COMPUTERIZED HEALTH RECORDS MANAGEMENT SYSTEM CASE STUDY KITAGATA HOSPITAL

BY

NABIMARA CHARLES Reg. No. 2005/PGD18/514U BLIS (MAK) Email: abimaracharles@yahoo.co.uk; Tel.: +256772618296

A Project Report Submitted to the School of Graduate Studies in Partial Fulllment of the Requirements for the award of the Postgraduate Diploma in Information Technology of Makerere University

Option: Information Technology

January, 2007

Declaration
I Nabimara Charles do hereby declare that this Project Report is original and has not been published and / or submitted for any other diploma / degree award to any other University before. Signed.............................................................. Date.............................................. Nabimara Charles BLIS (MAK)

Approval
This Project Report has been submitted for Examination with the approval of the following supervisor. Signed:................................................... Date:............................................... Emily Bagarukayo BSc (Comp. Sc), MSc (Comp.Sc) Department of Information Systems Facult of Computing and Information Technology

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Dedication
To my Family: My dear wife Dativah, Children: Austine, Angela and Audrey, who have greatly missed my company during this whole period while pursuing this study.

Good things in life are not easily accomplished, but when accomplished, they will always be reckoned for many generations to come.

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Acknowledgments
Success in life is never attained single handedly. It is on this note that I express my heartfelt gratitude to God for the strength and wisdom; and to various people who have assisted me in various ways to accomplish this project. My sincere appreciation goes to Makerere University Faculty of Computing and Information Technology sta, more especially so to my supervisor, Emily Bagarukayo, without whose help this work would not be as it appears. Last but not least, I acknowledge all my friends and classmates on the Information Technology post-graduate program for having made my academic and social life comfortable at Makerere University.

MAY GOD BLESS YOU ABUNDANTLY

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Contents

1 INTRODUCTION 1.1 1.2 1.3 Background to the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Statement of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3.1 1.3.2 1.4 1.5 Scope General Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specic Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 1 2 2 2 2 3 3 5 5 5 5 6 7 7 8 8 9 10 11

Signicance of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 Literature Review 2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.1 2.1.2 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Records Management . . . . . . . . . . . . . . . . . . . . . . . . . . . Information System . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Steps in developing a Health Management Information System . . . . . . . . Keys to Successfully Adopting Electronic Health Records (EHR) . . . . . . . Push for Medical Record Computerization . . . . . . . . . . . . . . . . . . . The Role of IT in Improving Health care Delivery . . . . . . . . . . . . . . . Data Overload and out dated Technology . . . . . . . . . . . . . . . . . . . . Health care Challenges Solved Through Networking . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3 Methodology

3.1

System Study and Investigation . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.1 3.1.2 3.1.3 Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Observation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Document Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11 11 12 12 12 12 13 13 13 14 14 15 15 15 16 17 21 21 22 22 24 24 24 25 25 25 25

3.2

System Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1 3.2.2 Existing System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Problems of Existing System . . . . . . . . . . . . . . . . . . . . . . .

3.3

Requirements Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.1 3.3.2 3.3.3 3.3.4 User Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . Functional Requirements . . . . . . . . . . . . . . . . . . . . . . . . . Non-functional Requirements (NFR) . . . . . . . . . . . . . . . . . . System Requirements . . . . . . . . . . . . . . . . . . . . . . . . . .

3.4

System Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.1 3.4.2 3.4.3 Data Flow Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . Entity Relationship Diagrams . . . . . . . . . . . . . . . . . . . . . . Data Dictionary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.5

System Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5.1 3.5.2 3.5.3 PHP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MySQL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HTML . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4 Results / Findings 4.1 4.2 4.3 4.4 Patients Demographic data, Medical history, Diagnosis, Prescriptions, and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Existing Health Records Systems . . . . . . . . . . . . . . . . . . . . . . . . System Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

System Implimentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.1 4.4.2 The Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Graphical User Interface . . . . . . . . . . . . . . . . . . . . . . . . . vi

4.4.3 4.4.4 4.4.5 4.4.6 4.4.7 4.4.8 4.4.9

Screen Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . User log on Screen . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . Searching for the Registered Patient . . . . . . . . . . . . . . . . . .

26 27 28 29 30 31 32 33 34 36 38 38 39 39 40 43 44

Searching a Patient using Patient Name . . . . . . . . . . . . . . . . Search Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.4.10 Laboratory Investigation . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.11 Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.12 Ward Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Project Discussion, Conclusions and Recommendations 5.1 5.2 5.3 5.4 5.5 5.6 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Problems / Constraints Encountered . . . . . . . . . . . . . . . . . . . . . . Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interview Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Some Codes used for Design . . . . . . . . . . . . . . . . . . . . . . . . . . .

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List of Tables
3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Software Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hardware Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description of user login . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description of the doctors identication . . . . . . . . . . . . . . . . . . . . . Description patient registration . . . . . . . . . . . . . . . . . . . . . . . . . Description patient treatment . . . . . . . . . . . . . . . . . . . . . . . . . . Description of Ward information . . . . . . . . . . . . . . . . . . . . . . . . . User log on information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 15 17 18 18 18 19 19 19 20 20 21 21

Tracking the doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.10 Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.11 Treatment information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.12 Laboratory Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.13 Ward information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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List of Figures
3.1 3.2 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Diagram to show information ow in the proposed system . . . . . . . . . . ERD in the proposed system . . . . . . . . . . . . . . . . . . . . . . . . . . . Logon screen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Registering the incoming patient . . . . . . . . . . . . . . . . . . . . . . . . . Searching for the patient in the system . . . . . . . . . . . . . . . . . . . . . Search for a patient using rst name . . . . . . . . . . . . . . . . . . . . . . Search results displayed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnosis and Treatment information entered . . . . . . . . . . . . . . . . . Laboratory investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Daily OPD report / Census . . . . . . . . . . . . . . . . . . . . . . . . . . . Daily OPD report according to age groups . . . . . . . . . . . . . . . . . . . 16 17 27 28 29 30 31 32 33 34 35 36 37

4.10 Daily in-patient report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.11 Ward information is entered in the system . . . . . . . . . . . . . . . . . . .

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Acronyms
BLIS: Bachelor of Library and Information Science EHR: Electronic Health Records ERD: Entity Relationship Diagram DFD: Data Flow Diagram HTML: Hypertext Markup Language ICA: International Committee on Archives ISO: International Standard Organization IT: Information Technology MOH: Ministry of Health MUK: Makerere University-Kampala NFRs: Non Functional Requirements PHP: Hypertext Preprocessor WHO: World Health Organization

Abstract
This project is about computerized health records management system. Kitagata Hospital was used a case study. The current system was found to be completely manual faced with numerous problems like duplication, loss of records, huge storage space and time consuming. A computerized system was designed using tools like ERDs, DFDs MYSQL, and PHP embedded in HTML. This system is fast, convienient in terms of storage, makes it easy to share information and it is user friendly. Computerization of health records management system is therefore recommended for use in all hospitals in Uganda.

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Chapter 1 INTRODUCTION
Health records management is such an important area in health care delivery because without proper records, planning is rendered dicult. Hospitals and other health units base their decisions on records to know which drugs to stock and which services to prioritize. It is important therefore to give due attention to health records management to ensure that right information is available at the right time in the right place. The aim of this study was buid a computerized records management system that would be more eective and eecient than the existing manual system in Kitagata Hospital. This was done by looking at the existing health records management system , analysing its strong and weak points design and implementation of a new system. Interviews, observation and document reviews were tools used in data collection. MySQL database management system, Apache server, PHP scripting language embaded in HTMl were used for design. Data ow diagram, relationship diagram and the data dictionary were results of the design and implement5ation saw derent interfaces as seen in the last chapter of this project report.

1.1

Background to the Study

Kitagata hospital is a district government Hospital located in Bushenyi District in south western Uganda. It was started in 1967 and like any other district hospitals, according to (MOH, 2001) [11], it provides the following services : Clinical services such as Medicine, Surgery , Paediatrics, Obstetrics and gyaenecology, Dentistry, Anaesthesia, Radiology, Clinical laboratory, and Community health. Services like Medical records management, nance and administration, procurement, personnel and security are under administration. Catering, laundry, central stores, domestic hygiene, maintenance and repair, transport and communication plus sta residential housing fall under support services. On average the hospital handles about 300 patients / clients per day. Out of the services provided, and the load of work handled per day, a lot of records are generated which are handled manually. For example the clinical writer keeps a register, the laboratory keeps another, the wards and the theatre also keep theirs. Medical follow up charts are also produced and kept. This 1

registration at dierent levels usually leads to duplication. Various reports are generated periodically for use at dierent levels of management.The hospital is required to make weekly disease surveillance reports, hospital monthly reports and annual reports plus any situational reports in case of an outbreak. Production of these reports using manual system is not only dicult but also time consuming. Because all this is done with pen and paper, sharing of these records among the health professionals is usually dicult and time consuming. Health workers spend more time looking for information than they spend on caring for the patients therefore patients have to wait for a long time. There is a lot of paper work which is kept in the records center. This makes it dicult for clinicians to make right decisions which leads to prescription mistakes or mistreatment. It is the researchers considered view that a computerized system that will handle the huge records, quicken the generation of reports, ease the sharing of health information and store the huge amount of data more eciently and eectively is needed to replace the current manual system.

1.2

Statement of the Problem

The current manual system used at Kitagata Hospital generates huge amount of paper work that is dicult to deal with, in terms of storage, retrieval, maintenance and sharing among the medical personnel. The personnel spend more time looking for information than they would spend on health care delivery. Duplication of records resulting from multiple registration and misplacement of some of them makes the situation worse. This does not favor the generation of reports in terms of timeliness and accuracy. This project therefore develops a system for computerizing health records management.

1.3
1.3.1

Objectives
General Objective

To build a system for computerizing health records management, that will replace the current manual records management.

1.3.2

Specic Objectives

The specic objectives of the research program are to: (i) To investigate issues related to patients demographic data, medical history, diagnosis, prescriptions, and treatment.

(ii) Analyse existing health records systems (iii) To design a computerized health records management system. (iv) To Implement and test the system.

1.4

Scope

The study will be done at Kitagata Hospital in Bushenyi District. Departments that directly deal with clinical services will be dealt with. Only medical records will be considered and these include: 1. Patient personal information 2. Laboratory examinations 3. Diagnosis 4. Prescriptions and Treatment 5. Follow up of the patient

1.5

Signicance of the Study

1. There has been automation and streamlining of clinicians work ow. This has reduced medical errors, as there is readily available of necessary information on which to base their decisions. 2. Patients records can now be accessed anywhere in the departments of the hospital on a computer screen. The problem of moving from department to department to get some records is no more which has increased time to attend to the patient. 3. Paper work has been considerably reduced with the introduction of computer-assisted method of storing the records. Misplacement of records, space for keeping the paper les, molding / depreciation of paper and all other problems associated with paper work have been dealt with accordingly. 4. Paper-based record-keeping system was adding to the expense of health care. Doctors and nurses used to spend time away from patients attending to a great deal of paperwork. The reliance on paper-based medical records used to add enormous nancial burden, with substantial costs for records storage and administrative support sta. 5. Delayed or missing paperwork used to add time to patient hospital stays and could lead to unnecessary or duplicate clinical tests.

6. Periodic reports are now easier to make and on time. Since the necessary data is available in one place and the computer is able to manipulate it like sorting, stratifying, carry out computations, then the reports are easy to make unlike using the manual system where functions like computations were dicult to handle.

Chapter 2 Literature Review

2.1
2.1.1

Introduction
Records Management

Records Management is the practice of identifying, classifying, archiving, preserving, and sometimes destroying records according (ISO, 2001) [7]. (ISO, 2001) [7] denes records as information created, received, and maintained as evidence and information by an organization or person, in pursuance of legal obligations or in the transaction of business. The International Committee on Archives (CIA) and Electronic Records denes a record as, a specic piece of recorded information generated, collected or received in the initiation, conduct or completion of an activity and which comprises sucient content, context and structure to provide proof or evidence of that activity. While the denition of a record is often identied strongly with a document, a record can be either a tangible object or digital information which has value to an organization. For example, birth certicates, medical x-rays, oce documents, databases and application data, and e-mail are all examples of records.

2.1.2

Information System

(Obrien, 2002) [13] denes Information System as any organized combination of people, hardware, software, communication networks and data resources, that control, transform and disseminate information in an organization. (Obrien, 2002) [13] further reveals that the data resources of information systems are typically organized, stored and accessed by a variety of data resource management technologies into: 1. Databases that hold processed and organized data 2. Knowledge bases that hold knowledge in a variety of forms such as facts, rules, and 5

case examples about successful business practices. According to World Health Organization, (WHO, 2004) [18] the following terms are dened as: 1. Health information System: A system that integrates data collection, processing, reporting and use of information necessary for improving health service eectiveness and eciency through better management at all levels of health service. 2. Health management information system: This is an Information system specially designed to assist in the management and planning of the health programs as opposed to delivery of care .

2.2

Steps in developing a Health Management Information System

World Health Organization regional oce for western pacic, (WHO, 2004) [18] recommends the following steps while developing health management information system: (a) Review the existing system (b) Dene the data needs for relevant units within the health system (c) Determine the most appropriate and eective data ow (d) Design the data collection and reporting tools (e) Develop the procedures and mechanisms for data processing (f) Develop and implement a training program for data providers and data users (g) Pre-test, and if necessary re-design the system for data collection, data ow, data processing and data utilization (h) Monitor and evaluate the system (i) Develop eective data dissemination and feedback mechanisms (j) Evaluate the system According to (Chrisanthi and Cornford, 1998) [4], the process of development of an Information System can be seen as a list of tasks, starting with identication and launching of an information systems project and ending with maintenance of its optional components for a period before the system is phased out or replaced. However, they say that this varies from one organization description to another. On their part they suggest the following steps to be typical for most organizations: 6

(a) Identication of a problem, pressure, or opportunity (b) Determination of general requirements for change (c) Feasibility study to explore possible approaches (d) Systems analysis to model detailed requirements for technical components or organizational reform (e) Systems design to work out how requirements are to be met (f) Development or acquisition of software and hardware and their conguration (g) Systems implementation with the organizational settings (h) Operation and maintenance (i) Phase out when the system is no longer needed or used.

2.3

Keys to Successfully Adopting Electronic Health Records (EHR)

(Scott and Rundall, 2005) [15], in a fund-supported study nd that the keys to successful adoption and implementation of EHR include a participatory selection process, exibility regarding sta roles and responsibilities, and decisive leadership at critical stages. EHR systems have great potential to improve health care quality. So far, however, real and perceived barriers from high costs and decreased productivity to sta frustration-have prevented most providers from implementing them.

2.4

Push for Medical Record Computerization

(Meghan, 2006) [9] reports that advocates say that electronic medical records could save140 billion dollars a year in health care expenses on things like le clerks and space for le cabinets, while also saving tens of thousands of lives each year by reducing medical errors. When Medical Records management is computerized, there are no rooms full of shelves lined with manila folders stued with charts. Instead, patients insurance, medication, examination, and treatment records are maintained on eight Dell servers stacked in a large closet, (Meghan, 2006) [9]. The technology dramatically reduces the time between a patients initial consultation with a physician and his receiving treatment, allowing physicians to see between 30 to 35 patients a day. (Meghan, 2006) [9] quotes Dr. Doroshik as saying that doctors think outside the box, increasing the likelihood that a patient will get an accurate diagnosis sooner. Analysts say that the use of EHR signicantly reduces redundant and improper treatments, and cuts 7

back on potentially fatal medical errors resulting from incomplete or erroneous information in a patients medical le. According to (Lucey, 2002) [10], all organizations operations are ever changing. Management and information systems that support them have to deal with that change and adapt to their operations, systems and organizations themselves in order to survive and prosper. (Lucey, 2002) [10] reveals the following as factors that lead to these changes: 1. More competition: All types of organizations face greater competitive pressures for example hospitals competing for business 2. Faster pace: The knowledge and development that people have rapidly become obsolete because of changing requirements. Existing work patterns and practices need to be updated more or less continuously to keep pace. Current information rapidly becomes out of date as technology seems to change month by month 3. Increased globalization (Ndagire, 2003) [12] reveals the following as some of the problems of manual information systems: 1. Paper based systems are generally very bulky both to handle and to store, and oce space is expensive 2. Information manual techniques of processing information are more tedious, laborious, slow and inecient 3. Labor productivity is low and the process is slower where large volumes of data need to be dealt with.

2.5

The Role of IT in Improving Health care Delivery

(Klein, 2006) [8] states that there is an opportunity to transform health care and improve patient safety by better leveraging information technology to improve the eciency, accuracy, and eectiveness of the health care system. However, adoption has been slow and the results have been mixed up. If deployed incorrectly, without well-conceived process improvements, IT systems can do just the reverse, leading to critical delays or mistakes.

2.6

Data Overload and out dated Technology

According to (Hendee et al., 2006) [6], the 20th Century had a challenge of a decit of patient information, but the 21st Century is faced with a surplus. Compounding matters is the fact that the human brain, even a physicians, cannot keep up with the exponential growth in medical knowledge that will occur in forthcoming years. 8

The ability of most humans to memorize things has remained at, but the medical knowledge that needs to be assimilated is increasing at a very high rate. Sub-optimal medical care often is provided to patients because of the failure to access all the data necessary to make the right decision, (Chaiken et al., 2006) [3]. (Bush, 2004) [2] argues that many Americans die each year from medical errors. Many more die or have permanent disability because of inappropriate treatments, mistreatment, or missed treatments in ambulatory settings. All these problems of high costs, uncertain value, medical errors, variable quality, administrative ineciencies, and poor coordination are closely connected to the failure to use health information technology as an integral part of medical care. Unlike other industries, medicine still operates primarily with paper-based records. The doctors and nurses have to manage 21st century medical technology and complex medical information with 19th century tools. (Bush, 2004) [2] further reveals that in the outdated, paper-based system, patients vital medical information is scattered across medical records kept by many dierent care givers in many dierent locations - and all of the patients medical information is often unavailable at the time of care. He believes that innovations in electronic health records and the secure exchange of medical information help transform health care in America by improving health care quality, preventing medical errors, reducing health care costs, improving administrative eciencies, reducing paperwork, and increasing access to aordable health care.

2.7

Health care Challenges Solved Through Networking

According to (Cisco, 2005) [5], managing a clinical environment today involves a large amount of paper. Clinical information stored in paper charts is dicult to access, takes up costly space dedicated to chart storage, and can impact on quality of care . On the other hand, networking can be benecial as: 1. Connected electronic health records provide eective distribution of information to care givers at the point of care to support higher quality of care with increased eciency. 2. Care giver productivity and clinical eciency can be improved by automating common activities, including prescribing, ordering labs, viewing results, and taking clinical notes over a network. 3. Clinicians can access patient charts and medical histories without having to search les or wait for chart pulls. Connected health care applications, including electronic health records, that streamline information and communications at the point of care are critical to health care organizations under pressure to cut costs, increase productivity, and improve patient care, (Cisco, 2005) [5]. 9

2.8

Conclusion

Although many schoolars have written about computerization of health records as an urgent requirement and a lot of research has been carried out, implementation is still insucient. However, according to the literature available, there are numerous benets that accrue from EHR when compared with manual systems. For example there will be no duplication of records, sharing of information is made possible, the problem of missing and / or misplaced records is reduced and the information is available at the point of care. In order to continually improve the quality of healthcare, Ugandas Ministry of Health has put in place a routine reporting system backed up with electronic databases replacing all pre-existing totally paper-based reporting instructions in districts all over the country. This system, called the Health Management Information System (HMIS), is designed to produce relevant and functional information on the health services on a routine basis. It is kicked o at the grass-roots health units and the information gathered is transferred to health sub-districts, then on to the districts and nally to the national level for planning, managing and evaluating healthcare delivery. In other words, from the health unit it goes through the districts and straight to the National Health Databank. (Weddi, D.,2005). [17]. Despite the eorts by the ministry of health, hospitals remain completely manual with traditional pen and paper records management. It is also seen from the above example that the eorts are only on reporting systems not minding on how these reports are produced and other processes managed. Healthcare IT is a sleeping giant. Although healthcare budgets contribute to the bulk of government spending, healthcare information technology lags far behind other IT businesses including banking, telecommunications and the media. Local and countrywide eorts to implement electronic health record (EHR) systems have been intermittently reported. The common threads, however, that link these eorts and how they contribute to the success, barriers or failure of implementation have not been identied. (Steve, A. et al.2006) [16]. The researcher decided to build on the literature and eorts available to implement a practical solution for the problems of the manual system as a way forward. This exploits the benets of the new technology as they are widely talked about.

10

Chapter 3 Methodology
This section describes the steps and procedures that were followed in order to accomplish the project. The study was conducted as follows:

3.1

System Study and Investigation

In this section the researcher studied the existing system to establish its weak and strong points. The information acquired from this study gave the basis for the design of the new system. A number of steps, procedures and tools were employed as shown below:

3.1.1

Interviews

The researcher conducted face-to-face interviews with the stake holders. Doctors, Nurses, Clinicians, Records sta and the patients were interviewed to fully understand their experiences. Also an interview guide with open ended questions (Appendix A) was prepared and administered to the respondents so as to enable them give their views freely. This technique was chosen because: 1. It permits clarication of questions 2. Has high response rate than written questionnaires 3. It is suitable for use with both literate and illiterates 4. Get full range and depth of information 5. Develops relationship with client 6. Can be exible with client Note that the interview guide is particularly useful in obtaining information that cannot be obtained by other methods according to (Bell, 1992) [1]. 11

3.1.2

Observation

This technique was used to gather accurate information about how the system actually operates, particularly about processes. This involved the researcher to systematically watch and record the behaviors and characteristics of operations and processes in the hospital. Although the method was time consuming, it had a number of advantages, which include: It gives more detailed and context related information It permits the collection of information on facts not mentioned in the interview It permits tests of the reliability of the responses to the questionnaires View operations of a program as they are actually occurring Can adapt to events as they occur

3.1.3

Document Review

A thorough review of the documents used in the hospital was done with the intent to study how things are done and discover areas where improvement is necessary. A number of documents were reviewed including patient charts, registers, tally sheets, periodic reports and lab reports among others. This method was used because of its advantages, which include: 1. It is inexpensive because the data is already there 2. It permits examination of trends over the past 3. Doesnt interrupt program or clients routine in program 4. There are few biases about information

3.2
3.2.1

System Analysis
Existing System

The existing system was found to be completely manual, i.e. personal (patient) information is captured in a register at the reception. A medical form is issued to the patient which he / she takes to the Clinician for prescription and treatment. The Clinician takes the medical history, writes diagnosis and treatment on the form. The Clinician sometimes can refer the patient to the laboratory for investigation before diagnosis depending on the situation of the patient. To do this, he lls a form called Lab request form. There is another register in the Laboratory where they record their nding on the patient. 12

When the patient is not very ill, he / she will be recorded in the outpatient register, given treatment and go home. Otherwise an admission chart will be lled and the patient goes to the ward where he / she is recorded in the inpatient register and treatment is done there until recovery is realized so that he / she can be discharged. All the patient charts are collected and kept with the Records department. Filing and organization of the charts are done in the records department. Summaries and reports are also generated here.

3.2.2

Problems of Existing System

Considering the previous section, there are many problems associated with the existing manual system, they include the following: 1. It is evident that there is a lot of duplication in recording of the patients. For example there is recording at reception, in the laboratory, and in the ward where dierent registers are kept. 2. There is a problem of storage of these registers and forms / charts which are produced at dierent levels. 3. Information retrieval from these sources is not easy 4. Some charts get lost or misplaced. This is a problem in decision making as there is inadequate information. 5. Patients have to wait for a long time as health workers are looking for their charts.

3.3
3.3.1

Requirements Analysis
User Requirements

It is very important to get users of the system fully involved such that the problem of change management does not arise. The stake holders, who will use the system therefore were approached during the study and were asked what they expected of the proposed system and the following were the ndings: 1. A system that is easy to learn and use 2. A system that improves on the eciency of information storage and retrieval 3. A system that is fast in producing results which will be ready at the point of care therefore reducing on waiting time and increasing on time to attend to the patients. 4. A system that has an element of error validation, i.e. one that prompts the user on entering unusual command or data format inconsistent with the database. 13

5. A system that provides attractive interfaces with easy navigation throughout the system 6. A system that is faster, exible and convienient. 7. A system that stores data and produces reports timely and accurately 8. A system that restricts access to information to only authorized personnel

3.3.2

Functional Requirements

Functional requirements capture the intended behavior of the system. This behavior may be expressed as services, tasks or functions the system is required to perform. Therefore the proposed system is able to: 1. Capture the patient information, store it and make it available at the time of need. 2. Present the users with a real-time display of the number of records in a database. 3. Allow the sharing of the data by the users 4. Generate reports accurately and timely 5. Search and display patient information details

3.3.3

Non-functional Requirements (NFR)

Non-functional requirements are requirements which specify criteria that can be used to judge the operation of a system, rather than specic behaviors. This is contrasted with functional requirements that specify specic behavior or functions. Systems must exhibit software quality attributes, such as accuracy, performance, cost, security and modiability plus usability, i.e. easy to use for the intended users. NFRs help to achieve the functional requirement of a system. Thus the proposed system does the following: 1. The system has high performance and reliability level. The mean time between failures, mean time to repair, and accuracy are very high. 2. The system has user-friendly interfaces. This ensures the ease with which the system can be learned or used. The system can allow users to install and operate it with little or no training. 3. Handles growing amounts of work in a graceful manner as can be readily enlarged i.e. the ease with which the system can be modied to handle a large increase in users, workload or transactions . 4. The system prevents unauthorized access to the system with user authentication via log-on system. 14

3.3.4

System Requirements

1. Software Requirements Software Component Operating System for the server Operating system for the client PC Web Server Web Browser Database Management System System Requirement Windows NT, 2000 or above Windows XP/NT Apache Web Server Version 1.3 MS Internet Explorer 6.0 or above Mysql server version 3:23.48

Table 3.1: Software Requirements 2. Hardware Requirements Hardware Component Processor Processor Speed Web Browser Disk Space Bandwidth System Requirement Intel Pentium III or above 800MHZ or above 128MB RAM or above depending on the Operating System 50 GB or above 100MBps Table 3.2: Hardware Requirements

3.4
3.4.1

System Design
Data Flow Diagram

Data ow diagrams (DFDs) were used to illustrate the ow of information in a system. They are hardware independent and do not reect decision points. They demonstrate the information and how it ows between specic processes in a system. They provide one kind of documentation for reports. These diagrams help to show how data moves and changes through the system in a graphical top-down fashion. They also help to give graphical representation of the systems components, processes and the interfaces between them. When it came to conveying how data ows through systems (and how that data was transformed in the process), DFDs were the method of choice over technical descriptions for three principal reasons: 1. DFDs are easier to understand by technical and non-technical audiences. 2. They provide a high-level system overview, complete with boundaries and connections to other systems. 3. They provide a detailed representation of the system components. 15

The diagram below shows the ow of data through the proposed system. It depicts the ow the of information and the transformation that are applied as data moves from input to output.

Figure 3.1: Diagram to show information ow in the proposed system

3.4.2

Entity Relationship Diagrams

These were used to identify the data to be captured, stored and retrieved in order to support the activities performed. The diagrams were used to show the relationships between the entities involved in the system together with their attributes and indicate the number of occurrences an entity can exist for a single occurrence of the related entity. Entity Relationship Diagrams (ERDs) illustrate the logical structure of databases. Entity relationship diagrams were used because they are relatively simple, user friendly and can provide a unied view of data, which is independent of any data model. The diagram below shows the ERD for the new system

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Figure 3.2: ERD in the proposed system

3.4.3

Data Dictionary

This contains all data denitions for cross-referencing and for managing and controlling access to the information repository / database. It provides a very thorough interface description (comparable to Interface Control Documents) that is independent of the model itself. Changes made to a model may be applied to the data dictionary to determine if the changes have aected the models interface to other systems. Data dictionaries do not contain any actual data from the database, only book keeping information for managing it. Without a data dictionary, however, a database management system cannot access data from the database. Below are the illustrations:

User Attribute Data Type and Length Description Username varchar(30) user identication by name Password varchar(30) user security identication Table 3.3: Description of user login 17

Doctor Attribute Data Type and Length Description docId varchar(20) Unique identication of the Doctors who attends to the patient fname varchar(50) Identication of the doctor by rst name lname varchar(50) Identication of the doctor by rst name contact varchar(30) Telephone contact of the doctor Table 3.4: Description of the doctors identication

Patient Attribute patNo fname lname address sex Data Type and Length Description varchar(20) Unique serial number given to the patient varchar(50) Patient rst name varchar(50) Patient last name varchar(100) Physical address of the patient varchar(10) Patients sex Table 3.5: Description patient registration

Treatment Attribute patNo wardNo bedNo diagnosis treatment docId notes Data Type and Length Description varchar(10) Patients serial number varchar(11) ward number in case a patient is admitted varchar(11) bed number where the patient is admitted varchar(100) Diagnosis by the doctor varchar(500) Treatment given to the patient varchar(10) Identication of the doctor varchar(500) Clinical notes of the medical history Table 3.6: Description patient treatment

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Ward Attribute wardNo name bed-capacity Data Type and Length Description int(11) Identication of ward by number varchar(50) Ward identication by name int(11) Number of beds in the ward Table 3.7: Description of Ward information Basing on the above illastrations, the following describe the systems database togather with its corresponding tables which keep records or data and respond to querries.

User Log on Information Field Type Username varchar(30) Password varchar(30) Null Key Default Extra no null no PRI null Table 3.8: User log on information

In the table above the user name and the password are kept. They both have a maximum of 30 characters and the primary key is the password.

Doctors Information Table Field doc id name lname contact Type varchar(20) varchar(50) varchar(50) varchar(30) Null Key Default Extra no PRI null no null no null no null Table 3.9: Tracking the doctor

The doctor who treats the patient is also recorded by the system and the information kept. The doctors ID, his rst and last names and his telephone contact are captured for the purposes of tracking the doctors who works on a patient.

Patient Registration At reception, a patient is registered by capturing his / her demographic data. This includes full names, address and sex. A unique patient number is issued and all this is stored in the 19

patient information table. The primary key here is the patient number (patNo). This is seen in the table below. Field patNo fname lname address sex Type varchar(20) varchar(50) varchar(50) varchar(100) varchar(0.8) Null Key Default Extra no PRI null no null no null no null no null Table 3.10: Patient Information

When the patient goes to doctor, more information is captured in the system. This includes diagnosis, treatment, and clinical notes. In case the patient is admitted, the ward number and the bed number are captured. This is stored in the treatment table as shown below.

Treatment Information Field patNo wardNo bedNo diagnosis treatment docId notes Type varchar(10) varchar(11) varchar(11) varchar(100) varchar(500) varchar(10) varchar(500) Null Key Default no PRI null null null no null no null no null no null Extra

Table 3.11: Treatment information

Laboratory Investigations Some patients go for laboratory investigation. In the laboratory information like specimen, tests done, and laboratory results are captured and is stored in the laboratory investigation table as given below:

20

Field vdate patNo wardNo specimen test results

Type date varchar(10) varchar(11) varchar(200) varchar(200) varchar(300)

Null Key Default no PRI 0000-00-00 no PRI null yes null no null no null no null

Extra

Table 3.12: Laboratory Investigation Ward Information Other information captured by the system is the ward information. The ward number, bed number and the bed capacity are captured and stored in the ward information table. Field wardNo name bed-capacity Type int(11) varchar(50) int(11) Null Key Default Extra no PRI null no null no null Table 3.13: Ward information

3.5

System Implementation

System implementation was achieved using MySQL for database design. PHP scripting language and HTML were used to develop the codes that link up the system interfaces and the database.

3.5.1

PHP

PHP scripting language is famous for the four Ss, Pushman (2000) [14], i.e. Speed, Stability, Security and Simplicity a reason that justies its choice for this project. Below is the description for the four Ss and more advantages of PHP language: 1. Speed: not only is the speed of execution important, but also that it does not slow down the rest of the machine. So it does not demand a lot of system resources. PHP is a thin wrapper around many operating system calls, so can be very fast. 2. Stability: its no good being fast if the system crashes every few thousand pages. No application is bug free, but having a community of PHP developers and users makes it much harder for bugs to survive for long. 21

3. Security : With PHP, the system is protected from malicious attacks from users, both as programmers and as surfers because it provides many levels of security which can be set in the individual le to the desired level. 4. Simplicity : With PHP, even HTML coders can start integrating PHP into their pages straight away. 5. PHP is available for MS Windows, provides interface for many dierent database system, has high performance capability and is extendible. 6. PHP will run on (almost) any platform. 7. It has lots of HTTP server interfaces. PHP currently will load into Apache, IIS, AOLServer, Roxen and THTTPD.

3.5.2

MySQL

MySQL, a popular database with Web developers,was chosen because of the following advantages: 1. It is faster. 2. It is inexpensive. MySQL is free under the open source GPL license, and the fee for a commercial license is very reasonable. 3. It is easy to use. A few simple statements in the SQL language are needed to build and interact with a MySQL database. 4. It can run on many operating systems. MySQL runs on a wide variety of operating systems - Windows, Linux, Mac OS, most varieties of UNIX and others. 5. Strong Data Protection: MySQL oers exceptional security features that ensure absolute data protection. In terms of database authentication, MySQL provides powerful mechanisms for ensuring only authorized users have entry to the database server, with the ability to block users down to the client machine level being possible. 6. It supports large databases. MySQL handles databases up to 50 million rows or more. 7. It is customizable. The open source GPL license allows programmers to modify the MySQL software to t their own specic environments.

3.5.3

HTML

HTML was used as the web template because of the following advantages: 1. HTML web templates can be easily edited with a minimum knowledge of HTML.

22

2. The codes of HTML templates are easy to understand and change in order to convert the template into the unique web site 3. As HTML is a widely spread format, there are many materials on it. 4. HTML is available for MS Windows

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Chapter 4 Results / Findings

This charpter explains in summary, the outputs or ndings as per specic objectives of the study.

4.1

Patients Demographic data, Medical history, Diagnosis, Prescriptions, and Treatment

At the reception, a patients demographic data would be captured on a chart and in a register. Medical history, diagnosis precicription and treatment would be taken by a clinician on the chart. The data on the chart would again be recorded in the register when the patient was recieving drugs in case of outpatient department patients. The patient would required to come with the chart on subsquent visits. In case of admission, the chart would be retained in the records centre and the patient would be issued with discharge form. This was found with the following problems: 1. Patients would forget to bring the charts at their second visit 2. Some charts would be misplaced or got lost in the records centre 3. There was duplication in registration of patients

4.2

Existing Health Records Systems

1. The existing system was found to be completely manual, i.e. all data was captured with pen on paper (registers and patient charts). A lot of duplication in registration patients was found to be common. For example there was registration at reception, in the laboratory, in the wards and so on as these places manage their own registers. 24

2. It was very slow and time wasting as personnel would send time looking for information in charts and registers before they could attend to the patients. This increased patient hospital stay. 3. The bulky charts and registers were kept in the records centre in the custody of records sta. This was found to be expensive and risky as these charts would be attacked by molds and sometimes misplaced. 4. Reports were generated manually, for example computations where necessary were done with a calculator and information fed in forms to make reports. This was found relatively dicult and time consuming. Timing and accuracy of these reports would not be guaranteed.

4.3

System Design

The system was designed on Microsoft windows platform, using Apache server, MySQL for database design and PHP scripting language i.e. WAMP5 1.6.4 version. It is web-based and therefore can be installed on a computer (server) on a Local Area Network (LAN) or Wide Area Network (WAN) depending on the environment being used. Once the application is installed, any authenticated user can access it from any work station by using hypertext protocol, servername, and port number. For example, the system is located at the address http://localhost/home.php. The system is composed of two sections; the database server and the graphic user interfaces (GUI) i.e. a two tier architecture.

4.4
4.4.1

System Implimentation
The Database

The database was designed using MySQL database management system. The database was named chals and it contains six tables which keep records or data as entered by the user.It is this database that is consulted to answer querries

4.4.2

Graphical User Interface

The user interfaces consist of various windows that enable dierent categories of users to interact with the system. The forms were developed using HTML and PHP. Dierent forms were developed to enable the users perform the following tasks: 1. Login to the system 25

2. Register the patients by capturing personal information 3. Searching for the registered patient in the system 4. Capturing patients information i.e. medical history, entering diagnosis and treatment 5. Entering the laboratory investigation results 6. Viewing reports generated.

4.4.3

Screen Formats

The information that is managed by the system is captured on dierent screens at dierent stages. This section shows these screen shots and how they are used to capture the information managed by the system. The user logs in the system by entering his / her username and password in order to access the system. For example in the form below, the user is logging in using gilbert as username.

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4.4.4

User log on Screen

Figure 4.1: Logon screen

After logging in the system, the user can register the incoming patient by capturing the personal information as in the following screen format. Here the user means the one who registers the patient at reception by capturing the demographic data only. Details of the patients demographic data is captured including rst and last names, sex, age and address. He / she is assigned a unique patient number. The screen shot below shows demographic data being captured:

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4.4.5

Patient Registration

Figure 4.2: Registering the incoming patient

The system allows to search for the patient who is registered . I.e. if he / she is a reattendance case or has moved from one stage to another. For example, when a patient is registered at reception and goes to the clinician. On presenting his / her patient number or names, the Clinician will use search facility in the system to get the details of the patient as in the screen below:

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4.4.6

Searching for the Registered Patient

Figure 4.3: Searching for the patient in the system

In the above form, the patient number was used to search for the patient in the system. Since the patient number is unique, only that patient will be displayed when the it is used. Patient name can be used to search for the registered patient as well. In the following screen a patient whose rst name is Bob is being searched in the system.

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4.4.7

Searching a Patient using Patient Name

Figure 4.4: Search for a patient using rst name

When patient name is used, details of similar names will display allowing the user to identify the very patient. The form below therefore shows the results that display when a patient rst name Bob is used. All the registered patients whose rst name is Bob will display.

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4.4.8

Search Results

Figure 4.5: Search results displayed

The user now can pick the patient he is looking for since the details are displayed on the screen above. On consultation, the doctor / clinician will enter diagnosis and treatment information in the system as shown in the screen below:

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4.4.9

Patient Treatment

Figure 4.6: Diagnosis and Treatment information entered

If the patient is admitted, he / she will be assigned a bed in a ward and therefore the need for ward number and bed number. In the example above the patient is admitted in ward number 4 at the bed number 34. Where it needs to have laboratory investigations, the systems captures the laboratory information as in the following screen:

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4.4.10

Laboratory Investigation

In the laboratory, specimen and the tests done are entered and results submitted in the system. This is shown in the following screen.

Figure 4.7: Laboratory investigation

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4.4.11

Reports

The system is able to generate a number of reports which can be used in planning. The following examples of reports show the census of daily outpatient, in-patients and diagnosis according to age groups.

OPD Report

Figure 4.8: Daily OPD report / Census

In the following example, patients are grouped according to age and a report of those diagnosed that day can be generated as shown in the screen shot.

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Age Group Report

Figure 4.9: Daily OPD report according to age groups

Another report that is generated is that of in-patients. The system is able to show how many patients have been admitted and in which ward. This is shown in the following screen.

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In-patient Report

Figure 4.10: Daily in-patient report

4.4.12

Ward Information

Once the patient is admitted, the information on the ward can be captured and entered in the system as in the following screen:

36

Figure 4.11: Ward information is entered in the system

The next of kin, patient complaint, and whether he / she has been referred from another hospital will be captured.

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Chapter 5 Project Discussion, Conclusions and Recommendations

This chapter discusses the work carried out in this project. It examines how the objectives of the project were achieved using Kitagata Hospital as the case study. The design, implementation, conclusions and recommendations are discussed.

5.1

Discussion

The purpose of the study was to build a computerized health records management system to replace the existing manual system. The case study was Kitagata hospital in southwestern Uganda. To achieve the objectives of study, the existing systems was studied and analyzed, by comparing the strong and weak points of the system. Stake holders were interviewed, documents reviewed and observation techniques were employed. Existing literature was also analyzed. Implementation was done using PHP scripting language embedded in HTML for the user interfaces and MYSQL for database design. PHP enabled Apache web server to eect the connections between the database and the web browser. The new system is therefore able to do the following: 1. Capturing of Personal / bio data is done once; on reception as opposed to the manual system where the patient would be recorded at every level in dierent registers. This avoids duplication and saves time. 2. Retrieve Information from the database as quickly as one searches on the screen compared to the old system which involved paper les which were vulnerable to displacement and damage. 3. Authenticate the users with the access control facility to prevent unauthorized users from accessing the data. 38

4. Validate the entries by prompting the user whenever a wrong command is entered to avoid unnecessary errors that can distort information. 5. Update the database whenever new information is entered 6. Reports are generated quickly and correctly, unlike in the old system where information would be scattered in charts

5.2

Problems / Constraints Encountered

During the study the researcher encountered a number of problems which to some extent seemed to stand in the way of success of the study. These among others include: 1. Financial constraints: The study being a self sponsored venture, the researcher would sometimes face problems to nance some of the activities involved in the study. However, through hard and thin, it has come to an end successfully. 2. Time constraints: The time allocated to the study looked not friendly given that the same period involved the class work where there are a lot of course works ,tests and lectures. 3. Busy schedules: The people working with current system were most of the time busy and this made the work of the researcher dicult especially during data collection. Nevertheless, they proved very cooperative despite their busy schedule which made the successful at the end of the day. 4. Fear for retrenchment: Some of the members sta at the hospital, especially the records sta, feared for their jobs with the introduction of the computerized system. They expressed fear that they would be left with no work and risk being retrenched. 5. Throughout the whole study, electric power was never on the researchers side. It would go o at critical times and this hindered smooth progress and planning was made dicult

5.3

Recommendation

A more comprehensive study to exploit the full benets of the new technology in this eld of health records management is highly recommended. This may be able to unveil more gaps and therefore improve on the system more than this study has been able to do. The ministry of Health should step in to have all hospitals and health units computerize their records management systems by providing the necessary funds for such projects. Given the current power situation in Uganda, the system would be rendered useless if measures are not put in place to avert power problem. The researcher therefore recommends 39

that a standby generator be considered such that when power goes o the system does not stop working. Training of the hospital sta in minimum computer skills is paramount. It was found out that most sta are computer illiterate. Without these skills system implementation will be dicult therefore it is recommended that a training program be made a priority.

5.4

Conclusions

Basing on the ndings and analysis, computerization of health records management is venture worth to invest in. Once taken seriously and embraced, there are alot of benets that can be realized therein. Both the hospital and the community it is serving will benet from it. For example patients will no longer wait for long hours to be attended to because the time that would be spent looking for information would be saved. Medical errors that were resulting from lack of information for proper decision making on the part of doctors / clinicians will be minimized. Records which were stored in the records center, in form of charts and sometimes get lost there, will now be stored electronically and will be more safe. Therefore there will be the right information at the point of care. Periodic reports which are generated with the help of a computer are more accurate and quick. Therefore with the introduction of computerization, the problem of late reporting and errors in the reports will be no more. It is important to note that this system is based on a local area network. This facilitates the sharing of data in dierent departments. This helps personnel access the data at their departments instead of moving from department to department looking for information which is time consuming.

40

References
1. Bell, J.(1992). Doing your research project,Milton Keynes:open University Press,UK 2. Bush, G.W. (2004). President George W. Bush, Transforming Health Care through Health Information Technology: State of the Union Address, January 20, 2004 , retrieved June 10,2006 from http://www.whitehouse.gov/infocus/technology/ 3. Chaiken, B. P., Edward, B., Bevan, K. B.,and Seth, F. (2006). Clear and Lasting Danger: Pandemic Flu, and How IT Can Help:Proceedings of the WTN Medias 2006 Digital Health care Conference, retrieved June 15, 2006 from http://wistechnology.com/ 4. Chrisanthi, A. and Tony, C. (1998). Developing Information systems: Concepts, Issues and Practices. Palgrave,Newyork. 5. Cisco (2005). Health care Industry Inuencers of Change:Cisco Systems, Inc.:Overview Brochure, retrieved June 8,2006 from http://www.cisco.com/web/strategy/docs/health care/ ehr-connected.pdf 6. Hendee, W., Gary, W., Prekop, J. , Traxler, J. , and Melski, J. W. (2006) Data Overload: The Quest to Deliver Knowledge.Proceedings of the WTN Medias 2006 Digital Health care Conference, retrieved June 15, 2006 from http://wistechnology.com/ 7. International Standard Organization,15489 (2001).Wikipedia: The free encyclopedia, retrieved June 2,2006 from [http://en.wikipedia.org/wiki/Records-management] 8. Klein, M. (2006). Will Technology improve health care delivery.Wisconsin technology Network Journal article [online],retrieved June 12th 2006 from http://wistechnology.com/ 9. Meghan, C. (2006).President to Push Medical Record Computerization The New York Sun article January 6, 2006, retrieved June 8,2006 from www.nysun.com/ 10. Lucey, T. 2002. Management Information Systems.Continuum, 11 York Road, London. 11. MOH (2001). Uganda Health Bulletin Volume 7 - No 4 12. Ndagire, Mary Lucy (2003). An inventory management system: Case study Rubaga Hospital 13. Obrien, J. A. (2002). Management Information Systems: Management information Technology in the e-business enterprise. Tata McGraw-Hill,New Delhi. 41

14. Pushman, J. (2000) , Tips on web page design,HTML and Graphics, Web Developers Journal, Retrieved October 5 2006, 2002, from ABI/INFORM Global database. 15. Scott J. T., Rundall T. G., Vogt T. M. (2005). Kaiser Permanentes Experience of Implementing an Electronic Medical Records: A Qualitative Study, (BMJ, December 3,2005), vol.29 Retrieved May 20,2006 from http://www.cmwf.org/publications 16. Steve, A.,Joseph, W, Susan, J. H.,Gary, M. K. (2006).Electronic Health Records: A Global Perspective Overview Retrieved Sep 12 2006 from 17. Weddi, D. (2005). Using information systems to manage health in Uganda: 2004-2005 Annual Health Sector Performance report.Retrieved Sep 12 2006 from www.iconnectonline.org 18. WHO (2004). Developing Health Management Information System: A practical guide for developing countries Retrieved June 7, 2006,from (www.wpor.who.int/publications/

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Appendix A
5.5 Interview Guide

1. What is your job title? 2. How many patients do you see daily? 3. What role do you play in the health records management? 4. How do you nd the existing system of health records management? 5. What problems do you face with the existing system? 6. Do you recommend to continue with the existing system, if yes why? 7. Are you a computer literate? 8. Suppose the existing system were replaced with a computerized one, how would this help to improve health records management? 9. What would you expect from the new system (if introduced) as a person going to use it?

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Appendix B
5.6 Some Codes used for Design

44