A Cross-case Analysis of the Effects of EMR Deployment on Antenatal Care Services in Rural Health Centres in Malawi
AbstractBackground and Purpose: The use of Electronic Medical Records in developing countries is considered important for monitoring and facilitating the achievement of health-related Millennium Development Goals. Many studies have analysed the effects of EMRs in supporting care provision in hospitals, mostly with a focus on HIV/AIDS services. However, there are limited studies on EMR use for maternal health services in small primary care facilities in rural settings. This paper aims to address this gap by presenting findings from evaluation of two EMR systems implemented to support Antenatal care in two rural health centres in Malawi.Methods: This study was undertaken as part of an Action Research project exploring the use of EMRs in Malawi. The paper presents a qualitative analysis of the effects of EMRs on Antenatal care services in two rural health centres. Data was collected through interviewing end-users and pregnant women, participant observation of health services, and analysis of Antenatal care data.Results: The study reveals that EMRs have the effects of redistributing work and increasing collaboration among different types of health workers; increasing attention and knowledge on the health domain, and redistributing risks in care and data quality.Conclusions: The findings highlight the need for EMR system designs that support coordination of work and provide for easy correction of errors. The study also shows that introducing EMRs can facilitate learning about the healthcare domain in addition to gaining computer skills.Keywords: Antenatal care, EMR systems, evaluation, effects, rural health centres, developing countries, Malawi, qualitative research.
Anantraman, V., Mikkelsen, T., Khilnani, R., Kumar, V. S., Pentland, A. & Ohno-Machado, L. Open Source Handheld-Based EMR for Paramedics Working in Rural Areas. AMIA 2002 Annual Symposium 2002,12-16.
Ash, J. S., Berg, M. & Coiera, E. Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors. Journal of the American Medical Informatics Association, 11,2, 104-112.2004.
Berg, M. Patient care information systems and health care work: A sociotechnical approach. International Journal of Medical Informatics, 55,2, 87-101.1999.
Berg, M. Implementing information systems in health care organizations: myths and challenges. International Journal of Medical Informatics, 64,2–3, 143-156.2001.
Berg, M., Aarts, J. & van der Lei, J. ICT in Health Care: Sociotechnical Approaches. Methods Archive, 42,4, 297-301.2003.
Blaya, J. A., Fraser, H. S. F. & Holt, B. E-Health Technologies Show Promise In Developing Countries. Health Affairs, 29,2, 244-251.2010.
Boulus, N. Sociotechnical Changes Brought about by Electronic Medical Record. Americas Conference on Information Systems (AMCIS) 2009,
Car, J., Black, A., Anandan, C., Cresswell, K., Pagliari, C., Mckinstry, B., Procter, R., Majeed, A. & Sheikh, A. The Impact of eHealth on the Quality & Safety of Healthcare: A Systematic Overview & Synthesis of the Literature. Imperial College London.2008.
Castelnuovo, B., Kiragga, A., Afayo, V., Ncube, M., Orama, R., Magero, S., Okwi, P., Manabe, Y. C. & Kambugu, A. Implementation of Provider-Based Electronic Medical Records and Improvement of the Quality of Data in a Large HIV Program in Sub-Saharan Africa. PLoS ONE, 7,12, e51631.2012.
Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E., Morton, S. C. & Shekelle, P. G. Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. Annals of Internal Medicine, 144,10, 742-752.2006.
Chawani, M. S. Development of Electronic Medical Record Systems for Maternal Health Services in Rural Settings: An Action Research Study from Malawi. PhD, University of Oslo,Department of Informatics.Forthcoming.
Chawani, M. S., Kaasbøll, J., Finken, S., Herstad, J. & Malata, A. Balancing Work Practices and Protocols in the design of EMR systems. The case of developing an EMR system for Antenatal Care services in Malawi. Electronic Journal of Information Systems in Developing Countries, 63.2014.
Chetley, A. (ed.) Improving Health, Connecting People: The Role of ICTs in the Health Sector ofDeveloping Countries: InfoDev.2006.
Chi, B. H., Vwalika, B., Killam, W. P., Wamalume, C., Giganti, M. J., Mbewe, R., Stringer, E. M., Chintu, N. T., Putta, N. B., Liu, K. C., Chibwesha, C. J., Rouse, D. J. & Stringer, J. S. A. Implementation of the Zambia Electronic Perinatal Record System for comprehensive prenatal and delivery care. International Journal of Gynecology & Obstetrics, 113,2, 131-136.2011.
Clausen, C. & Yoshinaka, Y. Social shaping of technology in TA and HTA. Poiesis & Praxis, 2,2-3, 221-246.2004.
Cresswell, K. & Sheikh, A. Undertaking sociotechnical evaluations of health information technologies. Informatics in Primary Care, 21,2, 78-83.2014.
Douglas, G. Engineering an EMR System in the Developing World: Necessity is the Mother of Invention. Doctor of Philosophy PhD, University of Pittsburgh,School of Medicine.2009.
Douglas, G. P., Gadabu, O. J., Joukes, S., Mumba, S., McKay, M. V., Ben-Smith, A., Jahn, A., Schouten, E. J., Landis Lewis, Z., van Oosterhout, J. J., Allain, T. J., Zachariah, R., Berger, S. D., Harries, A. D. & Chimbwandira, F. Using Touchscreen Electronic Medical Record Systems to Support and Monitor National Scale-Up of Antiretroviral Therapy in Malawi. PLoS Med, 7,8, e1000319.2010.
Fitzpatrick, G. & Ellingsen, G. A Review of 25 Years of CSCW Research in Healthcare: Contributions, Challenges and Future Agendas. Computer Supported Cooperative Work (CSCW), 1-57.2012.
Fraser, H. S., Biondich, P., Moodley, D., Choi, S., Mamlin, B. W. & Szolovits, P. Implementing Electronic Medical Record Systems in developing countries. Informatics in Primary Care, 13.2005.
Fraser, H. S. & Blaya, J. Implementing medical information systems in developing countries, what works and what doesn’t. AMIA Annual Symposium Proceedings 2010, 232-236.
Greenhalgh, T., Potts, H. W. W., Wong, G., Bark, P. & Swinglehurst, D. Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method. Milbank Quarterly, 87,4, 729-788.2009.
Kamadjeu, R. M., Tapang, E. M. & Moluh, R. N. Designing and implementing an electronic health record system in primary care practice in sub-Saharan Africa: a case study from Cameroon. Informatics in Primary Care, 13,3, 179-186.2005.
Kaplan, B. Evaluating informatics applications—some alternative approaches: theory, social interactionism, and call for methodological pluralism. International Journal of Medical Informatics, 64,1, 39-56.2001.
Kinney, M. V., Kerber, K. J., Black, R. E., Cohen, B., Nkrumah, F., Coovadia, H., Nampala, P. M., Lawn, J. E., on behalf of the Science in Action: Saving the lives of Africa's mothers, n. & children working, g. Sub-Saharan Africa's Mothers, Newborns, and Children: Where and Why Do They Die? PLoS Medicine, 7,6, e1000294.2010.
Lewis, T., Synowiec, C., Lagomarsino, G. & Schweitzer, J. E-health in low- and middle-income countries: findings from the Center for Health Market Innovations. Bulletin of World Health Organisation, 90332-340.2012.
Lungu, F., Malata, A., Chirwa, E. & Mbendera, I. Quality assessment of focused antenatal care services in Malawi. African Journal of Midwifery and Women's Health, 5,4, 169-175.2011.
Mamlin, B. W., Biondich, P. G., Wolfe, B. A., Fraser, H., Jazayeri, D., Allen, C., Miranda, J. & Tierney, W. M. Cooking Up an Open Source EMR for Developing Countries: OpenMRS- A Recipe for Successful Collaboration. AMIA Symposium Proceedings 2006,529.
May, C., Mort, M., Williams, T., Mair, F. & Gask, L. Health technology assessment in its local contexts: studies of telehealthcare. Social Science & Medicine, 57,4, 697-710.2003.
McKay, M. V. & Douglas, G. P. Touchscreen clinical workstations at point of care: A paradigm shift in electronic medical record design for developing countries. Appropriate Healthcare Technologies for Developing Countries, 2008. AHT 2008. 5th IET Seminar on 2008, 1-8.
MOH Participants Manual in Integrated Maternal and Neonatal Care.2009.
Msukwa, M. K. B. User Perception of Electronic Medical Record System in Malawi. Master thesis, University of Malawi,College of Medicine.2011.
Ngoma, C., Kimaro, H., Igira, F., Mukulu, J., Kaasbøll, J., Yona, A., Mkabara, N., Sarikoki, S., Sangu, I., Njau, C., Mnaya, A., Mpoyo, S., Mlongakweli, Z., Mwaga, W. & Pilyimo, R. Challenges in Implementing a Computerized Name-based Information Tracking System: Practical Experiences from Maternal Health Care. IST Africa 2012.
Oluoch, T., Santas, X., Kwaro, D., Were, M., Biondich, P., Bailey, C., Abu-Hanna, A. & de Keizer, N. The effect of electronic medical record-based clinical decision support on HIV care in resource-constrained settings: A systematic review. International Journal of Medical Informatics, 81,10, e83-e92.2012.
Piette, J. D., Lun, K., Moura, L. A., Fraser, H. S., Mechael, P. N., Powell, J. & Khoja, S. R. Impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here? Bulletin of World Health Organisation, 90365-372.2012.
Rotich, J. K., Hannan, T. J., Smith, F. E., Bii, J., Odero, W. W., Vu, N., Mamlin, B. W., Mamlin, J. J., Einterz, R. M. & Tierney, W. M. Installing and Implementing a Computer-based Patient Record System in Sub-Saharan Africa: The Mosoriot Medical Record System Journal of the American Medical Informatics Association, 10,4, 9.2003.
Sharan, M., Ahmed, S., Malata, A. & Rogo, K. Quality of Maternal Health Services in Malawi: Are Health Systems Ready for MDG 5. Africa Human Development, The World Bank.2009.
Singh, A. K., Kohli, M., Trell, E., Wigertz, O. & Kohli, S. Bhorugram (India): revisited A 4 year follow-up of a computer-based information system for distributed MCH services. International Journal of Medical Informatics, 44,2, 117-125.1997.
Sood, S. P., Nwabueze, S. N., Mbarika, V. W. A., Prakash, N., Chatterjee, S., Ray, P. & Mishra, S. Electronic Medical Records: A Review Comparing the Challenges in Developed and Developing Countries. 41st Hawaii International Conference on Systems Sciences 2008,
Stoop, A. P. & Berg, M. Integrating Quantitative and Qualitative methods in Patient Care Information System Evaluation: Guidance for the Organizational Decision Maker. Methods of Information in Medicine, 42,4, 458-462.2003.
Summers, D. Department of Making Pregnancy Safer Annual Report 2008. In: Heine, M.-A. (ed.). Geneva: WHO.2009.
Thompson, A., Castle, E., Lubeck, P. & Makarfi, P. S. Experience Implementing OpenMRS to Support Maternal and Reproductive Health in Northern Nigeria. MEDINFO 2010 2010, 332-336.
Tomasi, E., Facchini, L. A. & Maia, M. d. F. S. Health Information Technology in primary health care in developing countries: a literature review. Bulletin of the World Health Organization, 82,11.2004.
Vikkelsø, S. Subtle Redistribution of Work, Attention and Risks: Electronic Patient Records and Organisational Consequences. Scandinavian Journal of Information Systems, 17,1, 3-30.2005.
Waters, E., Rafter, J., Douglas, G. P., Bwanali, M., Jazayeri, D. & Fraser, H. S. F. (eds.) Experience Implementing a Point-of-Care Electronic Medical Record System for Primary Care in Malawi.2010.
Were, M. C., Shen, C., Bwana, M., Emenyonu, N., Musinguzi, N., Nkuyahaga, F., Kembabazi, A. & Tierney, W. M. Creation and evaluation of EMR-based paper clinical summaries to support HIV-care in Uganda, Africa. International Journal of Medical Informatics, 79,2, 90-96.2010.
WHO Electronic Health Records: Manual for Developing Countries. In: Office, W. P. R. (ed.). Manila.2006.
WHO Management of patient information: trends and challenges in Member States: based on the findings of the second global survey on eHealth. Global Observatory for eHealth series Switzerland.2012.
Yusof, M. M., Kuljis, J., Papazafeiropoulou, A. & Stergioulas, L. K. An evaluation framework for Health Information Systems: human, organization and technology-fit factors (HOT-fit). International Journal of Medical Informatics, 77,6, 386-398.2008.