International Journal of Medical Informatics 60 (2000) 21 – 28

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The Mosoriot medical record system: design and initial implementation of an outpatient electronic record system in rural Kenya
Terry J. Hannana, Joseph K. Rotichb,c,e, Wilson W. Oderob,c,e, Diana Menyae, Fabian Esamaie, Robert M. Einterzc, John Sidlec,e, Joy Sidlec, Faye Smithb, William M. Tierneyb,c,d,*
a St. George Pri6ate Hospital, Kogarah, NSW, Australia Regenstrief Institute for Health Care, Indianapolis, IN, USA c Department of Medicine, Indiana Uni6ersity School of Medicine, Indianapolis, IN, USA d Roudebush VA Medical Center (11H), 1481 West Tenth Street, Indianapolis, IN 46202, USA e Moi Uni6ersity Faculty for the Health Sciences, Eldoret, Kenya b

Received 16 March 2000; received in revised form 10 May 2000; accepted 15 May 2000

Abstract Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Kenya in sub-Saharan Africa. The region is characterised by widespread poverty and a very poor technology infrastructure. Many houses do not have electricity, telephones or tap water. The health center does have electricity and tap water. In a collaborative project between Indiana University and the Moi University Faculty of Health Sciences (MUFHS), we designed a core electronic medical record system within the Mosoriot Health Center, with the intention of improving the quality of health data collection and, subsequently, patient care. The electronic medical record system will also be used to link clinical data from the health center to information collected from the public health surveys performed by medical students participating in the public health research programs of Moi University. This paper describes the processes involved in the development of the computer-based Mosoriot medical record system (MMRS) up to the point of implementation. It particularly focuses on the decisions and trade-offs that must be made when introducing this technology into an established health care system in a developing country. © 2000 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Computer information systems; International health; Public health

* Corresponding author. Tel.: + 1-317-5540000, ext. 5057; fax: +1-419-7937256. E-mail address: wtierney@iupui.edu (W.M. Tierney).

1386-5056/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S1386-5056(00)00068-X

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1. Introduction The Indiana University and the Moi University Faculty of Health Sciences (IUMUFHS) collaboration began in 1989 with the purpose of improving the public health of Kenyans by enhancing medical education and public health research, the latter through a program called community-based education and service (COBES) [1,2]. The ultimate goal of this collaboration is to influence the development of health care leadership in Kenya and the US. Critical elements of this collaboration include the exchange of ideas and manpower, not the transfer of money and technology. All programs introduced as part of this collaboration must become self-sustaining by the Kenyan community.

2. Description of the Mosoriot Health Center The health center is situated in a rural area : 25 km (15 miles) from Eldoret. It provides free medical support for antenatal care, children B 5 years and family planning. Patients are charged small fees (15 Kenyan shillings each = : US$0.20) for visits to adult medicine, child care for children \ 5 years of age and selected services, such as very basic X-ray and clinical laboratory facilities. Patients are also charged 15 shillings for each drug dispensed from the Mosoriot pharmacy that contains moderate quantities of a small number of drugs, mostly anti-infectives. The pharmacy fee must be paid prior to receiving the treatment. Patients unable to pay are referred to an outside chemist (pharmacist) where they may or may not receive the service. The only central record of treatments given is kept in the financial office. Therefore, no records of treatments are kept for patients who cannot pay for treatments and patients who get the treatments free (i.e. pregnant

women, children B 5 years of age and patients visiting the family planning clinic). There is no other record of the costs of care or resource utilization. The health center is the sole health care provider for a surrounding population of 30– 40 000 people; it provides care during : 40 000 clinic visits per year. Most of the population live in small villages with mudwalled houses and thatched roofs. There is generally no running water, electricity or telephones. On arrival at the health center, each patient is currently registered by recording his or her name in a registration book, along with a visit number, which is the sequential number of that visit for that year. This number is reset to one at the beginning of each year. There is no unique patient identifier comparable to the social security number in the US. After registration, patients are triaged by the medical records clerk who directs them to the appropriate clinic. In each clinic within the health center, the patient is re-registered in a separate book, again recording the name, visit number, complaint and diagnosis. The same information is also recorded in a small booklet that each patient (adult and child) must purchase and replace annually. This book is the main ‘permanent’ longitudinal medical record, the source where the health care providers seek information about prior visits. Inherent in this process of care is the constant re-entering of patient record numbers, complaints and diagnoses, much of which is illegible and with significant transcription errors. Currently the medical record department stores the records representing 10 years of patient visits that fit into an area equivalent to two or three standard suitcases. The Mosoriot Health Center is predominantly an outpatient facility. More critically ill patients are either admitted to a small,

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20-bed inpatient unit at the Mosoriot Health Center or referred to Eldoret Teaching and Referral Hospital or another district hospital. The Mosoriot Health Center is required to produce regular reports to the Kenyan Ministry of Health on the health center’s activities. These monthly, quarterly and yearly reports contain counts of selected reportable conditions, such as malaria, seen by the various clinics. Again, because there are no unique patient identifiers, these are reports of visits and not individual patients. Counts of individual patients cannot be obtained from these data.

3. Designing the Mosoriot medical record system (MMRS) In February and October 1998, and again in January of 2000, members of the project team from the US (RME, JS, WMT), Australia (TJH) and Kenya (JKR, WWO, DM) visited the Mosoriot Health Center. They met with the Health Officer, the matron (head nurse), director of medical records, nurses and staff in all offices and clinics. They directly reviewed the administrative and clinical activities of all aspects of the health center along with the health center’s reporting requirements. These visits helped define the clinical and administrative core data requirements for the health center and provided guidelines as to how the basic record model should look. They also provided the needed guidance to develop the data dictionary. We desired to be as unobtrusive as possible in order to force the minimum number of changes on the flow of patients and the tasks of the Mosoriot staff. The project team therefore decided to base the entire MMRS in a single computer located in the registration office. Because each clinic records data for each patient and the patients move from the

registration office to the clinics, then back to the registration office, and finally to the financial office, the model that seemed to fit the best was to develop an ‘encounter form’ that the patient will be given at the time of registration and then carry to each care site (clinic, laboratory, X-ray etc.). At the end of the visit, the patient using the new encounter form will return to the registration office where selected data from the form will be entered into the MMRS. The encounter form will then be given to the patient in lieu of recording information in his or her personal health booklet (described above). These visits to the Mosoriot Health Center were critical for establishing a rapport with the health center’s staff and enlisting their support. At the same time, directors of the COBES program at Moi University were involved in supporting the MMRS project as the data collected in the health center from the patient care process could then be linked to the public health data (e.g. description of households, risk factors for selected infectious diseases) that are collected by medical students during their household interviews.

4. Overcoming barriers to establishing an electronic medical record system None of the staff at the health center have prior experience with storing information in, or retrieving information from, computers or other electronic systems. It is essential that any system designed to meet the health center’s needs be simple in construct, easy to use by the health center and its support staff, and easy to maintain and modify once the initial development and implementation has occurred. The first barrier to overcome is electrical power. Although the Mosoriot Health Center

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is on the local electrical grid, there are frequent power interruptions and voltage fluctuations. Therefore, secondary power sources (uninterruptible power sources and a small generator) and surge protectors are critical to the survival and ongoing use of the computer hardware supporting the MMRS. The second barrier to establishing the MMRS is familiarity with computers. MUFHS has substantial computer resources for the developing world, including student and faculty computer laboratories. The Dean of the MUFHS allocated two microcomputers to be placed at Mosoriot for training. Training of the Mosoriot staff (mostly the registration clerks who will mainly be using the MMRS) will be performed by members of the Indiana University faculty and Moi University medical students who are trained to be computer ‘super-users’. The third barrier to establishing the MMRS is the lack of a unique patient identifier. Kenyan society has no national number such as the social security number in the US. Therefore, we had to decide, based on the knowledge of our Kenyan colleagues of Kenyan society and culture, which set of variables would most parsimoniously uniquely identify each patient. After long discussion, we decided to include the following fields in the registration process to assign a MMRS record number (with check digit) to each patient: the patient’s first name (usually English), middle name (usually Swahili) and last name (usually of African origin); the patient’s birth date; the patient’s mother’s first name; and the patient’s home village. (Although in many cases Kenyan adults do not know their exact date of birth, such a date is required on a national identity card they must obtain when they become 18 years of age. Therefore, they pick a birthdate which, even if not exact, is consistently held by the patient.) These same fields will be

collected by the COBES surveys so that the public health data collected therein can be linked to clinical care delivered at the Mosoriot Health Center. The fourth and greatest hurdle to establishing a functioning electronic medical record system is making the transition from paper to the electronic medium. The Mosoriot Health Center currently has no facilities for electronic data capture; instead, as described above it has a redundant system where the same few pieces of information are collected and recorded on paper at multiple clinics. Therefore, the system for data acquisition must be simple. Electronic data entry must occur only once and the system must encourage accuracy. The foundation of each successful electronic medical record system is an effective data dictionary [3]. It must reflect both the clinical realities of the care delivered and serve the administrative and reporting needs of the providers. A sample of the core data dictionary for the MMRS is shown in Fig. 1. It was built for the MMRS by the authors in face-to-face meetings in Kenya over a 3-day time frame utilizing the experience of two authors (WMT, TJH) who have worked on larger electronic medical record systems in the US and Australia [4,5]. The resultant dictionary contains records for selected data elements that are currently recorded in the health center, with a heavy emphasis on those required for reporting to the Kenyan Ministry of Health. We have also entered clinical diagnoses from all records to the adult medicine clinic for November 1999, in order to further populate the data dictionary with records for clinical diagnostic terms. The fields in the data dictionary include term number, term name, term type, term system (e.g. body system, such as cardiology or gastroenterology, or clinical system, such as laboratory or radiology), term description, International Classification of Dis-

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eases, Version 10, code and item cost (if relevant). The other two tables in this relational database system are the registration table, containing one record per patient (its fields being the unique identifiers described above along with the registration date), and the visit table, containing one record per visit (its fields include the patient identifier; the date and time of check-in; the clinic(s) visited; ancillary services provided, such as laboratory, radiology and pharmacy; charges for the above services and/or items; the amount paid; and the time of check-out). Accurate entry of clinical data is critical to an electronic medical record system such as that being created at Mosoriot. Paper-based encounter forms can serve as data templates for capturing and entering these data. Even in places with sophisticated electronic medical record systems, such encounter forms are often used [3 – 6]. Such an encounter form could also help bridge the gap between paper

and electronic media for nurses and staff who might be fearful that the computer would radically change their jobs or, worse, replace them. The Mosoriot encounter form described above has been drafted (Fig. 2) and will be printed on folded cards that, once used to enter data into the MMRS, will be given to the patient in lieu of writing information into his or her personal health care booklet. In order to gradually move towards the electronic patient record, this encounter form will be used for capturing data 3–6 months prior to installing the MMRS. Data from these forms will be back-entered into the system which will not only populate the MMRS with useful data at its start but will also allow pilot testing of the data entry screens and procedures. The data will be back-entered by the same clerks who will eventually be entering the data prospectively. In this way, we can train them to enter data from the encounter forms and set into mo-

Fig. 1. Data dictionary for the Mosoriot medical record system.

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Fig. 2. Proposed encounter form for collecting clinical data during patient visits to the Mosoriot Health Center.

tion the checks for transcription accuracy. The data dictionaries and encounter form have been integrated into the core electronic medical record system by two of the authors (JKR and FS) at Indiana University using the commercial software Microsoft Access®.

3.

4. 5. System security and functionality As part of the implementation process, the MMRS must contain adequate security to the data and patient information yet fit within the cost restraints of the Mosoriot Health Center. Initially, the program will run on a single standalone microcomputer. It is envisioned that security will be as follows: 1. Access to the system for all personnel — developers and users — will be by userdefined passwords. 2. System security will vary by task and be assigned only to those users who require access to each part of the system, e.g.

5.

6.

clinical data entry, dictionary maintenance, program development, etc. Backup of data will be password protected and performed daily to a Zip drive. (US$200 plus US$25 per 250 megabyte capacity disk). Weekly backup of the system and data will be password protected on a writable CD-ROM. (US$250 plus 600 megabyte capacity disks at two for US$25). This will be stored off site in a secure location at MUFHS. An uninterruptible power source (UPS) apparatus and alternative power source (i.e. a small generator) will provide adequate power. Surge protectors will be used on all electrical connections. All copies of the completed encounter forms will be retained initially as a paper backup to the electronic record during the 3–6 month period when the encounter forms are used prior to installation of the MMRS.

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7. During the above 3–6 month period, patients will have information written in their booklets, as is the current practice for the health center. When the MMRS ‘goes live’ and data entry is in real time, the encounter forms will be given to the patients for permanent keeping in order to replace the booklets. Each patient will be given a small manila envelope in which to carry the encounter forms. 8. Each patient will have a unique identifier of six numbers with a check digit that will be recorded within the record and, in the future, on the encounter form as a bar code. This MMRS registration number and its bar code will also be written on a label that will be placed on the front of the patient’s encounter form envelope. The bar code will increase the speed and decrease errors of data entry. 9. Using MMRS data for research that is beyond the usual functions of the Mosoriot Health Center (e.g. linking clinical outcomes data with the COBES data collected during household interviews) will require authorization by the Moi University’s Ethics Committee (its version of the NIH Institutional Review Board that must approve all research) in order to protect patient confidentiality and assure the appropriate use of these data.

Records of the health center) to collect clinical data prior to installing the record system.

7. Conclusions and insights Critical to the success of the MMRS project is the initial and ongoing involvement of the clinical and academic stakeholders in the system at all levels. They have been associated with the design planning, software development and plans for the future evolution of this electronic medical record system. The patients remain closely involved in the use of their medical information by retaining their accessibility to the individual paper records. Experience with installing electronic medical record systems in the US [4] and Australia [5] have allowed the authors fit a model system to the Mosoriot Health Center that is likely to be successful and yet serve the clinical and research missions of both the Mosoriot Health Center and Moi University. This experience has led to the rapid development of the registration system, data dictionary, visit database and encounter forms likely to be clinically useful in the near term, while undergirding an electronic medical record system capable of evolving as the local clinical and research needs change. Similar outcomes have been seen with the IAIMS projects, although at levels of magnitude of greater sophistication [6]. The MMRS experience reflects the similarities rather than dissimilarities between diverse electronic patient record systems. In an economically and technologically deprived society, any developments in clinical information management must meet the local needs and be sustainable by local resources. Applying a ‘big bucks’ approach would not be sustainable by Kenyans once external funding ends, as it always does. Initially, the entire MMRS will require only a single se-

6. Time frame for implementation Having established the model for the MMRS, it is envisioned that the time frame for development will be 6 months and on-site implementation as a working computer-based medical record at Mosoriot will take an additional 3 – 4 months. As stated above, during the 6-month development period, the encounter form will be used (once approved by the Medical Officer and Director of Medical

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cure microcomputer, printer, uninterruptible power source and affordable data security systems such as bar codes, Zip drives and CD-ROMs. The 12-year-old Indiana University–Moi University collaboration and its 5-year NIHfunded medical informatics fellowship program will lead to the institutional independence of both the Mosoriot Health Center and Moi University. This fulfills one of the aims of the Indiana–Moi University collaboration, as embodied in a maxim that is common to both Kenya and the US societies: ‘‘Give a man a fish, and you feed him for a day. Teach him to fish, and you feed him for a lifetime.’’ The facilities for system maintenance and development must reside among the Kenyan faculty (initially with JKR, director of this project in Kenya). Hence, new developments and individualization of the system to meet the clinical and research needs of the Mosoriot Health Center and Moi University can occur when required. The history of system development for electronic medical records and other types of clinical information systems are sometimes characterized by poor software support and very little adaptability to an institution’s individual needs [7]. Such errors must be avoided if the MMRS and the clinical and research enterprises which it serves, are to survive and grow.

Moi University Faculty for the Health Sciences for their support of this project and the Regenstrief-Moi Medical Informatics Fellowship. We also thank the managers of the Indiana University-Moi University collaboration for their logistic and intellectual support of this project. This work was supported by grant number 1-D43-TW01082 from the National Institutes of Health through the Fogarty International Center. The opinions are solely those of the authors and do not necessarily represent the opinions of the NIH or the authors’ home institutions.

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Acknowledgements The authors wish to thank Mr Kimitei, the Clinical Officer in Charge, and the staff of Mosoriot Health Center and members of the

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