EMRS used in SSA

The development or adaption of EMRS solution in SSA is no more a luxury today. Many SSA countries have experienced the use of EMRS in care delivery. As mentioned before, the terms EMRS is mostly interchangeably used with other acronyms (EHR, EPR, PHR, etc) [53]. Therefore this sub-section highlights major EMRS projects related to the different acronyms used in this area in SSA.

Mosoriot Medical Record System (MMRS), Eldoret, Western Kenya

MMRS is a computer-based patient record for a primary healthcare center in rural Kenya which has been operating since February 2001 [25, 91]. This was the result of collaboration between the Moi University Eldoret Kenya and the Indiana University School of Medicine USA. The implementation place (the Mosoriot rural HC) provides all primary healthcares to a surrounding community of 40,000 persons with minimal financial means. The MMRS consists on module programmed in Microsoft Access (MA) and a paper form encounter [92].

The modules include registration, encounter data, reports, and data dictionary. Project evaluation highlighted a high patient satisfaction with the system, considerable time saving, the use of report generated for clinical and community-based public health research purposes [93].

In 2002 MMRS was extended for prospective investigation of acute respiratory illnesses with the use of PDAs as data entry instrument. The use of PDAs enabled a home follow up of patients in the village and therefore improved the efficiency in the clinical research [28].

Lessons learned: patient registration and clear patient identification were not easy to manage because of the absence of national unique personal identifier. Multiple redundant back-up systems were implemented and solar-powered battery was used to face the unreliable local electric power. Cultural stigma due to HIV/AIDS had to be overcome so as to capture more accurate data. The evaluation shows that the “digital divide” could be crossed using a simple, inexpensive EMRS and mobile devices despite significant logistical, and cultural barriers [28, 93].

AMPATH Medical Record System (AMRS), Eldoret, Western Kenya

The Academic Model for Prevention and Treatment of HIV/AIDS (AMPATH) was established by the Moi University Eldoret Kenya and the Indiana University School of Medicine USA in collaboration with the Moi Teaching and Referral Hospital Eldoret [37].

AMRS being an improvement of the MMRS is focused on the enhancement and management of the care of HIV/AIDS patients. Its evaluation shows a standardized patient data collection, an evidence-based decision-making for patient encounters and for the health system and therefore a better management of HIV/AIDS patient in the pilot environment [40].

Medical Electronic Data base and Comprehensive Application for Medical Cabinet (MEDCAB)

MEDCAB was a prototype EHR developed in Cameroon for use in primary healthcare (PHC) as a means to improve providers’ performance, quality and continuity of care, and the availability of routine outpatients’ consultation data [94]. Major constraints before implementation included limited institutional framework and political commitment, work overload, insufficient training, low motivation, intensive medical shopping with a patient consulting more than one provider for a single episode of care, and an unfavorable culture to data collection from both patient and providers.

MEDCAB was developed in a Microsoft environment using visual basic and MA for stand-alone application. The functionalities include among others: medical encounter, appointment management, and report generator. After implementation, a great acceptance of users was highlighted as well as an improved patient management [94].

Lessons learned: lack of well organized paper-based documentation increased the difficulty to design the EHR. Instability of trained personnel and management staff, hardware breakdown, and departure of main investigators led to a massive dropout of MEDCAB users after 14 months. This sustainability issue could be overcome if end-users involvement and capacity building were addressed at the early stage of the development process.

Lilongwe EMR

This patient management information system was developed and implemented as instrument to support order entry in the Pediatric Department of the Lilongwe Central Hospital in 2001.

After implementation, it was highlighted that the use of this platform contributed to the

elimination of errors in medication dosage calculations made by clinicians and the requirement for nurses to transcribe orders [27].

CareWare

CareWare is a stand-alone EMR originally developed by the health resources and services administration within the department of health and human services for entering, collecting, and reporting demographic, service, and clinical information in USA. An international version focused on the treatment and management of HIV/AIDS patient was developed and implemented in Uganda, Kenya, Zambia, Tanzania, and Nigeria [95]

Open Medical Record System (OpenMRS)

OpenMRS is an open source EMRS for developing countries. Originally, it is an improvement of the AMRS [96] with major adaption of work made in this area in the Regenstrief Institute of Indiana in USA. The first version of OpenMRS implemented in Eldoret was therefore focused on managing information to facilitate treatment and management of HIV/AIDS patients [97]. The successful used of this EMRS for the treatment and management of HIV/AIDS patients led to its adaption for the management of MDR-TB in SSA. The OpenMRS foundation is based on the collaborative effort between Regenstrief Institute and the non philanthropic organization Partner in Health (PIH) in Boston which later on included the Medical Research Council in South Africa. This collaborative effort led to major technical improvements of the first system including a new core application programming interface, a framework for a web-based application, a patient-centric data model, and the integration of the Health Level Seven (HL7) standard representations. The development environment is based on open source and free technologies [24, 36, 38] used in a three layers architectural environment (Figure 9) [96].

Figure 9: OpenMRS architecture. New modules (e.g. ‘Inpatient Care’, ‘Medical Problem’, and ‘Diabetes Management’) can be used to extend the web application, the application interface, and the data model.

‘Dojo’ facilitates the dynamic web application development

Today, OpenMRS is implemented in many SSA countries as an instrument for the improvement of the care delivery and management of HIV/AIDS, MDR-TB [97], and mother-child health [98].