The impact of EMRs in resource-limited settings has not been well-demonstrated. Most EMRs implementations are primarily used for gathering information for generating reports to various institutional stakeholders. This is unfortunate, because these systems can potentially play a significant role in improving patient-care in these resource-constrained settings. In this paper, we demonstrate that even in settings where providers have almost no direct interaction with the computer, it is possible to provide well-organized, relevant, and up-to-date EMR-based clinical information to assist in patient care. In a resource-poor setting in Uganda, an EMR generating clinical summaries improved the efficiency of care for PCPs, allowing them to spend more time directly interacting with and examining the patient. The presence of clinical summaries for providers was also associated with shorter visits for patients. Providers expressed very positive opinion about clinical summaries, and felt that it improved quality of care and reduces mistakes.
To implement EMR-based clinical summaries and decision support tools, systems must be designed with special sensitivity to the workflow, and the resources available.[11
] Further, developers of clinical summaries must be in constant contact with the providers (to understand their needs), and with staff responsible for developing or modifying encounter forms and updating concept dictionary terms for the specific implementation. These steps will ensure that summaries generate are relevant to care, and that the correct data-elements are extracted from the information stored in the EMRs.
The clinical summary can also be used to improve the quality of data stored in the EMRs. Through the summaries, deficiencies in data-quality can be recognized – for example, it is easy to tell that when only two ARVs are displayed on a summary, this is likely a mistake as patients should be on triple-therapy. By identifying the source of an error – whether in the capture or entering of data, the error can be corrected and the quality of EMR data improved.
At the HIV clinic we studied, providers have been asking for more elements to be incorporated into the summaries once they realized their usefulness. For example, they want the dates ARVs were first prescribed to be included in the summary. In response to these requests, we are modifying the clinical summary module to enable it to scale easily along several dimensions, namely: (a) to easily produce different kinds of summaries (e.g. for TB or antenatal care); (b) to more easily add new elements to existing summaries (e.g. SGPT); and (c) to create more complex derived concepts (such as “never on ARVs”) which require integration of several concept terms. Maintaining dictionaries and derived concepts is quite challenging but is key to interoperability and thus needs to be critically addressed, especially in these resource-limited settings.[12
Several limitations in our study deserve mention. The before-and-after design may introduce bias. Observing the providers and patients may have changed their behavior (Hawthorne effect). Observations for the clinicians were not randomly selected, and the number of providers and clinics studied was small, thus limiting the generalizability of the results. The survey results may not have been representative of the whole group, and paper-based clinical summaries could have an uncertain role in clinics where providers interact directly with the computer or have no electronic records. Our study also did not account for seasonal changes, and the time duration between the two phases of the study was almost a year.
Through this study, we were able to demonstrate the impact of implementing EMR-based clinical summaries to support HIV-care at an HIV clinic in Uganda. Our findings add to the growing body of evidence on the impact of EMRs in developing countries [5
]. Functionality to generate clinical summaries, both at the level of the individual patient and at the patient cohort level, should be considered essential in any EMRs implementation in these resource-limited settings. We have made the clinical summary module available to the wider OpenMRS community, and this should enable this functionality to be rolled out to other sites. Future evaluations will assess the impact of the clinical summaries and reminders on patient outcomes. We also intend to conduct cost-benefit analyses of these systems.