Gone are the days where patients files would disappear miraculously at health facilities and the visit to a doctor would take hours, with a nurse trying to figure out where your file disappeared to.
Over the years, different systems have been piloted and implemented at health facilities to manage patients better, and solve the different challenges that were faced with the use of paper to document patient details and treatment progress.
Centre for Health Solutions – Kenya (CHS), through the Shinda Tena project, has facilitated the rollout of Kenya Electronic Medical Records (EMR) to all our supported health facilities in Siaya County, which has been a game changer on how operations run. Shinda Tena is a five-year HIV prevention, care and treatment program funded by the US President’s Emergency Program for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC).
Noah Tuma, the health informatics officer at CHS, explains that by introducing the EMR system, it has become so easy to manage patients without necessarily having to look for files or even try to figure out if samples of a patient were taken.
“KenyaEMR is an electronic medical record system that is designed on an OpenMRS database, which is opensource software that allows users all over the world to develop and customise it to meet their needs. CHS has played a key role in transitioning from multiple EMR(s) to the mono-EMR implementation system, Kenya EMR, in Siaya County since 2016.”
CHS works very closely with the health informatics partner who is in charge of developing the KenyaEMR software. “We work closely with the informatics partner to support in troubleshooting, conducting user acceptance testing, strategic alignment, capacity strengthening, structured user support, HIS community of practice, data demand and information use, and also to improve on the system functionality,” adds Tuma.
The Kenya EMR has several modules that are designed to support patient management. Some of the notable modules include registration, where all clients are registered into the system. The system has also been enhanced to assign a unique patient identifier (UPI) through the central registry; this has helped the users and the program to easily avoid double registration.
After registration, there is a client flow where clients are supposed to move to the clinician. Through the clinician module, patients are managed as they come to the clinic, medicines prescribed, clinical examinations conducted, as well as referral of clients to the lab.
“We have an USHAURI module, which is a mobile and web-based platform developed with the objective of improving the health outcomes of PLHIV by providing timely and reliable messages, including appointment reminder messages, treatment adherence messages, and wellness messages,” says Tuma.
He further adds, “NiShauri, which is a patient-centric Android application uses the data collected by mLab and Ushauri to inform the patient and provide guidance on specific parameters that both systems generate, e.g., lab results, appointment tracking, adherence summary, among others.”
According to Tuma, the HIV Testing and Screening module is also available, which caters for screening for HTS eligibility, testing, client referral for enrolment, and further management. The Lab Manifest module allows the lab providers to request lab procedures.
The system has been enhanced to seamlessly send lab requests to the central lab and pull results back into the facility EMR. This has improved timely patient management, avoided misfiling, and ensured timely reporting.
But how was it back then?
“Before, clients used to be managed using manual methods, that is, paper. There were client files in which you would find enrollment forms, locator forms, clinical receipts forms, and lab forms, and it was tedious to manage through that manual process and offer service to patients,” explains Tuma.
“The KenyaEMR is currently using artificial intelligence technology to enhance case detection in HTS as well as promote patient retention in HIV care by providing predictions on patients who are likely to drop out of active care,” said Tuma.
Yvonne Muhongo, a clinician at Siaya County referral hospital, explains that, “When we started practice, we were using registers and files. Handwritten documents would always disappear. For PrEP clients, we could not use the system to attend to clients.”
William Osong’o, a clinician at Siaya County referral hospital, adds that previously they used to have physical registers that were used for tallying. “It was tiresome compared to the introduction of Kenya EMR, and the data integrity issues have really improved.”
An interesting feature on the EMR system is the availability of a referral module. Clients enrolled at different facilities can be received in a facility without being taken through the enrollment process again.
In this particular module, a tool known as eCHIS (electronic community health information systems) has also been added. This tool allows the primary health workers in the community to refer clients directly to the health facility.
“Since the system is integrated, it pulls the client to the facility, meaning the providers don’t need to register clients twice. This has improved cases of surveillance management and reports. It also ensures clients receive immediate care when they arrive at the facility,” explains Tuma.
Dr. Bob Owino, the HIV Coordinator in Siaya County, and the CASCO elaborates on just how impactful the KenyaEMR has been over the years.
“Impact has been huge; looking back at when we used to have a paper-based system, it was expensive, and storage was a big issue in terms of space. Looking at the volume and size the files were taking at the facility, it was a huge challenge. Some files used to get lost, and retrieving them was difficult. Now, manipulating the system is easy since all systems are integrated. It has made patient care easy and user-friendly from the time a client comes in, to the point where the client exits the system in a single visit.”
Tuma says that over time there has been an evolution of systems like C-pad and IQ care, among others, in Kenya, especially in Siaya County. “There was no standardisation and no stand-alone developer to manage those systems. However, with the introduction of Kenya EMR to manage patients in all facilities, it has enabled us to have centralised data, a centralised concept, and a standardised way of patient management and storage of data.”
The Kenya EMR has stood the test of time with some of its unique features. It is able to flag important indicators or variables that prompt the clinicians to offer effective service. “If a client is due for a viral load, test, cervical cancer screening, or even she is pregnant, the system prompts the provider. Artificial intelligence (AI) prompts have been included and are able to predict if a client is high-risk or a client is most likely to disappear.”
The system is able to request a viral load, meaning that the human labour is reduced in that process. In the HTS eligibility screening section, the system is able to use artificial intelligence to predict the risk score of any client before they are managed. CHS currently supports 81 facilities in Siaya County, which all operate on the Kenya EMR.
“Previously, termites would destroy files, or even a fire breakout ended up being costly. I remember in Madiany sub-ccounty hospital the CCC got burned with all patient records in 2017. Such issues when we have the EMR system, you can easily recover the data.” Explains Tuma.
With every system, there is always a risk at hand. However, the EMR system is able to track who does what and at what time. Any changes made can be tracked to the particular date, time, and the user who tried to tamper with records.
“The system is role-based and has role-based access. If you are not a system administrator, you cannot delete records. However, an administrator can be tracked to understand if any changes on the system were malicious or if it was in the process of clearing data errors in the system,” elaborates Tuma. CHS has subscribed to the Data Protection Act, and no one is allowed to tamper with data.
To facilitate and improve the quality of services at health facilities, CHS has also invested heavily in cloud EMR. This ideally means digital versions of patient data are accessed and managed online. The cloud-based EMRs are hosted on remote servers and accessed via the internet.
“One of the reasons we decided to roll out cloud computing was because of theft, burglaries, power cuts, and some times, facilities would go up to half a year without power. In a facility, a server would suddenly get lost. When you lose a server, you are putting a lot of things at risk, like patient records, equipment, and the cost attached to the equipment, as well as interrupting services,” Tuma further adds. “Currently, our server is secure at Konza, and we have introduced mobile tablets where users are able to access the server using these portable gadgets.”
At the health facilities, they have designated places where the tablets are kept safe under the care of the facility incharge. CHS has further invested in solar panels to facilitate the use of the Kenya EMR in the county. This has addressed the power outage issues at facilities.
According to Dr. Bob, currently, when a health care worker goes to the field, they carry the tablet and are able to see a client while key information is entered into the system, unlike previously, where the service was facility-based.
“With the facility-based one, you can only see a client when you are at the desktop in the facility; the moment you step out, no clients can be seen. That is at service level. At the supervision level, the Cloud EMR has made my work easy. On my laptop, I am able to access all treatment sites that are on the cloud. I am able to see any data issues, and my work is just to call the service providers, and we discuss it immediately. You can also do supervision anywhere, and we can discuss reports or any challenges since I can see data up to client level.”
It is easy to upgrade the Kenya EMR and the modules; before cloud EMR, it would force a systems information officer to go to each facility to upgrade the system, but today all systems can be upgraded in a day. There is reduced investment in security like burglary proofing, as well as maintenance of servers, which was very expensive.
“Since the introduction of EMR, we are able to follow up on patients in a better way as most of our records are in order. We are also able to monitor and review them,” says Yvonne.
According to William, “It also helps in clinic management since you can see the number of patients booked that day, allowing you to manage your clinic and also prioritise patients who are on differentiated care among the children and adults.”
CHS continues implementing programmes with the aim of ending the HIV epidemic in Siaya County. By introduction of Kenya EMR and Cloud, patients are able to receive timely and appropriate high-quality management by the clinicians.
“Before you would find a patient having a high viral, with their results not in the patient file. This patient would continue to suffer and some would die; with the Kenya EMR and with the automated transmission of viral from the central lab to the facility and vice versa, we are able to get the viral load in time, and this helps in managing patients, including children,” says Tuma.
“When it comes to sexual gender-based violence reports, you cannot get that report on the Kenya EMR, although there is a module. This should be addressed so that we can drop the physical registers,” adds William.
Amid the gaps, the Kenya EMR has proved to benefit the health facilities in managing patients better. At CHS, our patients are our priority, and we continue to offer them quality care as we work towards ending the HIV epidemic.