• Manuals and toolkits

Manuals and toolkits

This article describes the rationale and experience of using a touchscreen electronic medical record (EMR) system at the point-of-care (POC)  to monitor and support antiretroviral therapy (ART) scale up in Malawi.

The EMR eliminates the process of manual updating of paper registers and data aggregation for cohort and survival analysis reports, and produces cohort reports at the touch of a button on the screen.

The paper presents a model, developed and refined in Malawi, that has the potential to improve data quality and clinical efficiency in low-resource settings by integrating EMR and monitoring and evaluation (M&E) systems.

Key summary points from the article are:

• complete, accurate, and timely data are critical for providing high quality patient care, programmatic monitoring and evaluation of ART scale-up, continuity of care for chronic illness, and rational drug forecasting.
• manual paper-based aggregation of data and compilation of reports become unfeasible as patient cohorts on treatment and data increase.
  
• a POC EMR system combines healthcare delivery and data collection processes into one activity, with the added bonus of providing enhanced decision support to clinicians during the patient encounter.
  
• challenges associated with operating computers in a resource-constrained setting are many, but have been rigorously addressed during the scale-up of POC EMR to monitor and support ART scale-up in Malawi.
  
• the experience gained and infrastructure built through successful deployment of the ART EMR will facilitate its adaptation and use for other chronic diseases (e.g., tuberculosis, diabetes mellitus, and hypertension), preparing a foundation for a comprehensive electronic health record system.

Conclusions from the article include:

• implementing a POC EMR has been more challenging than initially anticipated.
• many of the technical difficulties have been addressed and resolved in the 8 years of ongoing system development in Malawi.
• the success of a POC system ultimately depends as much on a commitment from system users as on the technologies employed.
  
• poor adherence to system use will result in incomplete data.
  
• supervision is a necessary but insufficient requirement to ensure system use.
  
• health workers will not adopt a system if they do not find sufficient value in it. Consequently, the primary challenge is to identify and address the value proposition for the user. This is an iterative process that requires a commitment to regular and ongoing dialog with the users if this paradigm shift to POC system use is to be sustainable.
  
• the experience gained, and infrastructure built, through successful deployment of the ART EMR will facilitate further rollout to other high-burden ART sites in Malawi.
  
• there is great potential for its adaptation and use for other chronic diseases as mentioned above.
  

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