: From the study it is clear that EMR users are satisfied with EMR and that they find it more effective and efficient than paper-based records. There is however need for a proper and well-structured training for users before they start using the EMR.
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CHAPTER 1: BACKGROUND AND JUSTIFICATION
1.1
Introduction
This document is a report on the research study of user perception on the effectiveness, efficiency, satisfaction, challenges and training of electronic medical record system (EMR) in Malawi. The study mainly focused on evaluating users perception of the EMR in comparison to paper based records. The document is organized in chapters and sections, such that, chapter one gives the study background, problem statement, study purpose and specific objectives. Chapter two provides relevant literature and is followed by chapter three which reports the methodology used including study design, sample selection, instruments, data collection process, data management and study limitations. Chapter four outlines results of the study. Discussion of the results, conclusions and recommendations, form parts of chapter five which is also the last chapter of the document. All the study instruments and letters of permission are included in the appendices.
1.2
Study Background
Most medical records are still paper-based, which means it is difficult to be used to properly and consistently coordinate care, routinely measure quality, or reduce medical errors due to challenges with storage and difficulties to easily access or retrieve information when its needed [1]. Consumers of health care generally lack the information they need about costs or quality to make informed decisions about their health care [1]. This information would easily be accessible and available with an Electronic Medical
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Record (EMR) system. An Electronic Medical Record is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting [2]. Included in this information are patient demographics, progress notes, problems, medications, vital signs, current and past medical information, immunizations, laboratory data and radiology reports [1]. The Baobab Health Trust recently introduced an EMR system which is able to capture all necessary patients medical information for supporting routine HIV care.
1.3
Problem Statement
Despite enormous investment world-wide in computerized health information systems their overall benefits and costs have been rarely fully assessed and evaluated [1]. Since Baobab Health Trust started implementing EMR in Malawi ten years ago, no study has been done to evaluate whether the system meets its intended goals or not, this study only evaluated only one area of the Electronic Medical Records (users experiences on using the electronic medical records). The Ministry of Health is rolling out EMR to more high burden antiretroviral (ART) sites without evaluating its effectiveness in settings where it is currently implemented, how useful users find EMR and whether the training users get before they start using the EMR is enough or not.
1.4
Purpose of the Study
The purpose of this study was to evaluate users perspective on the effectiveness, efficiency and satisfaction of the EMR system introduced by Baobab Health Trust in Malawi.
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1.5
Specific Objectives
The specific objectives of this evaluation study were: To assess user perception on the effectiveness and efficiency of EMR in comparison to paper based records To analyze users satisfaction on the benefits and challenges on using the electronic medical records in selected sites To identify and evaluate training gaps and specific training needs for users before they start using EMR system
1.6
Significance of the Study
Baobab Health Trust is assisting the Ministry of Health in Malawi to address the human resource crisis in healthcare by focusing on improving the efficiency and effectiveness of the existing limited workforce through the deployment of reliable, easy to use electronic systems in high burden Antiretroviral Therapy (ART) clinics. So far these electronic medical systems have been deployed at more than eleven hospitals and clinics throughout Malawi and the Ministry of Health plans to scale up further. However, it is not clear how this electronic medical system work, how useful it is to users and whether the training users get before they start using the EMR is enough or not. This study was conducted to address these questions from the Ministry of Health, Baobab Health Trust and users
perspective.
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CHAPTER 2: LITERATURE REVIEW

2.1 Introduction
The Electronic Medical Record comprises health-related information that is created by health care providers on behalf of a patient, such as diagnostic tests or prescriptions for medications. The main objective of an EMR is to improve the ability of a care provider to document observations and findings and to provide more information on treatment of persons in his or her care. EMR can also provide the underlying patient information for functions such as drug-drug interactions, recommended care practices or interpretation of data to support and improve clinical decisions [1]. However, these functions are limited by the extent of the information available in a provider-focused EMR within a single health care organization, hence the need to document how EMR is utilized and supports medical services in centers that use EMR system in Malawi.
The EMR is expected to replace paper-based medical records as the primary source of medical history for each person seeking health care, while still complying with all clinical, legal and administrative requirements in developed countries [2]. Enormous investment has gone into computerized hospital information systems worldwide. The estimated cost for each large hospital is about 50 million United States dollars per year and in most developed countries, yet the overall benefits and costs of hospital information systems have rarely been assessed [3]. When systems are evaluated worldwide, about three quarters are considered to have failed and there is no evidence that they improve the productivity of health care professionals [4]. In Malawi, to date Baobab Health Trust has issued unique patient identity (ID) numbers and barcode labels to roughly 1.1 million
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patients, and since Baobab Health Trust's inception it has received roughly $1.1 million in funding. If all Baobab Health Trust had achieved were issuing nationally unique IDs this might not be considered a cost effective intervention by many, but in reality, Baobab has achieved far more than this, with currently over 30,000 patients being managed daily using the Baobab Health Trust electronic medical system.
To date, the digitization of health care typically has focused simply and solely on electronic records for patients. Most EMR systems are relational databases with a finite number of intra-enterprise applications and are limited to in-house use by health care facilities. Very few of these systems have realized fully functional, scalable, distribution capabilities, not to mention interoperability with external systems. This short-sighted tendency to build large-scale but restrictive automated systems that ignore the interactive nature of health care has resulted in limited operational success and acceptance [5]. Electronic records have the potential to improve the quality of health care delivery and reduce costs [6-9]. Accurate and up-to-date health information is critical. When an individual seeks health care, in order to provide effective and timely treatment, the provider needs to have information about the patient, including known allergies, chronic conditions, current medications and other pertinent health care data. However, such information is not always readily available. It may sometimes be available but incomplete or inaccurate, depending on whether the patients records have been updated or not.
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2.2
Benefits of the Electronic Medical Record (EMR)
Though there have been challenges and failures in the implementation of EMR, their potential benefits are numerous. Some of the benefits are: complete and accurate information; universal and timely access to a patients lifetime health information; knowledgeable sources to direct a patient to the appropriate care and substantially fewer medical errors. The EMR may exist in a distributed database, accessible from anywhere through a networked environment or a mobile smart card that a patient carries with him/her. If appropriate security measures are adopted, computerization also provides greater protection of confidential information via sophisticated keys and access controls. Additionally, the EMR system helps improve the quality of patient visit documentation and data, free up facility storage space, improve efficiency by eliminating time spent hunting down lost charts and provide immediate, simultaneous access to patient records [2].
Imagine the day when EMR systems will warn the caregiver when a patient being treated is allergic to medication prescribed, will provide the latest research on treatment modalities, and will organize volumes of information about a patients chronic condition. When linked to the World Wide Web (e.g. via web services), EMRs can provide customized patient-related information retrieval via push technology [3]. This capability will enable access to data from anywhere in the world.
EMR has the ability to generate a complete record of a clinical patient encounter as well as supporting other care-related activities directly or indirectly via interface including evidence-based decision support, quality management and outcomes reporting [7].
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2.3
Challenges of Electronic Medical Records
The EMR raises issues of confidentiality, privacy and security [10,11]. Advances in information technology, the need to cut costs of health care delivery, and consumer demands for more effective and better-quality care have all hastened the exploration of alternatives for storing and retrieving health care information, and yet the implementation of EMR faces several technical challenges. Compared to other industries, the acceptance of information technology in health care has been slow [12,13]. Compounding this is the limited experience available in deploying applications, which has resulted in a steeper learning curve for health care organizations.
A number of problems have been identified with the EMR, including increased provider time, computer down time, lack of standards, and threats to confidentiality. Studies at (some) institutions in America [8,13] have shown that electronic order entry increases the amount of time physicians spend entering a prescription. In a study by Powner, physician residents required 44 more minutes per day using computerized order entry, although internal medicine residents using the order entry gained half of that time back in cost savings elsewhere [13]. Furthermore, the study showed a high overall rate of user satisfaction of the system. Developing means to streamline order entry for residents are now a priority.
Another concern with EMR systems is computer down time. Although the threat of not having access to the right piece of information at the right time is real, the increasing reliability of computer systems makes this less of a problem. At Oregon Health Sciences University, for example, the daily scheduled down time has been reduced over the last
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several years from 1 hour to 10 minutes [14]. Most hospital computer systems and the databases that run on them are being designed for non-stop usage.
A more significant problem with EMR systems is the lack of standards to interchange information. While a number of standards exist to transmit pure data, such as diagnosis codes, test results, and billing information, there is still no consensus in areas such as patient signs and symptoms, radiology and other test interpretation, and procedure codes. Although some associate the National Library of Medicines Unified Medical Language System (UMLS) with a comprehensive clinical vocabulary, its goal is much more modest, to serve just as a meta-thesaurus linking terms across different terminology systems [15].
A related problem to standards is that a large proportion of clinical information is locked in form of narrative text. Although a number of systems have been successful in limited domains, the technology for natural language processing (NLP) is still unable to interpret narrative text with the accuracy required for research and patient care applications. While NLP is difficult for well-written published medical documents, it is even harder for medical charts that contain poorly structured, highly elliptical language, with frequent misspellings to boot. Even if such language could be parsed, the lack of an underlying framework makes its semantic interpretation more difficult [15]. Some have proposed to solve this problem with menu-driven data collection systems, but these have generally been successful only in limited areas, such as obstetric ultrasound [16]. Baobab Health Trust has adopted the system of using only categorical data elements that can be selected from menus wherever possible for the reasons described above. Since the
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system does not use narrative text in most cases it makes the use of an entirely touch screen-driven system that much more feasible.
A final concern about the EMR is the problem of security and patient confidentiality. This problem, of course, exists independent of the EMR, as a great deal of medical information abstracted from paper records, already exists in electronic repositories. Wellknown privacy experts have documented the threats that misuse of this information has on personal privacy [17]. As noted above, the paper record is no barrier to duplication, as medical records are routinely copied and faxed among health care providers and insurance companies already. While some fear the EMR will exacerbate this problem, others note that computer-based records, with appropriate security, are potentially more secure than paper based records. Most medical centers already have security. Employees given access are usually required to sign a confidentiality statement indicating their understanding of the privacy of patient data.
At most centers, a password is required to enter the system, although some institutions also use a physical device, such as a key card. Virtually all systems also keep an audit trail of who accessed which patients data, providing a retrospective mechanism for discipline should breaches of security occur [18]. While there is an array of technologies, including encryption and authentication that could erect barriers between medical information and its unauthorized use, it must also be noted that there is a tradeoff, as every computer user knows, between security and ease-of-use. Since the pace of medical care in emergency settings as well as busy clinical areas can be hectic, providers may become frustrated with layers of security.
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Challenges to the implementation of the EMR in primary care practice and in resource poor settings are huge and may seem outside the priority agenda in this era of public health emergencies. However, the information generated during routine medical consultation and its capture in the EMR could provide valuable information of public health interest. As elsewhere, challenges to adoption are great, but a successful implementation for a specific setting will require comprehensive modeling of the local medical practice and a coordinated approach, involving all stakeholders.
2.4
Use of EMR in Developed Countries
Countries such as the United States, United Kingdom and Australia have mature and advanced healthcare infrastructures that receive substantial funding and support from their governments. Although significant failures still exist in these systems, there is strong support and motivation to accomplish goals associated with comprehensive development of successful medical information technology systems [19]. These countries are able to make significant investments in research to develop information systems that would meet the need of their particular healthcare system. This is in sharp contrast to the healthcare infrastructure of many developing countries. For many of these countries the delivery and management of healthcare services alone comes with many challenges. In many of these countries, implementers of healthcare information technology based solutions are faced with complex challenges such as inadequate funding, lack of resources and weak healthcare infrastructure.
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When EMR systems were first introduced, it was widely believed that their broad adoption will lead to major health care savings, reduce medical errors, and improve health [20]. But there has been little progress toward attaining these benefits. The United States trails a number of other countries in the use of EMR systems. Only 1520 percent of U.S. physicians offices and 2025 percent of hospitals have adopted such systems. Barriers to adoption include high costs, lack of certification and standardization, concerns about privacy, and a disconnection between who pays for EMR systems and who profits from them [20].
Despite the appeal of EMR, available data suggest that the majority of office practices in the United States, especially smaller offices, do not have this technology [20]. For example, using 2003 data from the National Ambulatory Medical Care Survey, Burt and Sisk reported that an average of 17.6 % doctors used EMRs in their office-based practices [20]. In contrast, other countries, such as Australia and the United Kingdom, are nearing universal adoption of EMRs [20]. In Massachusetts in 2005, only 18% of medical and surgical office practices reported using EMRs [21]. Larger practices that provided primary care and those with other computerized systems were more likely to have adopted EMRs. Among practices with EMRs, most systems did not include advanced functionalities, such as order entry for medications, laboratory tests and diagnostic imaging. While 58% of practices with EMRs had electronic clinical decision support available, more than 1 in 4 practices indicated that a majority of their clinicians were not actively using that support [21].
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In 1995, Newton performed a study titled The first implementation of a computerized care planning system in the UK. The implementation included both a new way of structuring work, using the nursing process and a new technology which was the use of computers. The results showed that it took more than a year after implementation until the nurses negative attitudes towards the system shifted to positive attitudes. The study also showed a significant improvement in the quality of care planning [22]. In their review on the use of computers in a health care setting, Smith et al. (2005) found no conclusive evidence that could provide the foundation for an effective computer implementation strategy. However, more common use of computers in society today has increased the use of computers in nursing and also made it possible to implement standardized care plans in EMR [23].
Goorman and Berg (2000) called attention to problems associated with the design of structures in EMR and suggested that there is a risk that such structures will be difficult to work with in practice. Timmons described nurses resistance to using computerized systems for planning nursing care; their resistance did not entail direct refusal, but was instead quite subtle. They tended to minimize use of the system or postpone it to another time or to the next work shift. Timmons considered that the nurses behavior was characterized by resistance to changes in the nursing process and to the technology [22]. Smith and others investigated charting time before and after computer implementation and found that no change had occurred. The advantage of using the software was observed when the technology and the concept brought together the care plans and subsequent documentation. This shows that use of the system improved the function and meaning of the care plan process [23].
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2.5
Use of EMR in Developing Countries and Sub Saharan Africa
In Africa millions of people die every year, and Sub-Saharan Africa, in particular, shows little progress towards achieving five of the six health-related Millennium Development Goals (MDG) targets [24]. Countries in this region require health information systems that will enable them to generate the data needed to monitor progress towards the achievement of the targets. The health information systems in most African countries currently are primarily paper based and are woefully insufficient to meet both patient and reporting needs. On the other hand, information and communication technologies (ICTs) offer unparalleled opportunities to respond adequately to this challenge [24].
Just five years ago, the use of electronic medical records (EMRs) in resource-poor countries in the Global South was, at best, experimental. Few organizations thought their usage was realistic, and fewer still had deployed such systems. The handful of projects that used an EMR system fell mainly into two groups: those that used expensive commercial software in specialist projects and private hospitals and those that developed the software in-house, usually to manage a specific disease [25]. Since then, several successful medical information systems and EMRs have been implemented in developing countries and information technology is much more widely available in resource-poor areas. These factors, along with recognition of the benefits of EMRs in improving quality of care in developed countries, have created a broad interest in the use of health information technology systems (HIT) in the management of diseases such as HIV and drug-resistant TB [25].
In 2001, the Departments of Medicine and Child Health and Pediatrics at Moi University, Eldoret and the Department of General Internal Medicine and Geriatrics at the Indiana
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University School of Medicine, in collaboration with the Moi Teaching and Referral Hospital in Eldoret, Kenya, established the Academic Model for Prevention and Treatment of HIV/AIDS (AMPATH) [26]. The AMPATH Medical Record System (AMRS) was the first functioning comprehensive electronic medical record system committed to managing and improving the quality and efficiency of care for patients with HIV/AIDS in sub-Saharan Africa. It has played a significant role in patient care in all AMPATH sites. It has standardized patient data collection and made data retrieval much faster than the traditional paper-based record. It has enabled evidence-based decisionmaking for patient encounters and for the health system. The AMRS is affordable and represents a model system for recording critical HIV/AIDS data in resource poor settings that will be delivering an increasing amount of HIV care. This model will also allow those funding the rapid increase in the provision of HAART to know the return they are getting on their investment and hopefully encourage continued treatment of the worst medical disaster to ever befall humanity.
While most sophisticated EMRs in low-income regions are in large cities, where infrastructure and staffing needs are more easily met, Partners in Health (PIH) pioneered web-based EMRs for HIV and TB treatment in rural areas [27]. The HIV-EMR, developed in Haiti, was deployed in two Rwandan health districts starting in August 2005. In less than six months (August 2005 through January 2006), the EMR tracked over 800 patients on ARV treatment. The addition of new features and adaptation to local needs was happening concurrently with the rapid scale-up and evolution of the medical program itself. The EMR in Rwanda provides support for patient monitoring, program monitoring, and research. Patient monitoring includes information for care of individuals,
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such as historical medical summaries and alerts. This is especially useful given the large distances between the clinics. The EMR in Rwanda also has an instrument to predict drug requirements and aid pharmacists in packing.
PIH in Rwanda learnt that well-trained data entry persons are required to maintain an EMR system; the team also learnt that at least 4 months of on job-training is needed to properly train data entry persons. Data entry persons must have the ability to solve problems and follow up ambiguous or suspect data, and IT support persons must be available. Care providers must also be trained to properly report changes in treatment.
2.6
Introduction and Use of EMR in Malawi
Malawi is in Southern Africa with a rapidly increasing population density, currently estimated at 13.6 million. Malawi, ranked as one of the worlds poorest nations, also has one of the highest adult HIV/AIDS prevalence at 12% [28]. About one million people in Malawi are HIV positive and there are very few clinical care providers; for example the country only has 280 doctors practicing. [28] This tremendous disparity between healthcare workers and people in need of treatment contributes to high mortality rates particularly for women and children. Treatment protocols exist that do not require physician expertise. These protocols can ensure a minimum standard of care, but to be effective they must be rigorously followed and carefully monitored.
Baobab Health Trust, a Malawi-based nongovernmental organization, has been working with the Ministry of Health to address the human resources for health crisis for the past
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nine years by applying medical informatics principles to resource-poor settings. The core of Baobab Health Trusts approach is the application of easy-to-use EMR touch screen clinical workstations at the point of patient care. This system efficiently and accurately guides healthcare workers through the diagnosis and treatment of patients following national treatment protocols. The system also captures timely and accurate data that is used by healthcare workers during patient visits to supplement decision making. The data are aggregated and used at national level for policy making and analysis.
This technology-dependent approach has required both hardware and software innovations, including alternative energy approaches, intuitive touch screen-based user interfaces for users with no computing experience, and low-cost information appliances that are significantly more robust in harsh environments than traditional computers. To date more than 1,100,000 patients have been registered and over 30,000 receive HIV care facilitated by Baobab Health Trust electronic data system. [Personal communication: Sabine Joukes, Country Director, Baobab Health Trust, Malawi, January 2010].
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CHAPTER 3: METHODOLOGY
3.1 Type of Research Study
This was a cross sectional evaluation research study. The study used both quantitative and qualitative research methods. The study used qualitative research methods because it mainly focused at obtaining subjective experiences and observed behaviors of EMR users. Quantitative research methods were used where pre-defined variables like personal data and type of profession of users were obtained.
3.2
Study Place, Population and Sampling
The study used purposive sampling strategy to get study participants. Three EMR sites out of nine within the central region were selected using purposive sampling method. The three sites were Ntcheu, Dedza and Salima. These were the only sites where EMR was rolled out by Ministry of Health with no partner support. All users from the three sites were eligible to take part in the study after giving a written consent. There was no one who denied participating in the study. All users that participated in the study had done at least 100 patient encounters using the EMR system on the date of interview and had used paper based data system before the date of the interview. The study took seven months from the final approval of the proposal, pretesting of the questionnaire and guides, data collection, analysis, report writing to the final dissemination of the studys findings.
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3.3
Data Collection Tools
The study used a standard questionnaire, focus group discussion guide and an observation guide (appendix 1, 2 and 3) for data collection. Multiple data collection tools (triangulation of tools) were used in order to make sure that information given during the interview and in focus groups is consistent with what is being practiced.
3.4
Data Collection
Direct observations, interviews and focus group discussions with users were used to collect data from study participants. At every site the investigator was immersed in the setting, acting as an unobtrusive observer (ethnographic approach). The behavior of users and patients, including interactions between users, patients and the system, were closely noted (field notes of what was being experienced, learned through interaction with other people and what was being observed was documented and expanded into a more descriptive and narrative form). Feedback from users during interviews and focus group discussions were recorded using a tape recorder at the same time and were replayed during transcription. Data collection tools were pretested for validity and feasibility and appropriate corrections were made before the actual study was done.
EMRs effectiveness was measured using the five primary constructs, namely system quality, information quality, service quality, usage and user satisfaction with EMR [29]. They were primarily used to get users perspective on both technical and behavioral aspects of its usage. Items for the questionnaire were formulated in line with the five constructs and were operationalized as follows: system quality, information quality and
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service quality were evaluated as aspects of quality of EMR and were defined as the evaluation of EMR quality, its outputs and its responsiveness. The attributes for the quality of EMR include accuracy, adequacy, timeliness, user-friendliness, availability and reliability amongst others. Usage of EMR is the extent an EMR is being used in
completing patient-related tasks by users and was measured using one attribute self reported frequency of use and triangulated the user self-reports with what the system shows as usage by them [29]. User satisfaction is the extent users believe EMR is important in improving their work and was measured using attitudinal statements examining quality improvements, importance attached to EMR, and worthiness of EMR amongst others.
3.5
Data Management Analysis
This section describes data management and analysis method and tools used to analyze the data.
3.5.1 Qualitative Data Analysis Transcription of recordings and typing of field notes was done soon after each data collection event. Tapes of interviews and focus groups were processed after each session; they were not allowed to accumulate. All field notes were typed as soon as the data collector had expanded them.
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The investigator and the data collector held regular meetings for further synthesis and interpretation of themes. Analysis of the data was interpretive (explain meaning of words said and actions) and iterative (repetition of uttered words). Credibility and trustworthiness of data analysis was enhanced by rigorous checking of interview transcripts, replaying of the tape recorder, detailed review of field notes and debriefing sessions after interviews by the investigator and the data collector. All interviews were in English.
3.5.2 Quantitative Data Analysis Quantitative data was entered into and analyzed using the Statistical Package for Social Sciences version 16.0 (SPSS version 16.0). Data was entered manually into the software application and analyzed. Graphs and charts were created using Microsoft Excel.
3.6
Study Limitations
This study had several limitations. The first one was the high staff turnover observed in all the three districts ART clinics where trained and skilled staff keeps being transferred from one facility to the other or from one department to a different one. This is what led to the limited sample size and made it difficult to sample the study participants. This is also why all users were interviewed to help get enough participants.
The second limitation is that the study was only done in one region of Malawi and was only done at district hospital level, users at central hospital and health centre level might have
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different experiences and feelings about the EMR system. The third limitation was lack of space in most areas for the data collector and investigator to adequately be immersed in the setting and act as an unobtrusive observer to properly observe the behavior of users and patients, including interactions between users, patients and the system. Despite these limitations, the outcomes and information obtained is enough to generalize users feelings on the EMR system. The other limitation was lack of funds to cover all sites using EMR. Time was also another limitation because the study was supposed to be completed within a specified period of time to meet the academic requirements.
3.7
Ethical Considerations
Participation in the study was strictly voluntary through a written consent (appendix 4). The proposal did not need College of Medicine Research and Ethical Committee (COMREC) approval because though it was both qualitative and quantitative study, the data collection was not psychologically or emotionally "invasive" and did not involve participants private, personal, intimate life stories, and experiences. The study centered on EMR.
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CHAPTER 4: RESULTS
4.1 Description of Participants
The study had thirty-one participants and all gave written consent to participate. Participants differed with respect to profession, experience, length of use of the EMR, age, and were from three different districts. The study took place in three districts that were using the EMR procured and run by the Ministry of Health. Of the thirty-one participants, 39% were from Dedza, 32% from Salima and 29% from Ntcheu. The study had 52% female participants and 48% male participants. Table 1 and figure 1 below summarize the demographic data of the study participants.
Table 1: Age of users of Electronic Medical Records Age in years 20-25 26-30 30-35 36-40 41 and above Frequency (%) 4 (13) 4 (13) 7 (23) 5 (16) 11 (36)
Table 1 above shows age distribution of users. The minimum age group was 20-25 years and maximum age group was above 41 yrs. The mean age group was 30-35 years with a
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standard deviation of 1.4 years. All this was calculated as grouped data in SPSS 16.0 since that is how it was collected.
Of the thirty-one participants, 39% were nurses, 29% were clinical officers, 23% were data entry clerks and 9% were others (HSAs, Ward Attendants and Patient Attendants). Figure 1 below summarizes the profession of participants that took part in the study.
Figure 1: Participants' profession
4.2
Experience of Users
Participants in the study had different experiences on the EMR use; some had used the system longer than others. Table 2, summarizes the period participants have worked in the clinic and used EMR and paper based records.
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Table 2: Experience of Users Period worked in Period used paper Period the clinic (%) less than 6 months 2 6-12 months 13-18 months 19-24 months above 24 months Total 6 6 3 14 31 (7%) (19%) (19%) (10%) (45%) (100%) based records (%) 3 4 4 8 12 31 (10%) (13%) (13%) (26%) (39%) (100%) used
EMR (%) 9 5 4 8 5 (29%) (16%) (13%) (26%) (16%)
31 (100%)
The majority of participants (93%) had been working in the ART clinic for more than six months and had been using paper based records. The study also revealed that 71% of participants had used the EMR for more than six months on the date of the interview. All users that had used the EMR for less than six months were from Ntcheu because EMR system had just been installed at the site. The majority (71%) of participants that have used the EMR for more than twenty months were from Dedza and Salima; these were the sites where the Ministry of Health first installed the EMR in Malawi.
4.3
Effectiveness and Efficiency of EMR
The findings on effectiveness and efficiency on the electronic medical system were all subjective from participants. The study used perceptions of users to evaluate the effectiveness and efficiency of the EMR system. EMR effectiveness in this study is
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defined as the extent to which users felt the EMR was able to produce good quality data, help improve quality of service delivery and user friendliness and satisfaction. EMR efficiency is the ability of the EMR to produce quick and satisfactory results this included accuracy, adequacy, timeliness, user-friendliness, availability and reliability.
4.3.1
System Perceived as Faster and Easy to Use
Of the thirty-one participants, 94% (n=29) indicated that the EMR was faster and easy to use compared to paper based records, 3% (n=1) indicated that paper based records was faster and easier while 3% (n=1) indicated that there was no difference between the two systems. Ninety four percent of participants indicated that the use of EMR has reduced the waiting time of patients for consultations with 61% indicating that the waiting time is much shorter while 29% reported that the waiting time is slightly shorter than before. These findings are summarized in figure 2 below.
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Figure 2: System perceived as faster and easy to use (efficient and effective)
4.3.2 Effect of EMR on the Quality of Care Quality of care is the extent to which users felt they were able to adequately look after and provide for all the needs of their clients. The findings indicated that 71% (n=22) of participants thought that the quality of care has improved significantly since the introduction of EMR while 26% (n=8) indicated that the quality of care has improved a little, only 3% (n=1) indicated that there was no change in the quality of care. Figure 3 below summarizes the narrative.
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Figure 3: Reported effect of EMR on quality of care
Respondents perceived that there has been an improvement in quality of care which they attributed to EMR based on the following benefits:
a) Providers spend more time taking patients history and doing physical examination than wasting a lot of time with paper work b) The EMR is able to automatically calculate dates of appointments and specific number of pills to be given to the patient instead of providers doing it hence efficiency in task performance
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c) The EMR is able to automatically calculate Body Mass Index (BMI) of the patient at every visit and able to alert the provider if the BMI is low so the patient can receive nutritional support d) The EMR is able to automatically assess patients adherence using the date of last appointment, number of pills dispensed and remaining pills on the date of the visit. If the patient has a lot of remaining pills the EMR will remind/alert the provider to refer the patient for adherence counseling e) The EMR has a list of all antiretroviral side effects that have to always be checked at every visit by the provider. These act as checklist for providers to effectively monitor side effects on all patients f) With EMR the provider can easily get all information of the patients health even if the patient loses a health passport as long as they give the provider their full name and village and this helps promote the continuity of care.
The only respondent who indicated that quality of care has not changed pointed out that despite the many positives EMR has brought, there are still a lot of gaps with the EMR especially the limitation in the information it captures like full pati ents history, physical examination findings and some laboratory findings. The EMR needs to accommodate more information.
4.3.3 Report Generation Of the thirty participants that took part in the study, 71% (n=22) had generated reports from the EMR and paper based records, while 29% (n=9) had only generated reports
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from paper based records because EMR had just been introduced at their facility. Thus data on report generation is on the twenty-two respondents that had generated reports using both EMR and paper based reports. Ninety six percent (n=21) of respondents indicated that EMR reports are easier to generate, useful and easy to understand compared to paper based reports. 77% (n=15) indicated that it takes a maximum of two days to generate a quarterly report including data cleaning from EMR while all respondents indicated that it takes more than three days to generate a quarterly report from paper based records. The three-day manual process has no data-cleaning component to it, it is just the aggregation and tallying of numbers from the register, so it actually takes more than three days to generate a paper based quarterly report.
Participants also indicated that with EMR a user can generate a lot of other reports like daily, weekly, monthly, quarterly and cohort analysis reports within a very short time (as little as five minutes). Participants also mentioned that all centers without EMR only generate quarterly and cohort analysis reports from paper based records.
The majority of participants (96%) indicated that EMR generated reports are more accurate than reports generated from paper based records.
4.4
User Satisfaction and Challenges of Using EMR
This section summarizes users responses on how satisfied they are with using EMR and highlights challenges encountered when using EMR.
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4.4.1 User Satisfaction with EMR There were mixed responses on satisfaction on specific functions of the EMR and paper based records as summarized in Table 3. All the eight (26%) who indicated that paper based records were more accurate and more complete were clinicians. Their main reason was that the EMR only has very few predefined conditions that users (especially clinicians) need to tick but most conditions are not included in the EMR but could very easily be written down on paper based records. The other reason given was that with paper based records clinicians and nurses can write all patients details like history, physical examination findings and diagnosis which cannot be collected by the EMR. Ninety-six percent (n=29) of participants found information in the EMR more secure than in paper based records because EMR is user protected by the use of username and password.
Table 3: Frequency of user satisfaction on the performance of EMR Information more accurate (%) EMR Paper form both are the same Total 12 8 11 (39) (26) (35) 29 0 2 Information safer (%) (94) (0) (6) 12 8 11 31 Information more complete (%) (39) (26) (35) (100)
31 (100)
31 (100)
There were also mixed responses on the overall satisfaction with introduction EMR in the clinics. Of all the respondents, 74 % (n=23) indicated that they were always satisfied with
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EMR, 19 % (n=6) indicated that they were mostly (to the greatest degree or extent) satisfied with the use of EMR while 7 % (n=2) indicated that they were somewhat (rather; a little) satisfied with the use of EMR. These findings varied according to professions.
Figure 4: Overall satisfaction with EMR amongst professionals
4.4.2 Challenges Users Face while Using the EMR The findings reveal that 90% (n=28) of participants rarely experience problems while operating the EMR. The most common problems experienced were; freezing or not responding to commands, provision of wrong information about patients at times for
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example indicating a patient is lost to follow up yet he/she is not, in some facilities the EMR was not able to provide WHO clinical staging for patients especially children. For instance, the EMR in Salima was not able show the WHO staging and CD4 count of any patient in the program. Printers do not work at times and it is really difficult to continue working without a printer. Most of these problems are resolved within a day. At times they are repaired by the teams on the ground after calling and getting advice from Baobab Health Trust staff, at times Baobab Health Trust staff repair them.
All participants indicated that despite the challenges with EMR use, they prefer using the EMR than paper based records; they also indicated that EMR is worth the time, effort and investment. One of the common reasons respondents gave for ranking the EMR higher than the paper based records was that with the ever growing number of patients being enrolled in ART clinics and still facing the human resource challenges in the health sector, there is need for an efficient way of collecting data than the current paper based system.
4.6
User Training
The training provided to users before introducing them to EMR varied between centers. In Ntcheu users had less than one day of classroom training and one week hands-on training in the clinic, while in Dedza and Salima they started with an exchange visit, then one day classroom training and more than three months of ongoing hands-on training with a Baobab Health Trust staff based at the centre full time. Overall participants
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expressed that trainings to prepare users to use EMR are not well structured and it is different between clinics.
All trainings to prepare users on EMR were done by Baobab Health Trust. Of the thirtyone participants that took part in the study 16% (n=5) felt they were fully prepared to use EMR after the training, 58% (n=18) felt mostly prepared to use EMR after the training while 26% (n=8) felt somewhat prepared to use EMR after the training.
Figure 5 below summarizes how adequate users felt prepared to use EMR after the training provided by Baobab Health Trust.
Figure 5: Preparation of users before EMR use
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The figure above shows a gap that needs to be addressed to ensure users are more prepared before they start using the EMR. Clerks felt least prepared to use EMR than other professionals interviewed.
The study also showed that Baobab Health Trust provided all the support on EMR and the majority (97%) of participants indicated that they received enough support after the training. The most common support provided to users was; data cleaning, system repair, system upgrade and generation of reports.
Though participants indicated receiving enough support from Baobab Health Trust, they also indicated that they would appreciate if Baobab Health Trust would do the following in all EMR sites:
a) Train all users on data cleaning, system repair, and report generation. Baobab Health
Trust needs to empower users and impart skills to be able to independently perform
without their support, b) Upgrade the EMR so it can include all information collected by a mastercard but also should accommodate patient medical history, physical examination, all laboratory findings and diagnosis of most opportunistic infections, c) Provide a more and better structured training with more time and some basics on the technical aspect of the EMR. All trainings on the EMR should be done outside clinic days since it affects patients care and the learning process. One of the participants during the focus group discussion session said, there has got to be a
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balance during training. Its very stressful to assist patients while you are also learning how to operate a new system in the clinic. d) Need to train more people on EMR because of the huge staff turnover within the Ministry of Health especially at operational level (district and within the clinic), e) There is need to upgrade the EMR if possible so it is able to give feedback on what has happened to patients referred for adherence counseling and nutritional support, f) There is need for the development of a user manual or guidelines with all trouble shooting needed and what to do when a system including the server has a problem.
All participants indicated that EMR is well integrated and there was no change in the original work flow in the clinic when the EMR was introduced. It was also observed that in Salima there was no clinician using EMR. In all the districts, users still use paperbased records though they would prefer to use only the EMR. There is data backup in all the clinics and it is outside the clinic. Data backup is done at a specific time automatically every day. For example in Ntcheu it was being done at 8pm every day.
4.7
Summary of the Results
Findings show that users prefer using the EMR than paper based records and that overall they find it more effective and efficient. There were mixed feelings on the accuracy and completeness of information collected using EMR and paper based records. Results also showed that EMR-generated reports were faster to generate and were considered more accurate. Study results also indicated that the training conducted to prepare potential users of EMR was not well structured and the support given after the training was not
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uniform and was perceived by some participants as not enough. The training is too short and usually time is not enough. The study also show that there are a number of issues that users expect Baobab Health Trust to look into to make sure the EMR is more user friendly and able to capture more information.
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CHAPTER 5: DISCUSSION
5.1 Introduction
This chapter discusses the findings of the study in relation to the reviewed literature and the Malawian health system context. The order of the discussion is as follows: Firstly, users perception on effectiveness and efficiency of EMR in comparison to paper based records in Malawi in comparison with documented data from elsewhere. Secondly, users perception of the benefits and challenges of using EMR in their clinics and experiences on EMR use are discussed. Thirdly, the type of the training provided to users before they start using EMR and the type of support users received after the training and what has been documented as the ideal training and support necessary for potential EMR users.
The number eight goal of the United Nations Millennium Development Goals (MDGs) is to Develop a global partnership for development [30] . One of the key targets of this goal is to make available in health care settings the benefits of new technologies, especially information and communications technologies, in cooperation with the private sector. There has already been rapid progress in bridging the gap on the mobile phone sector, but large gaps and challenges still remain in improving access to key technologies that are essential to increase productivity, sustain economic growth and improve service delivery in areas like health and education [30]. The introduction of the EMR in health care system in Malawi is one of the ways towards the attainment of this goal but also a way of improving service delivery in health service delivery in the face of increasing patients demands and critical shortage of human and material resources.
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5.2
Effectiveness and Efficiency of EMR
Findings on users perception on the effectiveness and efficiency of EMR clearly indicate that users felt that the EMR is more effective and more efficient compared to paper based records. Freeman et.al in their patient and user satisfaction survey conducted in a
headache specialty clinic documented that health care computerization is promoted on the basis of its numerous benefits. It saves time, improves record keeping, increases accuracy, enhances the flow of information, improves the quality of clinical data available, and reduces paperwork [31]. The study found that the EMR was faster and much easier to complete compared to the use of paper based records and this helped save a lot of time to concentrate on the provision of real physical care to the patient. The majority of participants (97%) in this study indicated that quality of patient care improved significantly with the introduction of EMR and would prefer using EMR than paper based records.
Another study by Kaplan in 2001 also indicated that the introduction of Electronic Medical Records in a health care system helped to achieve efficiency mainly through the elimination of routine tasks, such as pulling paper-based charts, flipping through numerous files and papers to get patients medical and drug history [32]. This is similar to some of the reasons cited by users in this study in support of the efficiency benefits of EMR. One of respondents in a focus group discussion said,
with the EMR we do not have to go into the filing cabinet to look for a patients mastercard which at times would take more than ten minutes to find; now we just scan
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the barcode and all the information about the patient appears on the screen in second. Another respondent from a different clinic in a focus group discussion said that,
Now cohort and quarterly reports take less than a day to generate from EMR by one person while it used to take the more than three days for the whole ART clinic team to generate the same reports from paper based records because the team had to go through each and every patients file.
Rotich et.al in his study done in Kenya found that patients spent substantially less time waiting to consult a care provider, and their total time per visit to the Mosoriot Rural Health Centre (MRHC) was marginally shorter after implementation of the Mosoriot Medical Record System (MMRS). Health care providers (nurses and clinical officers) also spent less time with patients and had substantially more time to concentrate on physical examination and history taking than spending time filling in paper based records. It was concluded in their study that, for health care providers, the MMRS also saved time, creating a resource that the managers of the MRHC could harness for additional activities (e.g., patient education) [33]. These findings are similar to the ones from our study which indicated that 94% of users found the EMR system faster and much easier to use than the paper based recording system and that this enabled users to see patients in a much shorter time than before. During focus group discussions one of the users pointed out that
the reduction of time they spent with patients has been enabling them to concentrate on improving the quality of care they give to patients by among other things doing a full
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examination and getting a thorough history from all patients with special needs for example; HIV/TB co-infected patients and patients with major opportunistic infections.
The findings from the study by Rotich et.al also indicated that clerks spent additional time registering patients but less time writing reports and interacting with other staff. For them, the MMRS was largely time-neutral for everyday tasks, although it was remarkably time saving in terms of producing monthly reports for the Kenyan Ministry of Health [33]. What was observed in the study by Rotich et.al is similar to the findings in our study where 97% of participants indicated that the EMR generated reports were much easier to generate compared to paper based report generation and that it took less than a day to generate a monthly report and a cohort analysis report for the HIV Unit in the Ministry of Health while it used to take more than three days to generate these reports from paper based report.
There have been studies that have shown that the introduction of EMR in health care settings has reduced providers efficiency and the quality of care given to patients. A study of EMR system use by Israeli primary care physicians showed th at screen-gazing occurred during an average of 25% of the patient contact time, with some providers spending close to 42% of the visit viewing their computers[31]. The greater the time the physician spent keyboarding, the less time he spent conversing with the patient. This is contrary to the findings from this study where providers were spending much more time providing direct patient care than they actually spent on the EMR and the overall waiting time for patients was reportedly drastically reduced due to the introduction of the EMR. This could mainly be attributed to the way the EMR is designed, the Baobab Health Trust
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EMR is designed to perform very specific roles and doesnt allow for any other applications to be used on the system and it also does not have an external keyboard.
5.3
User Satisfaction with EMR
Studies have shown that adoption of electronic medical record systems can lead to major health care savings, reduce medical errors, and improve health care delivery [5]. Warnings on drug interactions, reminders and alerts on patient with a low Body Mass Index after having their weight entered in the EMR and alerts on poor adherence if the patient brings back a lot of remaining pills were some of the factors that users attributed as having played a major role in the improvement of quality of patients care from this study and a key benefit of the EMR.
Hillestad et al wrote that studies showing improved patient safety from EMR use in hospital and ambulatory care largely focus on alerts, reminders, and other components of computerized physician order entry (CPOE). The computerized physician order entry makes information available to physicians at the time they enter an order for example, warning about potential interactions with a patients other drugs [6].
Chaudhry et al observed that the major effect of health information technology on quality of care was its role in increasing adherence to guideline or protocol-based care. Clinical Decision Support, usually in the form of computerized reminders, was a component of all adherence studies [7]. The decision support functions were usually embedded in electronic health records or computerized provider order-entry systems. This is the same
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way the Baobab Health Trust EMR system is designed and it has predefined key steps and medical examinations and questions the user need to fulfill on each and every patient. There are no short cuts with EMR system, if a user skips a step, the EMR will give an alert to the user and not go to the next step until the skipped variable is entered. The introduction of EMR just like in the Chaudhry et al study has helped to improve health care providers especially clinicians to adhere to National HIV guidelines at all times.
Despite benefits shown by a number of studies, there have been some studies that have been done and explored the challenges users encounter with the introduction of EMR system in health facilities. Kaplan in his 2001 study found that while some clinicians had positive experiences of EMR, most described their experiences of using the system with a mixture of cynicism, passive acceptance or weary resignation at yet another burden that had been imposed on them [32]. Our study also had similar findings on clinicians feelings on the accuracy and completeness of information collected by the EMR system where 22% clinicians interviewed were not fully satisfied with EMR and the main reason they gave was that; the EMR collects very limited information about the patient especially patients history, physical examination, laboratory findings and some opportunistic infections.
They all indicated that the EMR would be a great tool if it could be adapted to be able to collect all information that they are able to collect using the paper based record system. Baobab Health Trust has indicated that this can be done and that the EMR System is very adaptable. The adaptability of the Baobab Health Trust EMR is in line with most clinicians wishes in most developed countries as Smith et al in their evaluation study of
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the impact of computerized clinical documentation recommended that while there is an impossible difficulty for any system to capture reality in its totality, clinicians wanted systems that were sensitive and adaptable to the differing acuities of patients with ostensibly the different diagnosis. [23]
To date, the health information technology literature has shown more important quality and efficiency related benefits as well as limitations relating to generalizability and empirical data on costs but overall the benefits of adopting and using EMR outweigh the challenges by far.
5.4
User Training
There have been few studies done on what the ideal training period for potential EMR users to undergo before they use the system. There is no clear literature from both developed and developing countries that have well stipulated training guidelines or recommendations developed to guide training preparation for all potential users of the electronic medical records. The training for users in the three centers where this study took place was different at every site, the training did not consider educational background or previous exposure and experience to computer use of individuals. Knowing potential users basic computer knowledge and skills would help trainers estimate the length of time and amount of effort required to put into the training to make sure they are well prepared to adopt the software into practice.
Sanchez et.al indicated that training of users on new EMR software should occur as part of a comprehensive implementation plan, not just time allotted on a certain day for what
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the user thinks they want to learn [34]. It is important to provide users with a short overview, give them the life-size picture and some details about the most often used features, and let them play with the system. Evidence has shown that the greater sense of comfort a user can develop with the system and the various user interface screens before the formal training session begin the more effective that training will be. A well-defined and clear training curriculum with well-defined and realistic time frame is therefore crucial to successful implementation of any EMR system being introduced to health care providers. The study found that this is lacking and needs to be developed as the MOH, Baobab Health Trust and other partners plan to scale up EMR system to more ART sites in Malawi.
Sanchez et.al referred to education and training of EMR as the process of providing management and employees with the logic and overall concepts of the EMR system [34]. Users are the ones that produce results and should be held accountable for making the system perform to expectations. The main reason for education and training should be to increase the expertise and knowledge level of people within the health care system. Sanchez et al identified three aspects concerning the contents of training as: Logic and concepts of EMR, features of the EMR system software and hands-on training.
Concept training shows the people why the EMR system is implemented and why changes to the EMR system are necessary, while functional training helps overcome the fear for computer systems since some potential users would fear that they are computer illiterate and they would lose power if manpower is reduced due to computerization, and the education can help overcome such fear [34]. To achieve this, there is need to properly
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plan for all EMR designers and implementers to do enough homework needed to make EMR training effective. As Lowes argued, that effective training for new system operation will obtain value for money for developers and implementers [35].
From the findings it can be concluded that classroom trainings were rushed and users were made to learn too much too quickly while juggling a full load of patients since trainings were done during clinic days. This obviously had an impact on how they were prepared before they started using the EMR system. No wonder the majority of them indicated that they were not fully prepared before they started using the EMR. It logically follows that the demonstrable and perceived benefits of the EMR should have been far greater than indicated in this study if adequate training and support system for EMR was in place.
Consideration of context including patterns of service delivery is essential to achieve effective training for a new system while limiting disruptions to normal service especially considering increasing service demands and shortage of the health workforce. As Lowes suggests from his study, if the clinic cannot afford to shut down the office completely, alternative class times such as during the evening or early morning can be arranged [35]. Scheduling fewer patients than usual during planned training days or scheduling trainings during the time of the year when patient volume is low would be unrealistic in our ART clinics. Whichever schedule has been chosen it is important to ensure that computer illiterates have had enough time to learn the basics about computers and related programs before the actual training specific to EMR. All trainings in the three sites where the study took place were done during clinic days and with the clinic running, this most likely is
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what attributed to why most users (84%) felt they were not fully prepared after the training. There is need for proper planning and structuring of future trainings for them to be more effective.
In his conclusion, Lowes states that while users should accept the vendor's recommendation on training hours; they should not try to learn everything in one fell swoop [35]. Otherwise, they will not be able to master much, less remember the ins and outs of the system. There is evidence that an incremental phased approach is more acceptable and effective. The findings from the study clearly indicated that the majority of users from all the centers felt they were not fully prepared during the training mostly because the training was rushed and too short (about a day) for the materials they were expected to learn.
Sanchez et al also pointed out that EMR systems lend themselves to gradual training, and they should consist modules for example one for the electronic chart, another for prescribing, and others for transcription, scanning documents, data cleaning, system repair and report generation [34]. Training practices should start with one of the easiest modules, such as scanning, and work their way up to the more demanding modules that involve data entry.
One of the most important things that health care organization can accomplish as part of the training is to make sure that everyone is comfortable with most of software functions they will use most of the time, and ensure that everyone knows how to get the quickest
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answers if they get stuck or have question. This could be achieved thorough ongoing support after the training. Lowes recommended that once a new system is up and running, trainers should come back some months later and teach users some of the finer points for example advanced sessions on tools that will streamline their work like learning how to configure the system so that when they pick a diagnosis code for diabetes, a template for capturing blood sugar values will automatically appear on the screen [35].
EMR users require significant amounts of support, especially in the early phases after training and implementation. Sanchez et al observed that a myriad questions and issues arise soon after the EMR training; some trivial and others substantial, but all can lead to disenchantment and disillusionment if not handled appropriately. They observed that a problem as simple as users forgetting their password and not being able to resolve it can quickly make the whole system unusable for several people [34]. For example, a data entry clerk who forgets a password cannot schedule new patients, making it difficult for physicians to bring up patient charts in a timely manner, creating gridlock and mayhem in a very short time period. It was very pleasing to learn from our study that in all the three sites there has been enough support given to all users soon after the training and in the early stages of EMR implementation.
There, however, has been a difference in the duration this support has been given to users. For example in Dedza, there was a Baobab Health Trust staff at the site for more than six months giving ongoing staff to users while at Ntcheu clinic the technical person giving support was only there for a week after the training. It is not clear why there was such a difference.
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Kamadjeu, in Electronic Health Record project he piloted in Cameroon in 2005 observed that on top of support after the implementation of EHR, the presence of a champion, someone who is the leader for an information technology project, was often identified as a critical factor in successful mentoring and implementation of EHRs [36]. This concept was echoed by Terry et al in the acquisition, implementation and utilization of IT in family practice 2008 study, where the presence of a champion was cited as an important factor in the implementation process and kept EMR users motivated and willing to continue using the system [37]. This study observed the same approach being used by Baobab Health Trust in all the three centers where the study was conducted. Each site has a key person who was more knowledgeable and skilled than others and was used whenever others faced problems with the EMR. For example in Salima the data entry clerk was called multiple times to come and help nurses whenever they encountered problems with the EMR.
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CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS
6.1
Conclusion
This study evaluated the satisfaction, challenges and training of EMR users in Malawi. Overall, though there are challenges with EMR use, the majority of users was satisfied with the EMR and prefer using the EMR to paper based system. The study has also found that users feel that quality of care has significantly improved with the introduction of the EMR system and that patient waiting time at the clinic has greatly reduced. It has also been learnt from this study that with the introduction of the EMR, users can generate multiple reports with the system within a short time (less than a day, some in a few minutes) as opposed to the paper based system which was only able to generate very limited reports and would take a long time, effort and resources to generate a single report, reports (quarterly and cohort analysis) would take more than three days some as long as a week to generate using paper based records.
The study also observed that users felt that there is no established training curriculum used to train potential users of the EMR system but discussions with Baobab Health Trust team indicated that the training curriculum is available and kept being updated as experiences emerged hence the differences in the training approach (training duration and support given after the initial training) at different sites. These different responses on the training curriculum clearly reflect a policy-practice gap / intention-do gap which needs to be addressed.
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Simple and effective electronic data system can be established and adopted in a developing country like Malawi. The key though to its ultimate usefulness and success is provision of proper and adequate training for all users for sustainability. The EMR is used to guide care and improve patient outcomes. It can also be used as a research tool.
In the context of competing needs for health resources, the extent to which benefits of EMR system can be maximized and documented from results in these pilot districts might be a key factor in attracting further investment in the system. It is therefore, essential that the current momentum is sustained with worthwhile improvements made.
6.2
Recommendations
The following recommendations are warranted in order to attain full potential benefits from the EMR:
a) While training has been iteratively improved with time, more work needs to be done, and creative ways of addressing training needs should be considered like making sure that the existing training curriculum is closely followed and adhered to at all times. All trainings on the EMR should be done outside clinic days since it affects patients care and the learning process, b) Baobab Health Trust need to fully adapt the EMR to accommodate and all information captured in paper based system like patient medical history, physical examination findings, all laboratory findings and diagnosis of all opportunistic infections,
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c) Train all users on data cleaning, system repair, and report generation. Users need to be more empowered with knowledge and skills in order to use the EMR independently and effectively with minimal external support, d) Need to train more people on EMR because of the huge staff turnover within the Ministry of Health, district and within the clinic, e) There is need to upgrade the EMR if possible so it is able to give feedback on what has happened to patients referred, f) There is need for the development of a user manual or guidelines with all trouble shooting needed and what to do when a system including the server has a problem, g) The Ministry of Health should come up with a clear scale up plan of the EMR so potential sites and users are well prepared in advance and should have a clear and realistic time frame.
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REFERENCES
1. The department of Health & Human Services, and The National Alliance for Health Information Alliance Technology; The National Alliance for Health Information Technology Report to the Office of the National Coordinator for Health Information Technology on Defining Key Health Information Technology Terms 28th April, 2008. [Accessed on 23rd January 2009]. Available from:
http://www.nahit.org/images/pdfs/HITTermsFinalReport_051508.pdf. 2. Janusz S, Grzegorz K. Electronic patient record and archive of records in Cardio.net System for Telecardiology. PolJPathol. 2003; 54, 3, 223-226. [Accessed 15th November 2008]. Available from: http://www.poljpathol.cmuj.krakow.pl/033/SIE.pdf. 3. Friedman C, Wyatt J. Evaluation methods in medical informatics. New York: Springer-Verlag; 1997. 4. Gibbs W. Taking computers to task. Scientific American 1997;278:64-71. 5. Wullianallur R., Someswar K. Designing Electronic Health Records Versus Total Digital Health Systems: a systemic analysis. Systems Research and Behavioral Science Syst. Res. [Serial on the Internet]. 2009;29:63-79 [Accessed 18th November 2008]. Available from: www.interscience.wiley.com. 6. Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, Taylor R. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Affairs 2005; 24(5):11031117.
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7. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine 2006;144(10):742752. 8. Fiscella K, Geiger HJ. Health information technology and quality improvement for community health centers. Health Affairs 2006;25(2):405-412. 9. Willcocks L, Lester S. evaluating the feasibility of information technology. Research discussion paper. JAMA [serial on the Internet]. 1993;294(2):181. [Accessed on 3rd April 2009]. Available from: http://jama.ama-assn.org/cgi/content/full/294/2/181. 10. A Work Product of the HIMSS Enterprise Systems Steering Committee and the Global Enterprise Task Force. Electronic Health Records: A Global Perspective August 2008. Healthcare Information and Management Systems Society (HIMSS). [Accessed 23rd January 2009]. Available from:
http://www.himss.org/asp/topics_ehr.asp. 11. Shortliffe EH. The evolution of healthcare records in the era of the internet. Med Info. 1998;98:18. 12. Carter M. Integrating electronic health records and patient privacy: possible benefits but real dangers. EMJA 2000;172:2830. 13. Powner DA. Health information technology: HHS is continuing efforts to define a national strategy. GAO-2006-346T; 2006. 14. Hersh W.R. Improving Health Care through Information. JAMA 2002;288(16):19551958. 15. Sager N, Friedman C, Lyman, M. Medical language processing: Computer management of narrative data. Reading, MA: Addison-Wesley; 1987.
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16. Bates. D, Kuperman. G, Teich. J. Computerized physician order entry and quality of care. Quality Management in Health Care.1994;2:18-27. 17. Korpman. R, Lincoln. T. The computer-stored medical record: For whom? JAMA. 1988;259:3454-3456. 18. Bates D, Boyle D, Tcich. J. Impact of computerized physician order entry on physician time. Proceedings of the 18th annual symposium on computer applications in medical care. Washington DC.; 1996. p. 996. 19. Avison D, Young, T. Time to Rethink Healthcare and ITC. Communication of the ACM, 2007;50 (6):69-74. 20. Fonkych K, Taylor R. The state and pattern of health information technology adoption Santa Monica, Calif: Rand; 2005. 21. Simon RS, McCarthy ML, Kaushal R, Jenter CA, Volk LA, Poon EG, et al. Electronic health records: which practices have them, and how are clinicians using them? 22. Dahm MF, Wadensten B. Nurses experiences and opinions about using standardized care plans in electronic health records-a questionnaire study. JoCN. 2008;17:2137 2145. 23. Smith K, Smith V, Krugman M, Oman K. Evaluating the impact of computerized clinical documentation. Computers, Informatics, Nursing 2005;23:132138. 24. World Health Organization [Accessed 25th March 2009]. Available from http://www.who.int/africahealthinfoway/about/Executive Summary.pdf. 25. McGrath D, Herbst K, Fraser HS. Electronic Medical Record (EMR) systems for HIV care in resource poor settings: report from an international workshop. Int Conf AIDS. 2004 Jul 11-16;15 Abstract no. ThPeB7159.
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26. Siika AM, Rotich JK, Simiyu CJ, Kigotho EM, Smith FE, Sidle JE, et al. An electronic medical record system for ambulatory care of HIV-infected patients in KIJMI 2005;74:345355. [Accessed 23rd March 2009]. Available www.intl.elsevierhealth.com/journals/ijmi. 27. Allen C, Manyika P, Jazayeri D, Rich M, Lesh N, Fraser H. Rapid deployment of electronic medical records for ARV rollout in rural Rwanda. 2006:840 [Accessed on 22nd March 2009]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17238460. 28. Malawi Ministry of Health & National AIDS Commission (NAC). HIV and syphilis sero-survey and National HIV prevalence and AIDS estimates report; 2007. [Unpublished] 29. Herbst K, Littlejohns P, Rawlinson J, Collinson M, Wyatt JC. Evaluating computerized health information Systems: Hardware, software and human ware: Experiences from the Northern Province, South Africa. Journal of Public Health Medicine; 1999: 21(3):305-310. 30. United Nations. End poverty Millennium Development Goals, Make it happen; Highlevel event on the Millennium Development Goals. New York, United Nations Headquarters; 25 September 2008. 31. Freeman MC, Taylor AP, Adelman JU. Electronic medical record system in a headache specialty practice: A patient satisfaction survey. American Headache Society 2007:212-215. 32. Kaplan B. Evaluating Informatics Applications-Clinic Decision Support Systems Literature Review. IJMI. 2001;1:15-37. 33. Rotich JK, Hannan JK, Smith FE, Bii J, Odero WW, Vu N, Mamlin BW, Mamlin JJ et all. Installing and implementing a computer-based patient record system in subMPH Dissertation. University of Malawi-College of Medicine
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Saharan Africa: The Mosoriot Medical Record System. JAMIA 2003 Jul/Aug 110(4):295-303. 34. Snchez JL, Savin S, Vasileva V. Key success factors in implementing electronic medical records in University hospital of Rennes. EUROPHAMILI / AESCULAPIUS Professional Study, 2005 - ENSP Rennes, France 35. Lowes R. EMR success: Training is the key. Medical Economics Healthcare Communications 2004 May 7:81. 36. Kamadjeu RM, Tapang EM, Moluh RN. Designing and implementing an electronic health record system in primary care practice in sub-Saharan Africa: a case study from Cameroon. IPC 2005; 13:17986. 37. Terry AL, Thorpe CF, Giles G, and Brown JB, Harris SB et al. Implementing electronic health records: Key factors in primary care Canadian Family Physician. 2008 (54): 730-736. 38. Van der Meijden MJ, Tange HJ, Troost J, Hasman A.. Determinants of success of inpatient clinical information systems: A literature review. JAMIA 2003;10:23543. 39. Melvin VC. Health information technology-HHS is pursuing efforts to advance nationwide implementation, but has not yet completed a national strategy. 14 February 2008. 02 40. Powner DA, Koontz LD. HHS is taking steps to develop a national strategy (information technology). 41. Darbyshire O. Rage against the machine? Nurses and midwives experiences of using computerized patient information systems for clinical information. JAN 2004; 13:1725.
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42. Timmons S. Resistance to computerized care planning systems by qualified nurses working in the UK NHS. MIM 2003; 42:471476.
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APPENDICES
Appendix 1: QUESTIONNAIRE FOR IN-DEPTH INTERVIEWS Code number. Name of interviewer..Date of interview: ..././2010 Time start:..........Time finish:..
Demographics. First lets start with a little Information about you. 1. Gender: Male Female 2. Age: 20-25yrs 26-30 yrs 30-35yrs 36-40 yrs Over 41 yrs 3. What is your profession? Nurse Clinician Pharmacy technician Data entry clerk Other 4. How long have you worked in this clinic? Specify......................................
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Less than 6 months 6-12 months 13-18 months 19-24 months Above 24 months USE OF PAPER BASED RECORDS AND ELECTRONIC MEDICAL RECORDS 5. Have you used paper based (patients mastercards) medical records before? Yes No If yes, for how long have you been using paper based (patients mastercards) medical records? Less than 6 months 6-12 months 13-18 months 19-24 months Above 24 months 6. How long have you been using the EMR? Less than 6 months 6-12 months 13-18 months 19-24 months Above 24 months 7. Which one is faster and easier to complete between the EMR and Paper based records?
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EMR Paper form Both are about the same 8. In which is the information about patients more accurate? EMR Paper form Both are about the same 9. In which is the information about patients safer? (Privacy) EMR Paper form Both are about the same 10. In which is the information about patients more complete (no missing data)? EMR Paper form Both are about the same EMR KNOWLEDGE AND TRAINING 11. What type of training did you receive to introduce use of EMR to you? 12. Who trained you to use the EMR system? No one Was never trained By Baobab Health Trust staff By other ART clinic staff By other ..................
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13. How adequately did the training prepare you to use the EMR system? Fully prepared Mostly prepared Somewhat prepared Not at all prepared Not applicable I was never trained 14. Did you get enough support from Baobab after the training? No support Some support Full support 15. What do they support you with? Data cleaning System repair System up grade Others Specify..
16. Do you receive other support from outside other than Baobab? Yes No If yes, please specify the type of support you received. EFFICIENCY OF EMR 17. When you need to use the EMR, is there always one available for you to use, or do you sometimes have to wait for someone else to finish using it first? I strongly agree I agree
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I somewhat agree I disagree I strongly disagree 18. If so, how long do you wait on average? 0-5 minutes 6-10minutes 10-15minutes More than 15 minutes 19. What is the longest you have ever waited? 0-5 minutes 6-10minutes 10-15minutes More than 15 minutes 20. Does this waiting discourage you from using the EMR? Always Sometimes Rarely Never 21. How long (on average) is the wait on line for patients? 0-20 minutes 21-40 minutes 41-60 minutes More than 60 minutes 22. Where do patients have to wait longer?
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Registration Laboratory Nurse Clinician Other Specify
23. Is wait time for patients any different now with EMR compared to paper based records? Shorter Same Longer Please explain your answer above 24. Think back to the way you did things before the introduction of the EMR, how much has the order in which you see patients using the EMR changed compared to before? Significantly To a small degree Not at all 25. If there is any change, how is patients waiting time now? Significantly shorter Shorter No change Longer Significantly longer 26. How has the EMR changed the quality of care to your patients?
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Decreased significantly Decreased a little Not changed Improved a little Improved significantly May you please explain your answer above EASE OF EMR USE AND ACCEPTABILITY OF EMR SYSTEM 27. Do you ever encounter problems when entering data? Always Sometimes Rarely Never If you encounter problems please elaborate 28. Between paper based record and EMR, which system do you prefer using? EMR Paper based Any (doesnt matter) Explain your answer above 29. Do you feel EMR is worth the time and effort required to use it? Yes No If yes, please explain how.. 30. Overall, are you satisfied with the EMR system? Always satisfied
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Mostly satisfied Somewhat satisfied Not at all satisfied Please explain your answer above
FOR ONLY THOSE RESPONSIBLE FOR COHORTS AND QUARTERLY REPORT GENERATION 31. Do you find EMR reports easier to generate than paper based report? Always Sometimes Rarely Never 32. How long (over all including data cleaning) does it take to generate a report using EMR? One day Two days Three days More than three days 33. How long does it take to generate a report from paper based records? One day Two days Three days More than three days Please explain the difference.
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34. Do you find the reports generated by EMR useful and easy to understand? Always Sometimes Rarely Never 35. What types of reports are/were you able to extract from paper based records? Monthly report Quarterly report Cohort analysis Patients treatment report Others Specify................................................... 36. What type of reports are you able to extract from EMR system? Monthly report Quarterly report Cohort analysis Patients treatment report Others Specify.................................................. 37. How would you compare the accuracy of the manually generated reports to that of the EMR-generated report? Paper is significantly more accurate Paper is slightly more accurate The accuracy of both reports is about the same
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The EMR-generated report is slightly more accurate The EMR-generated report is significantly more accurate
THANK YOU VERY MUCH FOR YOUR TIME!
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Appendix 2: FOCUS GROUP DISCUSSION GUIDE
To be conducted to a group of 6-8 EMR users at each selected site
Code number. Date of interview: ././2009 Time start..End time... Number of participants Location. Introductory Questions g) Tell us your name and how long you have been using the EMR system. h) Think back to when you first became involved with EMR. What were your first impressions? i) In what way is your work and performance different since the introduction of EMR? j) What type of activities do you use the EMR for? Understanding Barriers and Benefits 5. What are the barriers or challenges that you experience in using EMR at the clinic? What barriers have you observed your colleagues deal with while using EMR? What should be done to overcome these barriers?
6. Where is EMR most useful? 1. In what way has the introduction of EMR helped to improve the quality of care given to patients? 2. What should be done to make the EMR more useful to you? 3. What should be done to make the EMR more useful to patients?
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Professional Development 7. How would you assess your level of proficiency in using EMR? h) What is your comfort level in using EMR in the clinic? 8. What kind of training was given before the introduction of EMR? i) Was this training enough? Explain your answer. j) In what settings and formats would you like to receive such training? 9. What would be your preferred approaches for professional development in EMR? k) If you were designing training for EMR users in clinics, what would consider? 10. What are the gaps in the use of EMR? 11. Is there anything we should have talked about, but didnt?
Bring the meeting to a close by summarizing the main points
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Appendix 3: EMR USE OBSERVATION GUIDE
1. Is the EMR system well integrated into the normal workflow? Yes No 2. Is the EMR used for every patient that comes? Yes No If NO, record when is it not used?............................................................................. 3. How long (on average) is the wait in line for patients? (Follow a few patients and calculate the average time spent on the queue.) 0-20 minutes 21-40 minutes 41-60 minutes More than 60 minutes 4. How much time do care providers (Clinicians and nurses) spend with the patient? 0-20 minutes 21-40 minutes 41-60 minutes More than 60 minutes 5. How much time do users spend on the computer entering data? 0-20 minutes 21-40 minutes
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41-60 minutes More than 60 minutes 6. Do users have any problems with the use of EMR? Yes No If yes, please describe the observed problems 7. Other than EMR, is there another form of data collection and record keeping at the centre? Yes No If yes, describe it.. 8. How long does it take for users to extract information they need from the EMR? 0-20 minutes
21-40 minutes 41-60 minutes More than 60 minutes 9. Does the EMR system help highlight errors with data entered? Always Sometimes Rarely Never 10. Check the back up and when it was last updated.. 11. Observe if EMR data collection tools can be modified and if they can, explain how?..............................................................................................................................
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12. Observe if information in reports and the format of reports can be altered? Explain your observations 13. Check how the last monthly, quarterly etc reports were generated. APPENDIX 3: EVALUATION OF USER PERCEPTION ON THE EFFECTIVENESS, EFFICIENCY, SATISFACTION, CHALLENGES AND TRAINING OF ELECTRONIC MEDICAL RECORD SYSTEM (EMR) IN MALAWI
CONSENT FORM
Hello. My name is Martin Msukwa. I am a Masters in Public Health student at the College of Medicine.
I am doing a study to evaluate experiences, challenges and prospects on the use of electronic data system (EMR) by users at selected Ministry of Health sites within the central region of Malawi. Your health facility is among the facilities that have been randomly selected in the central region for this study. I would very much appreciate your participation in this study. The information that we will collect from you will help the government to better plan the implementation of EMR scale up to other health facilities but also improve the current EMR sites and help improve the quality of data collected and used. Our discussion will take about 45 minutes. The information that you will provide will be kept confidential and it will not be shown to other persons. I will not write your name or any of your relatives name, I will use codes.
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Please know that your participation in this study is voluntary and you are free not to answer any question or all of the questions. But since we value your opinion so much, we hope you will fully participate in this study.
Before we start our discussion, do you want to ask me anything concerning the study?
Do you agree to take part in this study?
May I begin the interview now?
Signature of Interviewer:
______________________________________
Signature of Interviewee:
______________________________________
Date:
______________________________________
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Appendix 4: REQUEST FOR PERMISSION FROM THE INSTITUTION
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UNIVERSITY OF MALAWI College of Medicine

User Perceptions on Electronic Medical Record System (EMR) in Malawi

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

_______________________________________________ (Chairman, Postgraduate Committee)

_________________________________________________ (Internal Examiner)

___________________________________________________ (Head of Department)

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Name of Candidate: Martin K.B. Msukwa

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Florence Nightingale, 1863

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

CHAPTER 2: LITERATURE REVIEW .......................................................................... 4

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

CHAPTER 3: METHODOLOGY .................................................................................. 17

CHAPTER 4: RESULTS ................................................................................................ 22

CHAPTER 5: DISCUSSION .......................................................................................... 37

CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS ...................................... 49

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

REFERENCES .............................................................................................................. 52 APPENDICES ............................................................................................................... 58

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

CHAPTER 1: BACKGROUND AND JUSTIFICATION

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Purpose of the Study

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Significance of the Study

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

CHAPTER 2: LITERATURE REVIEW

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Benefits of the Electronic Medical Record (EMR)

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Challenges of Electronic Medical Records

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Use of EMR in Developed Countries

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

MPH Dissertation. University of Malawi-College of Medicine

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Evaluation study on implementation of electronic medical record system (EMR) in Malawi

Use of EMR in Developing Countries and Sub Saharan Africa