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Cited by 116Electronic Health Records SystemsTechnology and Human Factors in Education and HealthMedical Coding and Health Information

Implementing an Open Source Electronic Health Record System in Kenyan Health Care Facilities: Case Study

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Muinga, Naomi, Magare, Steve, Monda, Jonathan, Kamau, Onesmus, Houston, Stuart, Fraser, Hamish, Powell, John, English, Mike +1 more·2018·JMIR Medical Informatics
DOI 10.2196/medinform.8403PMC PMC5932328

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Abstract

BACKGROUND: The Kenyan government, working with international partners and local organizations, has developed an eHealth strategy, specified standards, and guidelines for electronic health record adoption in public hospitals and implemented two major health information technology projects: District Health Information Software Version 2, for collating national health care indicators and a rollout of the KenyaEMR and International Quality Care Health Management Information Systems, for managing 600 HIV clinics across the country. Following these projects, a modified version of the Open Medical Record System electronic health record was specified and developed to fulfill the clinical and administrative requirements of health care facilities operated by devolved counties in Kenya and to automate the process of collating health care indicators and entering them into the District Health Information Software Version 2 system. OBJECTIVE: We aimed to present a descriptive case study of the implementation of an open source electronic health record system in public health care facilities in Kenya. METHODS: We conducted a landscape review of existing literature concerning eHealth policies and electronic health record development in Kenya. Following initial discussions with the Ministry of Health, the World Health Organization, and implementing partners, we conducted a series of visits to implementing sites to conduct semistructured individual interviews and group discussions with stakeholders to produce a historical case study of the implementation. RESULTS: This case study describes how consultants based in Kenya, working with developers in India and project stakeholders, implemented the new system into several public hospitals in a county in rural Kenya. The implementation process included upgrading the hospital information technology infrastructure, training users, and attempting to garner administrative and clinical buy-in for adoption of the system. The initial deployment was ultimately scaled back due to a complex mix of sociotechnical and administrative issues. Learning from these early challenges, the system is now being redesigned and prepared for deployment in 6 new counties across Kenya. CONCLUSIONS: Implementing electronic health record systems is a challenging process in high-income settings. In low-income settings, such as Kenya, open source software may offer some respite from the high costs of software licensing, but the familiar challenges of clinical and administration buy-in, the need to adequately train users, and the need for the provision of ongoing technical support are common across the North-South divide. Strategies such as creating local support teams, using local development resources, ensuring end user buy-in, and rolling out in smaller facilities before larger hospitals are being incorporated into the project. These are positive developments to help maintain momentum as the project continues. Further integration with existing open source communities could help ongoing development and implementations of the project. We hope this case study will provide some lessons and guidance for other challenging implementations of electronic health record systems as they continue across Africa.

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  • Countries like Kenya, Uganda, Nigeria, and Mozambique now run nationally endorsed EHR systems that are deployed in hundreds to thousands of public health facilities across each country.

    “Countries like Kenya, Uganda, Nigeria, and Mozambique now run nationally endorsed EHR systems that are deployed in hundreds to thousands of public health facilities across each country [4-7].”

    From mUzima Mobile Electronic Health Record (EHR) System: Development and Implementation at Scale (2021) · cites this paper as [4]

    The Introduction’s Government eHealth Policy, Projects, and Guidance section reports that KenyaEMR was implemented in over 300 Kenyan facilities and designed to meet national EMR guidelines. It also describes a Ministry of Health–backed EHR project for public facilities, but does not establish that the over-300 KenyaEMR sites were all public facilities or explicitly call KenyaEMR nationally endorsed. This paper addresses the Kenya portion of the multi-citation sentence, not the claims about the other countries. (LLM, conf=0.86)

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  • Several LMICs have gone beyond initial pilot EHR system implementations to large-scale rollout of these systems in government-run public facilities.

    “Several LMICs have gone beyond initial pilot EHR system implementations to large-scale rollout of these systems in government-run public facilities.”

    From mUzima Mobile Electronic Health Record (EHR) System: Development and Implementation at Scale (2021) · cites this paper as [4]

    The Results (‘Way Forward’; page not provided) report rollout of the EHR to more than 70 health centers across five Kenyan counties, supporting rollout beyond the initial implementation in public facilities. The paper describes Kenya, however, and does not establish that several LMICs have made this transition. (LLM, conf=0.86)

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Research works printed but not linked: 34

  1. [1]Fraser HS Biondich P Moodley D Choi S Mamlin BW Szolovits P Implementing electronic medical record systems in developing countries Inform Prim Care 2005 13 2 83 95 15992493 15992493
  2. [2]Fraser HS Blaya J Implementing medical information systems in developing countries, what works and what doesn't AMIA Annu Symp Proc 2010 2010 232 6 21346975 21346975 PMC3041413
  3. [3]Bates DW Cohen M Leape LL Overhage JM Shabot MM Sheridan T Reducing the frequency of errors in medicine using information technology J Am Med Inform Assoc 2001 8 4 299 308 11418536 11418536 PMC130074
  4. [4]English M Irimu G Agweyu A Gathara D Oliwa J Ayieko P Were F Paton C Tunis S Forrest CB Building learning health systems to accelerate research and improve outcomes of clinical care in low- and middle-income countries PLoS Med 2016 04 13 4 e1001991 10.1371/journal.pmed.1001991 27070913 PMEDICINE-D-15-01349 27070913 PMC4829240 · DOI
  5. [5]Friedman CP Wong AK Blumenthal D Achieving a nationwide learning health system Sci Transl Med 2010 11 10 2 57 57cm29 10.1126/scitranslmed.3001456 21068440 2/57/57cm29 21068440 · DOI · Paper page
  6. [6]Greene SM Reid RJ Larson EB Implementing the learning health system: from concept to action Ann Intern Med 2012 08 07 157 3 207 10 10.7326/0003-4819-157-3-201208070-00012 22868839 1305510 22868839 · DOI
  7. [7]Blumenthal D Launching HITECH N Engl J Med 2010 02 4 362 5 382 5 10.1056/NEJMp0912825 20042745 NEJMp0912825 20042745 · DOI
  8. [8]Jha AK Meaningful use of electronic health records: the road ahead J Am Med Assoc 2010 10 20 304 15 1709 10 10.1001/jama.2010.1497 20959581 304/15/1709 20959581 · DOI
  9. [9]Azubuike MC Ehiri JE Health information systems in developing countries: benefits, problems, and prospects J R Soc Promot Health 1999 09 119 3 180 4 10518358 10518358
  10. [10]Allen C Jazayeri D Miranda J Biondich PG Mamlin BW Wolfe BA Seebregts C Lesh N Tierney WM Fraser HS Experience in implementing the OpenMRS medical record system to support HIV treatment in Rwanda Stud Health Technol Inform 2007 129 Pt 1 382 6 17911744 17911744
  11. [12]Oluoch T Katana A Kwaro D Santas X Langat P Mwalili S Muthusi K Okeyo N Ojwang J Cornet R Abu-Hanna A de Keizer N Effect of a clinical decision support system on early action on immunological treatment failure in patients with HIV in Kenya: a cluster randomised controlled trial Lancet HIV 2016 02 3 2 e76 84 10.1016/S2352-3018(15)00242-8 26847229 S2352-3018(15)00242-8 26847229 PMC4777604 · DOI
  12. [13]Siedner MJ Santorino D Lankowski AJ Kanyesigye M Bwana MB Haberer JE Bangsberg DR A combination SMS and transportation reimbursement intervention to improve HIV care following abnormal CD4 test results in rural Uganda: a prospective observational cohort study BMC Med 2015 07 06 13 160 160 10.1186/s12916-015-0397-1 26149722 10.1186/s12916-015-0397-1 26149722 PMC4494725 · DOI
  13. [14]Were MC Nyandiko WM Huang KT Slaven JE Shen C Tierney WM Vreeman RC Computer-generated reminders and quality of pediatric HIV care in a resource-limited setting Pediatrics 2013 03 131 3 e789 96 10.1542/peds.2012-2072 23439898 peds.2012-2072 23439898 PMC4535055 · DOI · Paper page
  14. [16]Ministry of Medical Services Guidelines, Standards and Policies Portal 2011 12 01 2018-03-20 Ministry of Public Health and Sanitation Report on the review of EMR systems towards standardization http://guidelines.health.go.ke/#/category/15/124/meta
  15. [18]Kang'a S Puttkammer N Wanyee S Kimanga D Madrano J Muthee V Odawo P Sharma A Oluoch T Robinson K Kwach J Lober WB A national standards-based assessment on functionality of electronic medical records systems used in Kenyan public-Sector health facilities Int J Med Inform 2017 01 97 68 75 10.1016/j.ijmedinf.2016.09.013 27919397 S1386-5056(16)30206-4 27919397 · DOI
  16. [20]Manya A Braa J Øverland LH Nzioka C National roll out of District Health Information Software (DHIS 2) in Kenya, 2011 central server and cloud based infrastructure IST-Africa 2012 Conference Proceedings May 9-11, 2012 Tanzania
  17. [22]Manya A Nielsen P The use of social learning systems in implementing a web-based routine health information system in Kenya 13th International Conference on Social Implications of Computers in Developing Countries May 20-22, 2015 Negombo, Sri Lanka 552 60
  18. [24]Mamlin BW Biondich PG Wolfe BA Fraser H Jazayeri D Allen C Miranda J Tierney WM Cooking up an open source EMR for developing countries: OpenMRS - a recipe for successful collaboration AMIA Annu Symp Proc 2006 529 33 17238397 86578 17238397 PMC1839638
  19. [32]Hannan TJ Rotich JK Odero WW Menya D Esamai F Einterz RM Sidle J Sidle J Smith F Tierney WM The Mosoriot medical record system: design and initial implementation of an outpatient electronic record system in rural Kenya Int J Med Inform 2000 10 60 1 21 8 10.1016/S1386-5056(00)00068-X 10974639 · DOI
  20. [33]Hannan TJ Tierney WM Rotich JK Odero WW Smith F Mamlin JJ Einterz RM The MOSORIOT medical record system (MMRS) phase I to phase II implementation: an outpatient computer-based medical record system in rural Kenya Stud Health Technol Inform 2001 84 Pt 1 619 22 11604811 11604811
  21. [34]Paré G Raymond L de Guinea A O Poba-Nzaou P Trudel M Marsan J Micheneau T Barriers to organizational adoption of EMR systems in family physician practices: a mixed-methods study in Canada Int J Med Inform 2014 08 83 8 548 58 10.1016/j.ijmedinf.2014.06.003 24969270 S1386-5056(14)00104-X 24969270 · DOI
  22. [35]Scholl J Syed-Abdul S Ahmed LA A case study of an EMR system at a large hospital in India: challenges and strategies for successful adoption J Biomed Inform 2011 12 44 6 958 67 10.1016/j.jbi.2011.07.008 21846508 S1532-0464(11)00126-2 21846508 · DOI
  23. [36]Waller A Franklin V Pagliari C Greene S Participatory design of a text message scheduling system to support young people with diabetes Health Informatics J 2006 12 12 4 304 18 10.1177/1460458206070023 17093001 12/4/304 17093001 · DOI
  24. [37]Boonstra A Boddy D Bell S Stakeholder management in IOS projects: analysis of an attempt to implement an electronic patient file Eur J Inf Syst 2008 17 2 100 11 10.1057/ejis.2008.2 · DOI
  25. [38]Gothelf J Seiden J Eric R Lean UX: Applying Lean Principles to Improve User Experience 2013 California O'Reilly Media
  26. [41]Tierney WM Achieng M Baker E Bell A Biondich P Braitstein P Kayiwa D Kimaiyo S Mamlin B McKown B Musinguzi N Nyandiko W Rotich J Sidle J Siika A Were M Wolfe B Wools-Kaloustian K Yeung A Yiannoutsos C Tanzania-Uganda Openmrs Consortium Experience implementing electronic health records in three East African countries Stud Health Technol 2010 160 Pt 1 371 5 20841711 20841711
  27. [42]Forster M Bailey C Brinkhof MW Graber C Boulle A Spohr M Balestre E May M Keiser O Jahn A Egger M ART-LINC collaboration of International Epidemiological Databases to Evaluate AIDS Electronic medical record systems, data quality and loss to follow-up: survey of antiretroviral therapy programmes in resource-limited settings Bull World Health Organ 2008 12 86 12 939 47 19142294 S0042-96862008001200011 19142294 PMC2649575
  28. [43]Greiver M Barnsley J Aliarzadeh B Krueger P Moineddin R Butt DA Dolabchian E Jaakkimainen L Keshavjee K White D Kaplan D North Toronto Research Network (NorTReN) Using a data entry clerk to improve data quality in primary care electronic medical records: a pilot study Inform Prim Care 2011 19 4 241 50 22828579 819 22828579
  29. [44]Mwakyusa S Wamae A Wasunna A Were F Esamai F Ogutu B Muriithi A Peshu N English M Implementation of a structured paediatric admission record for district hospitals in Kenya--results of a pilot study BMC Int Health Hum Rights 2006 07 20 6 9 10.1186/1472-698X-6-9 16857044 1472-698X-6-9 16857044 PMC1555611 · DOI
  30. [45]Tuti T Bitok M Malla L Paton C Muinga N Gathara D Gachau S Mbevi G Nyachiro W Ogero M Julius T Irimu G English M Improving documentation of clinical care within a clinical information network: an essential initial step in efforts to understand and improve care in Kenyan hospitals Br Med J Glob Health 2016 1 1 e000028 10.1136/bmjgh-2016-000028 27398232 PMC4934599 27398232 · DOI
  31. [47]Wenger E McDermott R Snyder WM Cultivating Communities of Practice: A Guide to Managing Knowledge 2002 Boston Harvard Business Review Press 304
  32. [48]Kruse CS Kothman K Anerobi K Abanaka L Adoption factors of the electronic health record: a systematic review JMIR Med Inform 2016 4 2 e19 10.2196/medinform.5525 27251559 v4i2e19 27251559 PMC4909978 · DOI
  33. [50]Surana S Patra R Nedevschi S Brewer E Deploying a rural wireless telemedicine system: experiences in sustainability IEEE Comput Soc 2008 06 41 6 48 56 10.1109/MC.2008.184 · DOI
  34. [51]Seymour RP Tang A DeRiggi J Munyaburanga C Cuckovitch R Nyirishema P Fraser HS Training software developers for electronic medical records in Rwanda Stud Health Technol Inform 2010 160 Pt 1 585 9 20841754 20841754

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Authors
Muinga, N., Magare, S., Monda, J., Kamau, O., Houston, S., Fraser, H., Powell, J., English, M., & Paton, C.
Affiliations
  • Kenya Medical Research Institute (KE)
  • Ministry of Health (KE)
  • Brown University (US)
  • University of Oxford (GB)
Corresponding author
Muinga, Naomi
ORCID
Venue
JMIR Medical Informatics
Publisher
JMIR Publications Inc.
Published
2018-04-18
Volume
6
Issue
2
Pages
e22
ISSN
2291-9694 (ISSN-L)
DOI
10.2196/medinform.8403
PMC
PMC5932328
OpenAlex
W2802355308
Cited by
116
References
2
Citations by year
2026: 9 · 2025: 10 · 2024: 11 · 2023: 10 · 2022: 11 · 2021: 51 · 2020: 7 · 2019: 4 · 2018: 1 · 2017: 1
FWCI
19.86
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JMIR Medical Informatics (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Funders
  • Wellcome Trust (076827, 097170, 092654)
  • National Institute for Health and Care Research (PDA/02/06/096)
  • Medical Research Council (MR/N005600/1)
  • National Institute of General Medical Sciences (U54GM115677)
Topics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Technology and Human Factors in Education and Health
  • Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
Keywords
electronic health records, open source software, health information technology implementation, Kenya, public hospitals, eHealth policy, user training, technical support, health care indicators, HIV clinics, low-income settings, North-South divide, rural health care, health information systems, software licensing costs

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