title: Assessing the impact of a primary care electronic medical record system in three Kenyan rural health centers.
abstract: Efficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers.
  
  
  
  Local clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers' satisfaction with the EMR.
  
  
  
  Between September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care. Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers' work patterns, but the nurses' and the clerks' patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training.
  
  
  
  We successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses' and the clerks' patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow.
authors.affiliation: Departments of Medicine and Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA Center for Biomedical Informatics, Regenstrief Institute, Inc. Indianapolis, IN, USA wtierney@regenstrief.org.
authors.forename: William M
authors.initials: WM
authors.lastname: Tierney
authors.affiliation: Departments of Medicine and Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.
authors.forename: John E
authors.initials: JE
authors.lastname: Sidle
authors.affiliation: Department of Medicine, Moi University School of Medicine, Eldoret, Kenya Department of Medicine, Moi Teaching and Referral Hospital, Eldoret, Kenya The Academic Model Providing Access to Healthcare, Eldoret, Kenya.
authors.forename: Lameck O
authors.initials: LO
authors.lastname: Diero
authors.affiliation: Department of Medicine, Moi University School of Medicine, Eldoret, Kenya Department of Medicine, Moi Teaching and Referral Hospital, Eldoret, Kenya The Academic Model Providing Access to Healthcare, Eldoret, Kenya.
authors.forename: Allan
authors.initials: A
authors.lastname: Sudoi
authors.affiliation: Department of Medicine, Moi University School of Medicine, Eldoret, Kenya Department of Medicine, Moi Teaching and Referral Hospital, Eldoret, Kenya The Academic Model Providing Access to Healthcare, Eldoret, Kenya.
authors.forename: Jepchirchir
authors.initials: J
authors.lastname: Kiplagat
authors.affiliation: Department of Medicine, Moi University School of Medicine, Eldoret, Kenya Department of Medicine, Moi Teaching and Referral Hospital, Eldoret, Kenya The Academic Model Providing Access to Healthcare, Eldoret, Kenya.
authors.forename: Stephen
authors.initials: S
authors.lastname: Macharia
authors.affiliation: Departments of Medicine and Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.
authors.forename: Changyu
authors.initials: C
authors.lastname: Shen
authors.affiliation: Center for Biomedical Informatics, Regenstrief Institute, Inc. Indianapolis, IN, USA.
authors.forename: Ada
authors.initials: A
authors.lastname: Yeung
authors.affiliation: Departments of Medicine and Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA Center for Biomedical Informatics, Regenstrief Institute, Inc. Indianapolis, IN, USA Department of Medicine, Moi University School of Medicine, Eldoret, Kenya Department of Medicine, Moi Teaching and Referral Hospital, Eldoret, Kenya The Academic Model Providing Access to Healthcare, Eldoret, Kenya.
authors.forename: Martin C
authors.initials: MC
authors.lastname: Were
authors.affiliation: Departments of Medicine and Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.
authors.forename: James E
authors.initials: JE
authors.lastname: Slaven
authors.affiliation: Departments of Medicine and Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.
authors.forename: Kara
authors.initials: K
authors.lastname: Wools-Kaloustian
mesh_terms: D001292:Attitude to Computers; D017598:Efficiency, Organizational; D057286:Electronic Health Records; D006801:Humans; D007630:Kenya; D016347:Medical Records Systems, Computerized; D011320:Primary Health Care / Q000458:organization & administration*; D019035:Rural Health Services / Q000458:organization & administration*; D013996:Time and Motion Studies; D057188:Workflow