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