Binyam Tilahun

Success criteria for electronic medical record implementations in low-resource settings: a systematic review

OBJECTIVE Electronic medical record (EMR) systems have the potential of supporting clinical work by providing the right information at the right time to the right people and thus make efficient use of resources. This is especially important in low-resource settings where reliable data are also needed to support public health and local supporting organizations. In this systematic literature review, our objectives are to identify and collect literature about success criteria of EMR implementations in low-resource settings and to summarize them into recommendations. MATERIALS AND METHODS Our search strategy relied on PubMed queries and manual bibliography reviews. Studies were included if EMR implementations in low-resource settings were described. The extracted success criteria and measurements were summarized into 7 categories: ethical, financial, functionality, organizational, political, technical, and training. RESULTS We collected 381 success criteria with 229 measurements from 47 articles out of 223 articles. Most papers were evaluations or lessons learned from African countries, published from 1999 to 2013. Almost half of the EMR systems served a specific disease area like human immunodeficiency virus (HIV). The majority of criteria that were reported dealt with the functionality, followed by organizational issues, and technical infrastructures. Sufficient training and skilled personnel were mentioned in roughly 10%. Political, ethical, and financial considerations did not play a predominant role. More evaluations based on reliable frameworks are needed. CONCLUSIONS Highly reliable data handling methods, human resources and effective project management, as well as technical architecture and infrastructure are all key factors for successful EMR implementation.

Design and Development of a Linked Open Data-Based Health Information Representation and Visualization System: Potentials and Preliminary Evaluation

Background Healthcare organizations around the world are challenged by pressures to reduce cost, improve coordination and outcome, and provide more with less. This requires effective planning and evidence-based practice by generating important information from available data. Thus, flexible and user-friendly ways to represent, query, and visualize health data becomes increasingly important. International organizations such as the World Health Organization (WHO) regularly publish vital data on priority health topics that can be utilized for public health policy and health service development. However, the data in most portals is displayed in either Excel or PDF formats, which makes information discovery and reuse difficult. Linked Open Data (LOD)—a new Semantic Web set of best practice of standards to publish and link heterogeneous data—can be applied to the representation and management of public level health data to alleviate such challenges. However, the technologies behind building LOD systems and their effectiveness for health data are yet to be assessed. Objective The objective of this study is to evaluate whether Linked Data technologies are potential options for health information representation, visualization, and retrieval systems development and to identify the available tools and methodologies to build Linked Data-based health information systems. Methods We used the Resource Description Framework (RDF) for data representation, Fuseki triple store for data storage, and Sgvizler for information visualization. Additionally, we integrated SPARQL query interface for interacting with the data. We primarily use the WHO health observatory dataset to test the system. All the data were represented using RDF and interlinked with other related datasets on the Web of Data using Silk—a link discovery framework for Web of Data. A preliminary usability assessment was conducted following the System Usability Scale (SUS) method. Results We developed an LOD-based health information representation, querying, and visualization system by using Linked Data tools. We imported more than 20,000 HIV-related data elements on mortality, prevalence, incidence, and related variables, which are freely available from the WHO global health observatory database. Additionally, we automatically linked 5312 data elements from DBpedia, Bio2RDF, and LinkedCT using the Silk framework. The system users can retrieve and visualize health information according to their interests. For users who are not familiar with SPARQL queries, we integrated a Linked Data search engine interface to search and browse the data. We used the system to represent and store the data, facilitating flexible queries and different kinds of visualizations. The preliminary user evaluation score by public health data managers and users was 82 on the SUS usability measurement scale. The need to write queries in the interface was the main reported difficulty of LOD-based systems to the end user. Conclusions The system introduced in this article shows that current LOD technologies are a promising alternative to represent heterogeneous health data in a flexible and reusable manner so that they can serve intelligent queries, and ultimately support decision-making. However, the development of advanced text-based search engines is necessary to increase its usability especially for nontechnical users. Further research with large datasets is recommended in the future to unfold the potential of Linked Data and Semantic Web for future health information systems development.

Health Professionals' readiness to implement electronic medical record system at three hospitals in Ethiopia: a cross sectional study.

BackgroundElectronic medical record systems are being implemented in many countries to support healthcare services. However, its adoption rate remains low, especially in developing countries due to technological, financial, and organizational factors. There is lack of solid evidence and empirical research regarding the pre implementation readiness of healthcare providers. The aim of this study is to assess health professionals’ readiness and to identify factors that affect the acceptance and use of electronic medical recording system in the pre implementation phase at hospitals of North Gondar Zone, Ethiopia.MethodsAn institution based cross-sectional quantitative study was conducted on 606 study participants from January to July 2013 at 3 hospitals in northwest Ethiopia. A pretested self-administered questionnaire was used to collect the required data. The data were entered using the Epi-Info version 3.5.1 software and analyzed using SPSS version 16 software. Descriptive statistics, bi-variate, and multi-variate logistic regression analyses were used to describe the study objectives and assess the determinants of health professionals’ readiness for the system. Odds ratio at 95% CI was used to describe the association between the study and the outcome variables.ResultsOut of 606 study participants only 328 (54.1%) were found ready to use the electronic medical recording system according to our criteria assessment. The majority of the study participants, 432 (71.3%) and 331(54.6%) had good knowledge and attitude for EMR system, respectively. Gender (AOR = 1.87, 95% CI: [1.26, 2.78]), attitude (AOR = 1.56, 95% CI: [1.03, 2.49]), knowledge (AOR = 2.12, 95% CI: [1.32, 3.56]), and computer literacy (AOR =1.64, 95% CI: [0.99, 2.68]) were significantly associated with the readiness for EMR system.ConclusionsIn this study, the overall health professionals’ readiness for electronic medical record system and utilization was 54.1% and 46.5%, respectively. Gender, knowledge, attitude, and computer related skills were the determinants of the presence of a relatively low readiness and utilization of the system. Increasing awareness, knowledge, and skills of healthcare professionals on EMR system before system implementation is necessary to increase its adoption.

Comprehensive Evaluation of Electronic Medical Record System Use and User Satisfaction at Five Low-Resource Setting Hospitals in Ethiopia

Background Electronic medical record (EMR) systems are increasingly being implemented in hospitals of developing countries to improve patient care and clinical service. However, only limited evaluation studies are available concerning the level of adoption and determinant factors of success in those settings. Objective The objective of this study was to assess the usage pattern, user satisfaction level, and determinants of health professional’s satisfaction towards a comprehensive EMR system implemented in Ethiopia where parallel documentation using the EMR and the paper-based medical records is in practice. Methods A quantitative, cross-sectional study design was used to assess the usage pattern, user satisfaction level, and determinant factors of an EMR system implemented in Ethiopia based on the DeLone and McLean model of information system success. Descriptive statistical methods were applied to analyze the data and a binary logistic regression model was used to identify determinant factors. Results Health professionals (N=422) from five hospitals were approached and 406 responded to the survey (96.2% response rate). Out of the respondents, 76.1% (309/406) started to use the system immediately after implementation and user training, but only 31.7% (98/309) of the professionals reported using the EMR during the study (after 3 years of implementation). Of the 12 core EMR functions, 3 were never used by most respondents, and they were also unaware of 4 of the core EMR functions. It was found that 61.4% (190/309) of the health professionals reported over all dissatisfaction with the EMR (median=4, interquartile range (IQR)=1) on a 5-level Likert scale. Physicians were more dissatisfied (median=5, IQR=1) when compared to nurses (median=4, IQR=1) and the health management information system (HMIS) staff (median=2, IQR=1). Of all the participants, 64.4% (199/309) believed that the EMR had no positive impact on the quality of care. The participants indicated an agreement with the system and information quality (median=2, IQR=0.5) but strongly disagreed with the service quality (median=5, IQR=1). The logistic regression showed a strong correlation between system use and dissatisfaction (OR 7.99, 95% CI 5.62-9.10) and service quality and satisfaction (OR 8.23, 95% CI 3.23-17.01). Conclusions Health professionals’ use of the EMR is low and they are generally dissatisfied with the service of the implemented system. The results of this study show that this dissatisfaction is caused mainly and strongly by the poor service quality, the current practice of double documentation (EMR and paper-based), and partial departmental use of the system in the hospitals. Thus, future interventions to improve the current use or future deployment projects should focus on improving the service quality such as power infrastructure, user support, trainings, and more computers in the wards. After service quality improvement, other departments (especially inter-dependent departments) should be motivated and supported to use the EMR to avoid the dependency deadlock.

Modeling antecedents of electronic medical record system implementation success in low-resource setting hospitals

BackgroundWith the increasing implementation of Electronic Medical Record Systems (EMR) in developing countries, there is a growing need to identify antecedents of EMR success to measure and predict the level of adoption before costly implementation. However, less evidence is available about EMR success in the context of low-resource setting implementations. Therefore, this study aims to fill this gap by examining the constructs and relationships of the widely used DeLone and MacLean (D&M) information system success model to determine whether it can be applied to measure EMR success in those settings.MethodsA quantitative cross sectional study design using self-administered questionnaires was used to collect data from 384 health professionals working in five governmental hospitals in Ethiopia. The hospitals use a comprehensive EMR system since three years. Descriptive and structural equation modeling methods were applied to describe and validate the extent of relationship of constructs and mediating effects.ResultsThe findings of the structural equation modeling shows that system quality has significant influence on EMR use (β = 0.32, P < 0.05) and user satisfaction (β = 0.53, P < 0.01); information quality has significant influence on EMR use (β = 0.44, P < 0.05) and user satisfaction (β = 0.48, P < 0.01) and service quality has strong significant influence on EMR use (β = 0.36, P < 0.05) and user satisfaction (β = 0.56, P < 0.01). User satisfaction has significant influence on EMR use (β = 0.41, P < 0.05) but the effect of EMR use on user satisfaction was not significant. Both EMR use and user satisfaction have significant influence on perceived net-benefit (β = 0.31, P < 0.01; β = 0.60, P < 0.01), respectively. Additionally, computer literacy was found to be a mediating factor in the relationship between service quality and EMR use (P < 0.05) as well as user satisfaction (P < 0.01). Among all the constructs, user satisfaction showed the strongest effect on perceived net-benefit of health professionals.ConclusionEMR implementers and managers in developing countries are in urgent need of implementation models to design proper implementation strategies. In this study, the constructs and relationships depicted in the updated D&M model were found to be applicable to assess the success of EMR in low resource settings. Additionally, computer literacy was found to be a mediating factor in EMR use and user satisfaction of health professionals. Hence, EMR implementers and managers in those settings should give priority in improving service quality of the hospitals like technical support and infrastructure; providing continuous basic computer trainings to health professionals; and give attention to the system and information quality of the systems they want to implement.

How can the use of data within the immunisation programme be increased in order to improve data quality and ensure greater accountability in the health system? A protocol for implementation science study

BackgroundImmunisation remains one of the most important and cost-effective interventions to reduce vaccine-preventable child morbidity, disability and mortality. Health programmes like the Expanded Program of Immunization rely on complex decision-making and strong local level evidence is important to effectively and efficiently utilise limited resources. Lack of data use for decision-making at each level of the health system remains the main challenge in most developing countries. While there is much evidence on data quality and how to improve it, there is a lack of sufficient evidence on why the use of data for decision-making at each level of the health system is low. Herein, we describe a comprehensive implementation science study that will be conducted to identify organisational, technical and individual level factors affecting local data use at each level of the Ethiopian health system.MethodsWe will apply a mixed methods approach using key informant interviews and document reviews. The qualitative data will be gathered through key informant interviews using a semi-structured guide with open- and closed-ended questions with four categories of respondents, namely decision-makers, data producers, data users and community representatives at the federal, regional, zonal, woreda and community levels of the health system. The document review will be conducted on selected reports and feedback documented at different levels of the health system. Data will be collected from July 2017 to March 2018. Descriptive statistics will be analysed for the quantitative study using SPSS version 20 software and thematic content analysis will be performed for the qualitative part using NVivo software.DiscussionAppropriate and timely use of health and health-related information for decision-making is an essential element in the process of transforming the health sector. The findings of the study will inform stakeholders at different levels on the institutionalisation of evidence-based practice in immunisation programmes.

A comparison of electronic records to paper records in Antiretroviral Therapy Clinic in Ethiopia: What is affecting the Quality of the Data?

Background Anti-Retroviral Therapy (ART) care is a lifelong treatment, which needs accurate and reliable data collected for long period of time. Poor quality of medical records data remains a challenge and is directly related to the quality of care of patients. To improve this, there is an increasing trend to implement electronic medical record (EMR) in hospitals. However, there is little evidence on the impact of EMR on the quality of health data in low- resource setting hospitals like Ethiopia. This comparative study aims to fill this evidence gap by assessing the completeness and reliability of paper-based and electronic medical records and explore the challenges of ensuring data quality at the Anti-Retroviral Therapy (ART) clinic at the University of Gondar Referral Hospital in Northwest Ethiopia. Methods An institution-based comparative cross-sectional study, supplemented with a qualitative approach was conducted from February 1 to March 30, 2017 at the ART clinic of the University of Gondar Hospital. A total of 250 medical records having both electronic and paper-based versions were collected and assessed. A national ART registration form which consists of 40 ART data elements was used as a checklist to assess completeness and reliability dimensions of data quality on medical records of patients on HIV care. Kappa statistics were computed to describe the level of data agreement between paper-based and electronic records across patient characteristics. In-depth interviews were conducted using semi-structured questionnaires with ten key informants to explore the challenges related with the quality of medical records. Responses of the key informant interviews were analyzed using thematic analysis. Results The overall completeness of medical records was 78% with 95% CI (70.8% - 85.1%) in paper-based and 76% with 95%CI (67.8% - 83.2%) EMR. The data reliability measured in Kappa statistics shows strong agreements on the socio-demographic data such as educational status 0.93 (0.891, 0.963), WHO staging 0.86 (0.808, 0.906); general appearance 0.83 (0.755, 0.892) and patient referral record 0.87 (0.795, 0.932). The major challenges hindering good data quality was the current side by side dual data documentation practice (the need to document both on the paper and the EMR for a single record), patient overload and low data documentation practice of health workers. Conclusion The overall completeness of ART medical records was still slightly better in paper-based records than EMR. The main reason affecting the EMR data quality was the current dual documentation practice both on the paper and electronic for each patient in the hospital and the high load of patients in the clinic. The hospital management need to decide to use either the paper or the electronic system and build the capacity of health workers to improve data quality in the hospital.

Evaluation of Electronic and Paper Pen Data Capturing Tools for Data Quality in a Public Health Survey in a Health and Demographic Surveillance Site, Ethiopia: A randomized controlled crossover Healthcare IT-Evaluation (Preprint)

Background Periodic demographic health surveillance and surveys are the main sources of health information in developing countries. Conducting a survey requires extensive use of paper-pen and manual work and lengthy processes to generate the required information. Despite the rise of popularity in using electronic data collection systems to alleviate the problems, sufficient evidence is not available to support the use of electronic data capture (EDC) tools in interviewer-administered data collection processes. Objective This study aimed to compare data quality parameters in the data collected using mobile electronic and standard paper-based data capture tools in one of the health and demographic surveillance sites in northwest Ethiopia. Methods A randomized controlled crossover health care information technology evaluation was conducted from May 10, 2016, to June 3, 2016, in a demographic and surveillance site. A total of 12 interviewers, as 2 individuals (one of them with a tablet computer and the other with a paper-based questionnaire) in 6 groups were assigned in the 6 towns of the surveillance premises. Data collectors switched the data collection method based on computer-generated random order. Data were cleaned using a MySQL program and transferred to SPSS (IBM SPSS Statistics for Windows, Version 24.0) and R statistical software (R version 3.4.3, the R Foundation for Statistical Computing Platform) for analysis. Descriptive and mixed ordinal logistic analyses were employed. The qualitative interview audio record from the system users was transcribed, coded, categorized, and linked to the International Organization for Standardization 9241-part 10 dialogue principles for system usability. The usability of this open data kit–based system was assessed using quantitative System Usability Scale (SUS) and matching of qualitative data with the isometric dialogue principles. Results From the submitted 1246 complete records of questionnaires in each tool, 41.89% (522/1246) of the paper and pen data capture (PPDC) and 30.89% (385/1246) of the EDC tool questionnaires had one or more types of data quality errors. The overall error rates were 1.67% and 0.60% for PPDC and EDC, respectively. The chances of more errors on the PPDC tool were multiplied by 1.015 for each additional question in the interview compared with EDC. The SUS score of the data collectors was 85.6. In the qualitative data response mapping, EDC had more positive suitability of task responses with few error tolerance characteristics. Conclusions EDC possessed significantly better data quality and efficiency compared with PPDC, explained with fewer errors, instant data submission, and easy handling. The EDC proved to be a usable data collection tool in the rural study setting. Implementation organization needs to consider consistent power source, decent internet connection, standby technical support, and security assurance for the mobile device users for planning full-fledged implementation and integration of the system in the surveillance site.

Mobile Phone Access and Willingness Among Mothers to Receive a Text-Based mHealth Intervention to Improve Prenatal Care in Northwest Ethiopia: Cross-Sectional Study

Background Maternal mortality remains high in many low- and middle-income countries where limited access to health services is linked to low antenatal care utilization. Effective communication and engagement with care providers are vital for the delivery and receipt of sufficient health care services. There is strong evidence that simple text-based interventions can improve the prenatal care utilization, but most mobile health (mHealth) interventions are not implemented on a larger scale owing to the lack of context and preliminary evidence on how to make the transition. Objective The objective of this study was to determine access to mobile phones by pregnant women attending antenatal care as well as willingness to receive a text message (short message service, SMS)–based mHealth intervention for antenatal care services and identify its associated factors among pregnant women attending an antenatal care clinic in Gondar Town Administration, Northwest Ethiopia, Africa. Methods A cross-sectional quantitative study was conducted among 422 pregnant women attending antenatal care from March 27 to April 28, 2017. Data were collected using structured questionnaires. Data entry and analysis were performed using Epi-Info version 7 and SPSS version 20, respectively. In addition, descriptive statistics and bivariable and multivariable logistic regression analyses were performed. Furthermore, odds ratio with 95% CI was used to identify factors associated with the willingness to receive a text message–based mHealth intervention. Results A total of 416 respondents (response rate 98.6%, 416/422) were included in the analysis. About 76.7% (319/416) of respondents owned a mobile phone and 71.2% (296/416) were willing to receive an SMS text message. Among the mobile phone owners, only 37.6% (120/319) were having smartphones. Of all women with mobile phones, 89.7% (286/319) described that they are the primary holders of these phones and among them, 85.0% (271/319) reported having had the same phone number for more than a year. Among the phone owners, 90.0% (287/319) described that they could read and 86.8% (277/416) could send SMS text messages using their mobile phones in their day-to-day activities. Among pregnant women who were willing to receive SMS text messages, about 96.3% (285/296) were willing to receive information regarding activities or things to avoid during pregnancy. Factors associated with willingness were youth age group (adjusted odds ratio [AOR] 2.869, 95% CI 1.451-5.651), having attained secondary and higher educational level (AOR 4.995, 95% CI 1.489-14.773), and the frequency of mobile phone use (AOR 0.319, 95% CI 0.141-0.718). Conclusions A high proportion of pregnant women in an antenatal care clinic in this remote setting have a mobile phone and are willing to receive an SMS text message–based mHealth intervention. Age, educational status, and the frequency of mobile phone use are significantly associated with the willingness to receive SMS text message–based mHealth interventions.

A mobile health model supporting Ethiopia's eHealth strategy

Critical health information technology (IT) system deficiencies have left many low-income countries (LICs) the inability to support locally sustainable communicable and non-communicable disease prevention and screening initiatives and new therapeutic treatment plans that could save millions of lives. This is due, in part, to a lack of timely clinical intelligence from their peers at the point of care and the implementation of effective post-visit patient engagement tactics for self-care and treatment compliance.[1–7] The current solutions in LIC healthcare and Life Science domain are primarily third-party vendor systems, which require unsustainable IT infrastructure and software management support, or heavily paper-based processes supplemented with standard IT desktop applications and databases. Collectively, these systems do not enable the robust capabilities needed to sustain near-real-time and offline patient engagement and clinical innovation or meet the regulatory standards for local, national, and international collaboration efforts. As a result, LICs cannot transition effectively from manual administrative efforts to participate in multi-national clinical trials and public health innovation, which directly impedes their ability to mature as an organization.[1–7] This has left most public health analysts and health care teams that perform population health surveillance and treat high-risk patient population groups in these regions of the world, with little to no alternative but to reactively address disease outbreaks with inadequate biosurveillance and care management intelligence. Ultimately, this results in poor outcomes for preventive health and wellness programs. This impacts LIC’s ability to increase their capacity and take a more prominent role in collaborative research efforts with their peers internationally. As a result, they suffer from lost opportunities for expanded innovation and thought leadership initiatives that enrich the entire global research community in the advancement of public health worldwide.[8–13] Key drivers that impede sustainable adoption of information, communication, and technology in low income countries As a result, global health organizations, such as the WHO, and their member organizations, have been promoting the development and adoption of scalable health IT solutions that are sustainable in low-resource care settings to mitigate these healthcare disparities. The use of mobile technology has been shown to provide the most promising impact, given the ubiquitous use of mobile phones in the most resource constrained areas of the world. The introduction of mobile health (mHealth) capabilities for preventive health programs and patient engagement efforts that bridge gaps in care for vulnerable patient populations, are gaining momentum in all global health communities. However, their impact and sustainability are still uncertain due to the following factors as identified by the WHO:[9–13] Conflicting health-care priorities Unsustainable operating costs Inability to consistently measure clinical and cost effectiveness Lack of harmonized health-care policy and governance models to support mHealth initiatives Lack of knowledge concerning the possible application of mHealth and public health outcomes Lack of IT infrastructure to support mHealth programs Patient literacy, privacy, and cultural issues. This is evident in the current trend of health disparities associated with cervical cancer in LICs, due to low-resource constraints. According to the World Cancer Research Fund International 2012 report:[14] Cervical cancer is the fourth leading cause of cancer death in women worldwide About 84% of cervical cancer cases occurred in less developed countries The highest incidence of cervical cancer was in Africa and Latin America and Caribbean and the lowest incidence in Northern America and Oceania. PROGRESS IN CERVICAL CANCER SCREENING AND TREATMENT IN ETHIOPIA There is progress in LICs such as Ethiopia, that are developing national initiatives to overcome infrastructure and policy-based barriers to improve the outcomes of the preventable spread and prognosis of cervical cancer, with revitalized public health efforts. In spite of Ethiopia’s health care infrastructure constraints, its Ministry of Health is shaping a progressive approach to addressing health disparities by embracing mobile health technology, as an extension of their eHealth strategy to address these gaps in care. Demographic profile of cervical cancer within Ethiopia Ethiopia has an estimated 7000 new cases of cervical cancer each year, and nearly 5000 deaths from cervical cancer yearly.[15] This data is collected primarily from those who present to Addis Ababa for treatment, as currently Addis Ababa is the only oncology treatment center in the country with radiation capacity. The number of women with cervical cancer identified in Addis Ababa was inversely related to the distance the woman lived from the capital (Abate, 2015).[16] Women at risk for the development of cervical cancer are primarily those without access to screening and preventive measures. In Ethiopia, 0.8% of the eligible population have ever been screened for cervical cancer.[16] Further risk factors relevant in the Ethiopian region include exposure to chronic smoke inhalation, as Edelstein et al. 2008[17] reported 80% of the rural women in the Gondar region have exposure to chronic smoke inhalation with poor ventilation due to cooking practices. High-fertility increases the cervical cancer risk, as does young age at first pregnancy.[18] According to the Ethiopia’s Demographic and Health Survey (EDHS), the fertility of Ethiopian women is 4.8 children per woman, with more children born in rural areas per woman than urban. In addition, the median age of first birth in Ethiopia ranges from 18.1 in Amhara to 23 years old in Addis Ababa. In sum, there are significant risk factors for cervical cancer in Ethiopia, an already apparently high incidence, and yet missing data.