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AN ONLINE OBSTETRICS/GYNECOLOGY MEDICAL RECORD

SYSTEM
A CASE STUDY OF SAHLA MEDICAL CLINIC

Submitted By:
AJRA ABDULLATIF MOHAMED
REG NO.: JTC-BIT-0117/2009

Project Proposal submitted in partial fulfillment of the regulations governing the


award of the degree of Bachelor of Science in Information Technology.

Under The Supervision of:


MR. FANON ANANDA

DEPARTMENT:
MATHEMATICS AND INFORMATICS

YEAR 2012

Table of Contents
Acronyms ....................................................................................................................................................... i
List of Tables .................................................................................................................................................. i
List of Figures ................................................................................................................................................. i
ABSTRACT ..................................................................................................................................................... ii
CHAPTER ONE ............................................................................................................................................... 1
INTRODUCTION ........................................................................................................................................ 1
Problem statement ................................................................................................................................... 1
Justification of the problem ...................................................................................................................... 2
Project Objectives ..................................................................................................................................... 2
System Objectives ..................................................................................................................................... 2
Deliverables............................................................................................................................................... 3
CHAPTER TWO .............................................................................................................................................. 4
LITERATURE REVIEW ................................................................................................................................ 4
Definition and Terminologies................................................................................................................ 4
An Analysis on Medical Record Terminologies ..................................................................................... 4
The Electronic Medical Record (EMR)................................................................................................... 5
The Electronic Health Record (EHR)...................................................................................................... 6
EMR Implementation ............................................................................................................................ 6
Benefits of the Electronic Medical Record (EMR) ................................................................................. 7
Challenges of Electronic Medical Records ............................................................................................ 8
Use of EMR in Developed Countries ................................................................................................... 10
Use of EMR in Developing Countries and Sub Saharan Africa ............................................................ 12
Introduction and Use of EMR in Malawi ............................................................................................. 15
CHAPTER THREE.......................................................................................................................................... 17
RESEARCH METHODOLOGY ................................................................................................................... 17
Data Collection Technique .................................................................................................................. 17
Target Population................................................................................................................................ 17
Tools for Obtaining Data ..................................................................................................................... 17
Analysis and Interpretation................................................................................................................. 20
CHAPTER FOUR ........................................................................................................................................... 21
REQUIREMENTS SPECIFICATION ............................................................................................................. 21

Functional Requirements: ................................................................................................................... 21


Non-Functional Requirements ............................................................................................................ 21
CHAPTER FIVE ............................................................................................................................................. 22
SYSTEM DESIGN AND DEVELOPMENT .................................................................................................... 22
Methodology....................................................................................................................................... 22
Use case Diagram ................................................................................................................................ 25
Entity Relationship Diagram................................................................................................................ 26
Database Schema Diagram ................................................................................................................. 27
Hardware and Software Requirements .............................................................................................. 28
Initial Project Schedule ....................................................................................................................... 29
Revised Project Schedule .................................................................................................................... 30
Project Budget..................................................................................................................................... 32
CHAPTER SIX ............................................................................................................................................... 33
CHALLENGES ........................................................................................................................................... 33
RISKS........................................................................................................................................................ 33
LESSONS LEARNT AND CONCLUSIONS .................................................................................................... 33
CHAPTER SEVEN ......................................................................................................................................... 34
SUMMARY .............................................................................................................................................. 34
Conclusion ........................................................................................................................................... 34
References .......................................................................................................................................... 34

Acronyms

EMR
EHR
SQL
OB
GYN

Electronic Medical Record


Electronic Health Record
Structured Query Language
Obstetrics
Gynecology

List of Tables
Table 1: Requirements Table.
Table 2: Initial Project Schedule.
Table 3: Revised Project Schedule.
Table 4: Project Budget.

List of Figures
Figure 1: General Overview of Waterfall Model.
Figure 2: Use case Diagram.
Figure 3: Entity Relationship Diagram.
Figure 4: Database Schema.
Figure 5: Gantt chart for Initial Project Schedule.
Figure 6: Gantt chart for Revised Project Schedule

ABSTRACT
With the development in the science and technology sector, the methods of conducting a patient
has also changed with great effect. The advent of the EMRs has made a huge difference to the
treatment of Specialists and Physicians. EMR is a part of healthcare information technology that is
used to make paperless computerized patient data in order to increase efficiency of hospital
systems and reduce chances of errors in medical records.
This project aims at developing an online Gynecology Ambulatory EHR for Sahla Medical Clinic to
automate its daily operations such as patient registration, billing receipts, report generation, doctor
appointment scheduling and patient record keeping and tracking through the use of user interfaces
and databases for entry, storage and retrieval of records. The system will demonstrate the benefits
of using electronic methods to handle clinical operations, and will consist of different modules to
facilitate the clinics daily operations which will be used to manage and maintain the clinics
records.
The development of this system will follow a specified system development methodology as well as
a schedule and specified budget and will be dependent upon specific hardware and software
requirements all covered in detail herein.

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CHAPTER ONE
INTRODUCTION
Sahla Medical Clinic is a small consultancy medical practice in South C-Nairobi City that deals with
the care of women in the gynecology field. It has been in existence for 8 years since its
establishment in 2004.
The clinics daily routine usually involves patients coming in and out, with a variety of cases. A
normal process is the registration process, which involves the registration of new patients. Another
common routine is patient information retrieval for usual patients as well as history files for patient
history review by the doctor. (Refer to appendix for sample patient card)
Throughout its establishment, the clinic has been carrying out most of its operations manually with
no automation. Most of the time, the receptionist has to go through loads of paper/files looking for
patient treatments details or patient history as well as list of schedules previously recorded. The
doctor and patients have to wait as this time consuming task takes place until records are found.
The Doctor then attends to a patient and refers to patient history if necessary, then records the
treatment/diagnosis and records prescription details.
From the Doctors office, a patient heads to the reception desk where she is billed for consultation
charges and any service treatment expenses. As this is a small clinic, patients have to purchase
drugs prescribed externally after visits. In case of any tests, the doctor directs patients on where to
go for testing and then the results are dropped by the test center to the receptionist at the clinic,
who then files them and takes them to the doctors office for review.

Problem statement
Anyone who has ever worked in a fast paced medical practice knows that finding files can often be
time-consuming. Filing is a human component and sometimes records can be misfiled. There are
times when the record is in another location for a function of the office restricting flow of work. For
example, to find out about a patients history, the nurse/receptionist has to go through various
registers. This implies that there is need for a system to orderly store and track records. In addition,
handwriting can be hard to read. Often the pace is so quick that notes are written in a manner that
makes it hard to decipher.

Justification of the problem


A problem occurs when a medical practice cannot track patient records because the implication is
that the doctors efficiency to diagnose a patient may be affected without knowledge of the
patients history and prior treatments.
In addition, when records are handwritten, they can be hard to read and this may result in wrong
interpretation e.g. pharmacists interpreting a doctors handwritten prescription wrongly, giving
patients wrong prescribed medication or usage frequency and timing.
All these are risks to patients lives, reducing their confidence in such a clinic and hence, affecting a
clinics ability to offer high quality services to patients and this may lead to Patients going
elsewhere.
This software system will eliminate the legibility issue because notes will no longer be written, but
typed or picked from multiple choices in a predefined system, as well as eliminate the chance of a
misfiled or lost record, while also increasing office operations by making one file available
electronically to multiple authorities at the same time, by offering an electronic/automated
solution to the management of patient records.

Project Objectives

To apply software concepts learnt and skills like software development methodologies,
programming paradigm and enhancement of software quality standards and develop my
skills in report writing and research, by dedicating time and effort in research towards the
project.
To gather adequate practical skills through implementation of this project, that will be
useful in the business industry.

System Objectives

To implement an Electronic Medical Record system to manage and maintain the clinics
records
To improve on management operations by developing a system that will automate such
operations.
To provide a platform for patient appointment scheduling, electronic registration and
general record entry and retrieval via interfaces.
To provide a better alternative of organizing clinical records for patients through
introduction of Relational Database Management System.
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Deliverables

Patient Registration and information module:

This module will be for registering new patients and viewing or updating old patient
information. It will comprise of a form for patient detail entries, data grids and buttons for add,
delete and update functions as well as capability to print patient Id card.

Appointment Scheduling Module:

This module will be for recording and viewing appointments. It will comprise of a form for
appointment entries which will then be saved in the database as well as data grids and buttons
for data manipulation operations.

Login Module:

This module will offer and interface for logging into the system and depending on the privilege
type, grant access to specific related modules.

Database module:

This will be the back-end module that stores all the clinics records. It will comprise of tables
containing details regarding different information based on the clinics operational processes.

Billing module:

This is the module that will calculate total bill for patients in each consultation visit. It will
capture details regarding consultation fee as well as prescription charges if any and print a
receipt for the patient.

CHAPTER TWO
LITERATURE REVIEW
This Literature study starts by critically analyzing the various definitions of EMR. To understand the
contribution of EMR in the medical world, its strengths and weaknesses will be analyzed in detail.
Next, a study on the adoption of the EMR program will be presented to identify the acceptability of
the program by the various stakeholders in the healthcare environment.

Definition and Terminologies


In recent years, clinical and related medical information is increasingly managed by information
systems as so-called the electronic medical record (EMR). However, a common definition of the
term "electronic medical record" has not yet been established, causing problems in business
transactions as well. (JAMI, 2003) To date there are approximately 13 sets of terminologies and
definition for EMR. In the recent years, the terms Electronic Medical Records (EMR), Electronic
Health Records (EHR) and Patient Health Records (PHR) have gained popularity. Most of these
terms have arisen mainly from vendors marketing efforts to claim mind share over what EMR
should actually be called. The Google search trend data indicates an increased usage of EHR, but
EMR remains more prevalent. The same is true when we look at the usage of terminology by other
software vendors (Neal, 2006).

The next section will discuss the definitions of these terms to further understand the differences
and the similarities of these acronyms.

An Analysis on Medical Record Terminologies


Many terminologies such as Electronic Medical Record, Electronic Health Record and Electronic
Patient Health Record are in use in medical informatics to refer to a digitalized patient health data.
Although these terminologies share some common attributes, the distinctions between their
definitions, contents, sources and storage medium are significant and the nature of
implementation differs from one system to another.

The Electronic Medical Record (EMR)


Many researches in the information technology (IT) field have presented the definition of EMR
according to the nature and its field of application. In reference to the Japan Association of Medical
Informatics (JAMI) publication; a common definition of the term "electronic medical record" has
not yet been established, causing problems in business transactions. To present a meaningful
opinion under the present circumstances, we should primarily evaluate the current situation, since
various functions expected of the EMR and its current achievements need to be taken into
consideration (JAMI, 2003).

JAMI examined the necessity and the functions of the EMR and defined EMR in line with its
function whereby the main function of the EMR is to store patients' medical information such as
clinical findings and examination results. Meanwhile Pat Wise at Healthcare Information and
Management Systems Society, said that EMRs are what currently exist in most practices that have
adopted electronic record, but that EHRs are what the nation aspires to and what President Bush
calls for. An electronic medical record is owned by the organization, practice or corporation that
you received your healthcare from - be it St. Elsewhere, County-Municipal, or Doc Smith" Wise
explained.

Another common definition is an electronic medical record is a patient medical record that is
computer based. It was founded to make patients data available by clinical staff easily at any
location. A patients record contains any allergic and drug reactions (Clinfowiki, 2005). At this
point, very few hospitals have EMR solutions that can effectively reduce medical errors or improve
the quality and efficiency of patient care.

Therefore, EMR is the electronic record of health-related information on an individual that is


created, gathered, managed, and consulted by licensed clinicians and staff from a single
organization who are involved in the individuals health and care.

The Electronic Health Record (EHR)


Many in the healthcare industry including the Malaysian government and the press use the terms
Electronic Medical Record (EMR) and Electronic Health Record (EHR) interchangeably. However,
these terms describe completely different concepts, both of which are crucial to the success of
local, regional, and national goals to improve patient safety, improve the quality, efficiency of
patient care, and reduce healthcare delivery costs.

The EMR is the legal record created in hospitals and ambulatory environments that is the source of
data for the EHR. The EHR represents the ability to easily share medical information among
stakeholders and to have patients information follow him or her through the various modalities of
care engaged by that individual (Garets and Davis, 2006).
EHR are a more complex version of an EMR and fundamentally depending on the interoperability
or communication among and between multiple healthcare stakeholders.

An EHR is a linking system rather than an independent database, and is more of a process than a
product. An integrated EHR will link to separate sources detailing medical history and images,
laboratory results and drug allergies.

Therefore, EHR is the aggregate electronic record of health-related information on an individual


that is created and gathered cumulatively across more than one healthcare organization and is
managed and consulted by licensed clinicians and staff involved in the individuals health and
care.

EMR Implementation
The implementation of the EMR promises significant advances in patient care because such
program enhances readability, availability, and data quality. EMR are readily accessible, increases
the standardization for seamless use where and when required and greatly reduces the likelihood
of error in either entry or interpretation of medical information (Asefzadeh, 2005).
Having a patients medical and contact information readily available can be potentially life-saving
during critical medical events such as severe allergic reactions or heart attacks. Moreover, by
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reducing errors and saving time, EMR may therefore help reduce the large number of deaths
attributed to medical errors.

Electronic records have the potential to improve the quality of health care delivery and reduce
costs. Accurate and up-to-date health information is critical. When an individual seeks health care,
in order to provide effective and timely treatment, the provider needs to have information about
the patient, including known allergies, chronic conditions, current medications and other pertinent
health care data. However, such information is not always readily available. It may sometimes be
available but incomplete or inaccurate, depending on whether the patients records have been
updated or not [ref no. 1-4].

Benefits of the Electronic Medical Record (EMR)


Though there have been challenges and failures in the implementation of EMR, their potential
benefits are numerous. Some of the benefits are: complete and accurate information; universal
and timely access to a patients lifetime health information; knowledgeable sources to direct a
patient to the appropriate care and substantially fewer medical errors. The EMR may exist in a
distributed database, accessible from anywhere through a networked environment or a mobile
smart card that a patient carries with him/her. If appropriate security measures are adopted,
computerization also provides greater protection of confidential information via sophisticated keys
and access controls. Additionally, the EMR system helps improve the quality of patient visit
documentation and data, free up facility storage space, improve efficiency by eliminating time
spent hunting down lost charts and provide immediate, simultaneous access to patient records [ref
no. 5].

EMR has the ability to generate a complete record of a clinical patient encounter as well as
supporting other care-related activities directly or indirectly via interface including evidence-based
decision support, quality management and outcomes reporting [ref no. 2].

Challenges of Electronic Medical Records


The EMR raises issues of confidentiality, privacy and security [ref no. 6, 7]. Advances in information
technology, the need to cut costs of health care delivery, and consumer demands for more
effective and better-quality care have all hastened the exploration of alternatives for storing and
retrieving health care information, and yet the implementation of EMR faces several technical
challenges. Compared to other industries, the acceptance of information technology in health care
has been slow [ref no. 8, 9]. Compounding this is the limited experience available in deploying
applications, which has resulted in a steeper learning curve for health care organizations.

A number of problems have been identified with the EMR, including increased provider time,
computer down time, lack of standards, and threats to confidentiality. Studies at (some)
institutions in America [ref no. 3, 9] have shown that electronic order entry increases the amount
of time physicians spend entering a prescription. In a study by Powner, physician residents required
44 more minutes per day using computerized order entry, although internal medicine residents
using the order entry gained half of that time back in cost savings elsewhere [ref no. 9].
Furthermore, the study showed a high overall rate of user satisfaction of the system. Developing
means to streamline order entry for residents are now a priority.

Another concern with EMR systems is computer down time. Although the threat of not having
access to the right piece of information at the right time is real, the increasing reliability of
computer systems makes this less of a problem. At Oregon Health Sciences University, for example,
the daily scheduled down time has been reduced over the last several years from 1 hour to 10
minutes [see ref no. 10]. Most hospital computer systems and the databases that run on them are
being designed for non-stop usage.

A more significant problem with EMR systems is the lack of standards to interchange information.
While a number of standards exist to transmit pure data, such as diagnosis codes, test results, and
billing information, there is still no consensus in areas such as patient signs and symptoms,
radiology and other test interpretation, and procedure codes. Although some associate the
National Library of Medicines Unified Medical Language System (UMLS) with a comprehensive
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clinical vocabulary, its goal is much more modest, to serve just as a meta-thesaurus linking terms
across different terminology systems [ref no. 11].

A related problem to standards is that a large proportion of clinical information is locked in form
of narrative text. Although a number of systems have been successful in limited domains, the
technology for natural language processing (NLP) is still unable to interpret narrative text with the
accuracy required for research and patient care applications. While NLP is difficult for well-written
published medical documents, it is even harder for medical charts that contain poorly structured,
highly elliptical language, with frequent misspellings to boot. Even if such language could be
parsed, the lack of an underlying framework makes its semantic interpretation more difficult [ref
no. 11].
Some have proposed to solve this problem with menu-driven data collection systems, but these
have generally been successful only in limited areas, such as obstetric ultrasound [ref no. 12].
Baobab Health Trust has adopted the system of using only categorical data elements that can be
selected from menus wherever possible for the reasons described above. Since the system does
not use narrative text in most cases it makes the use of an entirely touch screen-driven system that
much more feasible.

A final concern about the EMR is the problem of security and patient confidentiality. This problem,
of course, exists independent of the EMR, as a great deal of medical information abstracted from
paper records, already exists in electronic repositories. Well-known privacy experts have
documented the threats that misuse of this information has on personal privacy [ref no. 13].

As noted above, the paper record is no barrier to duplication, as medical records are routinely
copied and faxed among health care providers and insurance companies already. While some fear
the EMR will exacerbate this problem, others note that computer-based records, with appropriate
security, are potentially more secure than paper based records. Most medical centers already have
security. Employees given access are usually required to sign a confidentiality statement indicating
their understanding of the privacy of patient data.

At most centers, a password is required to enter the system, although some institutions also use a
physical device, such as a key card. Virtually all systems also keep an audit trail of who accessed
which patients data; providing a retrospective mechanism for discipline should breaches of
security occur [ref no. 14].

While there is an array of technologies, including encryption and authentication that could erect
barriers between medical information and its unauthorized use, it must also be noted that there is
a tradeoff, as every computer user knows, between security and ease-of-use. Since the pace of
medical care in emergency settings as well as busy clinical areas can be hectic, providers may
become frustrated with layers of security.

Challenges to the implementation of the EMR in primary care practice and in resource poor settings
are huge and may seem outside the priority agenda in this era of public health emergencies.
However, the information generated during routine medical consultation and its capture in the
EMR could provide valuable information of public health interest. As elsewhere, challenges to
adoption are great, but a successful implementation for a specific setting will require
comprehensive modeling of the local medical practice and a coordinated approach, involving all
stakeholders.

Use of EMR in Developed Countries


Countries such as the United States, United Kingdom and Australia have mature and advanced
healthcare infrastructures that receive substantial funding and support from their governments.
Although significant failures still exist in these systems, there is strong support and motivation to
accomplish goals associated with comprehensive development of successful medical information
technology systems [ref no. 15].

These countries are able to make significant investments in research to develop information
systems that would meet the need of their particular healthcare system. This is in sharp contrast to
the healthcare infrastructure of many developing countries. For many of these countries the
delivery and management of healthcare services alone comes with many challenges. In many of
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these countries, implementers of healthcare information technology based solutions are faced with
complex challenges such as inadequate funding, lack of resources and weak healthcare
infrastructure.

When EMR systems were first introduced, it was widely believed that their broad adoption will lead
to major health care savings, reduce medical errors, and improve health [ref no. 16]. But there has
been little progress toward attaining these benefits. The United States trails a number of other
countries in the use of EMR systems. Only 1520 percent of U.S. physicians offices and 2025
percent of hospitals have adopted such systems. Barriers to adoption include high costs, lack of
certification and standardization, concerns about privacy, and a disconnection between who pays
for EMR systems and who profits from them [ref no. 16].

Despite the appeal of EMR, available data suggest that the majority of office practices in the United
States, especially smaller offices, do not have this technology [ref no. 16]. For example, using 2003
data from the National Ambulatory Medical Care Survey, Burt and Sisk reported that an average of
17.6 % doctors used EMRs in their office-based practices [ref no. 16]. In contrast, other countries,
such as Australia and the United Kingdom, are nearing universal adoption of EMRs [ ref no. 16].

In Massachusetts in 2005, only 18% of medical and surgical office practices reported using EMRs
[ref no. 17]. Larger practices that provided primary care and those with other computerized systems
were more likely to have adopted EMRs. Among practices with EMRs, most systems did not include
advanced functionalities, such as order entry for medications, laboratory tests and diagnostic
imaging. While 58% of practices with EMRs had electronic clinical decision support available, more
than 1 in 4 practices indicated that a majority of their clinicians were not actively using that support
[ref no. 17].

In 1995, Newton performed a study titled The first implementation of a computerized care
planning system in the UK. The implementation included both a new way of structuring work,
using the nursing process and a new technology which was the use of computers. The results
showed that it took more than a year after implementation until the nurses negative attitudes
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towards the system shifted to positive attitudes. The study also showed a significant improvement
in the quality of care planning [ref no. 18].

In their review on the use of computers in a health care setting, Smith et al. (2005) found no
conclusive evidence that could provide the foundation for an effective computer implementation
strategy. However, more common use of computers in society today has increased the use of
computers in nursing and also made it possible to implement standardized care plans in EMR [ref
no. 19].

Goorman and Berg (2000) called attention to problems associated with the design of structures in
EMR and suggested that there is a risk that such structures will be difficult to work with in practice.
Timmons described nurses resistance to using computerized systems for planning nursing care;
their resistance did not entail direct refusal, but was instead quite subtle. They tended to minimize
use of the system or postpone it to another time or to the next work shift. Timmons considered
that the nurses behavior was characterized by resistance to changes in the nursing process and to
the technology [ref no. 18].

Smith and others investigated charting time before and after computer implementation and found
that no change had occurred. The advantage of using the software was observed when the
technology and the concept brought together the care plans and subsequent documentation. This
shows that use of the system improved the function and meaning of the care plan process [ ref no.
19].

Use of EMR in Developing Countries and Sub Saharan Africa


In Africa millions of people die every year, and Sub-Saharan Africa, in particular, shows little
progress towards achieving five of the six health-related Millennium Development Goals (MDG)
targets [24]. Countries in this region require health information systems that will enable them to
generate the data needed to monitor progress towards the achievement of the targets. The health
information systems in most African countries currently are primarily paper based and are woefully
insufficient to meet both patient and reporting needs. On the other hand, information and

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communication technologies (ICTs) offer unparalleled opportunities to respond adequately to this


challenge [ref no. 20].

Just five years ago, the use of electronic medical records (EMRs) in resource-poor countries in the
Global South was, at best, experimental. Few organizations thought their usage was realistic, and
fewer still had deployed such systems. The handful of projects that used an EMR system fell mainly
into two groups: those that used expensive commercial software in specialist projects and private
hospitals and those that developed the software in-house, usually to manage a specific disease
[25]. Since then, several successful medical information systems and EMRs have been implemented
in developing countries and information technology is much more widely available in resource-poor
areas. These factors, along with recognition of the benefits of EMRs in improving quality of care in
developed countries, have created a broad interest in the use of health information technology
systems (HIT) in the management of diseases such as HIV and drug-resistant TB [ref no. 21].

In 2001, the Departments of Medicine and Child Health and Pediatrics at Moi University, Eldoret
and the Department of General Internal Medicine and Geriatrics at the Indiana University School of
Medicine, in collaboration with the Moi Teaching and Referral Hospital in Eldoret, Kenya,
established the Academic Model for Prevention and Treatment of HIV/AIDS (AMPATH) [ref no. 22].

The AMPATH Medical Record System (AMRS) was the first functioning comprehensive electronic
medical record system committed to managing and improving the quality and efficiency of care for
patients with HIV/AIDS in sub-Saharan Africa. It has played a significant role in patient care in all
AMPATH sites. It has standardized patient data collection and made data retrieval much faster than
the traditional paper-based record. It has enabled evidence-based decision-making for patient
encounters and for the health system. The AMRS is affordable and represents a model system for
recording critical HIV/AIDS data in resource poor settings that will be delivering an increasing
amount of HIV care. This model will also allow those funding the rapid increase in the provision of
HAART to know the return they are getting on their investment and hopefully encourage continued
treatment of the worst medical disaster to ever befall humanity.

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In the same year also, the Mosoriot Medical Record System (MMRS) was installed as a collaborative
project between Indiana University and Moi University. The overall aim of developing this system
was to improve health care delivery and as a clinical and public health research tool. In brief the
MMRS was comprised of a paper encounter form-data template, data entry module, report
generating module, and a data dictionary. The system ran on two IBM-compatible computers
linked by a cross over network cable. One computer was used for check in and registration and the
other used for check out and entering encounter data. The core MMRS utilized a Microsoft Access
relational database that consisted of four tables, namely the registration table, visit table,
drug/laboratory test results table, and data dictionary. The registration table contained one record
per patient, the fields in this table included patient identification number, name, village, and date
of the registration visit. The visit table contained a record per visit (identified uniquely by patient
identifier number and visit date), the clinic(s) visited, diagnoses, services provided, plus the amount
of money paid. The drug/lab table contained records for each drug prescribed and results of each
diagnostic test performed. The data dictionary contained a record for each data elements with
descriptors and, where appropriate, limits on data entry. Only coded and numeric data, as defined
by the data dictionary, were entered into the MMRS.
On arrival at the health center patients were given paper encounter forms upon which health
center staff recorded patient data. The patient carried this form to the health center's various
clinics, laboratories, pharmacy, and financial office. At the end of the visit, the data from this form
were keyed into the MMRS checkout computer.
An assessment of the impact of MMRS on the workflow at Mosoriot rural health centre was done
by performing formal time motion studies before and after implementation. After MMRS
implementation, patient visits were 22% shorter, they spent 58% less time with providers and 38%
less time waiting. The MMRS reports had also facilitated detection of clustering of sexually
transmitted diseases in one village and lack of immunization in another village and this lead to a
team of health personnel being dispatched to the villages to carry out appropriate interventions.

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While most sophisticated EMRs in low-income regions are in large cities, where infrastructure and
staffing needs are more easily met, Partners in Health (PIH) pioneered web-based EMRs for HIV and
TB treatment in rural areas [ref no. 23].

The HIV-EMR, developed in Haiti, was deployed in two Rwandan health districts starting in August
2005. In less than six months (August 2005 through January 2006), the EMR tracked over 800
patients on ARV treatment. The addition of new features and adaptation to local needs was
happening concurrently with the rapid scale-up and evolution of the medical program itself. The
EMR in Rwanda provides support for patient monitoring, program monitoring, and research.
Patient monitoring includes information for care of individuals, such as historical medical
summaries and alerts. This is especially useful given the large distances between the clinics. The
EMR in Rwanda also has an instrument to predict drug requirements and aid pharmacists in
packing.

Introduction and Use of EMR in Malawi


Baobab Health Trust, a Malawi-based nongovernmental organization, has been working with the
Ministry of Health to address the human resources for health crisis for the past nine years by
applying medical informatics principles to resource-poor settings. The core of Baobab Health
Trusts approach is the application of easy-to-use EMR touch screen clinical workstations at the
point of patient care. This system efficiently and accurately guides healthcare workers through the
diagnosis and treatment of patients following national treatment protocols. The system also
captures timely and accurate data that is used by healthcare workers during patient visits to
supplement decision making. The data are aggregated and used at national level for policy making
and analysis.

This technology-dependent approach has required both hardware and software innovations,
including alternative energy approaches, intuitive touch screen-based user interfaces for users with
no computing experience, and low-cost information appliances that are significantly more robust in
harsh environments than traditional computers. To date more than 1,100,000 patients have been
registered and over 30,000 receive HIV care facilitated by Baobab Health Trust electronic data
15

system. [Personal communication: Sabine Joukes, Country Director, Baobab Health Trust, Malawi,
January 2010].

Conclusion: The solution proposed here is not so different from what has been done in that it will
involve computerization of paper-based clinical records. However, the system will be completely
localized to Sahla Medical Clinic, and its scope and functionality will be dependent on the clinics
resources and services offered. Reference will be made to what has been done, and emphasis on
implementing acceptable features similar to what is out there.

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CHAPTER THREE
RESEARCH METHODOLOGY
Data Collection Technique
For the purpose of data collection, the preferred method in this case is conducting personal
interviews (preferably open-ended) and observing a clinic visit as it occurs to completion in order to
ascertain all processes involved in the system that is currently in use.

Target Population
The population to be sampled will be Sahla Medical Clinic staff who will include the doctor, frontdesk receptionist and pharmacist.

Tools for Obtaining Data


For the purpose the interviews, a simple voice recorder and pen and paper will be appropriate.

Sample Interview Collected


INTERVIEW
INTERVIEW WITH DR. AISHA A. ABDALLA, CONSULTANT OBSTETRICIAN & GYNECOLOGIST, SAHLA
MEDICAL CENTER, AT TONONOKA MAJENGO IN MOMBASA, ON THURSDAY, 8TH NOVEMBER 2012 AT
2.30PM.

Question: Briefly describe the Centers operational process i.e. the entire process of what
happens the 1st time a patient comes to the clinic.
Answer: When a patient comes to the Center, the first process is the registration process where
the receptionist fills in the patient card for the patient and gives the patient a registration card. This
card is the one the patient uses through every visit to enable the receptionist search for patient
records as well as history forms and appointments from available files.
After registration or after the receptionist finds the patients file, the patient waits for when I am
ready to see her. (Most of the patients that visit the center are women, as they feel more
comfortable with me and my services are well-known).
When I see the patient, I usually ask questions about reason for visit, as well as fill a history form
for 1st time patients or review it if necessary, for regular patients. Aside from that, the receptionist,

17

who is also my assistant, hands me the patient card that she filled in the patient details in order for
me to record the treatment for each visit.
Once I have diagnosed and recorded any findings, I issue where I find fit, a prescription or advice on
dietary routine. This is written on paper and given to the patient to follow. Usually, I never record
the dietary advice I give to patients but I do record the prescription on the treatment column of the
patient card for future reference.
From my office, it is the patients own choice on whether to get the drugs at our pharmacy or from
chemists elsewhere. If the patient however decides to do so, the prescription is given to the
pharmacist who responds by issuing drugs if available, else informs the patient. The pharmacist
then writes down on a piece of paper, the price for prescription if issued, which the patient takes to
the receptionist for billing.
The receptionist then bills for consultation and prescription accordingly and issues a receipt to the
patient.
New or regular patients may choose to make an appointment for their next visit. This is booked by
the receptionist who gets back to patients via the phone in the course of the week to confirm any
appointments, postpone or cancel them.
Question: Is it a must for Patients to make an appointment?
Not necessarily. Most patients who make appointments do so when they would like priority service
over other patients. The clinic operates on a first come first served basis, but priority is always
given to patients who had made appointments, even when they arrive and find a waiting line. I
often advise patients who would like to consult me during weekends to make an appointment
because weekend working hours are shorter compared to weekdays.
Question: From your description of the processes, it seems everything is always written down
and stored on paper file. What kind of backup do you have for these files?
Answer: We had never considered any backup under the assumption that patient files are safe on
cabinets and so long as they are locked and the right people have the key, nothing can compromise
the situation.

Question: How come the Center never considered electronic means of operations and storage in
the previous years?
Answer: Well, the way times were before are different now. When I 1 st started this Center, I didnt
have many Patients and so keeping and maintaining records on paper was easy and less tedious.
Customers increase as businesses expand; the Center has grown since then and so has the patient
18

number, making it very difficult and costly to maintain and keep track of patient files using paper. It
has been difficult and operations tend to be slowed down by having to search through files for a
patients record.
Computers have also reduced in cost and it is slightly easier to adapt and embrace technology now,
than it was before.
Question: If you prefer change to the current system, what would you suggest?
Answer: I would like for the Centers operations to be more efficient and feel strongly that in
automating activities, we can achieve that. A system that will facilitate easy and quick searches for
files enable us track patient records as well as be able to print them.
Question: Do you have any computers, and is there a working internet connection in your clinic?
Yes, I have a laptop which I use for my own personal activities but no internet connection at the
Center. I usually use Orange Modem for internet when at work, although I recently subscribed for
Internet services from WebRunners Ltd at Blueroom, which was set up at my home. If the Center
acquires an automated system for its medical records, then it will need several computers plus
internet set up, which will not be a problem.

CHAT INTERVIEW OVER SKYPE WITH DR. AISHA A. ABDALLA, CONSULTANT OBSTETRICIAN &
GYNECOLOGIST, SAHLA MEDICAL CENTER, AT TTUC VOI, ON THURSDAY, 17TH NOVEMBER 2012 AT 5.00PM.

Question: Can a patient be treated for more than one medical problem in a single appointment?
Answer: Yes, it is possible that a patient might be treated for more than one medical problem in a
single appointment. For example, a patient might be treated for uterine fibroids and ovarian cysts,
all of which are different problems.
Question: Can a patient be prescribed more than 6 drugs for a single problem or for more than
one problem?
Answer: Highly unlikely. Most drugs tend to be toxic to the liver and kidney when taken with other
drug combinations. For that reason, most of the time doctors know better and you will find that a
maximum of 3-5 drugs is the common prescription. However, in a single prescription, the doctor
might prescribe twice or thrice the number of the same drug for special reasons such as; if the
patient is travelling and wont make it for the next few appointments or for a long while, maybe
going out of the country and so on.
Sometimes, all a doctor has to do is treat one thing and observe the other throughout the next
appointments. If it doesnt improve, thats when another drug is prescribed.
19

Also in some cases, several problems might be prescribed the same or a single drug. For example, a
patient comes in with the following symptoms or problems; a simple headache, simple back ache,
menstrual cramps and muscle aches. I find out that the patient went for hiking maybe yesterday or
earlier today. All the patient needs is painkillers. So you see, all these were different problems but
had one drug as the solution.

Analysis and Interpretation


From the Interview, the following processes were derived:

Registration of patients.
Issuing of a registration card.
Diagnosis and treatment.
Prescription generation.
Drug issuing (if any).
Patient billing.
Appointment booking.

From these identified processes, modules are described in the requirements specification section.

20

CHAPTER FOUR
REQUIREMENTS SPECIFICATION
Functional Requirements:
a. The System shall allow front-desk staff to register new patients to the system, make
necessary updates or modifications to existing registered patients as well as manage
appointments.
b. The Administrator can manage data in the database as well as perform backups.
c. The system shall generate reports on patients about the following information: patients
treatment summary, history forms, prescription details and bills.
d. The Doctor can manage treatments (view, add, update, delete), generate prescriptions and
print patient reports, shall have access to all patient related records.
e. Patients can request for an appointment on the Clinics website. They can also view their
appointment details.

Non-Functional Requirements
1. Availability: System shall be available and operable at all times to the users wherever they
are.
2. Accessibility: System shall be available to as many users as possible and users should be
able to access and benefit from the system whenever they want.
3. Backup: The system shall offer effective and efficient backup of clinic records for restore in
incase of data loss.
4. Maintainability: The system shall be easily maintainable in the present and future i.e.
future maintenance should also be easy.
5. Performance- The systems response time to the user operations and requests in real time
shall be minimal.
6. Reliable: It shall perform all required functions under operable conditions throughout its
operational life, thereby, being reliable to users in their tasks.
7. Security: It shall only allow access to authorized personnel.
8. Portability: The system shall be transferable from one computer to another with basically
the same architecture.
9. Usability: It shall be easy to use and learn.

21

CHAPTER FIVE
SYSTEM DESIGN AND DEVELOPMENT
Methodology
The System Development Methodology that will be used will be the Waterfall Methodology.
The choice of selection of this model is due to the fact that:

Feedback loops exist between each phase, so that as new information is uncovered or
problems are discovered, it is possible to "go back" a phase and make appropriate
modification.

The system requirements are clear and fixed in this particular case.

In addition, the staged development cycle in the waterfall methodology enforces discipline:
every phase has a defined start and end point, and progress can be conclusively identified
(through the use of milestones) by both vendor and client.

The emphasis on requirements and design before writing a single line of code ensures
minimal wastage of time and effort and reduces the risk of schedule slippage, or of
customer expectations not being met.

Getting the requirements and design out of the way first also improves quality; it's much
easier to catch and correct possible flaws at the design stage than at the testing stage, after
all the components have been integrated and tracking down specific errors is more
complex.

It does, however, have some drawbacks:

Requires an all-or-nothing approach to systems development.


Does not allow incremental development.
Requires very early isolation of the problem. In the real world, often the problems are uncovered in
the process of development of systems.

The steps involved in the Waterfall Methodology are:


1. Requirements Analysis and Definition
All possible requirements of the system to be developed are captured in this phase. These
requirements will be gathered from the end user, in form of functions and constraints that are
expected from the system. Fact-gathering techniques will be used to gather requirements, after
which they will be analyzed for their validity, and possibility of incorporating requirements into the
22

system to be developed will also be studied. Finally, a requirement specification document will be
created which will serve the purpose of guideline for the next phase.
2. System and Software Design
Before starting the actual coding phase, it is highly important to understand the requirements of
the end user and also have an idea of how the end product should look like. The requirement
specification from the first phase will be studied and a system design will be prepared. System
design helps in specifying hardware and system requirements and also helps in defining the overall
system architecture. The system design specification will serve as an input to the next phase.
3. Implementation and Unit Testing
On structuring the system design, and creating a system design document, the development work
will be divided into modules and actual coding will start. The system will first be developed in small
programs called units, which will be integrated in the next phase. Each unit will be developed and
tested for its functionality i.e. what is referred to as unit testing. Unit testing verifies if the
modules/units meet their specifications.
4. Integration and System Testing
As specified above, the system will first be divided into units which will be developed and tested for
their functions. These units will be integrated into a complete system during integration phase and
tested to check if all modules/units coordinate with each other and the system as a whole behaves
as per the specifications. After successfully testing the software, it will be delivered to the
customer, or in this case, presented.
5. Operations and Maintenance
This phase of the model is virtually a never-ending phase. Generally, problems with the system that
will be developed (which are not found during the development life cycle) will come up after its
practical use starts, so the issues related to the system will be solved after deployment.

23

Requirements Analysis
and Definition

System & Software


Design

Implementation & Unit


Testing

Integration & System


Testing

Operations &
Maintenance

Figure 1: General Overview of Waterfall Model.

24

Use case Diagram

Figure 1: Use case diagram


25

Entity Relationship Diagram

Figure 2: Entity Relationship Diagram

26

Database Schema Diagram

Figure 3: Database Schema

27

Hardware and Software Requirements


For this project, the development of the system will require the following hardware and software
specifications:

Hardware
1 Laptop/Desktop PC with:

Software

HTML, CSS, Jquery library for


javascript, and integrated web
development environments (such as
Adobe
Dreamweaver)
for
site
prototyping.

XAMPP web
RDBMS.

Image editors such as Adobe


Photoshop or Fireworks for creating
site graphics.

Pentium III/IV Processor and above.


Minimum 512MB RAM onwards.
Removable storage systems(flash disk)
Printer.

server

with

MySQL

Table 1: Requirements Table.

28

Initial Project Schedule


Activity

Start Date

Duration (Week)

End date

Deliverable

Project Research

10/Sept/2012

01/Oct/2012

Project Title &


Client

Proposal Writing

01/Oct/2012

15/Oct/2012

Proposal

Requirements
Gathering &
Analysis

15/Oct/2012

29/Oct/2012

Requirements
Specification
Document

System &
Software design

29/Oct/2012

12/Nov/2012

System Design
Document

Coding & Unit


Testing

12/Nov/2012

14

18/Feb/2013

System
Modules/units

Integration &
System testing

18/Feb/2013

11/Mar/2013

Fully tested
working System

Writing Project
Report.

11/Mar/2013

25/March/2013

Final Report

Presentation.

25/March/2013

01/Apr/2013

Developed
System

Table 2: Initial Project Schedule

29

Revised Project Schedule


Revised Project Schedule
Activity

Start Date

Duration (Week)

End date

Deliverable

Project Research

10/Sept/2012

01/Oct/2012

Project Title &


Client

Proposal Writing

01/Oct/2012

15/Oct/2012

Proposal

Requirements
Gathering &
Analysis

15/Oct/2012

05/Nov/2012

Requirements
Specification
Document

System &
Software design

05/Nov/2012

03/Dec/2012

System Design
Document

Coding & Unit


Testing

03/Dec/2012

12

25/Feb/2013

System
Modules/units

Integration &
System testing

25/Feb/2013

11/Mar/2013

Fully tested
working System

Writing Project
Report.

11/Mar/2013

25/March/2013

Final Report

Presentation.

25/March/2013

01/Apr/2013

Developed
System

Table 3: Revised Project Schedule

30

Figure 4: Gantt chart for Initial Project Schedule

Figure 5: Gantt chart for Revised Project Schedule

31

Project Budget
Item

Amount (KES)

Travelling Expense for data gathering

2,000

Office Equipment
Stationery (printing costs, notebook for
data gathering, pen etc.)
Data storage and backup devices (flash

1,500
2,000

disk, CDs etc.)


Materials and Services required
HP Deskjet Printer for (printing reports
and documentation).
Cartridge
Printing Paper (one ream).
Communication charges (call costs etc.)

4,500
1,600
400
1,000

Miscellaneous Expenses and Expendables

2,000
3,000

Food
Emergency Fund and unforeseen
expenses

Total:

16,400

Table 4: Project Budget

32

CHAPTER SIX
CHALLENGES

Booking an appointment for the face-to-face interview I faced this challenge by organizing
for phone and web communication for the remaining interviews.

Conforming to project schedule Some activities have taken longer than expected.

RISKS

Failure to implement some key functionality such as report generation according to the
clinics need. E.g. organizing all details of the history form into a report format.

Implementing regular database backup through triggers may be a challenge.

LESSONS LEARNT AND CONCLUSIONS

How to use softwareS such as MsVisio, SQLyog Enterprise.

The field of Obstetrics and Gynecology requires extensive research to be able to develop an
effective and efficient system that meets the requirements of clinics in this field.

33

CHAPTER SEVEN
SUMMARY
Conclusion
System design is to begin immediately after requirements gathering and analysis. The way forward
is to continue working on the system until a visible product that meets requirements specified can
be seen.

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