A Case Study of a Point-of-Care Electronic Medical Record [SABER] in Totonicapán, Guatemala: Benefits, Challenges, and Future Directions

Nicholas H. Aldredge; Dorian Rodriguez; Jessica González; David R. Burt

doi:10.5334/aogh.3041

Figures & Tables

Table 1

Characteristics of Survey Respondents and Their Practices.

Characteristic	Respondents (n = 37)
*Physicians*	n = 6
Sex
M	4
F	2
Years of medical practice
1–9	4
10–19	1
20+	1
Completed residency?
Y	3
N	3
Physician specialty
Primary care	2
Not primary care	3
Unspecified	1
Time working in Totonicapán Emergency Room
< 1 year	2
1–4 years	2
5–9 years	–
10+ years	2
Used EMR previously
Y	4
N	2
Time using SABER (months)
0–5	4
6–12	1
24+	0
Data not collected	1
*Medical Students*	n = 31
Sex
M	10
F	21
Year in medical school
4th	19
5th	2
6th	10
Medical school attended
Universidad Mesoamericana	26
Universidad de San Carlos	3
Not specified	2
Used EMR previously
Y	1
N	30
Time using SABER (months)
0–5	23
6–12	3
13+	4
Data not collected	1

Table 2

Survey Results of Provider Perceptions of SABER.

Survey response Medical students (n = 31)	1	2	3	4	5
Quality of continuing service and support for SABER
UVA-GI provides continuous appropriate support in order to use SABER effectively.	0	3 (10%)	2 (7%)	12 (39%)	14 (45%)
UVA-GI helps with the training necessary to use SABER.	3 (10%)	1 (3%)	4 (13%)	17 (55%)	7 (23%)
Overall satisfaction with SABER
If I had the opportunity to select another EHR, I would choose SABER.	0	0	4 (13%)	20 (65%)	7 (23%)
SABER improves the quality of care in the emergency room in Totonicapán.	0	0	9 (29%)	17 (55%)	5 (16%)
I would recommend SABER to another healthcare provider.	0	0	1 (3%)	16 (52%)	14 (45%)
If I could return to paper-based medical records, I would do so	7 (23%)	10 (32%)	8 (26%)	4 (13%)	2 (7%)
Survey response *Physicians (n = 6)*	1	2	3	4	5
Quality of continuing service and support for SABER
UVaGI provides continuous appropriate support in order to use SABER effectively.	0	1 (17%)	0	2 (33%)	3 (50%)
UVaGI helps with the training necessary to use SABER.	0	1 (17%)	0	2 (33%)	3 (50%)
Overall satisfaction with SABER
If I had the opportunity to select another EHR, I would choose SABER.	0	0	0	3 (50%)	3 (50%)
SABER improves the quality of care in the emergency room in Totonicapán.	0	0	0	4 (67%)	2 (33%)
I would recommend SABER to another healthcare provider.	0	0	0	3 (50%)	3 (50%)
If I could return to paper-based medical records, I would do so	3 (50%)	0	1 (17%)	1 (17%)	1 (17%)

Table 3

Survey Results of Participant Skills Using SABER.

Survey response Medical students (n = 31)	1	2	3	4	5	6	7
In general, I have sufficient experience using a computer	0	0	1 (3%)	5 (16%)	2 (7%)	4 (13%)	17 (55%)
In general, I have sufficient experience using SABER	1 (3%)	1 (3%)	1 (3%)	7 (23%)	7 (23%)	7 (23%)	7 (23%)
I know how to print a chart using SABER	1 (3%)	1 (3%)	0	0	0	5 (17%)	24 (77%)
I know how to admit a patient using SABER	3 (10%)	0	0	1 (3%)	0	4 (13%)	22 (71%)
I always user SABER to input patient information in the Totonicapán Emergency Room	2 (7%)	0	0	3 (10%)	3 (10%)	6 (19%)	17 (55%)
Survey response *Physicians (n = 6)*
In general, I have sufficient experience using a computer	0	0	0	0	0	0	100
In general, I have sufficient experience using SABER	1 (17%)	0	0	0	1 (17%)	2 (33%)	2 (33%)
I know how to print a chart using SABER	1 (17%)	0	0	0	1 (17%)	2 (33%)	2 (33%)
I know how to admit a patient using SABER	1 (17%)	0	0	0	0	2 (33%)	3 (50%)
I always user SABER to input patient information in the Totonicapán Emergency Room	1 (17%)	0	0	0	0	1 (17%)	4 (66%)

Table 4

Recommendations for Implementation of EMRs in Low-Resource Settings.

Identified Barriers	Suggested Solutions
Organizational: Focuses on (managerial) circumstances within the organization itself, e.g. human resources, adequate support staff, attitude toward EMR, stakeholder involvement
Healthcare professionals are not motivated to adopt the EMR system	– Increase participation in EMR implementation in specific phases – Provide adequate and ongoing professional training – Ensure robust leadership that encourages all providers to use the EMR – Consider making EMR use voluntary with financial and social incentives
Staff do not understand the importance of the data collected by EMRs	– Hold frequent department-wide meetings to discuss data collected from the EMR and to create data-driven goals for future preventative care measures
Lack of managerial support/leadership for EMR implementation	– Hold frequent meetings with hospital leaders to provide adequate technical support and encourage leaders to promote EMR adoption within the culture of their hospital unit – Ensure that management provides effective monitoring of appropriate EMR use by hospital staff
Workflow of the unit/hospital does not match the design of the EMR	– Adjust the workflow of both the unit/hospital and EMR to ensure seamless integration. For example: Place workstations at each patient bed to ensure information is entered in a timely fashion Encourage specific procedures that include EMR use at the time of patient care Draw out map of hospital workflow; customize EMR to match hospital workflow
Political: Trust, attitude to change, general political willingness, includes legal health policies and country-wide circumstances including hospital location
Resistance from providers who have not used EMRs in the past	– Provide adequate and ongoing training to providers before they are required to use the EMR – Hold meetings with providers resistant to change to understand why they do not wish to adopt the EMR
Lack of communication between different healthcare providers within the unit or hospital	– Hold interdisciplinary department-wide meetings to discuss the integration of EMR systems among different professional
Lack of provider trust in data collected by EMR system; fear of accountability	– Discuss with providers the improvement in quality of care through the reduction of medical errors by EMR data collection and analysis
Functionality: System architecture and functions, e.g. data handling in different forms, having a system dictionary, usability
EMRs add additional tasks that take longer to complete	– Eliminate unnecessary and redundant data input into the EMR system – Include a system dictionary with algorithms allowing user-shortcuts for data entry
EMR system requires “double work”, meaning that providers fill out the same information twice both electronically and on paper	– Eliminate redundancy between paper and electronic forms – Design a completely digital system that may be easily printed out if records are needed for reporting to government agencies
Training: Training using the system, handover to local support staff, educational background and knowledge such as computer literacy of staff
Vulnerability of program to loss of critical programmer	– Coach and train additional programmers who understand the electronic medical record – Develop EMR on open-source platform
Lack of around-the-clock technical support	– Establish hours for phone support manned by program administrators – Train participants to troubleshoot common hardware and software problems – Create technical handbook with step-by-step solutions to common EMR problems – Hire additional technical support staff to provide additional hours of in-person support
Limited technical proficiency of end-users	– Implement a basic technology professional education program to ensure sufficient technical capacity to use computers and software – Provide adequate and ongoing support to all potential users of the EMR system
Technical: Includes infrastructure, e.g. internet access, power supply, software architectural characteristics, security and privacy
Power supply is unreliable	– Install a backup power supply with surge protection for EMR equipment, such as a generator system or series of batteries – Consider alternative power supply (e.g. solar)
Troubleshooting problems, including both hardware and software	– Create a laminated technical handbook with the most commonly identified troubleshooting problems and a step-by-step solution; place strategically around hospital; mirror this print edition with a digital backup
Financial: Availability of resources and funding, efficiency
Lack of available dedicated EMR support staff	– Train hospital staff to troubleshoot common problems, minimizing reliance on support staff
Ethical: Sustainability, privacy and security, regulatory and cultural issues
The EMR is dependent on technical and financial contributions from outside stakeholders	– The sustainability of a project is heavily dependent on effective leadership and training of the involved stakeholders in the target population. – After start-up costs have been covered and ongoing costs have stabilized, slowly transition more financial responsibility onto the receiving institution.