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

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1 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

2 CERTIFICATE OF APPROVAL The Thesis of Martin K.B. Msukwa is approved by the Thesis Examination Committee: (Chairman, Postgraduate Committee) (Supervisor) (Internal Examiner) (Head of Department) MPH Dissertation. University of Malawi-College of Medicine Page II

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

4 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 Nyang wa, 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. MPH Dissertation. University of Malawi-College of Medicine Page IV

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

6 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 Study Background Problem Statement Purpose of the Study Specific Objectives Significance of the Study... 3 CHAPTER 2: LITERATURE REVIEW Introduction Benefits of the Electronic Medical Record (EMR) Challenges of Electronic Medical Records Use of EMR in Developed Countries Use of EMR in Developing Countries and Sub Saharan Africa Introduction and Use of EMR in Malawi MPH Dissertation. University of Malawi-College of Medicine Page VI

7 CHAPTER 3: METHODOLOGY Type of Research Study Study Place, Population and Sampling Data Collection Tools Data Collection Data Management Analysis Qualitative Data Analysis Quantitative Data Analysis Study Limitations Ethical Considerations CHAPTER 4: RESULTS Description of Participants Experience of Users Effectiveness and Efficiency of EMR System Perceived as Faster and Easy to Use Effect of EMR on the Quality of Care Report Generation User Satisfaction and Challenges of Using EMR User Satisfaction with EMR Challenges Users Face while Using the EMR User Training Summary of the Results CHAPTER 5: DISCUSSION Introduction Effectiveness and Efficiency of EMR User Satisfaction with EMR User Training CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS Conclusion Recommendations MPH Dissertation. University of Malawi-College of Medicine Page VII

8 REFERENCES APPENDICES Appendix 1: QUESTIONNAIRE FOR IN-DEPTH INTERVIEWS Appendix 2: FOCUS GROUP DISCUSSION GUIDE Appendix 3: EMR USE OBSERVATION GUIDE Appendix 4: REQUEST FOR PERMISSION FROM THE INSTITUTION MPH Dissertation. University of Malawi-College of Medicine Page VIII

9 LIST OF TABLES Table 1: Age of users of Electronic Medical Records Table 2: Experience of Users Table 3: Frequency of user satisfaction on the performance of EMR MPH Dissertation. University of Malawi-College of Medicine Page IX

10 LIST OF FIGURES Figure 1: Participants' profession Figure 2: System perceived as faster and easy to use (efficient and effective) Figure 3: Reported effect of EMR on quality of care Figure 4: Overall satisfaction with EMR amongst professionals Figure 5: Preparation of users before EMR use MPH Dissertation. University of Malawi-College of Medicine Page X

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

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

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

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

15 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 user s perspective on the effectiveness, efficiency and satisfaction of the EMR system introduced by Baobab Health Trust in Malawi. MPH Dissertation. University of Malawi-College of Medicine Page 2

16 1.5 Specific Objectives The specific objectives of this evaluation study were: To assess user perception on the effectiveness and efficiency of EMR in comparison to paper based records To analyze users satisfaction on the benefits and challenges on using the electronic medical records in selected sites To identify and evaluate training gaps and specific training needs for users before they start using EMR system 1.6 Significance of the Study Baobab Health Trust is assisting the Ministry of Health in Malawi to address the human resource crisis in healthcare by focusing on improving the efficiency and effectiveness of the existing limited workforce through the deployment of reliable, easy to use electronic systems in high burden Antiretroviral Therapy (ART) clinics. So far these electronic medical systems have been deployed at more than eleven hospitals and clinics throughout Malawi and the Ministry of Health plans to scale up further. However, it is not clear how this electronic medical system work, how useful it is to users and whether the training users get before they start using the EMR is enough or not. This study was conducted to address these questions from the Ministry of Health, Baobab Health Trust and user s perspective. MPH Dissertation. University of Malawi-College of Medicine Page 3

17 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 MPH Dissertation. University of Malawi-College of Medicine Page 4

18 patients, and since Baobab Health Trust's inception it has received roughly $1.1 million in funding. If all Baobab Health Trust had achieved were issuing nationally unique IDs this might not be considered a cost effective intervention by many, but in reality, Baobab has achieved far more than this, with currently over 30,000 patients being managed daily using the Baobab Health Trust electronic medical system. To date, the digitization of health care typically has focused simply and solely on electronic records for patients. Most EMR systems are relational databases with a finite number of intra-enterprise applications and are limited to in-house use by health care facilities. Very few of these systems have realized fully functional, scalable, distribution capabilities, not to mention interoperability with external systems. This short-sighted tendency to build large-scale but restrictive automated systems that ignore the interactive nature of health care has resulted in limited operational success and acceptance [5]. Electronic records have the potential to improve the quality of health care delivery and reduce costs [6-9]. Accurate and up-to-date health information is critical. When an individual seeks health care, in order to provide effective and timely treatment, the provider needs to have information about the patient, including known allergies, chronic conditions, current medications and other pertinent health care data. However, such information is not always readily available. It may sometimes be available but incomplete or inaccurate, depending on whether the patient s records have been updated or not. MPH Dissertation. University of Malawi-College of Medicine Page 5

19 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 patient s 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 patient s 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]. MPH Dissertation. University of Malawi-College of Medicine Page 6

20 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 MPH Dissertation. University of Malawi-College of Medicine Page 7

21 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 Medicine s 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 MPH Dissertation. University of Malawi-College of Medicine Page 8

22 system does not use narrative text in most cases it makes the use of an entirely touch screen-driven system that much more feasible. A final concern about the EMR is the problem of security and patient confidentiality. This problem, of course, exists independent of the EMR, as a great deal of medical information abstracted from paper records, already exists in electronic repositories. Wellknown privacy experts have documented the threats that misuse of this information has on personal privacy [17]. As noted above, the paper record is no barrier to duplication, as medical records are routinely copied and faxed among health care providers and insurance companies already. While some fear the EMR will exacerbate this problem, others note that computer-based records, with appropriate security, are potentially more secure than paper based records. Most medical centers already have security. Employees given access are usually required to sign a confidentiality statement indicating their understanding of the privacy of patient data. At most centers, a password is required to enter the system, although some institutions also use a physical device, such as a key card. Virtually all systems also keep an audit trail of who accessed which patient s 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. MPH Dissertation. University of Malawi-College of Medicine Page 9

23 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. MPH Dissertation. University of Malawi-College of Medicine Page 10

24 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 percent of U.S. physicians offices and 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]. MPH Dissertation. University of Malawi-College of Medicine Page 11

25 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]. MPH Dissertation. University of Malawi-College of Medicine Page 12

26 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 MPH Dissertation. University of Malawi-College of Medicine Page 13

27 University School of Medicine, in collaboration with the Moi Teaching and Referral Hospital in Eldoret, Kenya, established the Academic Model for Prevention and Treatment of HIV/AIDS (AMPATH) [26]. The AMPATH Medical Record System (AMRS) was the first functioning comprehensive electronic medical record system committed to managing and improving the quality and efficiency of care for patients with HIV/AIDS in sub-saharan Africa. It has played a significant role in patient care in all AMPATH sites. It has standardized patient data collection and made data retrieval much faster than the traditional paper-based record. It has enabled evidence-based decisionmaking for patient encounters and for the health system. The AMRS is affordable and represents a model system for recording critical HIV/AIDS data in resource poor settings that will be delivering an increasing amount of HIV care. This model will also allow those funding the rapid increase in the provision of HAART to know the return they are getting on their investment and hopefully encourage continued treatment of the worst medical disaster to ever befall humanity. While most sophisticated EMRs in low-income regions are in large cities, where infrastructure and staffing needs are more easily met, Partners in Health (PIH) pioneered web-based EMRs for HIV and TB treatment in rural areas [27]. The HIV-EMR, developed in Haiti, was deployed in two Rwandan health districts starting in August 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, MPH Dissertation. University of Malawi-College of Medicine Page 14

28 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 world s 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 MPH Dissertation. University of Malawi-College of Medicine Page 15

29 nine years by applying medical informatics principles to resource-poor settings. The core of Baobab Health Trust s 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]. MPH Dissertation. University of Malawi-College of Medicine Page 16

30 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 study s findings. MPH Dissertation. University of Malawi-College of Medicine Page 17

31 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 MPH Dissertation. University of Malawi-College of Medicine Page 18

32 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 Qualitative Data Analysis Transcription of recordings and typing of field notes was done soon after each data collection event. Tapes of interviews and focus groups were processed after each session; they were not allowed to accumulate. All field notes were typed as soon as the data collector had expanded them. MPH Dissertation. University of Malawi-College of Medicine Page 19

33 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 Quantitative Data Analysis Quantitative data was entered into and analyzed using the Statistical Package for Social Sciences version 16.0 (SPSS version 16.0). Data was entered manually into the software application and analyzed. Graphs and charts were created using Microsoft Excel. 3.6 Study Limitations This study had several limitations. The first one was the high staff turnover observed in all the three districts ART clinics where trained and skilled staff keeps being transferred from one facility to the other or from one department to a different one. This is what led to the limited sample size and made it difficult to sample the study participants. This is also why all users were interviewed to help get enough participants. The second limitation is that the study was only done in one region of Malawi and was only done at district hospital level, users at central hospital and health centre level might have MPH Dissertation. University of Malawi-College of Medicine Page 20

34 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. MPH Dissertation. University of Malawi-College of Medicine Page 21

35 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 (%) (13) (13) (23) (16) 41 and above 11 (36) Table 1 above shows age distribution of users. The minimum age group was years and maximum age group was above 41 yrs. The mean age group was years with a MPH Dissertation. University of Malawi-College of Medicine Page 22

36 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. MPH Dissertation. University of Malawi-College of Medicine Page 23

37 Table 2: Experience of Users Period worked in Period used paper Period used the clinic (%) based records (%) EMR (%) less than 6 months 2 (7%) 3 (10%) 9 (29%) 6-12 months 6 (19%) 4 (13%) 5 (16%) months 6 (19%) 4 (13%) 4 (13%) months 3 (10%) 8 (26%) 8 (26%) above 24 months 14 (45%) 12 (39%) 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 MPH Dissertation. University of Malawi-College of Medicine Page 24

38 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 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. MPH Dissertation. University of Malawi-College of Medicine Page 25

39 Figure 2: System perceived as faster and easy to use (efficient and effective) Effect of EMR on the Quality of Care Quality of care is the extent to which users felt they were able to adequately look after and provide for all the needs of their clients. The findings indicated that 71% (n=22) of participants thought that the quality of care has improved significantly since the introduction of EMR while 26% (n=8) indicated that the quality of care has improved a little, only 3% (n=1) indicated that there was no change in the quality of care. Figure 3 below summarizes the narrative. MPH Dissertation. University of Malawi-College of Medicine Page 26

40 Figure 3: Reported effect of EMR on quality of care Respondents perceived that there has been an improvement in quality of care which they attributed to EMR based on the following benefits: a) Providers spend more time taking patients history and doing physical examination than wasting a lot of time with paper work b) The EMR is able to automatically calculate dates of appointments and specific number of pills to be given to the patient instead of providers doing it hence efficiency in task performance MPH Dissertation. University of Malawi-College of Medicine Page 27

41 c) The EMR is able to automatically calculate Body Mass Index (BMI) of the patient at every visit and able to alert the provider if the BMI is low so the patient can receive nutritional support d) The EMR is able to automatically assess patients adherence using the date of last appointment, number of pills dispensed and remaining pills on the date of the visit. If the patient has a lot of remaining pills the EMR will remind/alert the provider to refer the patient for adherence counseling e) The EMR has a list of all antiretroviral side effects that have to always be checked at every visit by the provider. These act as checklist for providers to effectively monitor side effects on all patients f) With EMR the provider can easily get all information of the patients health even if the patient loses a health passport as long as they give the provider their full name and village and this helps promote the continuity of care. The only respondent who indicated that quality of care has not changed pointed out that despite the many positives EMR has brought, there are still a lot of gaps with the EMR especially the limitation in the information it captures like full patients history, physical examination findings and some laboratory findings. The EMR needs to accommodate more information 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 MPH Dissertation. University of Malawi-College of Medicine Page 28

42 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. MPH Dissertation. University of Malawi-College of Medicine Page 29

43 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 Information Information more accurate (%) safer (%) complete (%) EMR 12 (39) 29 (94) 12 (39) Paper form 8 (26) 0 (0) 8 (26) both are the same 11 (35) 2 (6) 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 MPH Dissertation. University of Malawi-College of Medicine Page 30

44 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 Challenges Users Face while Using the EMR The findings reveal that 90% (n=28) of participants rarely experience problems while operating the EMR. The most common problems experienced were; freezing or not responding to commands, provision of wrong information about patients at times for MPH Dissertation. University of Malawi-College of Medicine Page 31

45 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 MPH Dissertation. University of Malawi-College of Medicine Page 32

46 expressed that trainings to prepare users to use EMR are not well structured and it is different between clinics. All trainings to prepare users on EMR were done by Baobab Health Trust. Of the thirtyone participants that took part in the study 16% (n=5) felt they were fully prepared to use EMR after the training, 58% (n=18) felt mostly prepared to use EMR after the training while 26% (n=8) felt somewhat prepared to use EMR after the training. Figure 5 below summarizes how adequate users felt prepared to use EMR after the training provided by Baobab Health Trust. Figure 5: Preparation of users before EMR use MPH Dissertation. University of Malawi-College of Medicine Page 33

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