Along Came Standards and Guidelines for EMR Systems in Kenya

An Electronic Medical Record (EMR) is defined as a computerized  medical record created in an organization that delivers care, such as a hospital and doctor's surgery - (in wikipedia). EMR systems, information systems used in health facilities to manage EMRs have remained a popular topic of discussion among Kenya's eHealth initiative's over the last five years.  

A knowledge-based economy

A nation wide adoption of EMR systems in Kenya promises to increase effectiveness of the national health care system from policy making, to financing,  and to service  delivery at health facilities. This is by strengthening the practice of knowledge management in health care. Among other things, it would support evidence-informed decision making at the various service delivery levels of the national health system.  

A health care system in Kenya with efficient knowledge management and decision making will not only create a healthier and more economically productive Nation. It will also foster development and harnessing of such knowledge as a resource for wealth creation within and across Kenya’s borders.

Entrenched Fragmentation

A significant number of fragmented, strongly entrenched and donor funded EMR systems have come into existence at our health facilities over the last decade. The fragmented initiatives have diverse approaches to issues like stakeholder inclusiveness, health data ownership, systems development and support, systems ownership and sustainability. The total cost of ownership (TCO) profiles of the fragmented initiatives are also diverse. They range from low cost open source community supported systems to high cost vendor supported systems thriving on the occasional waves of donor funding.

With the fairly uncoordinated setting above, the debate on a road-map for nationwide adoption of EMR systems has been emotive if not controversial over the years. About 6 years ago, in August 2004 to be specific, the World Health Organization (WHO) convened a meeting of EMR systems stakeholders in Nairobi.  The stakeholders included National AIDS Control Programs of five African countries, clinicians and developers of EMR sytems and learning experts.

Delayed conclusion of matters

The WHO meeting of August 2004 recognised among other things that “development and implementation of EMRs in Africa has resulted in numerous small projects without data content or data exchange standards, running the risk of creating a fragmented and chaotic information environment in which national data reporting and mobile patient tracking would be severely impaired;

In recognising the above challenge, the same meeting also called upon the WHO to “work with partners including African Ministries of Health, the CDC, developers of EMR systems used for Africa, and clinicians to establish basic standards to allow interoperability, mobile patient tracking, and the possibility of national and cross national data mining.” To further quote the meeting’s report, The WHO’s support was also to recognize the fact that “These standards include electronic information exchange standards, agreement on the approach to core minimal data sets, and the establishment of a common data dictionary”.

The state of affairs

6 years later, Kenya has continued suffer an unduly protracted debate on EMR initiatives whose systems are nowhere near nationwide, cannot inter-change data and are without a common concept dictionary. More information on the August 2004 meeting and some of WHOs initiatives on Knowledge management platforms for clinical care can be found here. It remains difficult to understand why it has taken long to confront the challenges highlighted in the meeting. The explanation can get as complex as the stakeholder’s interests.

Major strides forward

It should be with some relief that stakeholders will be seeing the official launch of the 'Standards and Guidelines for EMR systems in Kenya' this November. The standard and guidelines document has been developed with the support of PEPFAR through I-TECH, a collaboration between the University of Washington and the University of California, San Francisco. Development of the document has also benefited extensively from the leadership of the government’s Division of Health Information Systems and the National STI and AIDS Control Program (NASCOP).

The document should go a long way to improve the framework and environment for development, deployment and implementation of EMR systems in Kenya. It attempts to leverage on recognized national and international standards for health informatics. The document also attempts to build on learning from experiences of historical EMR system implementations.

In the document’s section two, it sets national standards for information interchange and interoperability. This will help to foster information exchange between EMR systems at different health facilities. This should address among other issues mobility of health care clients.  The interoperability standards will help foster a deliberate awareness among EMR systems of pharmacy information systems, district health information systems, financial management systems and other subsystems in a health facility’s enterprise architecture.

The document’s section 4 on governance and policy attempts to set standards for systems ownership, TCO profiles and sustainability. It also goes further to set a standard for health data ownership. The document also spells out the responsibility of the Division of Health Information Systems to ensure the standards are enforced.  The possibility of this responsibility being delagated to NASCOP and other disease programs is also specified in the document.

Areas of improvement

As with a majority of standards documents, The ‘Standards and Guidelines for EMR systems in Kenya’ still has much room for improvement. One of the weakness could be how the document addresses “the approach to core minimal data sets, and the establishment of a common data dictionary” - identified in the August 2004 WHO meeting. A gray area remains on how well the use of medical concepts and terminologies can be standardised for uniformity and comparability of data held or shared across computer systems.

The apparent inadequate engagement of stakeholders in the ICT industry in developing the standards and guidelines can also be flagged against the document. For such a document, there would have been a need to seek the views of the ICT private sector - companies and private practitioners.  If the synergies such as those described in my earlier article on EMRs sytems and the Kenya software industry are to be pursued, future enhancements of the document would require a meaningful engagement of the ICT industry. Key players in Kenya’s ICT landscape include the Kenya ICT Board, the Directorate of e-Government and professional communities such as the iHub and KICTANET.

An evolving set of standards and guidelines

Although the document could arguably have some weaknesses, the document was cautious enough to invite readers to view its content as ‘evolving guidelines’. It proposes to be a ‘living document’ and states that  “the process to identify and agree upon EMR requirements and recommendations presented in this document is more important than the guidelines contained in this initial version”. Dr Patrick Odawo, I-TECH’s Country Director also indicated that they would set up an official forum for discussing the document and its continual improvements on the Google Groups platform.

For readers interested in more insights about standards for EMR systems and their practical implications, I shall embed a video of a presentation made by Dr. Paul Biondich of OpenMRS two years ago.  
The presentation touches on the possibility of having standardized concept dictionaries for vocabulary management. It was made during a WHO conference on data standards in December 2007

Bharti Airtel’s Muted Contribution to Kenya’s Knowledge-based Economy

Tweet triggered

In the afternoon of 23rd October 2010 I posted this micro-post (tweet): “Thinking telcos' price competition for voice market is contributing silently to Kenya's knowledge economy” As usual I got a couple of reactions. The reactions set off my intentions to say more and justify my thoughts - as it were, in this article, outside twitter’s confinement of 140 characters.

A knowledge based economy can be viewed from Peter Drucker’s work in the 90s as “an economy based on intangible goods and intellectual capital as the economic driver”. To also quote Vern McCorkle the late publisher of Alaska Business Monthly magazine, “In our traditional capitalist economy, a knowledge-based economy stands in sharp contrast to long-established economic theory because it relies upon innovation and intellectual capital rather than hard goods to generate economic value.

Perhaps in the tweet I should have used the phrase knowledge-based economy as opposed to knowledge economy, then I should have pre-emptied some of the confusion. However I shall insist that the competition among Kenya’s mobile network operators for both the Voice and SMS markets on the basis of price is contributing significantly to the growth of the country’s knowledge-based economy.

Bharti Airtel’s Daredevil Onslaught

I am attributing the benefits of plummeting communication costs to Bharti Airtel because their Zain Kenya LTD outfit is the ‘chief protagonists’ in ‘the war’. They have boldly and almost recklessly been taking the price war to the invincible player - Safaricom LTD. Whether Bharti Airtel’s artillary for the war includes the deep pockets of their extensive and diversified global business empire will be discussion for another day.

Not to forget the role of the regulator, it is noteworthy that the price wars followed the lowering of interconnection charges by Communication Commission of Kenya (CCK). Safaricom tried to use its market share muscle and well calculated network lock-in tactics to resist the expected fall in prices. At the same time Bharti Airtel has tried rather successfully to neutralise Safaricom’s network lock-in tactics by offering a network agnostic price structure. To a number of observers including Safaricom’s Michael Joseph, Bharti Airtel’s network agnostic pricing structure appears to be like a deliberate loss making strategy for the medium term. Many think it is largely financed from sources other than their expected revenue.

For a this moment I invite readers to forget the fairly inconsequential concern of who will win the war and the fact that outgoing Safaricom’s CEO predicts that the war will be won by Safaricom. I shall let us concentrate on the war’s net effects on Kenya’s knowledge-based economy.

For purposes of the forgoing argument, I shall lazily assume it is safe to estimate the current average drop in prices to be by least three times - roughly to an average of Ksh 3 per minute for voice calls and Ksh 1.5 per SMS. My other presumption is it appears safe to say that we are talking about huge permanent price cuts with permanent economic effects - seeing that Bharti Airtel’s Zain asserts that their new revolutionary pricing structure is permanent and not an offer.

I shall propose two effects specific to Kenya’s knowledge-based economy which I consider significant but currently muted in the sense that they may not be visible on the surface.

Effects on Decision Making

The drop in communication costs means that those Kenyans who have had X shillings monthly communication budget can retain their budget while upgrading their voice conversations and text messages to a higher level of communication quality and fidelity. In many cases, mobile communication has now been enriched from typically short ineffective exchange of messages (mostly instructions) to more meaningful discussions, deliberations, negotiations, and whatever other form of advanced knowledge exchange.

The more effective communication above (Voice or SMS) lends itself favourably for applications of knowledge transfer among correspondents. The increased knowledge exchange among communication correspondents implies improved, evidence based decisions in our economic sectors.

The resulting effect will be more obvious in the Jua Kali sector where the former prohibitive cost profiles reduced mobile communication to rushed, curt, ineffective conveyance of important information. These productive participants in the economy now have an increased luxury to meaningfully consult their mentors, peers, suppliers, consumers on more cost effective and efficient ways of delivering their value propositions.

The effect might appear more subtle but significant nonetheless among our larger enterprises. This will happen when consultative processes are leveraged with improved enterprise level communication using the significantly less resources as a result of an ‘enhanced’ communication budget.

Effects on Knowledge Distribution

The huge gap between the economic haves and have nots in Kenya may be easily attributed to disparities in the distribution of traditional wealth generation factors like land, labor and capital. However, to quote Peter Drucker again, “The basic economic resource - the means of production - is no longer capital, nor natural resources, nor labour. It is and will be knowledge”. I suggest that unequal knowledge distribution is a significant contributor to Kenya’s large economic disparities. I also suggest that knowledge as an economic resource is most valuable when it can be communicated and used.

Information technologies such as Voice telephony and SMS messaging which are now fairly pervasive in Kenya and the world over facilitate exchange of knowledge. The apparent price wars have meant that many more Kenyans can now afford to make many more conversations on phone and can send more text messages to enforce their information exchange with more people. As more people talk and send SMS texts without being overly encumbered by the cost factor, the resultant effect should be a more even distribution of the critical knowledge that differentiates the educated wealthy from the educated poor.

The resultant effect or increased communication should be a more evenly distributed collective country knowledge base.

The logical consequence

Whether Bharti Airtel’s venture in Kenya will eventually make business sense to them will remain a ‘wait and see matter’. However what should remain important to Kenyans is the fact that reduced communication costs should translate to more evidence informed decisions and a more evenly distributed national knowledge base. This should translate to a stronger knowledge-based economy in Kenya. I shall invite the scholars to try and extend or dismiss my arguments through some more research on a couple of hypotheses in this article.

Extended Thoughts on Reflections with Michael Joseph of Safaricom

This Mashujaa Day was a lazy one for me - some kind of forced day of rest to nurse a sore throat I had. On this day I got a coveted opportunity to form part of some 60pax audience at the iHubNairobi listening in to reflections from Mr. Michael Joseph. Michael or MJ as we call him is the out going CEO of Safaricom LTD - East Africa’s largest firm by corporate earnings. It was a lazy day so I really did not want to tweet through the session. Nevertheless I yielded to the temptation - as usual, and had some 32 tweets with the hash tag #mjreflections.

I was seated next to @UjenziBora who shared his intentions to blog his own tweet stream from the event. I liked the idea so here is my over-elaborated execution of the copied idea. I shall simply try and give my underlying thoughts on my ‘live-session’ tweets. I shall also number them so that when you get tired, you could go and come back to resume where you will have left.

  1. (tweet) Peculiar site to see MJ of Safaricom in blue jeans -> (the underlying thought) I was honestly shocked to see Michael Joseph in blue jeans, away from his corporate suit and tie signature look.
  2. (tweet) Per minute billing would have made more business sense but Safaricom could not afford the system then -> (the underlying thought) Michael had to make the best of what he did not have. He settled for the lesser revenue option of per second billing and invested in marketing to consumers the truth that per second billing was better for them than Kencell’s per minute billing
  3. One more lesson - please don't surprise your customers - not even for free things -> Personally I don’t mind pleasant surprises like some free KES 800 airtime. As a businessman, I still won’t mind but would execute surprises with guarded caution.
  4. MJ admits M-PESA, okoa jahazi, Sambaza etc were not invented in Kenya -> My regular readers might already know that the origin and ownership of the MPESA innovation is one of the topics I get a little over-patriotic about.
  5. 2m pounds went into the initial MPESA software by Vodafone - after some DfID competition -> These appeared to be MJ’s distractionary way of pre-empting the emotive debate of why Safaricom does not own the patent for M-PESA. In my mind he is not off the hook yet. But its too late, Kenyans have already made M-PESA indispensable, under the impression it was their (Safaricom’s) intellectual property.
  6. Success of #MPESA is not the technology, it is the distribution network -> This I agreed with partially. However I shall continue to insist on marketing blitz and a sense of nationalism around the product being additional ingredients
  7. IT guys have learnt the art of giving excuses when things go down -> At that point MJ appeared silently agitated about some technical hitch - I felt him. IT guys have an annoying way of assuming that embarrassing situations are acceptable to blame on technology.
  8. There is no redundancy for the TEAMS cable - where it lands in mombasa - Plans to arrange for redundancy in Dar es Saalam -> With the technical hitch in tweet 7, MJ was distracted away from M-PESA to data services. I did not like his way of justifying sustained high data prices - redundancy of to Optic fiber cable at the landing points, onward connectivity to the internet beyond under sea cables, etc. We need another big connectivity provider to dislodge Safaricom from an exploitative dominance position which they are gettin to.
  9. MJ thinks Safaricom will win the 'War' with Airtel Bharti - prefers not to call it 'Price War' -> May the best value proposition to Kenyans win!
  10. Best advice MJ got was 'You have to make decisions yourself' even if once in a while you go wrong -> That obviously worked for him, problem might be how much further this style had got into Safaricom’s corporate blood. Can Safaricom survive a different kind of leadership?
  11. MJ of Safaricom has never read more than 5 pages of any business book -> I was forced to read many such pages for my MBA. I think experience is an expensive teacher. No further comments
  12. MJ is not a great fun of social media. He thinks his successor is though -> We can only wait and see how @ , the new man at the helm fairs as he sounds like a completely different kind of guy. Hoping though he wont start off with RFP’s for change management consultants. I am told Bob Collymore will be the guest at Aly Khan Satchu's Mindspeak event on 4th December 2010.
  13. MJ appeals to bloggers and others to use social media sensibly - not to spread falsehoods etc -> I agree. I always try my best and hope my best is good enough
  14. MJ would not consider outsourcing customer care - it is so tempting yet so critical as far as he is concerned -> That was so clever of him. I agree with the principle, but when he gave the purported reason of creating local jobs near JKIA I was not convinced.
  15. For BPO we cant just rely on the fact that we speak english, or are in a good time zone. We have to deliver quality -> This I really liked and I really hope the Vision 2030 implementation secretariat is listening in
  16. To MJ, this BPO thing is overrated in Kenya's vision 2030 - I also agree -> See Tweet 15
  17. Safaricom expects payback from their base stations within one year, most of them pay back within 6 months -> I don’t know enough to comment but @mwolooto thought Safaricom was not being fair to someone - I can't tell how
  18. Solar energy for BTS makes sense only when air cooling is not required - I didnt know that -> Going green should make economic sense a lot of times. It appears this its not all the time though
  19. MJ would indulge in local capacity building only because it makes financial sense - sort of CSR view I dont like -> At the time of tweeting this I had got me incensed with MJ sounding like financial sense was all about being seen to undertake Corporate Social Responsibility (CSR) - hence increased revenue. I don’t understand why many multinational(ish) companies do not recognize the need to build local capacity as strategic inputs for their own local business processes. Creating jobs as CSR will always appear as though one is after sanitize their acts of exploitation!
  20. MJ is seriously not convincing on local capacity building reasons - methinks it should be more about economic synergies -> My instant rant on tweet 19 above - wont comment more
  21. MJ of Safaricom never believed in the idea of changing ringback tones. Now regrets ceding more revenue share than would have allowed -> Was great to see that even the mighty in Kenya can wink and get out-witted
  22. MJ of Safaricom now asserts that MKESHO is his (personal) idea - interesting < Great revelation. I need a followup on my ealier post on MKESHO as a hint to more intrigues to come. I pray the exclusivity ends soon
  23. Safaricom's deal with Equity on MKESHO ends next year - that should be good riddance to some -> See tweet 22, no
  24. Safaricom CEO @iHubNairobi,we will be launching M-PESA buy goods on Friday,u can pay for shopping @Uchumi with M-PESA -> I was re-tweeting an interesting announcement through Safaricom’s official twitter account. Too much to talk about there - wont start
  25. 700,000 M-KESHO accounts in three months other banks want to cash in also -> See tweet 22
  26. Safaricom will make it possible to pay for items via MPesa from Friday at Uchumi branches See tweet 24 - so shall the MPESA queue stall when there are delayed SMS notifications?
  27. Safaricom needs the banks - will address the exclusivity issue. They probably will not do it with Stanchart or Stanbic -> I could read Michaels bad blood with Stanchart from his lips as he said this. Could it be because they gave banking partnership to Zain for ZAP-the would be rival to MPESA?
  28. I like MJ's passion around #MPESA, gets carried away by the topic -> Great passion this man has, I can’t help but think he might be secretly sharing a stake with Vodafone on the MPESA patent.
  29. Really what's business enabling about paying a license to a regulator? -> It’s hard to tell when the regulator is genuinely seeking funds to protect consumers
  30. Consistency of management contributed to safaricom's market share staying at 80% over a couple of years  -> Now Safaricom must face the inevitable moment of changing guard. Good luck after some really strong/autocratic leadership
  31. RT @tonymuny: I hope there is no fee involved when paying 4 goods in uchumi via mpesa -> I had to retweet the concern raised therein - someone I met at Uchumi indicates that there should be no extra transaction charge to the customer in the planned arrangement. See tweet 24 also
  32. MJ of Safaricom thinks he is one person that does not admit defeat at all --> I shall not rule out the possibility of someone else admitting defeat at Safaricom - many months after MJ has left
With all that said, may the best value proposition to Kenyans win!
I most probably missed some big insights while I was tweeting away the session with Michael. I recommend you also check out @UjenziBora's post for a different if not complementary post-event-analysis based on his live tweets.