AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

AHI Electronic Medical Records Requirements

Eric Shadle, David Chung, Woldeeves Louigene, Debinder Vander

Loma Linda University

AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

Background
According to the Adventist Health International (AHI) website, the management
organization is committed to partnering with health care services in developing countries.
AHI has 26 hospitals and 67 clinics in 21 countries across the globe. Many of these are in remote
locations with very limited resources. Even the facilities with relatively more resources are
limited. The goal of AHI is to help as many people as possible however, that takes resources,
such as time and money, to achieve.
Every one of the hospitals and clinics run by AHI needs some way to maintain records
and do the accounting for its respective facility. One emerging way to address this issue is
through an electronic medical records (EMR) system. The benefits of EMR systems have been
well documented and its implementation on the mission field can facilitate more integrated and
efficacious care. Some of the benefits of an EMR include, but are not limited to, continuity of
care, decision support for drug ordering, warnings for abnormal test results, program monitoring
(outcomes, budgets, and supplies), and management of chronic diseases (Fraser et.al., 2005).
There have also been numerous studies on how EMRs can positively impact patient care
and other medical operations. In 2012, a study was done to determine what benefits doctors
perceived from EMR implementation throughout the nation. The results were as follows: 94% of
providers reported EMRs make records readily available, 88% reported EMRs produce clinical
benefits for the practice, and 75% reported that EMRs allow them to provide better patient care

AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

(Jamoom, Patel, King, & Furukawa, 2012). In addition to the benefits provided for patient care,
EMRs also make billing more effective.
In order to determine what EMR requirements could be feasible for AHI hospitals and
clinics, we researched whether any other lower or middle income countries have been able to
implement. Many other lower/middle income countries have been able to implement EMRs with
very limited resources. According to an article printed in 2005 in Informatics in Primary Care
regarding developing countries implementing electronic health records, Uganda and Kenya
implemented EMRs with only a few computers and Microsoft Access. Brazil implemented an
EMR by installing the EMR on each physicians desktop and then periodically syncing all the
records. Even with limited capabilities, they were able to develop EMRs that met their needs.
Currently the software that some AHI clinics using EMR systems are implementing is SunPlus
software. Although this software accommodates accounting and tracking of equipment being
used, this software has some limitations.
Some of the limitations are usability, workaround, communication, and collaboration.
The current system (SunPlus) is not user friendly in terms of patient care, billing and accounting.
In the hospitals where it is being used, nurses, doctors and other healthcare professionals, and
even the accounting departments do not find the system to be user friendly. Also, during a
meeting with members of the AHI leadership, we learned that a workaround was done to meet
some of the needs of the accounting department. Furthermore, the system does not foster a more
efficient workplace and does not facilitate collaborations between departments in a hospital or a
clinic setting. Because of these limitations and the importance of maintaining an up-to-date
accounting and billing service, AHIs new strategy is to find the requirements necessary for a
new EMR to be implemented at the various clinics and hospitals. The goal is to provide more

AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

efficient and efficacious care that is coordinated with the accounting and billing services.
Unfortunately, the way the SunPlus is currently designed, it is not meeting the needs and
expectations of the AHI leadership.
The reason why this project is important to AHI is because the AHI leadership would like
to present a proposal of an effective EMR at the 2nd Global Conference on Health and Lifestyle
in Geneva, Switzerland on July7, 2014 July 12, 2014. If approved, this project has real world
implications that can have tremendous impact on delivering a higher quality of care. Our goal
was to create a value model of required components of an EMR system that would allow AHI to
effectively select one to best suit its needs.
Methods
The first step in our project was to identify the necessary requirements the EMR must
have. We started by doing a literature review of EMRs in rural settings and going through the
list of patient care requirements listed by HIMSS (Healthcare Information and Management
Systems Society). Then, with key AHI project managers at Loma Linda University, we revised
the list of requirements for use in a rural setting. The focus was twofold: (1) Requirements for
EMR components (ie. data entry, chronic disease management, lab, pharmacy, billing, etc.) and
(2) qualitative elements (ie. cost of the EMR, start-up and training costs, ease of use, adaptability,
language variability, components needed to implement, etc.).
Our first meeting with the key stakeholder of AHI was on 1/30/2014. During that
meeting we discussed the requirements AHI wanted in an EMR. After the initial background
research and meeting, we began to assist AHI with comprising a document that would allow us
to determine the essential parts of an EMR. At the first meeting, we were presented with a 9 page
document of potential EMR requirements. The requirements were established from the HIMSS

AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

website and their recommendations for EMR systems. The list was prepared by Jere Chrispens,
am AHI team member with extensive experience in software engineering.
By the second meeting on 3/4/2014, the list of requirements had blossomed into a 29
page document with all the items we felt could be beneficial in the EMR system. We were
planning on speaking with the rest of the key stakeholders at the meeting however, we were not
contacted so we could not meet with them. After we developed this revised list of requirements,
we created a survey to send out to other key stakeholders currently working in the countries
where the EMRs would be implemented. Our plan was to have them complete the survey in
order for us to determine the EMR components the individuals in the field felt were most crucial.
The survey we created had 132 items and each item was rated on a scale from 1 (not at all
important) 10 (essential).
The introduction page of the survey provided the stakeholders with a reason to take the
survey (to identify the most important component of an EMR), and how to take it assigning a
value from 1 to 10 - with 1 being not at all important and 10 being essential - to the potential
items on how important they determine them to be. Once the stakeholder clicks the begin button,
he/she is presented with one of the item taken from the list that was prepared by AHI, and asked
to assign a value to it. If the stakeholder tries to skip the question or accidentally clicks on the
next button, a message appears instructing him/her to assign a value to item.
We presented this idea to the key stakeholders we were working with but they ultimately
felt that the process would take too long. In addition to that, they were satisfied with the 29-page
document they currently had and no one was willing to let any of the items go. We were not able
to implement our plan and therefore, we had no valid data from stakeholders to complete our
analysis.

AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

Prognosis Health Information Systems wrote a paper on overcoming barriers to EMR
implementation in rural hospitals. They suggested weighting the criteria a potential EMR system
using the value of importance. Due to this recommendation, our plan for the analysis was to use
the requirements identified by the survey and develop weighting criteria. With the criteria in
place, we were planning to develop a value model to determine which EMR would meet all these
requirements (Alemi & Gustafason, 2007). Since we were not able to do this, we had to take the
survey within our group in order to have data we could analyze. We were anticipating having the
weight of criteria and value table as follows:
Weight Level of Importance
10

Very High Importance

(Essentials)

9
8

High Importance

Important

6
5

Medium Importance

4
3

Low Importance

2
1

No Importance

The following table show how the weighted data collected from the survey are used to
determine the level of importance of each item on the AHI list:

Criteria
Data input templates are
user defined

Level of
Importance

EHR
System 1
X

EHR System
3

EHR System
3

9.5

AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

Seamless electronic
results reporting of labs
and radiology routed to
the correct person.
Provide the capability to
route such results to
remote specialists, i.e. a
basic form of
"telemedicine".
Patient educational
materials are available
and can be customized
Ability to view historical
information including
onsets, meds, surgeries,
and hospitalizations on
patients and family
members.

8.9

7.5

9.6

Data Collection
After our group completed the survey, we filtered our results using a two-step process.
First we organized the items to be used into a two tier system. The lower tier has a threshold of .
75, anything below that will be eliminated. The upper tier has a threshold of .85 to identify our
must have items. Of the EMRs remaining after satisfying all items above the .85 threshold,
whichever has the most items above .75 will be the EMR we recommend. If two EMRs tie then
we recommend the one with a lower cost. In the sample results we could further narrow our
results by increasing the initial threshold to .9.

AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

Figure 1 A summary chart of all 132 items on the survey

Figure 2 By eliminating items that scored below the .75 threshold we were left with 91 items

Figure 3 Only 21 out of the 132 items scored above the first threshold of .85

AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

For the sake of this paper we are assuming that only 3 EMRs are able to address all 21
items from the .85 list. Of those three EMRs, whichever one that addresses the most items from
the .75 list will be the EMR we recommend. Our model does not take cost into account. If cost
were considered, it is very likely that our recommendation would be different.
Discussion
The varying degrees of success at implementing electronic health systems in some
developing countries has encouraged Adventist Health International to move forward with
installing electronic health systems at their own clinics scattered across the globe. Still, there are
many barriers and concerns that must first be addressed. Many of the AHI clinics are
understaffed and are struggling with providing quality care with limited resources. Diverting a
significant portion of these resources and time from direct patient care to a new electronic system
must be weighed against the intended benefits of improved efficacy and quality of care.
In the process of selecting an EMR system to implement at the many different AHI
clinics, the main limitation of our analysis was our inability to use our initial plan of modeling to
facilitate decision. Instead, members of AHI decided to use a process that appeared to be
something between an Integrative Group Process and a Group Communication Strategy (Alemi,
Chapter 6). The entire process started by gathering local best experts who had experience
with implementing information technology in rural or missionary settings. One of these experts,
Jere Chrispens, constructed a straw model (abridged document of necessary EMR components)
based on a very lengthy document from the HIMSS website. The group then proceeded to meet
various times to fine tune the document after the input of other stakeholders. After the
construction of the first straw model, our team sought to create model parameters based on a
weighting system by utilizing an online survey of 132 EMR functions that would be sent out to

AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

as many stakeholders as possible. Rejected as being too lengthy, our survey was abandoned and
instead, the document went to other stakeholders for more revision and input. Thus, at the
conclusion of our time on the project, we were unable to see our designed model put into
practice.
Despite being unable to implement our model, the greatest barrier our team faced was the
very narrow time constraint. AHI is an organization that spans the globe. Coordinating a
meeting time with various providers, administrators, and other stakeholders in different countries
and time zone was difficult. Furthermore, when a meeting was held, many of the extremely busy
stakeholders at international clinics viewed the straw model for the first time. This restricted
the amount of revision that could be done in a single meeting. Furthermore, as mentioned earlier
providers in some of the international clinics were extremely busy working in understaffed
hospitals and were, therefore, unable to send comments on the model in a timely manner.
Another barrier encountered was the large variety of goals each stakeholder had. The
clinics and hospitals all have different infrastructures and technologic capabilities. Thus,
representatives from the more rural operations required less than their higher functioning
counterparts. Furthermore, the goals of AHI were not very clear. The 29 page document we
created a survey for was originally thought to be a list of potential requirements to be whittled
down. However, at the last meeting we were told the list would be used as a proposal to be sent
to various EMR companies.
Our recommendation to AHI would be to continue the Integrative Group Process and set
the model (EMR requirements document) parameters. This can be accomplished by using a
method very similar to the survey we suggested be used. No more than five key stakeholders,
like Jere Chrispens, would assign a point value for each item detailed in the EMR document.

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AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

The average of the point value for each item would be used as its weight. After sending out the
document and receiving replies from different EMR systems about what each system is capable
of, each system could be ranked by the amount of points it accumulates and certain EMR
systems could be eliminated if it does not have a total over a certain agreed upon threshold. It is
crucial that parameters are set on the model to help discern which EMR system will be most
beneficial to AHI.
Practically speaking, we do not think that AHI will implement our recommendation. The
members of AHI all have other responsibilities and have limited time. Setting point values or
weights to a document that is currently 29 pages would take a hefty time commitment.

References
Adventist health international. (2014). Retrieved from
http://www.adventisthealthinternational.org/
Emr international. (2014). Retrieved from http://EMRinternational.com/products/
Fraser, H., Biondich, P., Moodley, D., Choi, S., Mamlin, B., & Szolovits, P. (2005).
Implementing electronic medical record systems in developing countries. Informatics in Primary
Care, (13), 83-95.
Alemi, F., & Gustafson, D. (2007). Decisions analysis for healthcare mangers. (pp. 21-60).
Chicago. Health Administration Press.

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AHI ELECTRONIC MEDICAL RECORDS REQUIREMENTS

Jamoom, E., Patel, V., King, J., & Furukawa, M. (2012, August). National perceptions of
ehr adoption: Barriers, impacts, and federal policies. National conference on health
statistics.
Matthews, T. (n.d.). Overcoming the top five barriers to ehr implementation. Retrieved from
http://www.prognosisinnovation.com/pdf/Overcoming Barriers Whitepaper.pdf
Healthcare Information and Management Systems Society (HIMMS). (Jan 2010) Ambulatory
Electronic Medical Record. Retrieved from
http://www.himss.org/resourcelibrary/TopicList.aspx?
MetaDataID=565&navItemNumber=17645

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