HOSPITAL MANAGEMENT SYSTEMS AND PATIENTS RECORDS

MANAGEMENT IN RWANDA: A CASE OF OPENCLINIC

SOFTWARE OF CHUK HOSPITAL

ABSTRACT

Objectives: This research study aimed at investigating of the role of hospital

management systems in the patient’s records management at CHUK, Rwanda using the
following objectives; to evaluate the use of Hospital Management System (HMS) in
CHUK Hospital, Rwanda; to assess the level of patient records management in CHUK
Hospital, Rwanda; and to establish the relationship between use of HMS and the patient’s
records management in CHUK Hospital Rwanda.
Method: Using descriptive-correlation design, 147 participants were selected randomly
from a target population of 232 using Slovin’s formula and their views captured using
questionnaires and interviews.
Finding: HMS was used in various ways in the management of patients’ records and user
experience and type affected the use of OpenClinic.
Conclusion: HMS is useful for patient’s records management keeping other factor
constant.

Keywords: Hospital Management System; Openclinic, electronic records management,

patients’ records management

Introduction

Health care industry is an information intensive industry ever faced with the situations in

which quality and timely information is a critical resource. The need of Information

systems that provide support to health care industry by performing a variety of tasks

involved in data and information management is ever growing globally [ CITATION

Ayr06 \l 1033 ]. In low and middle income countries where health care units are faced

with the inability to provide high-quality, affordable and universally accessible care,

1
policy makers, donors and other program implementers are valuing the use of Hospital

Management systems such as e-record management system among other ICT enabled

technologies as possible innovative responses (Lewis, Synowiec, Lagomarsino, &

Schweitzer, 2012). The process of creating or receiving and preserving electronic health

records for evidentiary purpose is referred to as electronic health record management

(Force, 2004).

There are a number of reasons as to why information systems such as electronic records

management may be employed in a health care unit such as a hospital. Extension of

geographical access to data in which traditional visits may be minimized, facilitation of

patient and health worker communication for purposes such as general health education,

encouraging of patient compliance, emergence care, and improvement of diagnosis and

treatment. Widely noticed significance of e-record management is on the improvement of

data management processes such as collection, organization, and analysis. This quickens

and enables transmission of data by providing flexibility to the collection processes in

that someone can use personal digital assistants to electronically collect information about

particular diseases or health of children in certain regions (Lewis et al., 2012). Other

scholars argue that e-health record management has the capacity of improving health care

delivery by enhancing documentation, increasing efficiency, and even promoting

information sharing and responsibility with patients (Arar, Wen, J, Steinbach, & Pugh,

2005; Hersh, 2002; Shachak & Reis, 2009; Sullivan & Wyatt, 2005).

There is a collaborative effort in East Africa to integrate technology into the health care

system among others. For example the region has integrated e-Health Management

Information System (e-HMIS) and set up ICT infrastructure for e-Health and

telemedicine practice through its respective Health Ministries (EAC Health Sector, 2007)

2
with the aim of enhancing quality of health data for timely flow and sharing of

information (EAC Health Sector, 2007). Faced by socio-economic pressures such as

poverty, shortage of health care professionals, inefficient health care system, poor

infrastructure, and epidemics such as HIV/AIDS and malaria, Rwanda’s police makers

and the ministry of health are strongly convinced that HMS systems have the potential of

transforming and enabling sustainable healthcare system, by integrating services for

efficient delivery of high-quality and coordinated healthcare services (Ministry of

Health(MOH), 2009). Furthermore, the current mainly paper-based record keeping has

been identified as the cause of inefficiency and therefore a strategic move to provide at

least 100 primary healthcare facilities with networked computers from 2010 for

maintenance of standardized and sharable data in electronic formats has been planned.

However most medical records in Rwanda are still paper-based, which means that they

are difficult to be used for proper and consistent coordination of patient care. It is also

difficult to routinely measure quality or reduce medical errors due to challenges with

storage and easy access or retrieval of information when its needed (MOH, 2009).

Consumers of health care generally lack the information they need about costs or quality

to make informed decisions about their health care (MOH, 2009). This information would

easily be accessible and available with an HMS such as Electronic Medical Record

(EMR) system.

Starting in 1928 as Kigali Hospital Centre, University Teaching Hospital Of Kigali

( UTHK) has grown steadily to a national referral hospital in Rwanda with Internal

medicine services; Gynecology and Obstetrics / Maternity services, Surgery, urology,

neurosurgery, Pediatric services, ENT, Ophthalmology services, Radiology, Anesthetics

3
and resuscitation, Stomatology, Dermatology, Nursing, Emergency services, Laboratory,

Physiotherapy and Orthopedic workshop offered (Hategekimana, 2011). It was reported

that the hospital lacked immediate retrieval of its records, suffered from information

storage deficiency, lacked prompt updating, records had errors and document preparation

was a challenge (Evan, 2015); Ministry of Health, 2009). In attempt to resolve these

challenges, the hospital management requested for the installation of OpenClinic system

in key critical departments such as the finance department, and the laboratory to help

coordinate collection of bills from patients who have undertaken a laboratory test.

This research was conducted to investigate on the role of Hospital Management System

on the efficient management of patients’ records in Rwanda focusing on the OpenClinic

system currently being used in CHUK Hospital, Rwanda. The study was guided by three

specific objectives namely;

(i) To evaluate the use of Hospital Management System in CHUK Hospital, Rwanda

(ii) To assess the level of patients records management in CHUK Hospital, Rwanda

(iii) To establish the relationship between use of Hospital Management system and

patient’s records management in CHUK hospital Rwanda.

Literature Review

Hospital management system

A Hospital management information system (HMIS) is a system that enable a hospital to

accurately acquire and coordinate the various information sources for better decision

making (Chawla, Bansal, & Indrayan, 1997). Data is generated from different services in

the hospital and this merits the need of a good records management system (Chawla et al.,

1997). A well-managed patients record enables managers and hospital personnel to make

timely and accurate decision. This is achieved by the installation of Hospital Management

System in which daily activities of the hospital/clinic in all its departments such as

4
Pharmacy, Laboratory, Radiology, Physiotherapy, Records, Out Patient Departments

(OPD) and all wards – Medical & Surgical, Maternity, Intensive Care Unit (ICU),

Operating Theatre, Special side wards and isolations wards are captured and reported

(Patel, O’Brien, Jones, & Quintana, 2003).

Components of HMS

The main components of the system include; Management of International Classification

of Diseases (ICD), WHO disease codes, etc. and codification of all services in the

hospital/clinic for standardized reference and easy to use across the hospital/clinic;

Management of registered members details including digital identities where the system

stores members photos for easy of identification; Patients Record management through

records of medical services provided or rendered to the patient; Stock inventory control,

management of pharmacy drugs, laboratory supplies, etc.

Patients movement tracking within the hospital/clinic both for in-patients and out-

patients; Automated Medical Billing for various medical services provided to registered

members who include: out patients services, in-patient services, ambulance services, etc.;

Management of Cash transactions including, Registered Members Capitalization fees (or

subscriptions), Casual Callers (nonregistered patients); Generating of medical statistical

reports for internal use and submission to the health boards; Interfaces with various

electronic equipment in the hospital / clinic; Integration of the medical data with common

spreadsheets like excel for further analysis and adhoc report generation; Interfacing of

medical data to other systems especially accounting packages such as, Sun Systems,

Pastel, etc.; Customized and hospital/clinic specific features and many more; Availability

of separate forms for Outpatient department, laboratory, pharmacy, accountants,

radiology, physiotherapy, dental, ward and in patient information; Scheduling of daily

5
appointments; and Ward services management such as admissions, patients movement

and discharges (Lewis et al., 2012).

Open Source software

Many developing countries are experimenting with Open Source and the phenomenon is

growing (Vanmeulebrouk, Rivett, Richetts, & Loudon, 2008). These developments are

diverse and cover the management of general and multi-disciplinary medical records, as

well as more specialized information systems related in particular to public health issues

like HIV/AIDS surveillance (McDonald, Gunther, & Barnes, 2003).

OpenClinic is a PHP based open source software that has found a place in private clinics,

surgeries and private doctors due to its multilingual architecture and easy to use interface.

It comes packed with a number of modules including; Medical Records and Admin,

(OpenClinic, 2016). OpenClinic implementations in Rwanda at CHUK (Kigali) is used

for Hospital admissions & consultations. The Administrative and clinical procedures

including Patient identification, Archiving, Invoicing, Medical record – Patient tracking,

Admission, discharge and transfer management.

Hospital Management System and Patients’ records Management

A review of the impact of regional health information systems (RHISs) found that there

was an improvement in clinical data access, timely information and clinical data

exchange, as well as enhanced communication and coordination between professionals

when RHISs were used (Mäenpää, Suominena, Asikainenb, Maassb, & Rostilac, 2009).

While a 2009 before-after analysis shows that after the introduction of e-health Record

system, office visits were significantly reduced (Chen, Garrido, Chock, Okawa, & Liang,

2009) concurring with a previous systematic review in 2008 that found a decrease in

consultation time when six studies that analyzed the impact of e-health records

management with respect to consultation time were reviewed (Delpierre, 2004). Increased

6
provision of preventive care, prescriptions following an encounter with clinical

recommendations and adherence to guidelines was the outcome of a 2004 analysis of 26

studies related to quality of patient-physician encounters (Delpierre, 2004). Health

information systems including EHR were also found to increase adherence to guideline-

based care, enhance surveillance and monitoring, and decrease medication error

(Chaudhry, 2006; Welch, 2007) as well as acting as reminders to doctors (Cheung,

Mayhew, Weir, & Grimshaw, 2010).

According to Cheung, Mayhew, Weir, and Grimshaw (2008) there is some evidence

supporting the positive relationship between Electronic Medical Record System of patient

records however additional evidence is needed to provide a strong conclusion. Poor

planning, poor execution and failure by leaders to grasp the complexity of the systems are

among cited causes of EMRS failures. A general failure of EMR registered in India,

China and Brazil resulted from failure to get the doctors involved in its implementation,

the failure to understand the cost-benefits of the system, and the delays in project

completions that many times is as a result of management unsupportive attitude (Anne,

2012). The lack of skilled IT human resource has been identified as obstacles for African

countries and a case in Uganda lack of developers who can pick a program right from the

ground to its establishment has blocked the ambitious attempts to adapt EMR in their

systems (Albert, 2014).

Electronic Medical Record of patient record in Rwanda hospitals

The high poverty level of Rwanda reflects in it developing healthcare infrastructure.

National statistics reflects that in Rwanda the infant mortality is approximately 85 deaths

per 1000 live births, 45% of children below the age of 5 meet height-for-age criteria for

chronic malnutrition, HIV/AIDS prevalence rate of 3% in 2005 was considered epidemic

7
Martien Borgdorff (2008), and malaria considered the leading cause of morbidity and

mortality for both adults and children (Frasier, May, & Wanchoo, 2008).

Rwanda health information system is a historical paper-based (Frasier et al., 2008), but

the adoption of HMIS is used in the integration of collection of data, processing it,

producing report and other applications such as those aimed at improving health service

effectiveness and efficiency through better management at all levels (World Health

Organization (WHO), 2004). The ministry of health through the Center for Transmitted

and Research on HIV/AIDS, Malaria, Tuberculosis and other epidemics (TRACPlus) has

played a major role in the promotion of e-health products. The strategic adoption of e-

health in Rwanda has seen its health centers install a number of software including

OpenMRS collaboratively developed and deployed in 2004 and linking over 7000

patients (Frasier et al., 2008) and the development of Microsoft Access 2.0 GESIS

(Gestion du Système d’ Information Sanitaire) database application designed and

implemented by AEDES (Agence Européenne pour le Développement et la Santé) in

1997.

Method

The study was conducted in CHUK which had a staff population of 232, comprising of 73

doctors, 5 IT, 20 Accountants and 134 nurses. Using Slovin’s formula the sample size

was calculated and 147 estimated. A proportion was calculated from each category of

staff and 46/73 doctors, 3/5 IT staff, 13/20 accountants, 85/134 Nurses were randomly

sampled to participate in the study.

A questionnaire was developed and sent to the Hospital for distribution. Given the

working nature of some of the staff especially doctors who consulted at the hospital on

specific days and nurses who worked on day and night shifts, the head of Nurses was

8
helpful. The available staff were given the questionnaires to respond to and on an

appointed data they were collected. A face to interview was conducted with Five IT

staffs. The questions were structured with Likert scale question types rated at 5 levels

namely, 5 = Strongly Agree, 4 = Agree, 3 = Neutral, 2 = Disagree and 1 = Strongly

Disagree. The interview guides were structured to include key questions that explored

additional information not captured or elaborates the questionnaire.

The study carried out a pre-posttest at Kanombe Military Hospital to validate the research

tools and on analysis of reliability with SPSS, Cronbach’s Alpha of 0.936 was found and

the tool was considered reliable for the study.

Data analysis

Data was analysed using SPSS version 22 in which the response were imported from Ms

Excel sheet. The independent variable was measured by sub categories (Sharing purpose,

access and managing information, patient tracking) and the dependent variable had

subcategories of (Patients record management: records availability, utility of records,

presentation format of records, retrieval of records). Data was collected for each of these

subcategories and entered for analysis. The sum of response for each subcategory was

computed per respondent. Frequency and its respective percentages were computed, mean

and standard deviation calculated for each table showing the subcategories above.

Patients records management was a sum of all the subcategories that measured it.

To establish the relationship, the total of the subcategories of Independent variable were

correlated to the Patients Records Management (PRM) and the coefficient and

significance(p) interpreted for each. Cofounding variable which were controlled were Job

type, Age, knowledge and Acceptance.

Further a regression was performed between the subcategories of Usage of HMS on the

PRM to establish a model of the relationship thus:

9
PRM = β0 + β1X1 + β2X2 + β3X3 +є Where, PRM –Patients Records Management

β0, β1, β2, and β3 - Constant

X1 – Information sharing X2 – Accessibility and Manageability X3 – Patient tracking є =

Error term.

This model attempted to provide a mathematical relationship between factors that affect

patient’s records management on HMS usage.

Findings of the study

Fortunately, the response rate was 100% since all the respondents willingly participated

in responding to the questionnaire.

Gender of User

The gender of the respondents is shown in Table 4.1 in terms of percentages and

frequency.

Table 4.1 Gender of the respondents

Frequency Percent
Male 60 44.1
Gender Female 76 55.9
Total 136 100.0
Source: Primary data

Table 4.1 shows that 60 males which is equivalent to 44.1% and 76 females which is

equivalent to 55.9% responded respectively. The majority of respondents were female

According to Pala, Eker, and Melek (2008) demographic characteristics affect

relationships in researches and should be investigated further to establish how it

associated with other variables in the relationship. For this reason, gender of the

respondent was included in the partial correlation analysis.

10
Age Category

Age category is considered as an intervening variable with assumption that computer use

is affected by the age of the user. Table 4.2 summarizes the findings with respect to age

of the respondents.

Table 4.2 Age group of respondents

Frequency Percent
21-30 34 25.0
31-40 62 45.6
Age 41-50 35 25.7
51-60 5 3.7
Total 136 100.0
Source: Primary data

Table 4.3 clarifies that 34 which is equivalent to 25% were in age group 21-30 years, 62

which is equivalent to 45.6% in 31-40 years, 35 which is equivalent to 25.7% in 41-50

years and only five which is equivalent to 3.7% in 51-60 years. The majority therefore

were 31-40 years as shown in the descriptive statistic in Table 4.2.

Type of User

The use of computers in this study was assumed to vary with the type of user. Some

user’s type of work required compulsory use of computers while others were not. Table

4.4 summarizes the findings related to type of user.

Table 4.3 Type of user of computer and Electronic Records system

Frequency Percent
Doctor 45 33.1
Nurse 75 55.1
Job type Accountant 13 9.6
IT 3 2.2
Total 136 100.0
Source: Primary data

11
Table 4.4 shows that 45 which is equivalent to 33.1% were doctors, 75 which is

equivalent to 55.1% were nurses, accountants were 13 which is equivalent to 9.6% and

only three which is equivalent to 2.2% were working as IT. At the hospital were this

study was conducted, it is mandatory for IT and accountants to use the OpenClinic

however with the integration of departments, doctors and nurses have to use the system

too. This phenomenon therefore varies the degree of usage of computers and given that

the majorities are not mandatory computer users; the findings were presumed to have an

effect on the relationship under the study.

Knowledge level of User in Computer and Electronic Recording

The knowledge level of the user in computer and ER affects how the user uses computers

or gives value to it. Table 4.5 summarizes the findings of user’s knowledge level.

Table 4.4 Descriptive Statistics

N Minimum Maximum Mean Std. Deviation

Average score 136 1.750 4.000 3.20956 .488972
Source: Primary data

Table 4.5 shows that 136 responses were received and the minimum was 1.75 and

maximum (4.0), the mean (3.21) and SD = 0.489. Table 4.6 provides details of the

findings.

Table 4.5 Knowledge of Computer and ER

Count Table N %
<1 year 0 0.0%
1-2 years 11 8.1%
Computer Use experience 3-4 years 32 23.5%
5-6 years 17 12.5%
>6 years 76 55.9%
Computer Knowledge Terrible 0 0.0%
Bad 2 1.5%
Regular 23 16.9%

12
 Good 89 65.4%
Excellent 22 16.2%
Terrible 0 0.0%
Bad 6 4.4%
Internet Knowledge Regular 36 26.5%
Good 87 64.0%
Excellent 7 5.1%
>12 months 134 98.5%
6-12 months 2 1.5%
Experience in ER use
1-5 months 0 0.0%
Total 136 100.0%
Source: Primary data

According to Table 4.6, 76 (55.9%) of the respondents had used computers for more than

six years, 89 (65.4%) had good computer knowledge, 87(64%) had good internet

knowledge and 134 (98.5%) had used ER for more than 12 months. This study therefore

was conducted among respondents with very high knowledge level in computer and ER

use.

Acceptance level of the user

The acceptance level of the user was expected to affect how they use the system hence

this variable included in the intervening variables. The findings are presented in Table

4.8.

Table 4.6 Descriptive Statistics

N Minimum Maximum Mean Std. Deviation

Average score 136 1.000 4.667 3.13480 .752913
Source: Primary data

Table 4.7 shows that the minimum acceptance level was 1.0, maximum was 4.667, mean

was 3.135 and Std. Deviation = 0.753. The details of the findings are presented in Table

4.8.

13
Table 4.7 Acceptance level of Users

Count Table N %
<1 month 1 0.7%
few times a week 9 6.6%
Frequency of system use
Few times a day 105 77.2%
many times a day 21 15.4%
<30 Min 36 26.5%
30min-1hr 58 42.6%
Average system use time 1-2hrs 16 11.8%
3-4hrs 7 5.1%
>4hrs 19 14.0%
Only research 21 15.4%
use of ER Research & Entry 115 84.6%
Total 136 100%
Source: Primary data

According to the findings presented in Table 4.8, 105 (77.2%) of the respondents used the

system just a few times in a day and more specifically it was between 30 minutes to an

hour and the OpenClinic (ER) was used for both research and data entry.

The finding implies that though the hospital staff had good knowledge of computer and

ER system used, the use was very low.

Usage of Hospital Management System

Use for information Sharing purposes

The use of Hospital Management System for information sharing was assessed by asking

the respondents to rate their opinions on five questions rated using five rate scale from

Strongly Disagree (SD), Disagree (D), Not Sure (NS), Agree (A) and Strongly Agree

(SA). Table 4.9 presents the descriptive statistics for information sharing.

Table 4.8 Information Sharing

N Minimum Maximum Mean Std. Deviation

Average score 136 2.800 5.800 4.20147 .436482
Source: Primary data

14
Table 4.9 shows that the minimum response was 2.8 and maximum was 5.8, mean =

4.201 and the standard deviation (Std. Deviation) = 0.437. The details of the response for

this summary is summarized in Table 4.10 in which the SD + D = Disagreement, and

SA+A = Agreement.

Table 4.9 Use of HMS for information sharing

Agreement Disagreement Doesn’tNS

apply
Coun Row Count Row Coun Row Coun Row
t N% N% t N% t N%
It facilitates the analysis of 117 86.0 2 1.5% 17 12.5 0 0.0%
hospital bills % %

It facilitates the verification 128 94.1 2 1.5% 5 3.7% 1 0.7%

of the materials and %
medications used in the
surgical center

It allows medications to be 125 91.9 1 0.7% 9 6.6% 1 0.7%

requested from the pharmacy %
127 93.4 0 0.0% 8 5.9% 1 0.7%
It facilitates the work in the %
sector of the guidelines and
organizations
The system presents a good 130 95.6 2 1.5% 3 2.2% 1 0.7%
level of integration with %
other units
Source: Primary data

From to Table 4.10, the HMS is used to facilitate the analysis of hospital bills by

117(86%), for verification of the materials and medications 128(94.1%), for medication

request from pharmacy 125 (91.9%), for providing guidelines and organization of work

127(93.4%) and for unit integrations 130(95.6%). With the mean of 4.201, it is clear that

the majority agreed that HMS is used for information sharing in the hospital. According

to CooperNet Solutions (2014) hospital management systems have databases that enable

first information sharing and integrates several departments reports.

Use for accessibility and managing information

15
The use of HMS for accessing and managing information was assessed by seven
questions and the descriptive statistics as represented in Table 4.11 and its details in Table
4.12.

Table 4.10 Descriptive Statistics for access and management

N Minimum Maximum Mean Std. Deviation
Average score 136 2.714 5.000 4.25630 .346505
Source: Primary data

Table 4.11 shows that the minimum agreement was 2.714 and the maximum was 5, mean
= 4.256 and Std. Deviation = 0.347.
Table 4.11 Access and management of information

Disagreement Agreement NS
Coun Row Coun Row Count Row
t N% t N% N%
3 2.2% 133 97.8 0 0.0%
Easy to use
%
0 0.0% 130 95.6 6 4.4%
order of presentation meets needs
%
1 0.7% 119 87.5 15 11.0%
Information divided into consistent manner
%
1 0.7% 135 99.3 0 0.0%
System speed is good
%
1 0.7% 131 96.3 4 2.9%
It reduces the occurrence of frauds
%
It facilitates the implementation of internal 5 3.7% 127 93.4 4 2.9%
system %
It facilitates auditing in the processes of 1 0.7% 126 92.6 8 5.9%
authorization and release of procedures %
Source: Primary data

A total of 133 (97.8%) agreed that the HMS is easy to use, for order of presentation meets

needs 130 (95.6%) and 119 (87.5%) that it presents information in a consistent manner. A

large number of 135(99.3%) agreed that the system is speedy, reduces the occurrence of

fraud 131(96.3%), facilitates the implementation of internal systems 127(93.4%) and

facilitates auditing procedures 126 (92.6%). The majority of the respondents agreed that

the system facilitates management and accessibility of information in the hospital.

16
This result contrasts with those obtained by (Hyun, 2009), who identified the difficulty of

nursing professionals regarding the use of technology or information systems. The

authors concluded that this difficulty could be attributed to the fact that the respondents

had graduated more than ten years earlier.

Use for patient tracking

Table 4.12 Descriptive Statistics for patient tracking

N Minimum Maximum Mean Std. Deviation
Average Score 136 2.571 5.571 4.42227 .467174
Source: Primary data

The minimum response to the use of the system for tracking patients was 2.57, Maximum

was 5.57, mean = 4.42 and Std. Deviation = 0.467. The majority response was therefore

agreed and the detailed presentation of this is shown in Table 4.14.

Table 4.13 Response to patient tracking

Disagreement Agreement NS
Count Row Count Row Count Row
N% N% N%
The system facilitates patient care 135 99.3% 1 0.7%
It facilitates hospital billing 2 1.5% 123 90.4% 10 7.4%

It facilitates the nursing work of 2 1.5% 117 86.0% 17 12.5%

checking medications
It facilitates the prescribing of patient 3 2.2% 129 94.9% 3 2.2%
medications
It facilitates the medical evaluation of 2 1.5% 131 96.3% 2 1.5%
patients
It facilitates the nursing work in the 3 2.2% 131 96.3% 1 0.7%
evaluation of patients
It provides greater control over the 1 0.7% 130 95.6% 4 2.9%
consumption of medications
Source: Primary data

According to Table 4.14, 135(99.3%) agreed that the system facilitated patient care,

123(90.4%) agreed that it facilitated the nurses in checking a patient’s medication, 117

(86%) that it facilitated the prescription of patient medication, 129 (94.9%) that it

17
facilitated the medical evaluation of patients, 131(96.3%) that it both facilitated nurses

work of evaluating the patient and evaluating their individual medication, and finally

according to 130 ( 95.6%), the system provided greater control over the consumption of

medication. In his study Sinha (2010) found that Health information technology (HIT)

provided the umbrella framework to describe the comprehensive management of health

information and its secure exchange between consumers, providers, government and

quality entities, and insurers. Its role in public health is unmatchable because it plays a

vital role in early detection of infectious disease outbreaks around the country, improved

tracking of chronic disease management, monitoring healthcare programs and coverage,

evaluation of health care utilization, and in making transparent and evidence-based

decisions for health system interventions.

Patients Records Management in the Hospital

The second objective of the study was to assess the level of patient records management

in the hospital. This involved an assessment of the availability of the records, the utility of

the records, the presentation and retrieval of the records.

Assessment of the availability of patients’ records

Using six questions, the respondents were requested to provide their opinions about the

availability of the records of patients. The findings are presented in the descriptive

statistics table and the response summary table 4.15.

Table 4.14 Descriptive Statistics for availability of records

N Minimum Maximum Mean Std. Deviation

Average Score 136 2.667 5.000 4.51961 .406257
Source: Primary data

According to Table 4.15, the minimum response was 2.67 (disagree), Maximum was 5
(strongly agree), mean agreement was 4.52 (Strongly agree) and standard deviation of
0.41 implying minimal spread.

18
Table 4.15 Response to the availability of Records
Disagreement Agreement NS Total
Count Row Coun Row N Coun Row Coun Row N
N% t % t N% t %
The system has few 8 5.9% 127 93.4% 1 0.7% 136 100.0%
interruptions
The system has enough 4 2.9% 128 94.1% 4 2.9% 136 100.0%
screens for its activity
The system has enough 2 1.5% 131 96.3% 3 2.2% 136 100.0%
records for its activity
The generation of 1 0.7% 135 99.3% 0 0.0% 136 100.0%
records is fast
The records are reliable 0 0.0% 136 100.0% 0 0.0% 136 100.0%
The records have 0 0.0% 135 99.3% 1 0.7% 136 100.0%
updated information
Source: Primary data

In reference to Table 4.16, 127 (93.4%) of the respondents who answered this statement

were in agreement that the OpenClinic had few disruptions, 128 (94.1%) that it had

enough screens for its activities. This result is consistent with those of (Chaudhry et al.,

2006) who argued that there is always the need to synthesize information into a single

screen (or on a reduced set of screens). (Hyun, 2009) indicated that while necessary

information may be available on a screen, there is a natural preference in relation to their

organization that impacts the evaluation of the system. This screen may hide information

or make it altogether unreadable. A total of 131 (96.3%) were in agreement that the

system produced enough records for its activities, 135 (99.3%) that it generated

information faster, reliably according to 136 (100%) and the records were updated to

135(99.3%).

From the findings in Table 4.16, it is confirmed that the OpenClinic as a management

system has made the information about the patients more available right from its screen

design to updated versions of the records to the users. It was mainly availed the

19
information undisrupted, on adequate screens, in the amount needed for specific activity,

fast output, reliably and well updated. Sinha (2010) argued that the applications of

hospital management systems such as EHR, CPOE, HMIS, HIS and others provide easy

and instant access of health information and domain specific knowledge to the healthcare

professionals, planner, managers, policy maker, and national health agencies for the

provision of quality healthcare as well as informed decision making.

Assessment of the utility of patient generated records

Using two questions, the utility of records generated by the system were measured and

the findings presented as shown in tables 4.17 and 4.18.

Table 4.16 Descriptive Statistics for utility of records

N Minimum Maximum Mean Std. Deviation

Average Score 136 3.000 5.000 4.80515 .435349
Source: Primary data

The minimum response was 3 (Not sure), maximum was 5 (strongly agree), the mean

response was 4.81 (strongly agree) and standard deviation of 0.44 implying minimal

spread. Table 4.18 provides detailed presentation of the findings summarized in Table

4.17.

Table 4.17 response to Information Utility

D NS A SA Doesn’t apply
N N% N N% N N% N N% N N%
3 2.2% 1 0.7% 20 14.7% 112 82.4% 0 0.0%
The system
works well
The records 23 16.9% 112 82.4% 1 0.7%
are useful
Source: Primary data

According to Table 4.18, three (2.2%), one which is equivalent to 0.7%, 20 (14.7%), and

112 (82.4%) disagreed (D), were not sure (NS), agreed (A) and Strongly Agreed (SA)

20
respectively that the system worked well. According to Cheung et al.(2008) system utility

is measured by the number of users which is a function of the design attributes of the

particular system. The high number of users indicating that the system worked well

implied that it was being utilized for daily routine to a greater degree. A total of 23

(16.9%) of the respondents agreed, 112 (82.4%) strongly agreed and only one (0.7%)

indicated doesn’t apply respectively that the records are useful.

Assessment of the presentation of patient’s records

A total of eight questions were asked and the responses recorded in Table 4.19 and Table

4.20

Table 4.18 Descriptive Statistics

N Minimum Maximum Mean Std. Deviation

Average Score 136 2.750 5.000 4.64890 .466348
Source: Primary data

A minimum of 2.75(disagree) was attained, a minimum of 5 (strongly agree), mean of

4.65 (agree) and standard deviation of 0.466 implying minimal dispersion from the mean.

Table 4.20 presents the findings in details by categorizing agreements, disagreements and

the not sure responses.

Table 4.19 Presentation of Information

Disagreement Agreement NS
Count Row N Count Row N Count Row N
% % %
The system provides clear information 4 2.9% 132 97.1%

The system provides reliable 3 2.2% 132 97.1% 1 0.7%

information
The system provides useful 135 99.3% 1 0.7%
information

21
The system provides complete 3 2.2% 128 94.1% 5 3.7%
information
The screens of the system present good 3 2.2% 128 94.1% 5 3.7%
organization
The format of screen is pleasant 2 1.5% 132 97.1% 2 1.5%

The records of the system present an 2 1.5% 133 97.8% 1 0.7%

appropriate format
The records of the system are well 1 0.7% 135 99.3%
organized
Source: Primary data

The results presented in Table 4.20 show that 132 (97.1%) of the respondents agreed that

the system provided clear, pleasant and reliable information respectively. A total of 135

(99.3%) observed that the system provided useful and well organized information, 128

(94.1%) that the system presented well organized and complete information and 133

(97.8%) said the system screen is pleasant. These findings indicate that the majority

viewed OpenClinic as a system that facilitated better presentation requirements of the

records. This finding is in line with that of Verbake (2015) who found that OpenClinic

system has well organized database management system and this capability together with

clear user interfaces present information in a more pleasant manner.

With this finding, it is confirmed that HMS present the patient’s records in a better way

than the paper based systems. The information presented is clear, reliable, useful,

complete, well organized, appropriate formats, and on a pleasant screen.

Assessment of the retrieval of Patient’s records

Table 4.20 Descriptive Statistics

N Minimum Maximum Mean Std. Deviation

Average score 136 3 5 4.69 .534
Source: Primary data

22
The minimum was 3 (not sure), maximum, (strongly agree), mean of 4.69 and standard

deviation of 0.534. The findings on this item show that the responses were scattered as

shown by the high standard deviation. The details are as shown in Table 4.22 with

disagree (D), Not Sure (NS), Agree (A), Strongly Agree (SA) with their frequencies (N)

and percentages (N %).

Table 4.21 Retrieval of patient’s records

D NS A SA
Doesn’t
apply
N N% N N% N N% N N% N N%
It is easy to insert information into 1 0.7% 6 4.4 29 21.3 10 73.5% 0 0.0%
the electronic records % % 0

The screens of the system facilitate 2 1.5% 0 0.0 35 25.7 98 72.1% 1 0.7%
the search of the information % %
Source: Primary data

According to 100 (73.5%) of the respondents, storing information in the system is easy,

29 (21.3%) agreed, and one (0.7%) disagreed respectively. About if the system screen

facilitated search of information, 98 (72.1%) strongly agreed, 35 (25.7%) agreed, two

(1.5%) and one (0.7%) disagreed and didn’t know what to say respectively.

The findings on this table therefore show that the OpenClinic system enabled information

retrieval and the findings were in line with those of Anne (2012) who found that patient

records management through electronic means is far much better than the paper based

systems as far as retrieval and storage of information is concerned.

The relationship between use for information sharing and patient’s records

management

The relationship was established by performing a correlation analysis by controlling

intervening variables of job type, age, knowledge of the user and user’s acceptance. Table

23
4.23 presents the output of the analysis, with Pearson correlation coefficient, significance

level (2-tailed), and degree of freedom (df).

Table 4.22 Correlation output of information sharing and patient’s records

management

Intervening Variables PRM

Correlation 1.000
Patient’s Records
Significance (2-tailed) .
Job type & Age & Management
df 0
Knowledge &
Correlation .429
Acceptance Information
Significance (2-tailed) .000
sharing
df 130
Source: Primary data

According to Table 4.23, the correlation coefficient produced is 0.429 with P<0.01

implying that the relationship was moderately positive and statistically significant. The

independent variable accounted for 18.4% of the patient’s records management in the

hospital with the exclusion of whether the user is a doctor, nurse, accountant or IT, of a

varying age, or varying knowledge or the acceptability levels. This finding is not in

contradiction with the findings of Adams, Mann, & Bauchner (2003) who evaluated the

quality of pediatric primary care including preventive services, before and after the

introduction of an electronic medical record (EMR) developed for use in an urban

pediatric primary care center, concluded that EMR improved quality of care through its

information sharing capabilities.

The relationship between use for access and management and patient’s records

management

The correlation output in Table 4.24 shows the result of the analysis and its discussion

follows after.

24
Table 4.23 Correlation output of accessibility and manageability and patient’s

records management

Intervening Variables Accessibility PRM

&manageability
Correlation 1.000 .642
Accessibility Significanc . .000
&manageability e (2-tailed)
Job type & Age
df 0 130
&knowledge&
Correlation .642 1.000
Acceptance
Significanc .000 .
PRM
e (2-tailed)
df 130 0
Source: Primary data

According to Table 4.24 the Pearson correlation coefficient (r = 0.642) and p-value

(0.000) was produced implying the relationship between accessibility and manageability

of records and patient’s records management was positive and statistically significant.

Accessibility and manageability of records in the HMS accounted for (r 2) 41.3% of the

patient’s records management in the hospital. According to Knowledge, Khangura,

Grimshaw,and Moher, (2008) there is some evidence supporting the positive relationship

between Electronic Medical Record Systems and patient records however additional

evidence is needed to provide a strong conclusion. His study found several factors that

affected the system hence partially supporting the findings of the current study.

The relationship between use for patient tracking and patient’s records

management

Table 4.25 presents the output of the correlation analysis for patient tracking and patient’s

records management.

25
Table 4.24 Correlation output of patient tracking and record’s management

Intervening Variables Patient

Records
Managemen
t
Correlation 1.000
Patient
Significance (2- .
Records
tailed)
Job type & Age Management
df 0
&knowledge
Correlation .587
&Acceptance
Patient Significance (2- .000
tracking tailed)
df 130
Source: Primary data

The correlation coefficient (r = 0.587, P<0.01) showing that the relationship between

patient tracking and patient’s records management and the relationship was statistically

significant. Patient tracking use of Hospital Management System accounted for 34.55%

of total patient’s records management in the hospital irrespective of the job type, age

knowledge and acceptance level of the system by the user. The finding in this Table

confirms the finding that Health information systems including EHR increase adherence

to guideline-based care, enhance surveillance and monitoring, and decrease medication

error (Chaudhry, 2006; Welch, 2007) as well as acting as reminders to doctors (Cheung et

al., 2010).

The regression model

A regression analysis was finally performed to provide a definite direction for the

relationship between Hospital Management System and Patient’s Records Management

and the findings presented in Table 4.26

Table 4.25 Regression Model Summary

Model R R Square Adjusted R Square Std. Error of the

Estimate
26
Source: Primary data

The relationship between HMS and Patient’s Records Management produced multiple

Linear regression coefficient R = 0.994, R2 % = 98.8% implying that there is a very

strong positive relationship between the usage of Hospital Management System and

Patient’s Records Management. A review of the impact of regional health information

systems (RHISs) found that there was an improvement in clinical data access, timely

information and clinical data exchange, as well as enhanced communication and

coordination between professionals when RHISs were used (Mäenpää et al., 2009). While

a 2009 before-after analysis shows that after the introduction of e-health Record system,

office visits were significantly reduced (Chen et al., 2009) concurring with a previous

systematic review in 2008 that found a decrease in consultation time when six studies that

analyzed the impact of e-health records management with respect to consultation time

were reviewed (Delpierre, 2004). Increased provision of preventive care, prescriptions

following an encounter with clinical recommendations and adherence to guidelines was

the outcome of a 2004 analysis of 26 studies related to quality of patient-physician

encounters (Delpierre, 2004). Health information systems including EHR were also found

to increase adherence to guideline-based care, enhance surveillance and monitoring, and

decrease medication error (Chaudhry, 2006; Welch, 2007) as well as acting as reminders

to doctors (Cheung et al., 2010).

Model analysis

The model of HMS Usage and patient’s record’s management is modeled as indicated in

Table 4.27.

27
Table 4.26 Regression Coefficients for HMS and Patient's Records Management

(PRM)

Model Unstandardized Standardized t Sig.

Coefficients Coefficients
B Std. Error Beta
(Constant) 1.693 .343 4.939 .000
Information -.238 .109 -.252 -2.185 .031
Sharing
Accessibility .563 .122 .474 4.605 .000
1
and
manageability
Patient .356 .111 .404 3.221 .002
tracking
a. Dependent Variable: PRM
Source: Primary data

Given that the constant (β0= 1.693, P <0.01), β1 = -0.238, β2= 0.563, β3=0.356 and є =

0.343,

For, PRM = β0 + β1X1 + β2X2 + β3X3 +є Where, PRM –Patients’ Records Management

β0, β1, β2, and β3 - Constant

X1 – Information sharing X2 – Accessibility and Manageability X3 – Patient tracking +є

The model therefore expands as follows:

PRM = 1.693 – 0.238 (Information Sharing) + 0.563 (Accessibility and Manageability) +

0.356 (Patient Tracking) + 0.343

Interview Discussions

Five IT staffs in CHUK were interviewed and the information they provided was so vital

and supplementary to the questionnaire responses.

1. How is HMIS used in CHUK?

According to three (60%) of the respondents, the HMIS is used for entering data,

monitoring and tracking patients who report to the hospital. One respondent said “the

28
system has been too fundamental in the generation of reports in customized formats or

templates.”

2. What challenges do the users face with the system?

All respondents observed that user knowledge are major hindrance to the use of the

system. That the training that had been emphasized during the system design had been

neglected and even new entrants into the hospital are not well oriented into the system.

3. Do you think HMIS has any contribution to patient’s data management?

All respondents agreed that the HMIS are very significant for patient’s record keeping. A

respondent said “when we used to use the paper-based system the patients would lose

their files and doctors needed to sometimes restart a treatment.”

Conclusion

It is evident that HMS benefited CHUK in many ways. It facilitated the analysis of

hospital bills, verification of the materials and medications, medication request from

pharmacy, provision of guidelines and organization of work and for unit integrations. It

enabled CHUK hospital to access and manage the records because the system was easy to

use, order of presentation met user’s needs, presented information in a consistent manner,

was speedy, reduced the occurrence of fraud, facilitated the implementation of internal

systems and facilitated auditing procedures. It also helped in patient tracking and patient

care by helping nurses in checking a patient’s medication, tracking the prescription of

patient medication, medical evaluation of patients, evaluating the patient and their

individual medication, while at the same time providing greater control over the

consumption of medication.

29
The system had few disruptions, and had enough screens for its activities, enough records

for its activities, generated information faster, reliably and the records were updated. The

records in the hospital were useful and the system worked very well in this respect.

Therefore, the users highly regarded the presentations of the system and particularly

observed that the system provided clear, pleasant and reliable information respectively. It

also provided useful and well organized information on pleasant system screen. The

records were easy to retrieve store and search.

Though challenges have been identified in literature about the use of Hospital

Management systems, this study demonstrates that when Open Source Software is used

and implemented well, the records of patients are managed well and users appreciate it in

the long run.

5.3 Recommendations

Based on the researcher’s interaction with respondents and his own observation combined

with the findings of this study, the following recommendations merit stating so as the

various stakeholders may ponder over possible policy interventions.

To the hospital management at CHUK, it has been a recommendable investment made on

the improvement of the patient’s record’s management. The commitment of management

is visible through the several computerized systems at various levels especially through

the use of the OpenClinic software. However, there is laxity on policies that enforce the

use of the system. It is common to find medical personal still using paper-based systems

and only using the OpenClinic when they find it unavoidable. This makes the records

management very inefficient since gaps exist on individual patient records. The medical

staff already show high regards for the system and this motivational height should be

utilized by the management to win user buy in training programs need to be innovated,

30
simple mobile handheld gadgets that network with the OpenClinic bought and given to

the users so that it is not only desktop computers that the staff have to use always.

The Rwandan government has made tremendous strides towards implementing

information communication technology in the country. Several policies and important

concepts gouged for the improved use of ICT in the country. However, there is not much

empirical research being conducted upon which evidence based decisions may be made

for grassroots ICT implementations. More research needs to be conducted on how the

local person is receiving and accepting these wonderful policies.

However, more studies need to be conducted on this topic since the limited scope of the

current study limits generalizability of the findings. With more studies conducted on

several HMS, a concrete conclusion may be arrived.

Limitations of the study

This study was conducted on a single hospital with a limited population and funds. The

authors feel that if the sample size was increased with more hospitals included, a

generalizable finding would be reached at. A comparison of public and private hospitals

would be done and those located outside Kigali City would give a better picture given the

uniqueness of their environments.

31
 REFERENCES

Adams, W. G., Mann, A. M., & Bauchner, H. (2003). Use of an electronic medical record

improves the quality of urban pediatric primary care. Pediatrics, 111(3), 626–632.

https://doi.org/10.1542/peds.111.3.626

Albert, M. (2014). Where are Africa’s Developers. Retrieved June 12, 2015, from

http://www.hospitalemrandehr.com/2012/01/07/hospital-emr-failure-stories-very-

hard-to-find/

Anne, Z. (2012, January 7). Hospital EMR failure stories very hard to find. Retrieved

June 12, 2015, from http://www.hospitalemrandehr.com/2012/01/07/hospital-emr-

failure-stories-very-hard-to-find/

Arar, N., Wen, L., J, M., Steinbach, R., & Pugh, J. (2005). Communicating about

Medications during primary care outpatient visit: the role of electronic medical

records. Inform Prim Care, 13(1), 13–21.

Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E., … Shekelle, P.

(2006). Systematic Review: Impact of Health Information Technology on Quality,

Efficiency, and Costs of Medical Care. Ann Intern Med, 144, 12–22.

Chawla, R., Bansal, A. K., & Indrayan, A. (1997). Informatics technology in health care

in India. Natl Med J India, 10(1), 31–35.

Chen, C., Garrido, T., Chock, D., Okawa, G., & Liang, L. (2009). The Kaiser Permanente

Electronic Health Record: Transforming And Streamlining Modalities Of Care.

Health Aff, 28(2), 323–333. https://doi.org/DOI:10.1377/hlthaff.28.2.323

Cheung, A., Mayhew, A., Weir, M., & Grimshaw, J. (2008). Evidence Summary :

Electronic Health Records ( EHRs ). (K. Sara, G. Jeremy, & M. David, Eds.) (Vol.

7).

32
Cheung, A., Mayhew, A., Weir, M., & Grimshaw, J. (2010). Overview of the

Effectiveness of Reminders in Improving Professional Behaviour.

CooperNet Solutions. (2014). Hospital Management System. Lusaka, Zambia: CopperNet

Solutions.

Delpierre, C., Cuzin, L., Fillaux, J., Alvarez, M., Massip, P., & Lang, T. (2004). A

systematic review of computer-based patient record systems and quality of care:

more randomized clinical trials or a broader approach? Int J Qual Health Care,

16(5), 407–416.

EAC Health Sector. (2007). Towards establishment of an East African Regional

Integrated e-Health Management Information System (e-HMIS,Geographic

Information System (GIS) and its accompanying ICT infrastructure. EAC.

Evan, B. (2015). Case Study: Out-of-the-Box Reliability.

Force, A. e-H. T. (2004). The Strategic Importance of Electronic Health Records

Management. American Health Information Management Association, 75(9), 1–30.

Frasier, H., May, M., & Wanchoo, R. (2008). E-health Rwanda case study. … -Rwanda-

Case-Study ( …. Retrieved from http://ehealth-

connection.org/files/resources/Rwanda + Appendices.pdf

Hategekimana, T. (2011). University Teaching Hospital of Kigal IU.T.H.K/CHUK. Kigali

City. Retrieved from http://www.mifotra.gov.rw/fileadmin/citizen charter/2. UTHK

CHUK Service charter December .pdf

Hersh, W. (2002). Medical Informatics: Improving health care through Information.

JAMA, 288(16), 1955–1958.

Hyun, S. (2009). Development and evaluation of nursing user interface screens using

multiple methods. Journal of Biomedical Informatics.

Lewis, T., Synowiec, C., Lagomarsino, G., & Schweitzer, J. (2012). E-health in low- and

33
 middle-income countries: findings from the Center for Health Market Innovations.

Bulletin of the World Health Organization. https://doi.org/10.2471/BLT.11.099820

Mäenpää, T., Suominena, T., Asikainenb, P., Maassb, M., & Rostilac, I. (2009). The

outcomes of regional healthcare information systems in health care: A review of the

research literature. Int J Med Inf, 78, 435–445.

Martien Borgdorff. (2008). 39th World Conference on Lung Health of the International

Union Against Tuberculosis and Lung Disease (The Union). Journal of Tuberculosis

and Lung Disease, 18(11). Retrieved from

www.rbc.gov.rw/fileadmin/user.../tb_facts_info_summary_for_moh_january_2015.p

McDonald, C. J., Gunther, S., & Barnes, M. (2003). Open Source sofware in medical

informatics - why, how and what. IJMI, 69(175–184).

Ministry of Health. (2009). the National E-Health Strategic Plan 2009-2013. Kigali.

OpenClinic. (2016). What is OpenClinic project? Retrieved July 21, 2016, from

http://openclinic.sourceforge.net/

Pala, F., Eker, S., & Melek, E. (2008). The effects of demographic characteristics on

organizational commitment and job satisfaction: An empirical study on Turkish

Health Care Staff. The Journal of Industrial Relations and Human Resources, 10(2),

1–22.

Patel, A., O’Brien, R., Jones, P., & Quintana, Y. (2003). Interorability of Open Source

Medical Record Systems. AMIA, 965(Symposium Proceedings).

Shachak, A., & Reis, S. (2009). The impact of electronic medical records on patient-

doctor communication during consultation: a narrative literature review. JEval Clin

Pract, 15(4), 641–649.

Sinha, R. K. (2010). Impact of Health Information Technology in Public Health. Sri

Lanka Journal of Bio-Medical Informatics, 1(4), 223–236.

34
 https://doi.org/10.4038/sljbmi.v1i4.2239

Sullivan, F., & Wyatt, F. (2005). How computers help make efficient use of consultation.

BJM, 331(7521), 892–894.

Vanmeulebrouk, B., Rivett, U., Richetts, A., & Loudon. (2008). Open source GIS for

HIV/AIDS management. International Journal of Health Geographics, 7, 58–10.

https://doi.org/1186/1476-072X-7-53

Verbake, F. (2015). OpenClinic GA: Open Source Integrated Hospital Information

Management System. Retrieved June 5, 2015, from

http://sourceforge.net/projects/open-clinic/

Welch, W., Bazarko, D., Ritten, K., Burgess, Y., Harmon, R., & Sandy, L. (2007).

Electronic Health Records in Four Community Physician Practices: Impact on

Quality and Cost of Care. J Am Med Inform Assoc, 14, 320–328.

https://doi.org/10.1197/jamia.M2125

Who. (2004). Developing Health Management Information Systems : A Practical Guide

for Developing Countries. Health (San Francisco).

35