Real-time, provider-based electronic medical records (EMR) have been used extensively for health care in developed countries. They have been shown to improve legibility of clinical notes [1], patient safety [2] and quality of care [3]. They have also been introduced in Sub- Saharan Africa [4] and been successful in reducing patient waiting time and in increasing the time spent with the providers [5]. Provider-based EMR could be a valuable aid to health care providers working in HIV programs in resource-limited settings for clinic management and reporting, especially in urban clinics where large numbers of patients are registered [4]. For example touch screen aids have been used for voluntary counseling and testing, and have been shown to increase completeness and accuracy of data. In addition, they eliminate the need for retrospective entry which saves time and resources. Data is also available for monitoring and evaluation of clinic programs [6]. Therefore, provider-based EMR may be an attractive solution for HIV programs in Sub-Saharan Africa [4], [7] especially in busy, urban clinics.

The Infectious Diseases Institute (IDI) is an urban clinic in Kampala, Uganda [8], [9] with more than 27,000 adult patients cumulatively registered by December 2011, of which over 12,000 have been started on ART. Data collected in the clinic database is used for clinical care, internal audits, generation of reports for partners and stakeholders, as well as planning for drug procurement. Despite local ethics committee approval in 2009 to use IDI routine clinical data for analysis and publications, such data has been shown to have high rates of errors and missing information [10], [11], [12], [13], [14] and, therefore, may not be suitable for research purposes.

Prior to 2009, the IDI used both paper-based free text and standardized forms (Figure 1) completed by health care providers and subsequently entered in an electronic tool by data clerks to populate a patient database. This approach led to high rates of missing and inaccurate data in both steps, which were 1) the providers transcribing form the notes correct and 2) complete quantitative information onto the standardized forms and the data clerks entering this quantitative information in the database. [11]. In 2010 to present, the IDI introduced phased solutions leading to a provider-based EMR that was complimented with a structured process of data validation.

From November 2010 until July, 2011, all data collected in the HIV clinic was entered into both the standardized forms and the provider-based EMR to enable validation of the entered data. In March 2011, data entry by providers was enhanced, standardized forms were eliminated but doctors and nurses continued filling free text clinical notes (where any relevant finding is highlighted), which are used to validate the information in the database by two quality-control nurses.

To our knowledge, there is no data available from Sub-Saharan Africa showing the effect of provider-based EMR on the correctness and completeness of the data collected. The main objective of this study was to compare the rate of errors in the IDI routine HIV care database before and after the introduction of provider-based EMR. We also assessed the acceptability of provider-based EMR by the users and clients through a qualitative questionnaire. Finally we propose a transition model from paper based records filled by providers to real time provider-based EMR.

In the last decade electronic medical records have become widely available in resource-limited settings [5], [16], [17], [18]. In Sub-Saharan Africa, urban HIV programs are often congested, resulting in long waiting times [8], [9] and information storage constraints; provider-based EMR is an attractive solution to some of these challenges [4], [17].

This is the first study conducted in Sub-Saharan Africa to investigate the accuracy of data collected with user-based EMR in an HIV program. In our study we found that with the user-based EMR the rates of errors range from 0.9 to 12.5% depending on the variable. In addition the introduction of user-based EMR led to a reduction in the total error rates from 66.5% to 2.1%. Before the implementation of user-based EMR, the majority of errors for three of the four variables investigated were due to incompleteness, and particularly to information collected in the clinical notes but not entered by the providers in the standardized form, and consequently not made available to data clerks for entry. This suggests that skipping the data entry step and making providers the only responsible of data quality by the implementation of a user-based EMR can be greatly minimize missing information. Although mandatory fields have the danger of information being invented or faked to be able to continue with data entry, such instances, which would be labeled as “incorrect” information during the consistency checks carried out through prospective validation occurred at a low rate. Improved quality of data and the utilization of a user-based EMR could also translate into improvement in patient care, provider efficiency, human resource savings, and improved accuracy of reports [19].

However other factors should be taken in consideration to explain this drastic decrease in errors rates. Although the staff force did not substantially changed, as well as national guidelines for ART treatment in adults (except for phasing out stavudine in 2008 and introducing more slots of tenofovir), given the long period between the evaluations, there is no doubt that the clinic staff gained knowledge and experience, as well as data quality awareness. In 2008, with the aim of improving the quality of data, a real time prospective quality assurance process was introduced and despite improvement, the rate of errors was still unacceptable leading to a huge amount of workload to rectify errors.

Overall, the provider-based EMR by the clinic staff was rated positively, with 4 in 5 providers agreeing that the implementation of provider-based EMR resulted into improvement of the quality of care, access to patients’ information in order to make timely decisions, and automation of regular tasks such as prescription writing. Of note, while data entry staff was phased out, providers did not receive any additional incentive to enter the information collected during patients’ visits; therefore their level of satisfaction genuinely reflects improved working conditions. The addition of intelligent checks into system (e.g. the use of alerts to guide prescription writing), the automation of some tasks, and the availability of reports that summarize patient care and treatment history are some of the features most appreciated by providers. It should be emphasized that the developers of ICEA involved health care providers from the planning stage through the deployment of the system. In addition, they continue to offer ongoing technical assistance and dialog with the providers and can make modifications and additions to the systems if clinically required.

Although our patient population is largely computer-illiterate and could have misperceived this innovation, our patients welcomed provider-based EMR and they perceived that it improved the quality of care and reduced the time spent with the providers filling forms. This was confirmed by the comparison of two time motion surveys conducted in our program that showed a decreased doctor and nurse visit time after the implementation of the provider-based EMR.

Overall the ICEA system had several important strengths. First, the system was built in- house by system developers familiar with the local setting, HIV clinical care, the IDI clinic, patient management and workflow. Furthermore, it also resulted into cost savings. Second, the system guarantees completeness of the EMR, not only because all fields must be filled before saving a record, but also because different modules have to be saved in a rigid order; for example, information in the monitoring module cannot be entered if the registration module is not filled, or an electronic prescription cannot be filled if there is no monitoring information and a next appointment is not scheduled.

There are other advantages of ICEA and provider-based EMR not investigated in this study. The first one is the increased legibility since the information can be accessed as a text rather than handwritten clinical notes. The second is record keeping: paper records could be completely eliminated, with the advantage of eliminating the need for storage space and records clerk personal. Information is also always available to the providers through the database.

In Figure 5, we diagram the transition from paper forms to provider-based EMR in our program. Although a direct comparison can no longer be made because of changeover of most of the providers, in the first quarter of 2012 the rate of errors for all the four variables evaluated in this study were less than 1%. Given the very low error rate, the program may consider embracing a record system based exclusively on provider-based EMR.

Not surprisingly and similar to other programs in similar settings [5], [20], the implementation of ICEA faced some barriers to change. Among providers other than doctors, computer literacy was low and some providers felt intimidated by computerization. Each group of providers was then separately trained accordingly to the level of knowledge they needed to perform their task. After the formal training, a team of tutors was available to assist users on real operational work.

Secondly, even when computer knowledge was not a barrier, some providers were initially concerned that that information stored in a server could not be as secure as information stored in hard copies [4]. This misconception was overcome when they were taught about backup systems and also given a password. Providers also realized that even if the patient file containing the clinical notes was misplaced, patient management was still possible through the EMR. In our experience, the phase-in period when both paper and user-based EMR were filled in is necessary for the providers to gain confidence in the new system despite retarding work flow. However it is still possible that reluctance in abandoning completely the paper-based clinical notes constitutes a barrier to implementation of exclusively provider-based EMR.

A thorough user analysis and early involvement of the users ensured that the product reflected their needs and likely reduced the risk of provider rejection or poor compliance when it was implemented. Finally, a strong management [21], and support from system developers and information technology specialists are key components for a satisfactory transition from paper to user-based EMR.

In conclusion, the introduction of provider-based EMR had a favorable impact on the quality of data collected with a significant reduction in missing and incorrect information. The improvement of quality of the routinely collected data has the potential to impact care and lead to more accurate data for research purposes. The majority of both providers and clients expressed satisfaction with the new system. We recommend the use of provider-based EMR in large, urban HIV programs in Sub-Saharan Africa.