Martin Msukwa Approved

7/30/2019 Martin Msukwa Approved

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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


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

MPH Dissertation. University of Malawi-College of Medicine Page II

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)


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MPH Dissertation. University of Malawi-College of Medicine Page III

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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MPH Dissertation. University of Malawi-College of Medicine Page IV

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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MPH Dissertation. University of Malawi-College of Medicine Page V

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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MPH Dissertation. University of Malawi-College of Medicine Page VI

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 Study Background ........... .......... ........... .......... ........... .......... ........... .......... ........... .......... .......... ........... .......... . 1

1.3 Problem Statement .......... .......... ........... .......... ........... .......... ........... .......... ........... .......... .......... ........... .......... . 2

1.4 Purpose of the Study .......... ........... .......... ........... .......... ........... .......... ........... .......... .......... ........... .......... ........ 2

1.5 Specific Objectives ........................................................................................................................................ 3

1.6 Significance of the Study ......... ........... ........... .......... .......... ........... .......... ........... .......... .......... ........... ........... .. 3

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

2.1 Introduction ................................................................................................................................................... 4

2.2

Benefits of the Electronic Medical Record (EMR) ......... ........... .......... ........... .......... ........... .......... ........... .. 6

2.3 Challenges of Electronic Medical Records .......... ........... .......... ........... .......... ........... .......... .......... ........... .... 7

2.4 Use of EMR in Developed Countries ........... .......... ........... .......... .......... ........... .......... .......... ........... ........... 10

2.5 Use of EMR in Developing Countries and Sub Saharan Africa ......... ........... .......... .......... ........... ........... 13

2.6 Introduction and Use of EMR in Malawi ........... .......... ........... .......... .......... ........... .......... .......... ........... .... 15


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MPH Dissertation. University of Malawi-College of Medicine Page VII

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

3.1 Type of Research Study .............................................................................................................................. 17

3.2 Study Place, Population and Sampling ......... ........... .......... ........... .......... ........... .......... .......... ........... ......... 17

3.3 Data Collection Tools ........... ........... .......... ........... .......... ........... .......... .......... ........... .......... .......... ........... .... 18

3.4 Data Collection ............................................................................................................................................ 18

3.5 Data Management Analysis .......... .......... ........... .......... ........... .......... ........... .......... ........... .......... .......... ...... 19

3.5.1 Qualitative Data Analysis......................................................................................................................... 193.5.2 Quantitative Data Analysis....................................................................................................................... 20

3.6 Study Limitations ........................................................................................................................................ 20

3.7 Ethical Considerations ........... .......... ........... .......... ........... .......... ........... .......... ........... .......... .......... ........... .. 21

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

4.1 Description of Participants ........... .......... ........... .......... ........... .......... ........... .......... ........... .......... .......... ...... 22

4.2 Experience of Users .......... ........... ........... .......... ........... .......... .......... ........... .......... .......... ........... ........... ....... 23

4.3 Effectiveness and Efficiency of EMR ........... .......... ........... .......... .......... ........... .......... .......... ........... ........... 244.3.1 System Perceived as Faster and Easy to Use .......................................................................................... 254.3.2 Effect of EMR on the Quality of Care....................................................................................................... 264.3.3 Report Generation .................................................................................................................................... 28

4.4 User Satisfaction and Challenges of Using EMR ........... .......... ........... .......... ........... .......... .......... ........... .. 294.4.1 User Satisfaction with EMR ...................................................................................................................... 304.4.2 Challenges Users Face while Using the EMR .......................................................................................... 31

4.6 User Training ............................................................................................................................................... 32

4.7 Summary of the Results .......... ........... ........... .......... .......... ........... .......... ........... .......... .......... ........... ........... 35

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

5.1 Introduction ................................................................................................................................................. 37

5.2 Effectiveness and Efficiency of EMR ........... .......... ........... .......... .......... ........... .......... .......... ........... ........... 38

5.3 User Satisfaction with EMR ........... .......... ........... .......... .......... ........... .......... ........... .......... .......... ........... .... 41

5.4 User Training ............................................................................................................................................... 43

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

6.1 Conclusion .................................................................................................................................................... 49

6.2 Recommendations ....................................................................................................................................... 50


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MPH Dissertation. University of Malawi-College of Medicine Page VIII

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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MPH Dissertation. University of Malawi-College of Medicine Page IX

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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MPH Dissertation. University of Malawi-College of Medicine Page X

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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MPH Dissertation. University of Malawi-College of Medicine Page XI

ACRONYMS

AIDS - Acquired Immunodeficiency Syndrome

AMPATH - Academic Model for the Prevention and Treatment of HIV/AIDS

AMRS - AMPATH Medical Record System

ART - Antiretroviral Therapy

ARV - Antiretroviral

BMI - Body Mass Index

COMREC - College of Medicine Research and Ethics Committee

CPOE - Computerized Physician Order Entry

DHO - District Health Officer

EHR - Electronic Health Records

EMR - Electronic Medical Records

FGD - Focus Group Discussion

HAART - Highly Active Antiretroviral Therapy

HIT - Health Information Technology

HIV - Human Immune Deficiency Virus

HSAs - Health Surveillance Assistants

ICTs - Information and Communication Technologies

IDI - In-depth Interviews

IS - Information Systems

IT - Information Technology

KCH - Kamuzu Central Hospital

MDG - Millennium Development Goals


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MPH Dissertation. University of Malawi-College of Medicine Page XII

MMJ - Malawi Medical Journal

MMRS - Mosoriot Medical Record System

MOH - Ministry of Health

MRHC - Mosoriot Rural Health Centre

NLP - Natural Language Processing

OI - Opportunistic Infection

PIH - Partners in Health

SPSS - Statistical Package for Social Sciences

UK - United Kingdom

UMLS - Unified Medical Language System

UN - United Nations

USA - United States of America

WHO - World Health Organization


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MPH Dissertation. University of Malawi-College of Medicine Page XIII

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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MPH Dissertation. University of Malawi-College of Medicine Page 1

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 incomparison to paper based records

To analyze users satisfaction on the benefits and challenges on using theelectronic medical records in selected sites

To identify and evaluate training gaps and specific training needs for users beforethey 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 electronicmedical 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 Trusthad achieved were issuing nationally unique IDsthis 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 Trustelectronic 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. Well-

known 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 decision-

making 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 Qual itative 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 Quant itati ve 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 Frequency (%)

20-25 4 (13)

26-30 4 (13)

30-35 7 (23)

36-40 5 (16)

41 and above 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

the clinic (%)

Period used paper

based records (%)

Period used

EMR (%)

less than 6 months

6-12 months

13-18 months

19-24 months

above 24 months

2 (7%)

6 (19%)

6 (19%)

3 (10%)

14 (45%)

3 (10%)

4 (13%)

4 (13%)

8 (26%)

12 (39%)

9 (29%)

5 (16%)

4 (13%)

8 (26%)

5 (16%)

Total 31 (100%) 31 (100%) 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 Ef fect 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 physicalexamination than wasting a lot of time with paper work

b) The EMR is able to automatically calculate dates of appointments and specificnumber 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 patientat 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 lastappointment, 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 checkedat 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 evenif 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 patients 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 (%)

Information

safer (%)

Information more

complete (%)

EMR

Paper form

both are the same

12 (39)

8 (26)

11 (35)

29 (94)

0 (0)

2 (6)

12 (39)

8 (26)

11 (35)

Total 31 (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 Chal lenges Users Face whi le 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 thirty-

one 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 HealthTrust 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 butalso 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 onthe 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 theMinistry 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 whathas 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 troubleshooting 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 paper-

based 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 ofEMR 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 cli nic teamto

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 that 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 otherdrugs [6].

Chaudhry et al observed that the major effect of health information technology on quality

of care was its role in increasing adher

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