Touchscreen clinical workstations at point of care: A paradigm shift in electronic medical record design for developing countries

In healthcare there are two approaches to operationalising electronic medical record (EMR) systems. In the first approach clinical information is captured on paper by clinicians, and then retrospectively entered into the EMR from paper by dedicated clerks. In the second approach computers are placed at the point-of-care and clinicians use them in real-time to capture information. Implementation of the latter is still considered progressive and has been limited to developed-world sites where it has had mixed success largely due to the challenges associated with integrating the technology into existing clinical workflows. Conventional wisdom suggests that point-of-care also requires more hardware, and is therefore more expensive to implement. The potential costs and workflow challenges notwithstanding, point-of-care has the distinct benefit of facilitating realtime decision support (e.g. encoded diagnosis and treatment protocols), and this is where the true value of the technology may lie for countries facing catastrophic human resource shortages in healthcare. A Malawi-based NGO has been developing and deploying real-time point-of-care solutions since 2001. Custom hardware has been specially engineered for this application. Low cost, touchscreen-based clinical workstation appliances receiving both power and data connections from a single cable (Power over Ethernet) and consuming less than 15 Watts are deployed at nursing stations and in clinic rooms. Thermal printers allow information captured onscreen to be printed to labels as often as necessary to support improved documentation. Barcode technology is heavily utilised. Custom software has been developed to address a number of clinical areas including patient registration, paediatric management, radiology, lab sample management, pharmaceutical inventory control, HIV testing and counselling, and most recently HIV patient care. Currently -12% (-15,000) of all patients receiving HIV treatment in Malawi are managed by clinicians using a point-of-care system. Development has not been straightforward nor without failures. However, experiences from system use in Malawi have demonstrated that workflow issues can be overcome through detailed worksite observations and collaborative development with system users, and that costs can be contained through innovation and engineering.