title: Developing a point-of-care electronic medical record system for TB/HIV co-infected patients: experiences from Lighthouse Trust, Lilongwe, Malawi.
abstract: BACKGROUND
  Implementation of user-friendly, real-time, electronic medical records for patient management may lead to improved adherence to clinical guidelines and improved quality of patient care. We detail the systematic, iterative process that implementation partners, Lighthouse clinic and Baobab Health Trust, employed to develop and implement a point-of-care electronic medical records system in an integrated, public clinic in Malawi that serves HIV-infected and tuberculosis (TB) patients.
  
  
  METHODS
  Baobab Health Trust, the system developers, conducted a series of technical and clinical meetings with Lighthouse and Ministry of Health to determine specifications. Multiple pre-testing sessions assessed patient flow, question clarity, information sequencing, and verified compliance to national guidelines. Final components of the TB/HIV electronic medical records system include: patient demographics; anthropometric measurements; laboratory samples and results; HIV testing; WHO clinical staging; TB diagnosis; family planning; clinical review; and drug dispensing.
  
  
  RESULTS
  Our experience suggests that an electronic medical records system can improve patient management, enhance integration of TB/HIV services, and improve provider decision-making. However, despite sufficient funding and motivation, several challenges delayed system launch including: expansion of system components to include of HIV testing and counseling services; changes in the national antiretroviral treatment guidelines that required system revision; and low confidence to use the system among new healthcare workers. To ensure a more robust and agile system that met all stakeholder and user needs, our electronic medical records launch was delayed more than a year. Open communication with stakeholders, careful consideration of ongoing provider input, and a well-functioning, backup, paper-based TB registry helped ensure successful implementation and sustainability of the system. Additional, on-site, technical support provided reassurance and swift problem-solving during the extended launch period.
  
  
  CONCLUSIONS
  Even when system users are closely involved in the design and development of an electronic medical record system, it is critical to allow sufficient time for software development, solicitation of detailed feedback from both users and stakeholders, and iterative system revisions to successfully transition from paper to point-of-care electronic medical records. For those in low-resource settings, electronic medical records for integrated care is a possible and positive innovation.
authors.affiliation: The International Union Against Tuberculosis and Lung Disease, Paris, France. h_tweya@lighthouse.org.mw.|Lighthouse Trust, Lilongwe, Malawi. h_tweya@lighthouse.org.mw.|Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland. h_tweya@lighthouse.org.mw.
authors.forename: Hannock
authors.initials: H
authors.lastname: Tweya
authors.affiliation: Lighthouse Trust, Lilongwe, Malawi. cfeld@uw.edu.|International Training and Education Center for Health (I-TECH), University of Washington, 901 Boren Avenue, Suite 1100, Seattle, WA, 98104, USA. cfeld@uw.edu.
authors.forename: Caryl
authors.initials: C
authors.lastname: Feldacker
authors.affiliation: Baobab Health Trust, Lilongwe, Malawi. jintha@gmail.com.
authors.forename: Oliver Jintha
authors.initials: OJ
authors.lastname: Gadabu
authors.affiliation: Lighthouse Trust, Lilongwe, Malawi. w_ngambi@lighthouse.org.mw.
authors.forename: Wingston
authors.initials: W
authors.lastname: Ng'ambi
authors.affiliation: Baobab Health Trust, Lilongwe, Malawi. soyapim@gmail.com.|Department of Biomedical Informatics, Center for Health Informatics for the Underserved, University of Pittsburgh, Pittsburgh, PA, USA. soyapim@gmail.com.
authors.forename: Soyapi L
authors.initials: SL
authors.lastname: Mumba
authors.affiliation: Baobab Health Trust, Lilongwe, Malawi. dave.phiri@baobabhealth.org.
authors.forename: Dave
authors.initials: D
authors.lastname: Phiri
authors.affiliation: Baobab Health Trust, Lilongwe, Malawi. lmkamvazina@gmail.com.
authors.forename: Luke
authors.initials: L
authors.lastname: Kamvazina
authors.affiliation: Baobab Health Trust, Lilongwe, Malawi. shawo.mwakilama@baobabhealth.org.
authors.forename: Shawo
authors.initials: S
authors.lastname: Mwakilama
authors.affiliation: Malawi National Tuberculosis Program, Lilongwe, Malawi. hkanyerere@yahoo.com.
authors.forename: Henry
authors.initials: H
authors.lastname: Kanyerere
authors.affiliation: Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland. okeiser@ispm.unibe.ch.
authors.forename: Olivia
authors.initials: O
authors.lastname: Keiser
authors.affiliation: Lighthouse Trust, Lilongwe, Malawi. j_mwafilaso@lighthouse.org.mw.
authors.forename: Johnbosco
authors.initials: J
authors.lastname: Mwafilaso
authors.affiliation: Bwaila District Hospital, TB clinic, Lilongwe, Malawi. ckamba@lighthouse.org.mw.
authors.forename: Chancy
authors.initials: C
authors.lastname: Kamba
authors.affiliation: Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland. egger@ispm.unibe.ch.
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
authors.affiliation: International Training and Education Center for Health (I-TECH), University of Washington, 901 Boren Avenue, Suite 1100, Seattle, WA, 98104, USA. drandreasjahn@gmail.com.|Central Monitoring and Evaluation Division/Department for HIV and AIDS, Ministry of Health, Lilongwe, Malawi. drandreasjahn@gmail.com.
authors.forename: Andreas
authors.initials: A
authors.lastname: Jahn
authors.affiliation: Baobab Health Trust, Lilongwe, Malawi. b_simwaka@lighthouse.org.mw.
authors.forename: Bertha
authors.initials: B
authors.lastname: Simwaka
authors.affiliation: Lighthouse Trust, Lilongwe, Malawi. samphiri@lighthouse.org.mw.
authors.forename: Sam
authors.initials: S
authors.lastname: Phiri
mesh_terms: D000293:Adolescent; D000328:Adult; D000886:Anthropometry; D002648:Child; D002675:Child, Preschool; D060085:Coinfection; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D003710:Demography; D037001:Directive Counseling; D057286:Electronic Health Records / Q000458:organization & administration*; D015658:HIV Infections / Q000175:diagnosis* / Q000453:epidemiology / Q000473:pathology / Q000821:virology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008295:Malawi / Q000453:epidemiology; D008403:Mass Screening; D019095:Point-of-Care Systems / Q000458:organization & administration*; D011340:Problem Solving; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology / Q000473:pathology