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Research Article

Evaluation of the electronic health record system in maternal and child health centers of Marie Stopes International Ethiopia

[version 1; peer review: 2 not approved]
PUBLISHED 07 Nov 2019
Author details Author details

This article is included in the International Conference on Family Planning gateway.

Abstract

Background: The Health Information Management Systems Society (HIMSS) defines an Electronic Health Record (EHR) as a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting”. EHR systems improve quality and adaptability of care, contributing to patient safety. The system is also efficient and provides real-time administration to patients. Driven by the need to facilitate clinical and administrative process, and to reduce medical errors, Marie Stopes international Ethiopia (MSIE) implemented EHR system in its maternal and child health (MCH) centers. This study sought to evaluate the EHR system in six departments (inpatient, outpatient, pharmacy, laboratory, reception cashiers and MCH managers) of these MCH centers in terms of ease of performing tasks and satisfaction with the system.
Methods: A cross-sectional method with formative evaluation was used to address the objective. A sample size of 54 were used for the investigation. The participants were from six departments (inpatient, outpatient, pharmacy, laboratory, reception cashiers and MCH managers) within three MCH centers. Data was collected using structured, self-administered questionnaires and interviews and analyzed using SPSS 20.
Results: In total, 83% of respondents found that performing tasks using EHR made tasks easier; the lowest score was from Pharmacy department (48%). The overall satisfaction with EHR was 87%. The lowest score is from the indicator “the system meets my needs” (80%).
Conclusions: Staffs in all department reported the EHR system as “very good” for both ease of performing their daily tasks and satisfaction with the system. In addition, the study revealed that ease of performing tasks and satisfaction with the system were varied by department and specific task within the department. It is essential to know the needs and requirements of each department before implementation of the system and user feedback for long lasting uptake and impact.

Keywords

Electronic health recording system, user satisfaction, Ethiopia and evaluation

Abbreviation

EHR, electronic health record system; HIMSS, health information management system society; MCH, Maternal and Child health; MSIE, Marie Stopes International Ethiopia

Introduction

The Health Information Management Systems Society’s (HIMSS) define EHR as: “The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information, are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports” (Ahmed et al., 2013).

Recording of patient data on paper obstructs the coherence and nature of medical care offered to patients. Furthermore, paper-based frameworks have restricted usefulness, limiting reviewing of medical records by care givers simultaneously. Storage of paper records takes up more space and hinders easy access to patient information (Carayon et al., 2009). By contrast, EHR can create a complete patient record of the entire clinical experience. The system automates the clinical work process and improves quality of care (Ahmed et al., 2013). Patient records can also be easily retrieved using the patient’s name, phone number or registry number.

Currently, paper-based recordings are being migrated to electronic recording systems because electronic health recording (EHR) systems improves quality and adaptability of care recording, contributing to patient safety. The system is also efficient and provides real-time administration to patients (Rezaeibagha et al., 2015). Therefore, using HERs is an essential part in health care delivery to improve quality and safety (Ellsworth et al., 2017). The US Institute of Medicine has characterized EHRs as an essential technology for improving the safety, quality and efficiency of health care (Chiang et al., 2013).

An assessment of nine hospitals that implemented a comprehensive electronic health record (EHR) system discovered an improvement on the speed and accuracy of communication leading to less duplicative tests, quicker responses to client’s needs, and a complete capture of charges (Silow-Carroll et al., 2012).

The averted costs associated with efficiencies created by maintaining and availing patient data electronically contributes to the financial benefits of the EHR system. Some of the averted costs are related to reduced staff number required in patient management, reduced stationary and printing costs required to maintain paper records (Menachemi & Collum, 2011).

On the other hand, a study done in a residency’s family medicine center in Birmingham, AL, USA, revealed that Physicians and residents are very dissatisfied with the amount of time required for documentation using the EHR system (Bloom & Huntington, 2010). Following the implementation of EHR, both clinical staff and office staff spent more time on transcribing data to computer to maintain medical information system (Carayon et al., 2009).

In this study we will evaluate the EHR system implemented in three of the MCH centers in Marie stopes international Ethiopia (MSIE). The study will evaluate ease of performing tasks and satisfaction with the system in six departments (inpatient, outpatient, pharmacy, laboratory, reception cashiers and MCH managers). Each department performs a unique task that contributes to the overall performance of the facility. Thus, we hypothesized that the ease of performing tasks and satisfaction with the EHR system varies by department and by specific task within a department.

Methods

Study approach

We used a cross-sectional study with formative evaluation method to address the objective. At the time of the investigation there were 134 staff members from three of the MCH centers using the EHR system in their daily activities. Of the 134 staff members, only 68 fulfilled the selection criteria of working 6 months in the MCH center prior to the implementation of the system. From the selected 68 staff members, only those trained by MISE about the system were selected as final study participants. Therefore, a total sample size of 54 participants were used for the investigation. The participants were from six departments (inpatient, outpatient, pharmacy, laboratory, reception cashiers and MCH managers) within three MCH centers.

Data was collected using structured, self-administered questionnaires and interviews (available as Extended data (Sharew, 2019)). The interviews were conducted with two people from each department to find out their daily tasks. Then a unique set of task list was prepared for each department. Using these task lists, a different questionnaire for each of the six departments were developed. The questionnaires involved a section where the respondents answer by ticking and a section where respondents are asked to answer by writing.

Data analysis

Data were then checked for completeness, consistency and analyzed using SPSS for Windows v20. The usefulness dimension was measured by how the participants found the system affecting their day to day activities and operations. The user satisfaction-dimension was measured for relevant aspects. Each dimension and their indicators were judged using a judgement criterion: >95% excellent, 80–94% very good, 65–79% good, 50–64% fair, <50% poor. Descriptive statistics tables and graphs will be used to describe the findings.

Ethical approval

The study was conducted after ethical clearance was obtained from the Institutional Ethical Review Committee of Addis Ababa University School of Commerce. During the data collection period, the participants were well informed about the purpose of the study. Written informed consent of the respondents was obtained before the commencement of the study. Involvement was fully decided by the participants. The response was confidential. Monitoring and supervision of data collectors was done throughout the whole data collection period. To assess the completeness, clarity and consistency the collected data were checked daily after data collection.

Results and discussion

Demographic data of respondents

Of the total 54 respondents, 17 (31%) were from the inpatient department and 18 (33%) were from the outpatient department. Of all the participants, 31 (57%) worked between 4 and 5 years with the organization. Of the respondents, 14 (26%) were nurses and 11 (20%) were midwives (Table 1). Results from all surveys and questionnaires are available as Underlying data (Sharew, 2019).

Table 1. Descriptive of socio-demographic of respondents (n=54).

Sociodemographic variablesFrequencyPercentage
Department of respondentsInpatient1731%
Outpatient1833%
Pharmacy 59%
Laboratory47%
MCH Manager36%
Reception Cashier713%
Type of respondentsMidwife1120%
Nurse1426%
Health officer611%
Gynecologist47%
Pharmacist/Pharmacy technicians59%
Laboratory technicians47%
Non-health professionals1019%
Work experience, years4–53157%
5–61528%
7–10815%

Ease of performing tasks using EHR

Inpatient department

Most participants from the inpatient department agree that the EHR system made their daily tasks easier. Admitting patients, following admitted patients’ medical usage and monitoring consumables during procedure were indicated by all the participants from the department as activities made easier following EHR implantation (Table 2). Similarly, a study done in a small family practice clinic in USA also indicated an increase in time spent on patient care and decrease in time spent in meeting and performing lab works (Carayon et al., 2009).

Table 2. Ease of performing tasks using EHR in the inpatient department.

How has the EHR system changed the
performance of the following tasks?
More difficult/slightly more
difficult/no change
Slightly easier/easier/
significantly easier
To admit patients has become0%100%
To refer clients to other Medical center/
specialists/departments has become
6%94%
To follow admitted clients Medication usage0%100%
To monitor consumables during procedure0%100%
Billing for consumables6%94%
To follow 1st stage labor care12%88%
To follow 2nd stage labor care12%88%
To monitor labor using partograph12%88%
To follow post-delivery status6%94%
To monitor OR outcome6%94%
To monitor Neonate outcome24%76%
Overall ease of performing tasks using EHR/Inpatient92%

Outpatient department

In total, 94% of those in the outpatient department felt EHR made performing tasks easier (Table 3). All respondents agree that the system made it easier to seek out specific information from the client record, to produce data reviews for specific patient groups, to order clinical laboratory, to order and receive ultrasound results and to write prescription. However, only 61% of the respondents agree that the system made it easier to complete sick-leave forms.

Table 3. Ease of performing tasks using EHR in the outpatient department.

How has the EHR system changed the performance of the
following task?
More difficult/slightly
more difficult/No change
Slightly easier/easier/
significantly easier
To review the client’s problems has become6%95%
To seek out specific information from the client record0%100%
To follow the results of a test or investigation has become6%94%
To enter daily notes has become6%94%
To answer questions concerning general medical knowledge (e.g.
Concerning treatment, symptoms, complications etc.) has become
11%89%
To produce data reviews for specific patient groups (EG.
Complication rate) has become
0%100%
To order clinical laboratory analysis has become0%100%
To obtain the results from clinical laboratory analysis has become6%94%
To order ultrasound investigation has become0%100%
To obtain results from ultrasound has become0%100%
To refer the patients to other departments or specialists has
become
11%89%
To order treatments directly (E.g. medicines, operations etc.,) has
become
6%94%
To write prescription has become0%100%
To complete sick-leave forms has become39%61%
To give written individual information to patients (E.g. About
medications, disease status)
6%94%
Over all ease of performing tasks using EHR/Outpatient94%

Pharmacy department

The result showed that the system made it easier to know available drugs in the dispensing area and billing for medications. However, the respondents indicated that the system made the it difficult to rule out drug interactions and maintain allergy and active medication lists (Table 4). The study revealed that the need and the requirements of pharmacy department had not been reflected in the system design. The agency of healthcare research and quality to support research policy information in the area of EHR indicated that, if effectively implemented, EHR system reduces the need to rely on memory alone for information required to complete a task such as medical history, allergies and formulations (Armijo et al., 2009).

Table 4. Ease of performing tasks using EHR in the pharmacy department.

How has the EHR system changed the
performance of the following tasks?
More difficult/slightly more
difficult/no change
Slightly easier/easier/
significantly easier
To clearly read prescription40%60%
To dispense medications40%60%
To dispense multiple drug from the prescription60%40%
To know available drugs in dispensing area0%100%
Monitor medications by expiry date80%20%
Serving clients in order20%80%
Billing for medication0%100%
Implement drug-drug and drug-allergy interaction
checks
100%0%
To maintain an active medications allergy list100%0%
To maintain an active medications list100%0%
To detect duplication of therapies20%80%
To monitor controlled drug prescription60%40%
Over all ease of performing tasks using EHR/Pharmacy48%

Laboratory department

The overall ease of performing tasks using EHR in laboratory department was 82%. From the list of activities performed in laboratory department, only half of the agree that the system make processing lab packages by category of services easier (Table 5).

Table 5. Ease of performing tasks using EHR in the laboratory department.

How has the EHR system changed the
performance of the following tasks?
More difficult/slightly
difficult/no change
Significantly easier/
easier/slightly easier
Receiving lab orders0%100%
Serving clients in order0%100%
Avoiding errors in giving results25%75%
Billing for service25%75%
Ensure accuracy of lab results25%75%
Process reference laboratory results0%100%
Process lab packages by category of services
(ANC, CAC)
50%50%
Over all ease of performing tasks using EHR/Laboratory82%

Reception cashiers

All the respondents, reception cashiers, showed that the system made their daily task easier (Table 6).

Table 6. Ease of performing tasks using EHR for reception cashiers.

How has the EHR system changed the
performance of the following tasks?
More difficult/slightly
difficult/no change
Significantly easier/
easier/slightly easier
To register patient/client information-100%
Finding mistakes and missing information-100%
Billing and change capture-100%
Searching for patient file-100%
Finding the exact client document searching for-100%
Over all ease of performing tasks using EHR/Reception cashiers100%

MCH managers

MCH managers found the system easy to use when performing most of their day to day activities. However, 67% of the respondents indicated that the system makes it difficult to do income to cost ration (Table 7). Similarly, a survey done in Australian hospitals revealed that a majority of managers (82%) stated that EHR improved data quality by readily availing information and improving the legibility of records (Mckenzie, 2003).

Table 7. Ease of performing tasks using EHR system for MCH managers.

How has the EHR system changed the
performance of the following tasks?
More difficult/Slightly
difficult/no change
Significantly easier/
Easier/Slightly easier
Getting total number of clients as needed0%100%
Getting provider level performance0%100%
Getting number of clients/services0%100%
Producing data reviews for specific patient groups
(e.g. complication rate, diagnosis)
0%100%
Total cash collected daily/weekly and monthly0%100%
To calculate income to cost ration67%33%
To show service trend0%100%
Providing remote access to data33%67%
Providing live data for presentations33%67%
Controlling fraud0%100%
Over all ease of performing tasks using EHR/MCH Manager81%

User satisfaction

When participants asked to rank their satisfaction with various aspects of use, total reported satisfaction with the EHR system (agree/strongly agree) was 87% (Figure 1). With the work they do on EHR system, inpatient staff were least satisfied (72%) followed by outpatient (74%) and pharmacy department (76%).

94becbf5-d278-4daa-b33d-27098634d401_figure1.gif

Figure 1. Satisfaction reported by staff in each departments.

Limitations

Limited literatures were available to compare and discuss the findings with, and social desirability bias.

Conclusion and recommendations

Staff in all department reported the EHR system ease of use as ‘very good’ for ease of performing their daily tasks using EHR system. The lowest score for ease of performing tasks was from pharmacy department and highest score was from reception cashiers. The reported satisfaction with the system was also high. In addition, the study revealed that ease of performing tasks using EHR and satisfaction with the system varied by department and by task within a department. It is essential to know the needs and requirements of each department before implementation of the system and getting user feedback for long lasting uptake and impact. It is also imperative that the workflow and information needs of each unit are met to optimize system utilization resulting quality of care.

Data availability

Underlying data

Figshare: Evaluation of EHR system. https://doi.org/10.6084/m9.figshare.8203172 (Sharew, 2019).

This project contains the following underlying data:

  • CM.sav (responses from MCH managers)

  • IP.sav (responses from inpatient staff)

  • laboratory.sav (responses from staff in the laboratory department)

  • OPD.sav (responses from outpatient staff)

  • pharmacy.sav (responses from pharmacy staff)

  • receptionists.sav (responses from cashiers/receptionists)

Extended data

Figshare: Evaluation of EHR system. https://doi.org/10.6084/m9.figshare.8203172 (Sharew, 2019).

The project contains the following extended data:

  • questionnaire.pdf (questionnaire used in the present study with consent form)

  • Interview guide.pdf (survey given to all participants)

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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Gizaw T, Bogale M and Alemayehu T. Evaluation of the electronic health record system in maternal and child health centers of Marie Stopes International Ethiopia [version 1; peer review: 2 not approved]. Gates Open Res 2019, 3:1655 (https://doi.org/10.12688/gatesopenres.13001.1)
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Version 1
VERSION 1 PUBLISHED 07 Nov 2019
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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
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Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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