Assessment of the use of electronic medical records system and barriers in Rwanda

doi:10.21203/rs.3.rs-4763866/v1

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Research Article

Assessment of the use of electronic medical records system and barriers in Rwanda

https://doi.org/10.21203/rs.3.rs-4763866/v1

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Background

Since 2004, the global implementation of electronic medical records (EMR) systems has significantly improved healthcare delivery. However, challenges persist in achieving full EMR adoption, particularly in developing countries. In Rwanda, OpenMRS system was introduced in 2013 as a strategy to align digital health to the country's information and communication technologies (ICT)-for-development agenda. Reports from healthcare providers indicate varying EMR adoption levels in health facilities in Rwanda. This study aims to assess the current usage of EMR and identify implementation barriers in Rwandan health facilities.

Methods

A cross-sectional study was conducted in 257 Rwandan health facilities using an electronically designed questionnaire in Epi Info 7. Face-to-face interviews were held with 1074 participants, including facility representatives and staff from departments utilizing EMRs. The study covered all district hospitals and 44% of associated health facilities. Descriptive analysis was performed to assess EMR use, user knowledge, attitudes, and practices.

Results

A total of 257 health facilities were assessed (42 district hospitals and 215 health centers). All 42 district hospitals used EMRs, of which 35(83.3%) used OpenMRS while only 71 (33.0%) out of 215 health centers used EMRs of which about 55% used OpenMRS. Among 234 responses for non-use of EMRs, 98 (41.8%) had never used EMRs, 46 (19.6%) reported system damage, and 42 (17.9%) reported lack of internet. Reported barriers met by users included electricity and internet issues, limited computer access, and software glitches.

Conclusion

District hospitals in Rwanda showed to have widely utilized EMRs, while health centers exhibited lower utilization rates due to system unavailability or damage. OpenMRS was prevalent in hospitals, whereas health centers used diverse health systems. Respondents preferred EMRs over paper-based methods, but challenges such as internet issues, lack of user guides, power disruptions, staff shortages, and missing features hindered EMR adoption and use. Recommendations include providing comprehensive staff training, improving infrastructure (updating EMR modules, ensuring electricity and internet availability), and providing user guides to healthcare providers to enhance ICT implementation in health facilities.

Trial registration:

Not applicable

Electronic medical records

Assessment

use

barriers

Electronic medical records (EMR) are computerized medical information systems that gather, store, and display patient data (1). EMR functionalities facilitate the entry, retrieval, storage and analysis of health data (1). EMR systems and medical information exchange streamline staff communication, enhance care coordination, and ensure secure storage of patient data, ultimately promoting quality care (2, 3).

In many developing nations, the health sector relies on paper records, leading to time inefficiencies, errors, security issues, space constraints, and high maintenance costs (4). Since 2004, EMR systems have been implemented in 62 countries, and a large network of developers and implementers have supported the ongoing development of this system globally (3). The transition from paper to electronic systems has enhanced healthcare delivery, decision-making, drug list accuracy, legible notes, and provided instant chart access (5). One of the key advantages of EMR systems in health facilities is the reduction of time spent recording patient information and less waiting time for patients. OpenMRS was one the EMR systems which were adopted to facilitate service delivery(6). In 2005, Rwanda, in collaboration with health partners, introduced an EMR system aimed to improve patient care for tuberculosis (TB) and HIV, initially focusing on 16 health centers and clinics supported by Partners in Health (6). However, the system faced challenges in meeting the requirements related to service delivered to HIV patients (7), leading to the evolution of OpenMRS into a generic medical record system capable of supporting the comprehensive care of patients in all health facilities by 2013.

Despite the known advantages of EMR use, barriers to EMR system adoption have been documented in studies conducted in various countries, such as limited computer access, inadequate training, poor infrastructure, low computer literacy, absence of technical support and manuals, user resistance, corrupted files, and server failures, resulting in limited system utilization (5, 8–10). Additional barriers to EMR adoption included high initial costs, staff's limited tech knowledge, data exchange issues, and insufficient incentives (11–13). In Rwanda, perceptions of the OpenMRS system by end users revealed limitations such as the need for training, internet connectivity challenges, power grid and system server timeouts. Moreover, anecdotal reports from Rwandan public health officers have indicated varying levels of adoption among affiliated health facilities. Some facilities have not implemented the system at all, while others have only partially implemented it. Additionally, some facilities have opted for alternative systems instead of OpenMRS.

This study aimed at assessing the use of EMR systems and identify associated barriers to EMR adoption in Rwanda. By examining the current state of EMR utilization and understanding the challenges faced by healthcare providers, this study will inform strategies for improving EMR implementation and enhancing healthcare delivery in Rwanda.

Study design, period and settings

This study employed a health facility based descriptive cross-sectional study design to provide an understanding of healthcare staff perceptions and practices on EMR within a defined timeframe. From 17th April to 19th May 2023, data was collected among health care staff working in public health facilities across Rwanda. The study purposively sampled both district hospitals and health centers within their catchment areas, ensuring representation from different levels of the healthcare system.

Study population

The study targeted health facility representatives to collect information on availability of EMR and types of EMR systems used by the health facility. Healthcare staff who actively utilize EMR systems in their daily duties across primary healthcare (health centers) and secondary healthcare (district hospitals) levels in Rwanda were also interviewed to assess the level of EMR use. The selection of staff members was purposive, based on their direct involvement with EMR usage and patient care within the health facility.

Inclusion criteria

We included healthcare staff with roles that required regular interaction with EMR systems to capture their experiences and insights with EMR usage. At the district hospital level, the study included five key health professionals: one nurse from the reception department, one medical doctor from the Outpatient Department (OPD), one lab technician from laboratory department, one nurse from Antiretroviral (ARV) Services, and one cashier from cash point department. These staff members were selected to represent essential services involved in patient care, including Reception, OPD Consultation, Laboratory Testing, ARV Services, and Financial Transactions.

Similarly, at the health center level, the study comprised of four healthcare professionals: a nurse from OPD department, a receptionist from reception department, a nurse specializing in ARV services, and a lab technician from laboratory department. These staff members were chosen based on their integral roles in primary healthcare services, covering Reception, OPD consultations, ARV medication management and laboratory testing. In addition to healthcare staff members, health facility representatives were interviewed at both district hospitals and health centers to assess EMR utilization and the types of EMR systems used at health facilities. These interviews aimed to provide a comprehensive understanding of EMR implementation at the facility level.

Sample size and Sampling strategy

All existing 42 district hospitals from all 30 districts of Rwanda were included in the study to ensure comprehensive coverage of secondary healthcare facilities across Rwanda. Simple random sampling was used to select the number of sampled health centers. Due to lack of EMR use prevalence in Rwanda, the expected prevalence of EMR use of 50% was considered and a margin of error of 5%. This resulted in the sample size of 216 health centers from a sample frame of 491 health centers, which were calculated using Epi Info 7 software.

From all health facilities sampled, a total of 1332 participants were selected for inclusion in the study, comprising five staff members from each district hospital and four staff members from each health center and health facilities representatives. This included 210 staff and 42 hospital representatives from district hospitals and 864 participants with their 216 health center representatives, ensuring adequate representation from both levels of healthcare facilities.

Data collection

An electronic questionnaire was developed using Epi Info7 (additional file 1) and configured into mobile devices for data collection. Prior to data collection phase, a pilot study was conducted in four District hospitals and their 12 selected health centers to assess the questionnaire’s validity. Based on the pilot findings, adjustments were made to the questionnaire to ensure the questionnaire’s quality and validity prior to beginning study data collection.

Data collection was conducted by field epidemiology training program (FETP) Intermediate Cohort 1 residents, under the guidance of their mentors. Equipped with a mobile device containing the configured questionnaire, data collectors sought authorization from health facility representatives before initiating interviews with health facility staff members. Data was collected through face to face interviews using prepared questionnaire and collected data included socio-demographic information (e.g, Sex, education level, experience in health sector, professional category and department), health settings details (e.g.: visited health facility name and level of health facility visited), EMR usage (e.g, availability of EMR, types of EMR used, and frequency of EMR use), knowledge level (e.g.; availability of EMR user guide, trainings received, experience in using EMR system and skill level), and attitudes and practices regarding EMR systems (e.g.: preferred system, challenges faced in using EMR system, satisfaction level on the use of EMR system.).

Data analysis

Merging and cleaning data was conducted by all FETP residents in Intermediate Cohort 1 in Microsoft excel. For each objective, a list of indicators to be assessed was prepared and information regarding numerator and denominator about indicator calculation were shown in (additional file 2). A descriptive analysis was performed, generating results that illustrate EMR implementation and the existing barriers to EMR use in the Rwandan health system. Frequencies and percentages describing study participants and health facilities, EMR adoption and use by health facilities, participant knowledge, attitude and practices as well as barriers in EMR use were presented in tables.

Ethical Consideration

This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy. The study was approved by the Institutional Review Board (IRB) of the Rwanda National Ethics Committee (RNEC) within the Ministry of Rwanda, with the ethical approval reference number 131/RNEC/2023. Before starting data collection, each respondent was briefed on the study’s purpose, procedures, potential risks and benefits. Thereafter, written informed consent was obtained from each participant after ensuring that they fully understood the nature of their participation and their rights regarding confidentiality and data usage.

To protect participant confidentiality, stringent data security measures were implemented throughout the study. All electronic devices used for data collection were password protected, and data were merged onto a password protected laptop to prevent unauthorized access. Unique identification numbers were used instead of personal identifiers to anonymize participant information. Access to collected data was restricted to authorized study personnel only, who were responsible for data management and analysis.

Participants were assured that their involvement in the study was voluntary, and they were informed of their rights to withdraw from the study at any time without facing any consequences or loss of benefits. Additionally, participants were reassured that their decision to participate or not would not impact their access to healthcare services or employment status.

The assessment of the EMR system involved visiting 257 health facilities, including 42 (100%) DH and 215 (99.50%) health centers. One health center was excluded from the study due to lack of participants during data collection. All 42 (100%) district hospitals were utilizing EMR systems, as were 71 of the 215 health centers (33.0%) At the District hospital level, we surveyed 209 (99.5%) of the sampled 210 staff members who use EMR in their daily work, (Table 1). Health facility representatives were not included in the analysis as they did not participate in answering all questions posed to other staff.

Table 1

Description of health facilities and participants interviewed, and EMR use at the health facility level, Rwanda, 2023.
	Frequency	Percent (%)
Level of the visited health facilities
DH (n = 42)	42	100.0
Health center (n = 216)	215	99.5
Health facilities with EMR use among health facility visited (N = 257)
DH (n = 42)	42	100.0
Health center (n = 215)	71	33.0
Types of participants involved in the study at DH level (N = 252)
Health facility representative (n = 42)	42	100.0
EMR end users (n = 210)	209	99.5
Types of participants involved in the study at health center level (N = 499)
Health facility representative (n = 215)	215	100.0
EMR end users (n = 284)	259	91.2

Description of the participants (ende users) interviewed on the use of EMR

A total of 468 healthcare professionals who were EMR end users were interviewed across 42 District Hospitals and 215 health centers. Among these, females accounted for 55.5% (116/209) at District hospital level and 55.98% (145/259) at health center level. The education background varied, with the majority of staff holding a bachelor’s degree (61.2%, 128/209) at district hospitals, while (38.2%) of staff at the health center level attained advanced diploma level, 98/256). Regarding job roles, cashiers accounted for the largest proportion of respondents at district hospitals (21.5%, 45/209), whereas nurses and midwives were predominant at health center level (45.5%, 118/259). Most respondents had more than one year of professional experience in using EMR (94.1%, 192/204) at DH and at health center (97.2% ,249/256) (Table 2).

Table 2

Description of the participants (end users) interviewed on the use of EMR, Rwanda, 2023.
	District Hospital (n = 209)		Health Center(n = 259)
	Number of respondents	Percent (%)	Number of respondents	Percent (%)
Sex	District hospital(n = 209)		Health center(n = 259)
Female	116	55.6	145	56.0
Male	93	44.4	114	44.0
Age category	District Hospital (n = 209)		Health Center (n = 255)
18–30	51	24.5	45	17.7
31–45	122	58.3	180	70.6
> 45	36	17.2	30	11.7
Educational Level	District Hospital (n = 209)		Health Center(n = 256)
A1 Advanced Diploma	45	21.5	98	38.3
Upper secondary education certificate	32	15.3	86	33.6
Bachelors	128	61.2	72	28.1
Masters	4	2.0	0	0.0
Professional category	District Hospital (n = 209)		Health Center (n = 259)
Cashier	45	21.6	26	10.0
Data manager	1	0.4	3	1.1
Doctor	42	20.0	0	0.0
ICT Officer	1	0.4	2	0.8
Laboratory technician	42	20.0	61	23.5
Nurse and midwife	44	21.1	118	45.6
Other	31	15.0	49	19.0
Receptionist	3	1.5	0	0.0
Working department	District Hospital (n = 209)		Health Center (n = 259)
OPD	41	19.6	62	23.9
ARV	42	20.1	64	24.8
Laboratory	42	20.1	62	23.9
Reception	42	20.1	65	25.0
Cashier	42	20.1	6	2.4
Working experience	District Hospital (n = 204)		Health Center (n = 256)
Less than 1 Year	12	5.9	7	2.8
1–5 Years	73	35.7	76	29.6
6–10 Years	50	24.5	76	29.6
More than 10 Years	69	33.9	97	38.

Overall EMR use and type of EMR system that are being used in health facilities

The EMR system was available in all district hospitals and in 71/215 (33.0%) health centers. Among the study participants in district hospitals, 200/209 (95.6%) were found to be using EMR systems in their respective departments, whereas 139/259 (53.6%) staff members reported using EMR at health centers and more details are in discussion section. OpenMRS was the predominant EMR type used in health facilities, 35/42 (83.3%) in district hospitals and 39/71 (55.0%) in health centers. Furthermore, among those who use EMR, the majority reported to always use EMR 181/200 (90.5%) at district hospital and 119/138 (86.23%) at health centers (Table 3).

Table 3

Overall EMR use and type of EMR systems used in health facilities, Rwanda, 2023.
	District Hospital (n = 42 )		Health Center (n = 215 )
EMR use at health facility	Frequency	Percent (%)	Frequency	Percent (%)
Yes	42	100.0	71	33.0
No	0	0.0	144	66.9
EMR use by end users	District Hospital (n = 209)		Health Center (n = 259)
Yes	200	95.69	139	53.6
No	9	4.30	120	46.3
Types of EMR at HF	District Hospital (n = 42 )		Health Center (n = 71)
OpenMRS	35	83.3	39	54.9
OpenClinics	4	9.5	0	0.0
OpenMRS + OpenClinics	2	4.7	0	0.0
e-EHRIS Gitwe	1	2.3	0	0.0
Medisoft	0	0.0	9	12.6
Care system	0	0.0	9	12.6
IHMS (Iwacu hub Medical System)	0	0.0	5	7.0
EASY CARE	0	0.0	2	2.8
OpenMRS + Medisoft	0	0.0	5	7.0
OpenMRS + Care system	0	0.0	1	1.4
Dirsoft.net	0	0.0	1	1.4
Frequency of EMR use, among those who use EMR	District Hospital (n = 200)		Health Center (n = 138)
Always	181	90.5	119	86.2
Often	14	7.0	11	8.0
Sometimes	5	2.5	6	4.3
Rarely	0	0.0	2	1.5

Attitude of staff on EMR use

Participants at District hospitals, 193/199 (96.98%),and at health centers, 136/139 (97.84%), reported that EMR in use helps them improve their work in terms of productivity, efficiency and quality. The most utilized medical recording system at district hospitals was EMR, with 116/198 (58.58%), while at the health centers, 91/138 staff (65.94%) reported that a combination of EMR and paper use was more common. Moreover, majority of staff were satisfied with the use of EMR (186/199, 93.47%) at district hospital and at health centers (134/138, 97.10%) expressing satisfaction with using EMR. Regarding generation of necessary reports, majority of district hospital staff (130/194, 67.01%) and health center staff (110/136, 80.88%) reported that the EMR system generate report needed (Table 4).

Table 4

Participants’ attitudes towards EMR use
Whether the EMR system facilitate users in daily work	District Hospital		Health Center
Yes	193	97.0	136	97.9
No	6	3.0	3	2.1
The most used Medical recording system	District Hospital		Health Center
EMR Only	116	58.3	45	32.6
Paper based only	4	2.0	2	1.4
Both (Paper based & EMR)	79	39.7	91	65.9
Preferable medical recording system	District Hospital		Health Center
EMR Only	180	91.0	127	92.0
Paper based only	2	1.0	0	0.0
Both (Paper based & EMR)	16	8.0	11	8.0
User's thoughts on whether usage of EMR can be achieved	District Hospital		Health Center
Short term	100	50.0	71	52.2
Medium	35	17.5	26	19.1
Long term	63	31.5	38	28.0
Not achievable	2	1.0	1	0.7
Satisfaction of the participants on the use of EMR system	District Hospital		Health Center
Very satisfied	79	39.7	73	52.9
Satisfied	107	53.8	61	44.2
Not satisfied	13	6.5	4	2.9
EMR Improves the quality of patient care process	District Hospital		Health Center
Yes	175	89.3	125	90.6
Partially	18	9.1	12	8.7
Not at all	3	1.6	1	0.7
Available information in the EMR makes users to make clinical decisions confidently	District Hospital		Health Center
Yes	175	90.7	131	95.7
No	18	9.3	6	4.3
EMR system help the users to generate the report needed?	District Hospital		Health Center
Yes	130	67.0	110	80.9
No	64	33.0	26	19.1

Table 4. Attitude of staff on EMR use

Participant practices on EMR use

At District hospitals, 113/200 (56.50%) staff, and 101/139 (72.66%) health center staff were able to register all patient information in the system in no more than five minutes. EMR use was reported as easy to use by 178/198 (89.90%) District hospitals staff and 128/139 (92.0%) health center staff. The majoritym of staff at both District hospitals (136/200, 68.0%) and health centers (111/139 79.9%) reported that the EMR systems they use have all required information. The EMR system facilitating ingfaster health care delivery was reported by 182/200 (91.0%) District hospital staff and 132/138(95.65.0%) at health centers. Almost a third of District hospital staff (65/199, 32.6%) and health center staff (50/139, 35.9%) report experiencing backlogs of data not entered in the EMR System (Table 5).

Table 5

Participant Practices on EMR use, Rwanda, 2023.
	District Hospital (N = 200 )		Health Center (N = 139)
Time to record service delivered to one person (mins)	Frequency	Percent (%)	Frequency	Percent (%)
0–5 min	113	56.5	101	72.7
6–10 min	59	29.5	24	17.2
11–15 min	15	7.5	4	2.9
16–20 min	9	4.5	3	2.2
> 20 min	4	2.0	7	5.0
Ease of EMR system use	District Hospital (n = 198)		Health Center (n = 139 )
Very easy	104	52.5	83	59.8
Easy	74	37.4	45	32.3
Not easy	20	10.1	11	7.9
Availability of all required information to use in the EMR	District Hospital (n = 200)		Health Center (n = 139)
Yes	136	68.00	111	79.9
No	64	32.00	28	20.1
EMR system makes patient care delivery faster than paper based	District Hospital (n = 200)		Health Center (n = 138)
Yes	182	91.0	132	95.6
No	18	9.0	6	4.4
Backlog of records not entered into EMR	District Hospital (n = 199 )		Health Center (n = 139 )
Yes	65	32.7	50	36
No	134	67.3	89	64.

Barriers to EMR use

At district hospitals, the most frequent barriers encountered by staff while using EMR were internet connectivity issues 154/200 (77.0%), lack of EMR manual guide 101/200 (50.5%), shortage of staff 80/200 (41.0%), missing features within the EMR system 69/200 (34.5%), and lack of computer access 38/200(19.0%). At health centers, the most common barriers faced by staff using EMR wereinternet connectivity105/139 (75.5%), lack of EMR manual guide 85/139 (61.15%), shortage of staff 70/139 (50.3%), lack of computer access 65/139 (46.7%) and electricity related issues 50/139 (35.9%) (Table 6).

Table 6

Barriers encountered by staff while using EMR systems at health facilities in Rwanda, 2023.
	District hospital (n = 200)		Health center (n = 139)
Structural difficulties	Frequency	Percent(%)	Frequency	Percent (%)
Internet connection	154	77.0	105	75.5
Lack of manual guide	101	50.5	85	61.1
Complexity of the system	18	9.0	8	5.7
Lack of computer access	38	19.0	65	46.7
Electricity related issues	44	22.0	50	35.9
Server problems	0	0.0	3	2.1
Human capacity difficulties
Shortage of staff	80	40.0	70	50.3
Lack of technical support	37	18.5	30	21.5
Limited computer literacy	23	11.5	16	11.5
Others	8	4.0	3	2.1
None	58	29.0	41	29.5
Software related difficulties
Glitches in software	34	17.0	21	15.1
Lack of updated modules	37	18.5	23	16.5
Missing features	69	34.5	38	27.3
Lack of interoperability	29	14.5	22	15.9
None	92	46.0	65	47.7
Organizational difficulties
Time consuming	33	16.5	10	7.1
Lack of leadership support	4	2.0	6	4.3
None	146	73.0	116	83.4

The findings revealed varying EMR utilization rates, with district hospitals reporting full utilization (100%), while health centers exhibited lower utilization rates of 33.02%. This discrepancy aligns with findings from a similar study conducted in Ethiopia in 2020(14), which reported EMR implementation rates of 78.2% at district hospitals and 21.8% at health centers. The higher utilization rates observed at district hospitals may be attributed to factors such as higher number of staff, advanced skills, better infrastructure and equipment availability compared to health centers. A study conducted in Tanzania showed similar findings, (15). Efforts to improve EMR utilization should focus on harmonizing the EMR systems across health facilities, ensuring country-wide maintenance and repair, and establishing systems for continuous monitoring and evaluation of staff proficiency.

Health facilities in Rwanda were found to use various EMR systems including OpenMRS, Medisoft, Care system, IHMS (Iwacu Hub Medical System), OpenMRS + Medisoft, OpenClinic, OpenMRS + OpenClinics, Easy care, and Dirsoft.net. This use of various EMR systems is mainly due to varying funding or donor sources. This proliferation of different electronic systems highlights the need for system harmonization to ensure data security and prevent unauthorized data access.

Our study demonstrated a high level of consistentEMR usage among study participants, with 95.69% of staff at district hospitals and 53.67% at health centers reporting daily utilization. These rates surpass those reported in previous studies in Saudi Arabia and Ethiopia, which indicated daily usage rates of 54% and 26.6% respectively (16). This high usage rates observed in Rwanda may be attributed to the government’s commitment and investments in developing healthcare infrastructures, including investments in Information and Communication Technology (ICT), contrasting with challenges faced in Ethiopia where outdated EMR systems were observed, resulting from project phase-outs(17).

The perceived benefits of EMR usage were widely acknowledged among respondents, with 97.41% expressing that EMR enhances their work, and 91.47% preferring EMR over other methods for recording client information. These findings are consistent with a 2017 study conducted in Rwanda, where 87% of respondents perceived the evaluated EMR as accurate, and 88.5% expressed a preference for EMR over paper-based systems (18).

Furthermore, 90.92% of respondents reported that using EMR was easy, aligning with results from a 2017 study conducted in Rwanda referral hospitals where respondents reported an 80.1% ease of use(18). This consistency suggests a standardized approach to ICT implementation across Rwandan healthcare facilities, leading to obtaining similar results.

Major barriers to EMR use at both district hospitals and health centers included a lack of internet connection, absence of user guides, staff shortages which may have contributed to the existence of backlog records not entered in the system and limited computer access. Addressing these barriers requires availing IT infrastructures (computers, servers, routers…) and ensuring adequate staffing to improve utilization of EMR. Many health facilities struggle to procure these resources (internet modems, computers and recruiting staff) independently, necessitating support from the Ministry of Health. These lengthy processes may hindereffective EMR implementation,, which would be aided by providinging enough staff, availing IT infrastructures and elaborate proper mechanism for monitoring the usage of EMR in all health facilities.

LIMITATIONS

This study has a few limitations. Participants self-reported information about their experiences, behaviors, or opinions based on their memory and willingness to disclose accurate information. The second limitation is the possibility of recall bias, where the participants were asked to remember past events, or experiences, which can be influenced by selective memory and cognitive limitations. The last limitation encountered is that participants in this study represent only the health facilities which use EMR while those who do not use EMR could also provide information about barriers. Further studiesies that employ alternative data collection methods maymitigate recall bias or explore the perspectives of non-EMR users to gain a more comprehensive understanding of barriers to EMR adoption.

The assessment provides valuable insights into the implementation of EMR systems in public health facilities countrywide. It is encouraging to see that all district hospitals use EMRs to some degree, which can lead to better patient care and data management. However, lower adoption rate was identified at health centers. A high number of hospitals use OpenMRS as their system of choice while the health centers use different systems. This difference may be due to the limited capacity in maintenance of OpenMRS than other various systems and was not distributed in all health centers. This leads to nurses, receptionists and laboratory technicians at health centersprefer to use other EMR systems that are favorable to their capacities. Harmonizing one system of choice and providinging equal capacity in terms of infrastructure, enough equipment (computers and internet) and training for all end users at health facilities would improve uptake and system functionality. The majority of respondents prefer to use EMR rather than paper., Nevertheless, EMR accessibility was impacted by different barriers such as internet connection, lack of user guides, electricity related issues, limited technical support, limited computer literacy, missing features, lack of updated modules, and lack of interoperability. Moreover, comprehensive trainings to improve computer literacy, prioritization of infrastructure improvements by updating EMR modules, availing electricity, internet, user guides can boost ICT implementation in health facilities.

AFENET

Africa Epidemiology Network

ARV

Antiretroviral Therapy

CDC

Centers for Disease Control and Prevention

District Hospital

e- EHRIS

Electronic Easy Health Record Information System

EMR

Electronic Medical Records

FETP

Field Epidemiology Training Program

Health Center

HIV

Human Immunodeficiency Virus

ICT

Information Communication Technology

IHMS

Iwacu Hub Medical System

MoH

Ministry of Health

MRS

Medical Record System

Sample Size

OPD

Outpatient Department

RNEC

Rwanda National Ethical Committee

Tuberculosis

Ethics approval and consent to participate

Not appricable for this study as it was not conducted on human or animals, but ethical approval for conducting the study was obtained from Institutional Review Board (IRB) of the Rwanda National Ethics Committee (RNEC) within the Ministry of Rwanda, with the ethical approval reference number 131/RNEC/2023.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analysed during the current study are available in the supplementary files uploaded along with the manuscript in the name of EMR assessment final data set.

Competing interests

I declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper

Funding

Funds for data collection, analysis and reporting was provided by global fund

Authors' contributions

E. U, P.R, E.M, N.I, J.I, R.T, A.M, J.M, G.T, A.M, H.M, S.N S.H, E.N.K, B.U contributed to the manuscript through protocol preparation, data collection tools preparation, data collection, data analysis and report writing

E.N, J.C.N, V.M, E.N, N.B, A.H, E.R, E.R, A.U, C.S contributed to the manuscript review and correction before it is being submitted.

Acknowledgement

We acknowledge the unwavering support and collaboration of the Ministry of Health and the Rwanda Biomedical Centre. Their commitment to improving healthcare through the effective utilization of Electronic Medical Records (EMRs) has been instrumental in the success of this research.

We also extend our gratitude to the Center for Disease Control (CDC) and the African Field Epidemiology Network (AFENET) for their support and expertise, which significantly enriched the research and its findings.

We are indebted to the Directors General of all the hospitals involved in this study. Their willingness to participate and provide access to essential data and insights has been crucial in shaping the outcomes of this research.

Our sincere appreciation goes out to all individuals and organizations whose contributions, whether direct or indirect, have significantly contributed to the successful completion of this study. Thank you for being an essential part of our journey.

In gratitude,

FETP inermediate cohort I residents

Disclaimer

The findings and conclusions in thisreport are those of the authors and do not necessarily represent the official position of thefunding agencies. . This study has been supported by Global Fund to fight AIDS, Tuberculosis and Malaria, with technical assistance provided by ’Centers for Disease Control and Prevention (CDC).

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No competing interests reported.

Additionalfile1.docx
Additional file 1: Indicator definitions
EMRassessmentfinaldataset.xls
QuestionnaireontheassessmentofEMRuse.docx

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Assessment of the use of electronic medical records system and barriers in Rwanda

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Trial registration:

Introduction

Methodology

Study design, period and settings

Study population

Inclusion criteria

Sample size and Sampling strategy

Data collection

Data analysis

Ethical Consideration

Results

Description of the participants (ende users) interviewed on the use of EMR

Overall EMR use and type of EMR system that are being used in health facilities

Attitude of staff on EMR use

Participant practices on EMR use

Barriers to EMR use

Discussion

LIMITATIONS

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1