One of the outcomes of the 12-year-long collaboration between the Moi University Faculty of Health Sciences, Kenya, and the Indiana University, US, was the development of a computer-based medical record system at the Mosoriot Health Center in Kenya. The project took place in a rural sub-Saharan region with widespread economic poverty. The Mosoriot Health Centre was the sole health care provider for a surrounding population of 30-40 thousand people, who lived in mud-walled houses with no running water, electricity, or telephones. The health centre served the outpatient medical needs in children's care, antenatal care, family planning, common infective diseases, and drugs. The key operational goal of the project was to develop a sustainable electronic medical record system in a rural region characterised by the lack of technology bases. This article, published in the International Journal of Medical Informatics in October 2000, reports the project design process by highlighting challenges unique to a rural development country context characterised by poor technology infrastructure.


Research Methodologies:

The article presents a formative research, explaining the process leading toward the implementation of an electronic medical record system at the Mosoriot Health Centre. The authors used a participant-observation approach in which the researchers became part of the project development and implementation team. The researchers' first-hand observations were supplemented by detailed discussion of the context of the project. The aim of this paper was not to provide impact data; the main purpose was to illustrate the design process of a technology-based system in a resource-poor circumstance.


Key Findings:

The project team began the design process through a series of consultations with the local health agency, the head nurse, director of medical records, nurses, and staff in all offices and clinics within the Mosoriot Health Centre. Information gathered from stakeholders at various levels pointed to important design requirements for a sustainable clinical record system.

Stakeholder input highlighted several key challenges. First, the project team learned that electrical power supply was unreliable in the area. This mandated the use of power surge protectors and a small generator for interrupted power supply. Second, none of the staff at the health centre had prior experience with computers. Computers for staff training purposes were furnished by the Moi University, and the project team assigned computer experts for staff training. In terms of the hardware, the project team attempted to ensure the adoptability of the new system to the local circumstance by making the system as simple and easy to operate and maintain as possible. For this reason, the project team decided to base the entire system in a single computer. Third, the new electronic record system had to develop a patient identification number system. Kenyan society had no individual identification number such as the social security number in the US. The team developed a patient ID system that was simple and met with local conventions. Fourth, the new system was designed to radically streamline the existing, paper-based record system. In the paper-based system, a patient's information was recorded multiple times during a patient's visit to the health centre (e.g., registration counter, financial office, each clinic s/he visits, lab, etc.). To eliminate redundant steps, and to make the transition from a paper-based system to an electronic system smooth, the project team developed an encounter form, a standardised paper-based form serving as data templates for capturing each patient's service records. Entries in the encounter form would then be entered into an electronic database managed by a single personal computer located in the health centre's registration office.

Participation of stakeholders in the implementation process was an integral part of the project. Clinical and academic stakeholders took part in the design, planning, software development, and plans for the future evolution of the electronic medical record system. The authors argue that a "big bucks" approach is not sustainable once external funding ends in a circumstance like rural Kenya, and that any developments in health information management must meet the local needs and be sustainable by local resources.

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