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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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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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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 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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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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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 - 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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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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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 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