We recently worked on a research project commissioned by a digital government team in Africa. Their focus was scoping investment opportunities in the digital health space, and especially Electronic Medical Record (EMR) systems.

We reviewed existing research and spoke with experts who have supported the development of EMR systems across a diverse array of health facilities spanning Madagascar, Mozambique, Nigeria, Malawi, Kenya, and Egypt.

Our goal was to identify the success factors behind designing and implementing EMR systems in low and middle income contexts; the government team went on to use our findings to make an informed decision on whether or not to prioritise this initiative based on their needs and constraints.

EMR systems refer to a digital version of a patient's file which contains the history of medical care and treatments provided by a health establishment. EMRs can be beneficial in a range of environments. They deliver opportunities to reduce administrational labour and make efficiency gains, but first and foremost they can help improve healthcare services. For instance, joined up records enable clinicians to immediately see the health risks associated with a new patient, such as allergies to certain medication, and to tailor treatment accordingly.

However, our findings revealed that EMRs systems in these settings only function effectively and sustainably under specific conditions. Those which succeed are able to do so thanks to careful and early consideration of the needs of clinical staff and continuous improvement of the system, which requires long-term investment and resources.

This article explores some of the conditions necessary to allow African countries to reap the benefits of EMR systems. Although our focus was African countries, many of the findings were resonant with our work in the NHS.

Many EMR systems currently in use in African countries are the result of donor-led initiatives and are often focussed on specific diseases. Where these projects exist in isolation, perhaps with limited involvement from the countries’ Ministries of Health, they create challenges in creating a coherent digital experience and easy data sharing.

Lots of EMR investments began with a focus on AIDS patient monitoring. As both a serious public health issue and a condition requiring long-term monitoring of patients, AIDS became an entry-point for EMR systems across some African countries such as Kenya, Uganda, Malawi or Mozambique. This was helped by targeted funding programmes from international donors and sponsors, notably through the US AIDS programme PEPFAR.

While many of these projects have proved to be transformative in impact, donor-led initiatives are most impactful only under specific conditions, four of which we summarise below.

Condition 1: A clear expected outcome

EMR systems can offer several benefits to healthcare providers. But without a clear intended outcome - a problem to be solved - they do not inherently add value. In fact, there is a danger of funders investing in EMR systems without a clear idea of the added value of the service when balanced against the effort and resources required to achieve it, such as the extra administrative burden on clinical staff.

Our research revealed an example of an EMR implemented in Rwanda, where a key priority addressed by the system was to reduce the mortality rate of patients referred to hospital by community workers. As these patients didn’t have ready access to health facilities and only travelled to the hospital in urgent cases, they were unable to explain the urgency of their condition and were thus not always provided with suitable care.

Given the significant and tangible value in enabling clinical staff to solve this problem using an EMR, the value it delivered outweighed the costs inherent in the system’s implementation. However, if the EMR had been implemented purely for efficiency reasons (as opposed to a tangible journey to care improvement), the extra burden of its implementation on clinical staff might have led to huge adoption challenges.

Condition 2: Long term funding

The implementation of an EMR system is not a one-off expense, but a process requiring continuous investment of resources.

Processes and service design in healthcare settings evolve rapidly. This means that, following implementation, an EMR system must be adapted continuously by technical teams in order to keep abreast of clinical workflows, as well as to manage technical challenges and data security.

As such, technical teams must be maintained and funded beyond implementation, and kept in continuous dialogue with the clinical teams using the system.

This demands a model of sustained funding and continuity which is often underestimated at the start of funding projects. Infrastructure costs, such as IT equipment and connectivity costs, are often underestimated too.

Without essential financial and systemic continuity, EMR systems risk becoming defunct and eventually falling into disuse.

Condition 3: Incentives for clinical staff

EMR systems can be unappealing to some clinicians. They typically bring an initial administrative burden, and place new demands on levels of digital literacy.

More controversially, EMRs also raise accountability which can be viewed with suspicion by some clinicians. The transparency provided by the system makes it possible to verify the activities and decisions of medical staff (such as the number of patients examined, the diagnoses given, etc.). Although this is shown to increase quality and safety in the long term, in the short term clinicians can feel deskilled or patronised.

There is also the risk of resistance to EMRs due to internal politics and corruption. Anecdotally, our research pointed to cases where EMRs had been rejected by staff due to concerns around exposure of petty corruption.

This means an EMR system must deliver clear value and incentives for clinicians, rather than just large-scale efficiency gains, so that its benefits outweigh its perceived drawbacks. This demands careful consideration during development of the needs of clinicians and what will prove value-adding in their day-to-day work. These benefits should be complemented by transparency, technical support and training.

These challenges can be profound and complex, and will vary dramatically between different contexts. That said, our research revealed encouraging stories of success, such as a healthcare provider in Nigeria which has successfully implemented an EMR designed to improve clinical workflows and reduce errors in data collection. The success of the EMR was attributed in part to the early involvement of clinical staff in the system’s implementation, and the fact that they continue to benefit from training and user support.

Condition 4: Involvement of senior healthcare staff

An EMR system serves as a crucial medical tool. Which is why there must be collaborative ownership between the digital team constructing it and the healthcare team it serves.

It's imperative for clinical leaders to play a pivotal role in EMR implementation projects and their oversight, starting from the earliest stages of planning. Leadership must demonstrate a commitment to jointly shouldering the responsibility for the project's outcomes, and be prepared to advocate for the EMR system within their teams.

The genuine efficacy of EMR systems - designed and built for purpose - can only be achieved through a tightly knit partnership between clinical staff leadership and digital teams.

The development and implementation of EMR systems is challenging, and even more so in the context of countries that face obstacles of digital literacy, infrastructure issues, and funding constraints.

We encourage organisations that are considering investing in EMR to carefully consider what they want to achieve, assess the level of efforts and resources required to achieve it, and compare the two. In a world of unpredictable or limited funding availability, there may be simpler and quicker ways to leverage digital opportunities in the health space than EMR systems.

Yet for countries that have started to take this path, we can not emphasise enough importance of digital and clinical staff working together, and this beyond the launch of the system to ensure continuous improvement.

At Public Digital we are working at the intersection of digital and health, with a growing focus on the Global South. Reach out to chris.fleming@public.digital to learn more.

Image: Simon Davis/DFID