HealthManagement, Volume 14, Issue 1/2012

The Winner of the [email protected] Awards 2012

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It is globally recognised that the only way to effectively support continuity of care is to implement an electronic  health record (EHR) system on a large scale. The implementation of a national EHR is a high priority in  the e-health strategies of most countries, regardless of whether they are first world or low- and middle-income  countries. In South Africa, this has been successfully achieved in the Western Cape province.


Although South Africa has had some active  health information systems implementations,  only about a third of all public sector hospitals  have some form of electronic medical record  system. There is little or no integration between  these systems and network and Internet access  is not commonly found in public health facilities,  especially primary healthcare facilities (community  health centres and clinics).  

Prior to 2004 in the Western Cape, none of these  primary healthcare facilities were computerised.  In 2004, there was an initiative to connect the fifteen  largest community health centres to the  provincial WAN. Computers were also installed but  only provided email capability. For registry staff  who were struggling to process more than 1,000  patients a day, for doctors who had to see up to  100 patients a day and for patients, who had  queued outside from 4am, ill and often collapsing,  this was of little help. Registry staff battled under  chaotic circumstances, often using up to four  different filing systems in the same facility.  



A small team within the provincial government had  designed and implemented a successful centralised  system called CRADLE for use in the midwife obstetrics  units (MOUs), public sector facilities where  women receive ante-natal care and deliver their  babies. It was proposed that CRADLE be adapted  for use in all primary healthcare facilities, particularly  making use of the patient registration functionality.  The resulting system would be known as  PHCIS (Primary Healthcare Information System).  In 2003, the South African cabinet announced that  anti-retroviral treatment (ART) for HIV/AIDS would  be introduced in the public sector. It would be essential  to monitor the roll-out of ART and to provide  regular reports to the national Department of  Health. The decision was taken to use the same  CRADLE patient registration capability and to develop  this ART module in-house, with guidance  from the University of Cape Town Health Sciences  Faculty. The ART module, called eKapa, was therefore  to be part of the PHCIS suite and the development  was done in parallel.  The decision to enhance the CRADLE system  was taken because it had the necessary foundations  to suit the unique requirements and the cultural  context. The CRADLE system had already  been proven in the MOUs. Several commercially  available systems were investigated but it was felt  that, besides being very expensive, they were generally  not suitable. There was considerable pressure  at the time to use an open-source database  and development tools. However, it was felt that  the existing CRADLE team was skilled in the development  language and it would easier to find  reliable skills in this language. The CRADLE system  already used a commercial database management  system and there were economies of scale  in expanding this. From the outset the vision was  to take a step-wise approach, i.e. not to proceed  to the next level until the foundations were in place.  This is illustrated in Figure 1.  

Step 1. Connecting facilities to the WAN, giving  staff basic computer literacy training and enabling  them to use the computers to support administration  of the facilities, e.g. email, access to the  transversal financial system, BAS.  

Step 2.Providing the capability of registering the  patients on a centralised database, recording and  updating demographic details, both on the PHCIS  database and the provincial Patient Master  Index (PMI) which is maintained in the Clinicom  system (a centralised system used in provincial  hospitals). At this stage staff could print labels that  could be used by the pharmacy and to label specimen  containers.  

Step 3. Allowing more details to be recorded so  that specialised registers could be maintained, e.g.  for ART or TB treatment.  

Step 4. Begin to add clinical details onto the patient  record and proceed gradually until a comprehensive,  longitudinal health record is maintained.  

Step 5. Use the PHCIS database as a source for  management reporting and business intelligence  applications.  


An Agile Tailor-Made Solution  

The philosophy and methodology used for the design  and development of PHCIS can be described  as “agile”. The development team worked very closely  with the project manager and the business analyst,  who in turn, dealt with the users on a daily basis.  The roll-out began in 2006, using the approach previously described.. Two weeks after each “golive”  an on-site review was held where the users communicated  openly about the system with the entire  team, giving useful feedback to the developers.  Besides regular project meetings, the project  manager and business analyst met regularly with  facility staff and managers in a forum where they  discussed the project, the system and its impact  on clinic workflows. The team also spent a considerable  amount of time visiting the facilities and  speaking to staff and patients. This close relationship  with the users and the patients continues  and the result is that the “design reality gap” for  PHCIS is very small, i.e. it is tailored to the needs  of the users, the patients and the managers, closely  fits the socio-cultural context, and has an improved  chance of being adopted and retained.  


The System  

The hardware used for this system is very basic. All  hardware procured must conform to the standards  laid down for the provincial government,  must be affordable as the budget is constrained  and must be easy to support. Equipment used  consists of standard network cabling for the LAN  and WAN, compact workstations with flat screens,  specialised high-speed label printers and laser  printers for reports. In addition, bar-code scanners  are used in the registry to scan the patient’s  card on arrival in order to open the electronic  record. Barcode scanners are also used to record  details about a patient visit, with minimum effort  on the part of the clinician or clerk.  

One of the impressive features of the system is  that it accesses a central PMI via web services. This  PMI is used for all patient-based systems in the  province - at hospitals, MOUs, ART clinics and 100  clinics serviced by the City of Cape Town. The City  of Cape Town system has also been developed inhouse  by the city’s ICT services.  

PHCIS has an SMS capability which allows reminders  to be sent e.g. to patients who have missed  appointments, or to parents to bring their children  in for their next immunisation dose. On-going work  with facility managers and users has ensured that  PHCIS is an integral part of clinic workflows. Most  facilities are not modern and were not built with  computerisation in mind. It has been challenging  to adapt workspaces, already cramped and ergonomically  unsuitable, for the use of computer  technology while at the same time taking into account  high volume workflows.  



When roll-out of PHCIS began in 2006 the project  team had to overcome several challenges:  

  • There was very little funding for this project;  
  • There was considerable resistance and lack of  buy-in, especially at the outset. The behaviour  al patterns of staff and patients had to be  changed. Staff were accustomed to chaotic workflows  and facing long queues of frustrated patients.  Patients were used to spending a full day  in the facility each month in order to collect repeats  of chronic medication;  
  • There was a shortage of skills for support of the  system;  
  • The network infrastructure was not adequate  and/or accessible;  
  • There was a lack of reliable and affordable  connectivity;  
  • Processes for procurement of network infrastructure  and hardware were complex and slow;  
  • Buildings were not designed for computerisation;  
  • Electrical supply to the facilities could be  unstable;  
  • There were security and access issues. In some  areas gang warfare raged outside the facilities at  the time of “go-live”, several sites had all computers  stolen, electricity supplies were disrupted  when underground cables were stolen for their  copper content, and on more than one occasion  workers were involved in national strikes;  
  • The organisational structure did not include the  roles necessary for the success of this project,  i.e. information officers and data capturers.  

Over the past five years these challenges have  been overcome through innovation, teamwork and  buy-in from the provincial department of health’s  top management. The original goal of the project,  to implement a patient management system in 33  community health centres, has far been exceeded.  Today PHCIS has been implemented at 113 facilities  and the roll-out continues. The aim is to include  126 more sites within the next year. The system  tracks more than 5.6 million folders and the PHCIS  database alone (apart from the provincial PMI)  holds information for over four million patients.  


Patients and Staff  

This success has resulted in tremendous benefits  for the patients, the users and the managers.  Patients are benefiting from improved quality of  care resulting from informational continuity, i.e.  their records may be accessed at any PHCIS facility.  Improved organisation and quicker throughput  means that they do not have to queue for so  long. They do not have to arrive early to secure  a place in the line as those who must make repeat  visits are given appointments. Patients who  “walk in” for acute visits are also processed faster.  Overall this gives the patients respect and dignity,  the system knows them and recognises them,  their files are retrieved rapidly. Patients can plan  their time better and do not have to lose a day’s  work in order to pick up medicine.  

The users can be divided into two groups – the  clinicians and the administrative staff. The clinicians  benefit because the environment is now  generally less stressed. Their workload is better  paced and, knowing their schedules ahead of time,  they can plan their own time better. They are able  to deliver a better quality of care because they  have better information about the patient. The  administrative staff has become empowered  through computer literacy. The staff at the registry  windows experience less stress as the patients  are happier and the waiting room is less  crowded. They have more job satisfaction as the  job is more skilled and more is required of them.  

Both user groups benefit from the simple but  innovative use of barcode scanners to record  visit details. By scanning three times – the patient’s  barcode, the clinician’s barcode and the  reason for the visit, the user triggers the rapid creation  of an encounter within the patient’s electronic  health record. The patient encounter holds  the following essential information – which patient  was seen, when the patient was seen, where  the patient was seen, who attended to the patient  and what was the reason for the visit (e.g.  BCG first dose).  

Managers are benefiting from the easy availability  of high quality and accurate information.  They are able to base strategic planning  and decision-making on information reported  or extracted from the system. Regular reports  with the indicators they are required to  provide are also easily obtained. They are able  to monitor staff activities and workload as well  as perform patient profiling for improved  chronic disease management.  



There is no doubt that PHCIS is a major success.  In 2008 the PHCIS project won the African ICT  Achiever’s Award for the best ICT project in Africa.  In the same year the project won the silver award  in the Premier’s Service Excellence Awards. In  South Africa, the ART module of PHCIS has been  mandated as the national electronic medical  record system for the monitoring of treatment  of HIV/AIDS in public healthcare facilities.  

Work on PHCIS is ongoing and the team is always  looking for ways to improve the system. In  the words of Claudette Ruiters, the dynamic PHCIS  project manager: “The question you have to  ask yourself is ‘would you like to be a patient in  this facility’? And if the answer is ‘NO’ – then you  have to do something about it!


It is globally recognised that the only way to effectively support continuity of care is to implement an electronic  health record (EHR) system on a

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