Implementing EMR Systems in low- and middle-income Countries: A Strategic Framework for overcoming barriers.
Electronic medical records are defined as computerized medical information systems that collect, store and display patient information.
The first Electronic Medical Record System was developed by Regenstreif Institute in 1972, following the introduction of Problem-Oriented Medical Record that was proposed by Physician Larry Weed in the late 1960’s, with the aim to record patient information electronically to generate a data that would allow a third party to independently verify the diagnosis. EMR systems have the potential to transform health care in terms of cost-effectiveness, error reduction, and sharing of medical information. Despite the global economic recession, financial pressure on health care continues to be a key challenge in providing sufficient resources and substantial health care services to the populations.
In 2009, the United States government enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act, as part of American Recovery and Reinvestment Act (ARAA) of 2009, which seek to promote and expand the adoption of health information technology and to create a nationwide network of electronic health records. ARAA encourages the switch to electronic records by providing financial incentives for both hospitals and physicians to adopt EMR systems. Many low-to middle-income countries (LMICs) have recognized the value of EMRs in the wake of unprecedented surge in infectious disease outbreak and trauma as the leading cause of death in developing countries.
The rapid evolution of information and communication technologies has spurred multiple mobile health innovations and has helped to facilitate the design of digital health pilot projects in sub-Saharan Africa. Achieving the true benefits of electronic health record system (EHRs) requires the transformation of practices based on quality improvement, and evidence-based research to identify appropriate system architecture and design. Data quality and accuracy are critical to the success of any information system, lower cost personal computers and emergence of web-based communication technologies such as mobile email and personal digital assistant (PDAs) offered an affordable means to automate core health- care function to enhance patient-physician interaction, including the development of a system that has adaptability and interoperability. In other words, manual paper-based storage method offers a simple and easy to implement system but cannot be used to manage large amount of patient information, and it is an inefficient means to store, search and share data among providers, payers, and other health care participants.
Despite the growing evidence of EMR potential benefits, implementation in resource-constrained environment is hampered by complex challenges comprising both human, economic, and infrastructural factors. Understanding the organizational dynamics and the social context that affect the introduction of EMRs needs further assessment in the implementation phase. Increasing number of affordable and sustainable technology-based solutions is being developed and applied to strengthen health systems in low-to middle-income settings, through improved access to knowledge and excellent information management.
Developing countries is challenged with severe health crisis including HIV/AIDS and Tuberculosis, there is a need for a large-scale public health intervention in West Africa, EMRs adoption generally aimed at improving quality of care by reducing medical errors and ensuring timely and accurate data reporting.
Building on a paradigm model, it’s essential to construct an EMR implementation framework that will integrate the capacity of users and institutions to help address the contextual conditions of human and organizational factors. A comprehensive approach for effective service delivery in developing countries would require a new system to allow efforts scale-up rapidly by carefully applying Principles of Digital Development which seek to institutionalize lessons learned in the use of ICTs in mHealth development projects. The effectiveness of EMR deployment in resource-limited settings is hindered by lack of standardization in the study design, most mHealth project research to date was conducted in high-income countries where they have advanced mobile devices, reliable internet connectivity, and information infrastructure. To justify the most promising mHealth programs and shifting intervention from pilot to scale, there is a need to enable more rigorous experiment to inform EMR pre-implementation planning and logistics.
A recent survey carried out by InStrat Global Health Solutions and Lagos State Ministry of Health for the pre-deployment of CliniPAK360 electronic medical record system in Primary Health Care facilities in Lagos State Nigeria, helped to identify possible challenges that restrained EMR scale-up efforts in sub-Saharan Africa. The overall goal of CliniPAK is to improve quality health service delivery via electronic data capture and reporting. We use a set of interlocking survey and analysis to collect data on health-care infrastructural status, as well as the data management system across 33 health facilities. The site reconnaissance activities were conducted between 18th and 21st July 2016, with an objective to enumerate sites for the pilot project with respect to electronic health management criteria and requirements.
A standard procedure was used to determine the accessibility of road, internet networks and the reliability of power supply. Slow internet connection, unstable power supply, and lack of alternative power option constitute major part of our critical observations and a persistent issue.
The existing evidence and the empirical results of the studies suggests that by understanding the clinical setting as a complex adaptive system (CAS) may enable healthcare technology providers to effectively model change processes to mitigate EMR implementation barriers. To design a workforce that will facilitate successful implementation of EMRs in low-resource settings, it is necessary to:
Define EMR Goals and Priorities
It is necessary to characterize the expectation of electronic medical record to identify a workable deliverable concept that will help to achieve a measurable and realistic implementation process. Defining the goals of EMR use in clinical settings will help to establish a scope for a successful EMR practices. Setting realistic expectations will help to create a coherent transition to system that support EMR adoption and deployment. Understanding the priority and objectives of EMR setup will enable workflow customization and provide necessary criteria for measuring success with a specific timeline.
Adapt a Strategy for Digital Transformation
Leveraging the changes and opportunities of digital technologies will accelerate the progress of a profound EMR practices in developing countries through a process of digital transformation. The development of new competencies will drive effective change management within a digital health space. Adapting a clear-cut IT strategy will be more impactful when addressing barriers to technological innovations and adoption and observing factors that may likely disrupt transformation or hinder successful implementation of electronic medical record system in low-income countries.
Implementation Strategy and Scope
Per the World Health Organization (WHO), the most favorable approach to the implementation of eHealth at the national level is to have a framework of strategic plans and policies which lay the foundations for ICT development. Strategic plans and policies should promote equity and ensure interoperability (the ability of different technology system to work together), and allow for capacity development so that all citizens can access eHealth solutions.
Design Communication Platform to Enhance Interoperability and Standardization
A well-coordinated communication and information exchange platform is crucial when planning digital health projects to establish information and communication technology standards in health-care system. Medical device interoperability and communications are critical components of remote care and citizen-centric electronic health environment. It is necessary to integrate this information streams, and include communication management plan in the study design and to offer training/education and decision-support to ensure a better delivery system.
Build Commitment with The Stakeholders
Stakeholders at the national level and health care policy makers has essential roles to play to support a successful EMR implementation, an appropriate stakeholders’ engagement will significantly improve the mHealth project process and outcome. An increase in commitment with stakeholders during project planning activities will help to reduce distrust and enable reconciliation of work and resource requirements. Active stakeholders’ involvement would help to provide more insight regarding the project objectives and execution processes, and assure the credibility of the project outcome.