CITATION: William M Tierney et al. Assessing the impact of a primary care electronic medical record system in three Kenyan rural health centers. J Am Med Inform Assoc (2016) 23 (3): 544-552. doi: 10.1093/jamia/ocv074


Objective: Efficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers.

Method: Local clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers’ satisfaction with the EMR.

Results: Between September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care.

Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers’ work patterns, but the nurses’ and the clerks’ patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training.

Conclusions: We successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses’ and the clerks’ patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow.

‘Effective and efficient patient care management requires information. Improving information capture and flow should allow low-resource countries to deliver the most care and realize the best outcomes possible for the restricted funds available for health care. EMRs can enhance the timely capture and use of key medical data by providers and health system managers. Much additional research and development is needed before EMRs can be most useful, fully implemented into developing countries’ health care settings, and used to manage and improve patient care.’

As a personal comment, electronic medical records are desirable for many reasons and most high-income countries are investing large sums of money to implement them. They have the potential to improve individual patient care, partly because information about the patient can be collected (and be built upon) in one place, potentially accessible to all healthcare providers in primary, secondary and tertiary care. Individual patient care can also potentially be enhanced by the avoidance of the need constantly to re-collect the basic information on a patient each time he/she presents, and the consequent risk of missing an important piece of data in the medical history. There is also the potential for the electronic medical record to sit side-by-side with clinical decision-making tools, ranging from alerts to potential drug interactions to algorithms such as those produced by the Map of Medicine (we haven’t heard from them on HIFA for some time – can anyone provide an update?). There is also the issue of personal access to, and ownership of, electronic medical records. And then there is the huge potential benefit to public health, whereby the data from thousands of EMRs can be pooled to provide important evidence for population health and health systems research…

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