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. Author manuscript; available in PMC: 2014 Sep 19.
Published in final edited form as: J Med Trop. 2012;14(1):1–6.

Use of Electronic Health Records in sub-Saharan Africa: Progress and challenges

Maxwell O Akanbi 1,*, Amaka N Ocheke 2, Patricia A Agaba 3, Comfort A Daniyam 1, Emmanuel I Agaba 1, Edith N Okeke 1, Christiana O Ukoli 1
PMCID: PMC4167769  NIHMSID: NIHMS380682  PMID: 25243111

Abstract

Background

The Electronic Health Record (EHR) is a key component of medical informatics that is increasingly being utilized in industrialized nations to improve healthcare. There is limited information on the use of EHR in sub-Saharan Africa. This paper reviews availability of EHRs in sub-Saharan Africa.

Methods

Searches were performed on PubMed and Google Scholar databases using the terms ‘Electronic Health Records OR Electronic Medical Records OR e-Health and Africa’. References from identified publications were reviewed. Inclusion criterion was documented use of EHR in Africa.

Results

The search yielded 147 publications of which 21papers from 15 sub-Saharan African countries documented the use of EHR in Africa and were reviewed. About 91% reported use of Open Source healthcare software, with OpenMRS being the most widely used. Most reports were from HIV related health centers. Barriers to adoption of EHRs include high cost of procurement and maintenance, poor network infrastructure and lack of comfort among health workers with electronic medical records.

Conclusion

There has been an increase in the use of EHRs in sub-Saharan Africa, largely driven by utilization by HIV treatment programs. Penetration is still however very low.

Keywords: Electronic health records, Electronic Medical Records, sub-Saharan Africa

Introduction

Medical informatics is an intersection of information science, computer science and health care. It includes clinical guidelines, formal medical language, standards, and communication systems1,2. The various tools, technologies, and tactics are designed to support the progressive realization of the optimal delivery of health and medical care3,4. This field which began in the 1950’s has grown rapidly in developed countries5,6. The Electronic Health record (EHR) is a key component of medical informatics2. It provides the opportunity for health care organizations to improve the quality of patient care and safety, and also has the potential to reduce cost and improve efficiency of the workplace7. The use of electronic records has distinct advantages over paper records; these include: enabled access to medical records from remote locations, improved speed and ease of retrieval of records, avenues to flag abnormal results and the elimination of hand written prescriptions, which reduces the occurrence of prescription errors8-10. Other benefits are the simultaneous access to patient records by multiple users and the ability to perform data queries to inform decision making. These potential benefits of the EHR have enabled its wide acceptability in industrialized nations 11.

Developing countries, including sub-Saharan Africa, bear the brunt of the world’s deadliest epidemics, which include HIV/AIDS, malaria and tuberculosis12. There is a tremendous potential for the deployment of information and communication technology (ICT) to improve health care in these regions13. Access to the internet has dramatically improved in the last 10 years, and all countries in Africa now have direct access to the internet14. There is limited information on how healthcare in sub-Saharan Africa is being influenced by the current influx of ICT into the region. In order to bridge this gap, we sought to document the availability of EHR, in sub-Saharan Africa, and highlight the challenges hindering its wider adoption in the region.

Methods

Identification of publications

Searches were performed on PubMed and Google Scholar using the terms:

  • Electronic Medical Records AND Africa

  • Electronic Health Records AND Africa

  • E-Health AND Africa

  • Medical Informatics AND Africa

For countries in sub-Saharan Africa yielding no results from the search, country names were specifically included in the search terms, for example: Electronic Health Records AND Chad. References from identified publications were also reviewed.

Inclusion and exclusion criteria

Publications of interest were those on the use of EHRs in health care in Africa. Commentaries, opinions and reviews were excluded. Duplicate publications were also excluded.

Results

The search yielded 147 publications with EHR(s) related terms and the name of an African country. A total of 126 publications (86%) were excluded; of these 64 had no information on use of EHRs in an African country and 62 were duplications.

The remaining 21 articles were reviewed. These articles were from 15 African countries (Table1). Most of the publications were from Eastern and Southern Africa with Kenya having the highest number of publications (4, 19%)15-18. Two publications documented experiences in more than one country, the first in three East African countries19 and the second from ten countries20. The publication documenting experiences from 10 African countries was the ‘Drug Resources Enhancement against AIDS and Malnutrition’ (DREAM) project. This was a project of Sant’Egidio; a Christian based organization in Rome involved the fight against AIDS in sub-Saharan African. The 10 countries covered by the DREAM project are: Guinea Bissau, Republic of Guinea, Nigeria, Cameroon, Democratic Republic of Congo, Angola, Kenya, Tanzania, Malawi and Mozambique.

Table 1.

Summary of publications on the use of electronic medical records in sub-Saharan Africa

Publications Country Software Setting
Identification of losses to follow-up in a community based antiretroviral therapy clinic in South Africa using a computerized pharmacy tracking system30 South Africa Open Source (iDART) HIV care
Leapfrogging paper-based records using handheld technology: experience from Western Kenya15 Kenya Open Source Home based care
Innovative approaches to application of information technology in disease surveillance and prevention in Western Kenya16 Kenya Open Source Injury surveillance
The Mosoriot medical record system: design and implementation of an outpatient electronic record system in rural Kenya17 Kenya Open Source Tertiary care
“Talkin’ about a revolution”: How electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings18 Kenya Open Source (Open MRS) HIV care
Experience with implementing electronic health records in three East African countries19 Kenya, Tanzania & Uganda. Open Source (Open MRS) HIV care
Combining vital events registration, verbal autopsy and electronic medical records in rural Ghana for improved health service delivery10 Ghana Open Source (MGV-net) Vital registration
Implementing OpenMRS for patient monitoring in an HIV/AIDS care and treatment program in rural Mozambique34 Mozambique Open Source (Open MRS) HIV care
Using electronic medical records in HIV care in rural Rwanda35 Rwanda Open Source HIV Care
Rapid deployment of electronic medical records in rural Rwanda32 Rwanda Open Source (Open MRS) HIV care
Experience implementing OpenMRS to support maternal and reproductive health in Northern Nigeria23 Nigeria Open Source (Open MRS) Maternal & reproductive health
The computer in a Nigerian teaching Hospital: First year experience45 Nigeria Open Source Tertiary care center
Experience implementing a point-of-care electronic medical record system for primary care in Malawi22 Malawi Open Source (Open MRS) Primary care center
A global approach to the management of EMR (electronic medical records) of patients with HIV/AIDS in sub-Saharan Africa: the experience of Dream Software20 Guinea Bissau, Republic of Guinea, Nigeria, Cameroon, Republic of Congo, Kenya, Angola Mozambique, Malawi, Tanzania Open Source (DREAM Software) HIV care
Expanding an electronic medical record to support community health worker and nutritional support programs in rural Rwanda36 Rwanda Open Source HIV care
Hybrid data capture for monitoring patients on highly active antiretroviral therapy (HAART) in urban Botswana31 Botswana Open Source HIV care
Designing and implementing an electronic health record system in primary care in sub-Saharan Africa: a case study from Cameroon24 Cameroon MEDCAD Primary care
An electronic medical record system for ambulatory care of HIV-infected patients in Kenya33 Kenya Open Source (Open MRS) HIV care
Enumeration of non-communicable disease in rural South Africa by electronic data linkage and capture–recapture techniques25 South Africa Open Source Primary care
Open Source challenges for Hospital Information System (HIS) in a developing country: a pilot project in Mali26 Mali Open Source Tertiary care
Assessment of data quality of and staff satisfaction with an electronic health record system in a developing country (Uganda): a qualitative and quantitative comparative study44 Uganda Open Source (Open MRS) Primary care
Open in a new tab

The use of open source healthcare software was documented in 95.2% (20/21) of publications, with 47.6% (10/21) of publications being from HIV-related treatment programs. Open Medical Records System (OpenMRS) was the most popularly used open source health software and was used in 60% (6/10) of centers involved in HIV care and 27% (3/11) of non-HIV related programs.

The review also showed an increase in the number of publications between 1992, when the first article was published, and 2010 (Figure 1).

Figure 1.

Figure 1

Open in a new tab

Chart showing publications on the use of electronic medical records in sub-Saharan Africa

The major documented challenge to the establishment of EHR was the high cost of set-up and maintenance. This was due to poor existing infrastructure, frequent power outages and network failure. In facilities with EHRs, use was sub-optimal because of the need for parallel entry of data to paper and computer which increased the work-load of over-stretched staff. Despite these challenges, some authors have documented benefits of the use of EHR in sub-Saharan Africa; these include greater data accuracy, improved timeliness, availability of routine reports and reduced data duplication21-25.

Discussion

The implementation of Clinical Information Systems has been identified as an important component of improving health care, and the degree of adoption of technologies in health care has been shown to correlate with reduction of complications and mortalities in hospitals26-28. Although African nations are still lagging behind developed countries in the availability and use of EHRs29, this review shows that there has been an appreciable increase in the availability and utilization of EHRs in Africa over the last decade. This increase has been driven by collaboration between African institutions and international collaborators mostly in the area of HIV/AIDS treatment and care18,20,30-36.

The influx of EHRs in sub-Saharan Africa has been facilitated by several factors, key factors being the increased availability of personal computers12 and increased access to internet. Internet access in Africa has grown by 2,357.3% from 2000 to 2010. This however represents only 10% of the population, far behind the 30% world average coverage37. Although the internet is present in all 54 African countries, access is often concentrated in urban centers, with no access in most rural centers where over 80% of the population reside. This inequitable distribution has affected the realization of the full benefits of EHRs in sub-Saharan Africa.

To set up an EHR system is capital intensive38,39 and thus beyond the reach of most health providers in sub-Saharan Africa. Few African countries have the manpower and skills to develop the required infrastructure and the cost of commercial software packages is exorbitant. The emergence of Open Source Software has however enhanced the opportunity of several African countries to gain access to EHRs, and this was observed in the review15-20,22,30-35. The acquisition of Open Sources is less expensive and provides opportunities for adaptation for local use40.

Few studies have audited the use of EHRs in sub-Saharan Africa41,42. Expectedly, results have been as conflicting as those from developing countries. Several publications have documented benefits of the use of EHRs in Africa including greater data accuracy, improved timeliness and availability of routine reports21,22,24. A review by Foster et al 43 however showed that more effort is still required to optimize the benefits of EHRs in developing countries.

Despite the successful introduction of EHRs in sub-Saharan Africa so far, it has not been without challenges. Most EHRs are sustained by funding from international partnerships raising questions about the sustainability of these systems by the host institutions. Poor infrastructure also increases the cost to set up and maintain the systems. Specifically there have been reports of power outages and network breakdowns; the need for parallel data entry also contributed to overload of work for the limited health staff44,45.

A potential limitation of this review is the restriction of the search to published literature. This may exclude experiences from centers not documented in scholarly publications. Also striking is the dearth of publications from Francophone countries. Although the search through English literature may contribute to this, the paucity of use of EHRs in Francophone sub-Saharan Africa has been previously documented26.

Conclusion

The availability of EHR in sub-Saharan Africa has increased over the last decade, mostly driven by international efforts at stemming the HIV/AIDS epidemic. Based on the current literature, most countries in sub-Saharan Africa, particularly Francophone countries, are however being left behind in the progress towards EHR adoption. Government institutions in sub-Saharan Africa also appear to be slow in implementing EHR and other appropriate ICTs which are required to improve healthcare on the continent.

Acknowledgments

MOA was supported by NIH through a Fogarty International Center grant D43TW007995. The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the Fogarty International Center or the National Institutes of Health. The authors gratefully acknowledge the assistance of Pamela Shaw in retrieving relevant materials for this review.

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