Proceedings of the Third International Conference on Digital Information Processing, E-Business and Cloud Computing, Reduit, Mauritius 2015

Designing an Electronic Health Information System Integrating Mobile Phone

Technology Suitable for a Low and Middle-Income Country
CASE STUDY: Curative Care Services in Kenyan Level 5 Hospitals
Paul MACHARIA1, Maureen INIMAH1, Davies KIMANGA 2
1

Ministry of Health, National AIDS & STIs Control Programme

2

Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya

Mailing Address: P.O Box 3966 00100 Nairobi

E-mail: paulmachariah@gmail.com, maureen.amagove@gmail.com, kimangah@gmail.com

ABSTRACT
Shortage of healthcare workers (HCWs) hampers
treatment outcomes in Sub-Sahara Africa (SSA),
there is also a great need for scalable, cost-effective
and long-term strategies in curative care services.
The benefits of e-Government, the integration of
innovative Information and Communication
Technologies (ICTs) to conveniently provide access
to services are yet to be realized. m-Health is an
emerging concept with potential to revolutionize
delivery of healthcare, mobile phone technologies
potential to change healthcare for the better when
used as an enabler to immediate and secure access
to critical clinical information when needed in the
provision of patient care has not been fully
exploited. The study an exploratory research design
aims to discover ideas and insights on the use of
Electronic Medical Records integrating mobile
phone technologies. The research hopes to identify
potential problems of EMR system setup and
available opportunities for integrating mobile phone
technologies relevant to the provision of quality
healthcare and treatment outcomes.

KEYWORDS
e-Health, m-Health, Quality Healthcare, EMRs,
Mobile Phone Technologies

ISBN: 978-1-941968-14-7 2015 SDIWC

1.

INTRODUCTION

To efficiently provide services, Countries are

embracing e-Government, the integration of
innovative Information and Communication
Technologies (ICTs) in a way that conveniently
provides access to services & up-to-date
information to its citizens [1]. In leading
economies, e-Government has had great success.
However, more efforts are needed to realize
similar success in developing Countries [2].
Scalable, cost-effective and long-term strategies
in preventive and curative care services are
greatly needed. Information and Communication
Technologies (ICTs), when used in a health
system setup, could greatly improve how
healthcare is administered in a health facility [3].
e-Health is the enhancement of clinical care
through use ICTs in the delivery of treatment,
diagnosis and disease management [4]. e-Health
could also provide an opportunity to extend
healthcare ability to meet patient needs in a
manner that supplements traditional delivery of
healthcare [5].
The capacity to improve health outcomes SubSaharan Africa is greatly hampered by shortage
of health workers [6], exchange of clinical data

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can be bridged by the use of ICTs bringing great

benefit to healthcare systems and medical
information sharing [7]. An increase in cheaper,
efficient and reliable mobile phones avails
technological opportunities to offer m-Health
solutions for preventive and curative care
services in low and middle-income countries [8].

The service delivery levels integrating all

health programmes into a single package are
represented by the Kenya Essential Package for
Health (KEPH). These levels aim to provide
interventions that will improve peoples health
at every stage of human development [11].
KEPH defines the six levels of service delivery.
The levels of care are as shown in figure 1.

1.1 Rationale
The Government of Kenya (GoK) lays a
strong emphasis on strengthening prevention,
eradication and control of diseases by
endeavoring to provide quality healthcare
services to the whole population [9]. A number
of policy documents have been formulated to
operationalize and support implementation of
quality healthcare through the Ministry of
Health (MoH) and other relevant Government
Agencies.

Patient.about.com states that Curative care

refers to treatment and therapies provided to a
patient with the intent to improve symptoms and
cure the patient's medical problem. Examples of
curative care include antibiotics, chemotherapy
or a cast for a broken limb. Level 5 hospitals
now referred to as County hospitals are handling
curative and preventive care in the 47 Counties
of Kenya. The Level 5 hospitals form part of the
County level referral services of comprehensive
healthcare services [12].

To improve service delivery in healthcare,

GoK through the Ministry of Health (MoH) and
other stakeholders reviewed the First National
Health Sector Strategic Plan (NHSSP-I) service
delivery system devising a new strategy that
makes healthcare effective and accessible to all.
This new strategy is part of the second National
Health Sector Strategic Plan (NHSSP-II) that
proposed different levels of healthcare delivery
[10].
The 6 healthcare delivery levels in the Kenyan
health system are; level 1 a community level
service delivery point targeting a population of
up to 5,000 people. Level 2 and level 3
predominantly
handling
promotive
and
preventive care in a population of up to 40,000.
Level 4 service delivery points handles in and
outpatient services and is the first level of
curative care services to a population of up to
200,000. Level 5 facilities have a broader
spectrum of curative care services to a
population of 1,000,000. Level 6 facilities are
national hospitals providing referrals for all
specialized services of healthcare [11].

ISBN: 978-1-941968-14-7 2015 SDIWC

Figure 1: Levels of health care delivery in

the Kenya Package of Health (MoH, 2004)

2.

RESEARCH DESIGN

This research applied an exploratory research

design with a goal to discover ideas and insights
on the use of Electronic Medical Records
(EMRs) integrating mobile phone technologies.
The research would identify potential problems

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Proceedings of the Third International Conference on Digital Information Processing, E-Business and Cloud Computing, Reduit, Mauritius 2015

of EMR system setup and available

opportunities for integrating mobile phone
technologies relevant to quality healthcare and
health outcomes. The exploratory research was
conducted to provide a better understanding of a
patients access to curative care services,
document patient flow and map service delivery
points. Through the research, a conceptual
model of integrating mobile phone technologies
on EMRs was developed.

3.

LITERATURE REVIEW

The use of ICTs in healthcare including

mobile technologies to provide services could
transform service delivery. Mobile technologies
are experiencing rapid advancements, this opens
up opportunities to integrate the technology to
existing e-Health services and catalyze the use
of m-Health in provision of healthcare [13],
[14].
In sub-Saharan Africa, communicable,
maternal, nutritional, and newborn diseases are
still a leading cause of injuries and premature
deaths. Although there has been considerable
decline in communicable diseases in childhood,
these diseases still account for a large part of
health losses and public health concerns despite
the efforts. Malaria and HIV/AIDS still account
for many losses in this part of Africa, however
non-communicable diseases including diabetes,
heart conditions and Cancer have been on the
increase in the recent past [15].
In Kenya, HIV/AIDS, lower respiratory
infections, and malaria contributed highest to
disease burden in 2010. Underweight in children
is the leading risk factor in Kenya; other factors
include non-communicable and nutritional
causes of death. [16].
The GoK e-Health strategy is greatly
dependent on the success of Kenyas Vision
2030, the visions key achievement related to
health is to catalyze equitable and affordable

ISBN: 978-1-941968-14-7 2015 SDIWC

healthcare at the highest achievable standard.

This aligns well with radical changes in clinical
care which is defined as a comprehensive,
ongoing approach to care delivery excellence
that measurably improves quality, enhances
service, and reduces costs through the effective
alignment of people, process, and technology
[17]. The use of ICTs in healthcare makes a key
technology component that will enable clinical
transformation.
e-Health can be defined as a new field in
healthcare where ICTs are taking a greater role,
it is the putting to good use the Internet and
related technologies to connect and facilitate
provider-to-provider
communication
and
provider-to-patient communication in the
provision of healthcare services. It involves the
use ICTs to store and manage a patients data
and their relevant clinical information [18].
An EMR system is a computer application
supporting digitalization of a patients medical
history by electronically documenting all
relevant information to this patients healthcare.
EMR systems store and provide for retrieval of
information on a patients diagnosis, care and
treatment [19].
EMRs have been identified to make relevant
clinical data available to the providers with
minimal effort. A patients safety is assured to
due to safe storage of their confidential
information; providers have been noted to be
efficient and learning on their jobs when
working in a well setup health information
system [20]. EMRs should increase a health
providers ability to access patient data and
share confidential records among authorized
persons [21].
The EMR can track patients stored data over
time, scheduled visits and monitor all relevant
patient health information which could
potentially improve the quality of healthcare
[22]. An EMR captures information in a
structured
way
enabling
continuous

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Proceedings of the Third International Conference on Digital Information Processing, E-Business and Cloud Computing, Reduit, Mauritius 2015

improvement in healthcare delivery. System

interoperability, which is the ability to share data
with other EMRs is a key component in
providing quality healthcare. Standards of EMR
systems setup that include HL7 standard which
regulates interoperability standards of EMRs
should be strictly adhered to thus enhancing
sharing of patient data across systems and
quality of services [23]. Interoperability among
EMR systems enables healthcare providers to
actively interrogate healthcare procedures and
decisions from shared data thus ensuring quality
healthcare [24].
Although EMRs have great potential, there is
very little literature or studies specifically
designed to evaluate what already setup systems
have had to the quality of healthcare, making the
services affordable and accessible in LMICs.
Customizing the EMR to meet a communitys
culture and health expectations is still in great
need [25].
In the recent past mobile phone technologies
have experienced rapid growth, major
developments on both hardware and applications
is creating more opportunities to integrate
mobile phone technologies into existing eHealth services, this is catalyzing the use of mHealth in the provision of healthcare [26]. The
world has over 5 billion mobile phone
subscribers with over 70% of these residing in
LMICs making mobile technology a very ideal
platform in provision of quality healthcare in
these countries [27].
As an innovative way to face the challenges in
health systems in LMICs, m-Health offers an
opportunity to bridge the gap to barriers
including shortage of infrastructure, patient data
being accessible and enough healthcare workers
to deliver affordable high quality healthcare
[27]. Bastawrous states that The evolution of
mobile phone technology has introduced new
possibilities to the field of medicine. Combining
technological advances with medical expertise
has led to the use of mobile phones in all

ISBN: 978-1-941968-14-7 2015 SDIWC

healthcare
areas
including
telemedicine and research.

diagnostics,

A number of efforts are already in place to

harness the many health benefits that could be
derived from the use of mobile technologies in
public health in Kenya. In 2011, leading
research institutes met to deliberate on the
potential of sharing and using m-Health
solutions to provide healthcare. The meeting
also provided an opportunity for successful
research on the use of technology in healthcare
to showcase their successes, it was agreed that
efforts would be made to spearhead turning that
meeting recommendations to policy [28].
Bring your own device (BYOD) can be
described as the trend by employees to use their
own devices on the job disrupting the
traditional model in which IT had full control
over corporate productivity tools but also
driving greater employee productivity through
increased workplace flexibility [29]. To
maximize on the potential benefits of BYOD,
policy to regulate the use of employee-owned
mobile devices and how the facility ICT staff
can support need to be formulated [30].
An acute shortage of Human Resource for
Health (HRH) in Kenya like many other LMICs
significantly hampers GoKs capacity to
improve health outcomes and achieve the health
related MDGs [31]. Although health expenditure
has improved, there is minimal increase in
health system resources [32]. The BYOD
concept could benefit GoKs effort to meet the
health needs of its population. BYOD can
reduce the health facility investment costs of
hardware, this could increase and HCW
productivity by allowing staff to access a health
facilitys EMR system remotely and provided
needed care.
To secure EMRs supporting the BYOD
concept, device provisioning for devices allowed
to access the system is paramount. The mobile
devices should be well documented and

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managed by the systems administrators.

Policies on data security and privacy should be
enforced to keep patient data uncompromised
[33].
4.

RESULTS

An electronic interview guide was sent to 20

healthcare providers in March 2014, 16
providers responded. The participants included 7
nurses, 5 doctors, 3 clinical officers and 1 social
worker. Three in every five study participants
were working or had ever worked in a health
facility using paper-based health information
system to record, store and retrieve patient data.
The study respondents outlined a number of
issues that would inform the conceptual model
of the EMR integrating mobile phone
technologies. 40% of the respondents proposed
that the EMR system could be used for patient
diagnosis; 30% of the participants identified data
storage and the remaining 30% patient records
retrieval.

Other benefits of integrating mobile phone

technologies with the EMRs were noted; over
40% of participants felt healthcare could be
scaled up with lean healthcare providers by
technology enabling remote access of patient
records from different locations. Patient data
confidentiality was a big concern among the
study participants, 60% of respondents feared
breach of patient confidentiality if the electronic
data was accessed by unauthorized persons. To
secure patient data security features including
firewall, data encryption and secure wireless
connection need to be implemented. Challenges
envisioned by participants in the use of EMRs
integrating mobile phone technologies included
health provider skills, power failure, financing
and related infrastructural needs.

Remote Access

Phone

Network Switch
Firewall

Local Access
Personal Computer

Quality of healthcare could be improved by

the use of EMRs, the system could enhance
service delivery efficiency, reduce patient
waiting time and prevent data loss. One in every
two participants indicated less time would be
spent by patients waiting for a service
encouraging more and more patients to access
care, healthcare providers will also be able to
provide care to a larger population.
On mobile phone integration, study
respondents identified on-demand availability of
patient records as very important. Mobile phone
technologies would address this need. 90% of
identified access to patient records as the
greatest advantage. The issue of misplaced
patient records, a patients laboratory results
being mixed up, loss or any other issue that
makes patient records not to be available will be
reduced by an reliable EMR system.

ISBN: 978-1-941968-14-7 2015 SDIWC

Scanner
Healthcare Provider
Printer

Computer Server

Phone

Figure 2: Conceptual model of an EMR System

Integrating Mobile Phone Technologies

Figure 2 above demonstrates a conceptual

model illustrating the EMR system setup taking
into consideration health providers needs,
concerns and suggestions.
5.

CONCLUSION

The continuum of healthcare can be well

supported by an EMR that has interoperability
capacities allowing multiple health facilities to
share patients data; this would make it possible
for the clinical staff to access a comprehensive
medical history of their patients. In LMICs,
healthcare providers are not enough, EMRs

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integrating mobile phone technologies could

support the scale up services by available lean
clinical staff remotely accessing a patients
investigation, current medical condition,
exhibiting symptoms and the healthcare
providers at the remote locations will be able to
arrive at diagnosis and relay their results back
increasing healthcare access and reach to
patients even in remote parts of Kenya.
The research has identified considerable
benefits of using EMRs integrating mobile
phone technologies in curative care services. A
larger study needs to be done to include
healthcare providers in urban, rural and semi
urban settings; this will help to evaluate the
system usability and the cost benefit analysis of
the system.
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