Original Research
Vol. 5, Issue 1, 2025 · P1-12
Initial experience in implementing an Electronic Medical Record (EMR) in Nepal – A necessary step to sustainable change in patient-centered care
Anish K. Shah, MD,Sanjay Hinduja, MD,Subodh Mallik, MD,Hannah A. DeBerg, PhD,David M. Aboulafia, MD
Submission received: 2024-09-30 / Accepted: 2024-11-04 / Published: 2025-06-25
Abstract
Background
Transitioning from a hybrid electronic-paper medical record system to an integrated Electronic Medical Record (EMR) system can improve patient care and operational efficiency. However, such a transition presents challenges, especially in regions with limited technology resources. Here, we review initial efforts to implement an EMR system at the Binaytara Foundation Cancer Center (BTFCC) in Madhesh Province, Nepal.
Methods
We formed a multidisciplinary committee to oversee the EMR implementation plan. This committee customized the EMR efforts to meet BTFCC's unique needs including frequent staff training sessions and an ongoing and rigorous audit system. Regression analyses were conducted to examine the association between time and improvement in the quality of documentation. Various elements of progress notes were recorded such as: History of presenting illness (HPI), Physical examination, Assessment, Medical plan, and the scheduling of Follow-up appointments.
Results
Due to unfamiliarity with utilizing a comprehensive EMR system, medical staff were slow to incorporate an EMR system while caring for patients. By providing frequent updates to the medical record policy and by setting clear expectations for staff, audit reports showed substantial improvement in medical documentation over a 12-month period. Fisher's exact test was used to compare the adequacy of documentation between the first and the last months of analyses. HPI documentation improved from 27.3% (12 of 44 encounters) in the first month to 78.6% (33 of 42 encounters) by the last month (P<0.001). Physical examination documentation improved from 6.8% (3 of 44 encounters) initially to 83.3% (35 of 42 encounters) by the end of the study (P<0.001). Medical plan documentation also improved from 40.9% (18 of 34 encounters) to 83.3% (35 of 42 encounters) (P=0.0058) as did the assessment section from 18.2% (8 of 44 encounters) to 83.3% (35 of 42 encounters) (P<0.001). Follow-up documentation improved from 36.4% (16 of 44 encounters) to 81% (34 of 42 encounters) over the study period achieving statistical significance (P<0.001).
Conclusion
Our findings suggest potential benefits of developing a comprehensive EMR system, particularly in improving documentation quality. Further efforts are required to enhance the impact on direct patient care and medical staff workflow. Through a process of ongoing audits and staff education, we continue our work at achieving a fully functional and integrated EMR system.
Take Home Messages
1. Transitioning to an EMR system offers the promise of improving medical documentation as well as medical care.
2. The team addresses staff unfamiliarity and resistance to transitioning to an all EMR system through rigorous training, technical support, and continuous audits.
3. A structured approach involving specialized committees, user feedback, and supported by a comprehensive training plan is necessary for ensuring a successful EMR rollout.
4. Continuous monitoring and feedback loops lead to ongoing EMR refinements the potential for broader applicability.
Introduction
Electronic medical records (EMRs) have radically changed the way that traditional medical records are accessed, utilized, managed, and housed. Since the inception of the EMR system in 1972, the digital process of maintaining medical records has enabled healthcare providers to keep medical information in one space, as well as easily allowing these records to be shared between offices and providers.1 By the 1990s, technology had advanced sufficiently such that computers were being used to a modest degree in the healthcare setting for record-keeping purposes.2
However, it was not until the internet age that large-scale changes were adopted in health care which allowed for a relatively cheap and efficient way to record and transfer prescription drugs through the EMR. In 2004, then U.S. President George Bush created the Office of the National Coordinator for Health Information Technology, which sought to codify a plan to ensure that most Americans had electronic health records within a decade.3 These records were designated for healthcare providers to serve three basic needs: 1) to share information privately and securely with the patient's permission; 2) to improve the quality of healthcare, minimize medical errors, and reduce paperwork; and 3) to improve administrative efficiencies and healthcare quality.
The uptake of EMRs has translated into improving healthcare systems across developed countries.4,5 According to data from the U.S. Office of the National Coordinator for Health Information Technology, there has been a remarkable rise in the adoption of EMRs, with rates catapulting from a mere 8% in 2008 to a staggering 96% in 2021 in U.S. hospitals.6 The rapid uptake of the EMR has not only led to logistic ease but also has improved health care delivery through improving workflow, reducing medical errors, improving and personalizing patient care by better integration of different hospital-based groups that contribute to promoting better continuity of care, and generating a more reliable revenue stream through more complete documentation of billable work.7
The widespread use of EMRs has not, however, been similarly successful in developing countries because of a myriad of challenges that include, but are not limited to, financial constraints, technical expertise, internet and electricity infrastructure, health workforce capacity, and data privacy and security concerns.8 Many low- and middle-income countries continue to use paper-based medical record systems as their sole option.9 The problems with such systems are numerous and include a higher potential for errors in record keeping, important omissions in patient medical history, and limited access to physical records. Further drawbacks include a greater risk of medication errors, time-consuming manual tasks such as physically retrieving and re-filing records, and reduced comprehensiveness. These systems are also associated with inconsistencies and discrepancies arising from illegible handwriting, misinterpretation of information, or loss of data due to physical damage or misplacement.10 Given these challenges, initial efforts at EMR implementation can be daunting but are necessary for improved patient care.
Nepal, like many middle- and low-income countries, struggles with a predominantly paper-based medical record system. The potential advantages of an EMR system are considerable, particularly in rural settings where medical and social resources are often limited.11, 12 Furthermore, implementing such a system in Nepal presents a unique set of challenges. Limited internet connectivity, insufficient funding and staffing, and resistance to change, particularly among healthcare workers who have historically relied on a paper-based system and may be unfamiliar or uncomfortable with a digital transition, can further complicate the implementation process.13 The lack of universally applicable guidelines for EMR implementation compounds these challenges.
The Binaytara Foundation Cancer Center (BTFCC) is a dedicated medical facility located in Janakpur, Nepal, that provides a range of specialized medical services. Staffed by a team of two consultants, three medical officers, and seven nurses, the hospital provides comprehensive care, including chemotherapy, gynecologic oncology, and specialists in head and neck surgery. The BTFCC also offers 24-hour Emergency Services and In-Patient Care, supported by an Intensive Care Unit. The hospital's team comprises a variety of skilled professionals including a radiology technician responsible for operating imaging machines to produce diagnostic images, and a lab technologist, who performs complex laboratory tests and analyses. The team also includes a lab technician, a role that typically involves more routine processing and testing of lab specimens under the guidance of the lab technologist. The team is further complemented by a pharmacist, assisted by a pharmacy assistant, who handles medication distribution and consultation. Lastly, the team includes four administrative staff members who manage clerical tasks and patient services.
BTFCC initially used a hybrid medical record system, a combination of electronic and paper-based methods. In this hybrid system, certain elements such as patient history and examination charting were documented on paper, while electronic methods were utilized for lab results. The hybrid system, although more efficient than paper-based systems, was still prone to errors, including lost or misplaced paper records. This contributed to our decision to switch to a fully electronic system. We present here our initial experience of transitioning from a hybrid electronic-paper medical record system to a complete and more robust EMR system. We also discuss the many challenges we faced and how we have used these as opportunities to improve patient care.
Materials And Methods
We conducted a literature review using databases like PubMed and Google Scholar, focusing on EMR using the following keywords: EMR implementation; healthcare information technology; medical record digitization; healthcare technology; and EMR audit system. Our literature search spanned from 2000 to 2023 and was restricted to English language articles.
Following our review, we undertook a standardized process for implementing our EMR.14,15 This process was guided by principles of user-centered design and aimed to ensure a smooth transition for all stakeholders. It included ten major steps which we describe below (Table 1).
1. Forming an Implementation Committee
Our first step involved assembling an implementation committee, which included key stakeholders such as the Chief Medical Information Officer (CMIO), on-site physicians and nurses, and administrative staff. Each member was assigned specific responsibilities tailored to their role and expertise. To ensure progress and address any arising issues, we conducted weekly meetings. Two key figures within the committee were the "superusers", comprising a physician and an administrator. These superusers, along with the CMIO, served as the primary experts and problem-solvers throughout the implementation process. Their responsibilities included configuring the new software, creating templates and order sets, and promptly addressing any issues that arose during implementation.
The CMIO played a crucial role in bridging the gap between healthcare workers and non-medical staff and in facilitating effective communication and cooperation. Physicians were tasked with actively using the software, reporting to the committee any problems that were encountered while working in the EMR, and providing much-needed feedback for improvement. Similarly, administrative staff, pharmacists, and nurses were responsible for monitoring the flow of information within their respective departments. Their role was to ensure the software was effectively used in patient care and that the EMR system remained comprehensive and cohesive.
2. Software Identification and Configuration
We identified software capabilities to meet the specific needs of our healthcare system. During committee meetings, we outlined requirements of physicians, patients, and staff, leading to trials of various EMR systems. A key focus was on selecting software with basic templates that were both comprehensive and user-friendly.
After further discussions and evaluations, we decided on a digital healthcare platform known as KareXpert.16 This early-stage, open network platform is based in Haryana, India, and offers cloud-based technologies specifically designed for healthcare providers. Currently, it is being utilized in over 250 hospitals across six countries, including in the U.S. and Europe. We chose KareXpert because it offered a comprehensive suite of features, a user-friendly interface, and technical backup at a very competitive price point. Its versatile platform not only met our initial needs but also offered the potential for customizability and scalability, which are essential for adapting to evolving healthcare needs.
After we selected the software vendor, we convened multiple meetings with our lead physician, lead superuser, and IT vendor to configure the software to meet BTFCC's specific needs. The lead superuser played a pivotal role in this process, being primarily involved in software optimization and serving as the first to explore and be trained in the software's use.
3. Identifying the Hardware Needs
Selecting the right hardware is crucial for long-term efficiency and cost-effectiveness. High-quality hardware reduces documentation time, improves information flow, and minimizes repair costs. We evaluated our existing infrastructure and, with our IT vendor's assistance, identified and procured the necessary hardware, including computers, network services, and ergonomic accessories.
4. Transferring Medical Data From Hybrid Electronic-Paper Medical Records to the EMR
We utilized a stepwise approach to ensure that the process of transferring medical records was accurate and complete. Initially, we created a checklist of all essential elements involving patient files that needed to be transferred to the EMR system. Following this, specific staff members were assigned tasks to streamline the process and ensure accuracy. The division of labor ensured continuity of care by allowing each healthcare professional to focus on their area of expertise, thereby reducing errors. Physicians and nurses, who are most familiar with patient histories and examinations, were responsible for inputting this data, while other staff members handled the uploading of labs and images, ensuring that all relevant information was accurately represented in the EMR system. This approach minimized interruptions in patient care services while maximizing the likelihood that health information was accurately and promptly available for ongoing treatment decisions.
5. Optimizing Pre-Launch Workflows And Considering Convenient Room Layout
Prior to the EMR launch, we considered how to optimize workflow in our varied physical spaces with a goal of facilitating smooth system integration and user adaptation. Optimizing workflows in advance has the dual purpose of minimizing what is invariably a challenging and stressful time for staff as well as for patients and leading to better physical spaces for both parties. To achieve this, we made certain that we had an adequate number of staff who were well-prepared for the transition to our EMR system. This preparation included comprehensive training and familiarization with the new system, as well as contingency planning for any potential obstacles during the transition. We also considered the physical layout of the physicians' examination rooms. It was important to design a layout that allowed physicians to interview and assess patients while simultaneously interacting with the EMR system, and to do so without compromising the quality of the physician-patient interaction.
6. Initiating a Training Plan
The lead superuser and IT vendors, who were instrumental in the software configuration, facilitated several training sessions with the hospital team, which included on-site physicians, nurses, administrative staff, and pharmacists. We used these sessions to introduce different components of the EMR system in a gradual and repetitive manner, allowing sufficient time for staff to familiarize themselves with each component of the EMR. Subsequent meetings incorporated staff feedback to further optimize the software for our users. Recognizing that staff roles would evolve over time and new staff would join the team, we also established an ongoing training program. A designated physician was tasked with training new staff members, and online resources were made available for both new and current staff to revisit training modules as needed.
7. Launching of the EMR System With a "Big Bang"
After extensive discussions with the EMR team, we employed a "big bang" approach to launch the EMR system.17 We chose the "big bang" approach for a few key reasons. First, this approach allowed for a complete and simultaneous implementation, ensuring all users transitioned to the new system at the same time. This helped avoid confusion and inconsistencies that could arise from a phased rollout. Second, it enabled us to immediately start reaping the benefits of the system in its entirety, rather than having to wait for the gradual addition of functionalities—basic functionalities, such as patient documentation, e-prescription, and registration, were fully operational at the time of launch. However, more complex features, such as order sets required for inpatient and outpatient documentation, and specific diagnosis or therapy-based templates, were designed to be customizable. These could be added or utilized based on individual requirements and recommendations from on-site user physicians.
8. Developing Procedures for When the EMR Is Down
In anticipation of unforeseen circumstances that could disrupt EMR functionality, we recognized the need for a robust backup system. To ensure uninterrupted service, we arranged for secondary electrical and internet sources to be integrated into the system. Furthermore, to maintain accessibility during potential downtimes, we equipped all rooms with notebooks and writing supplies. These measures were put in place to minimize disruption to patient care workflow. In the event of a system outage, staff could continue documenting patient care manually, and these records could be updated in the EMR system once it was back online.
9. Developing An Audit System
To ensure proper utilization of the EMR system and rectify ongoing usage issues, we established an audit system. This system was designed to regularly review all documents uploaded into the EMR by on-site physicians and nurses. The audit team, led by the lead superuser, was tasked with checking these documents every two weeks. The audit team was responsible for ensuring the completeness of documentation and providing feedback to the staff. In addition, if the team identified any individual or systematic problems with the documentation, they were empowered to offer solutions to improve the documentation process. For example, if the audit team noticed a recurring issue where physicians were not properly documenting certain patient information, they would notify these physicians and request them to rectify the issue. If a systematic issue was detected, such as a technical glitch that prevented proper documentation, the IT team would be consulted to correct the problem through a system update. This audit system was designed as part of a continuous improvement process aimed at enhancing the quality and accuracy of EMR documentation.
10. Ongoing Analyses
Following the implementation of the audit system, we engaged in regular analysis of the collected data to measure document accuracy. This data was gathered monthly, allowing us to monitor the ongoing performance of the EMR system and its implementation by the staff. We used Fisher's exact test for this data analysis.18 We made use of a 2×2 contingency table to compare the adequacy of documentation between the initial month and the final month of the analysis. Key elements of the patient record (HPI, Examination, Assessment, Plan, and Follow-up) were analyzed to see how well our staff was using the EMR.
By identifying areas of strength and potential weaknesses, we were able to make informed decisions to continually enhance the system's effectiveness. The insights gained from this analysis played a crucial role in driving continuous improvements in the EMR system.
Table 1. Ten steps undertaken to implement the BTFCC EMR system
Results
We performed a descriptive analysis of our audit reports from September 2022 to August 2023, which shows a substantial enhancement in medical documentation (Figure 1). The HPI documentation improved from 27.3% (12 out of 44 encounters) in September 2022 to 78.6% (33 out of 42 encounters) by August 2023. The Fisher's exact test demonstrated a significant improvement in HPI documentation (P < 0.001). Physical examination documentation also improved from 6.8% (3 out of 44 encounters) to 83.3% (35 out of 42 encounters) from the beginning to the end of the analysis period (P < 0.001). The Assessment section showed an increase from 18.2% (8 out of 44 encounters) to 83.3% (35 out of 42 encounters) (P <0.001). Medical plan documentation improved from 40.9% (18 out of 34 encounters) to 83.3% (35 out of 42 encounters; P = 0.0058) as did the follow-up documentation which improved from 36.4% (16 out of 44 encounters) to 81% (34 out of 42 encounters) (P <0.001) (Table 2)
Figure 1. Progression of adequacy of documentation over time (September 2022 – August 2023). HPI = History of presenting illness.
aHistory of presenting illness
Table 2. Fisher's exact test comparing adequacy of documentation between September 2022 and August 2023
Discussion
BTFCC is in the city of Janakpur Dham, Nepal, in the Province of Madhesh, which lies to the southeast of Kathmandu. Madhesh is a province characterized by its cultural and ethnic diversity. It is home to numerous ethnic groups including the Madhesis, Tharus, Muslims, and several indigenous and marginalized communities, each with its unique customs and traditions, making up approximately 21% of Nepal's total population.19 This region covers almost 7% of the country's land area and borders India to the North and the Bagmati Province to the East.
BTFCC was established in 2018 in partnership with its local sister non-profit, the Binaytara Cancer Trust, to serve the region. The vision for BTFCC is not just to create a cutting-edge cancer care center, but also to address a significant gap in healthcare equity in the region, which includes parts of Nepal and neighboring areas in India. Specifically, the center serves the Janakpur region in Nepal and the bordering Indian states of Bihar and Uttar Pradesh.
Before the establishment of the BTFCC, the nearest cancer hospital was in Bharatpur. Bharatpur is a city located in the Chitwan district of Nepal, with a population of approximately 280,000 people. It spans an area of about 433 square kilometers, making it one of the largest cities in the country. Consequently, patients were forced to undertake a six-hour road journey for treatment. Geographical constraints, coupled with socio-economic challenges, meant that nearly 25 million people in the region were severely challenged if confronted with a need for timely and effective cancer care.
The primary mode of transportation for patients from Janakpur and surrounding villages to Bharatpur is by bus. This journey, although feasible, presents challenges for regular travel and can contribute to financial strain, particularly if treatment requires an extended stay, necessitating additional accommodation arrangements. According to data from the World Bank, the Gross National Income per capita in Nepal was $1,336.50 in 2022, indicating that most of the population lives on less than $4 per day.20 This economic reality makes it difficult for many individuals to afford regular travel and accommodation costs for treatment. Those who are financially able often opt for air travel to the capital city, Kathmandu, where they have more healthcare options. Similarly, individuals residing in nearby Indian regions may choose to seek treatment in Nepal, or at more advanced centers in Patna and Delhi, India despite the significant distance. However, these options are often cost-prohibitive for the average resident, further exacerbating health disparities in the region.
In a 2021 analysis, the number of new cancer cases and cancer-related mortality in Nepal increased by 92% and 95%, respectively, from 1990 to 2017. However, age-standardized incidence and mortality rates decreased by 5% and 7%, respectively.21 The healthcare system in Nepal seems to be improving, as reflected by the decrease in age-standardized incidence and mortality rates. On the other hand, the significant increase in the absolute number of cancer cases and cancer-related deaths suggests that cancer care specifically may be struggling with unique challenges. These challenges could stem from limited resources, lack of a comprehensive plan for cancer control, and other factors specific to the management and treatment of cancer – including a paucity of early detection and screening programs, limited access to specialized care, and the high cost of treatments.
Each country, and indeed each healthcare facility within that country faces unique factors that must be considered when seeking to adapt an EMR to improve clinical care. In Nepal, unique circumstances include its topographical challenges. Nepal's terrain is divided into three distinct ecological regions: The Mountain, Hill, and Terai plains regions. These regions impose significant barriers to efficient travel due to the varying altitudes ranging from 4,800 meters to 8,800 meters above sea level in the mountain region alone, which covers a land area of 52,000 square kilometers.19 Adding to these geographical challenges is the lack of well-developed and maintained roads, which can further complicate travel. This geographical diversity and other inherent transportation difficulties including limited public transportation and seasonal challenges (monsoon-induced landslides and road blockages) pose further challenges to patient care.
Nepal's linguistic diversity is another variable when developing an EMR. The country is home to over 100 different dialects, with major ones including Nepali, Maithili, Bhojpuri, Tharu, and Tamang.19 Many of these dialects are quite different from each other and present a significant challenge in standardizing an EMR system that could be used broadly and across medical centers. Despite Nepali being the national language, there are substantial numbers of people who exclusively speak these other dialects and who would struggle to interphase with an EMR system implemented solely in Nepali. This linguistic diversity highlights the importance of developing local language interfaces for the EMR system, with a goal of producing a user-friendly interface for healthcare workers and patients across the different regions of the country. Recognizing this, the BTFCC, while initially launching the EMR system in English, has plans to incorporate local languages in the future.
Specific public health concerns in Nepal include a high prevalence of infectious diseases. Tuberculosis and HIV, alongside increasing rates of non-communicable diseases like cardiovascular diseases, diabetes, and cancer, require the EMR system to have specialized modules for efficient tracking and management.22, 23, 24 These and other complexities are not exclusive to Nepal, as they overlap with challenges faced by other rural areas in middle- and low-income countries. Successful EMR implementation requires a tailored and comprehensive approach, considering these unique demographics, linguistic, and health factors.
The adoption of a robust EMR system in an electronically naïve healthcare environment is a demanding task that requires a systematic approach and expertise for successful implementation. Multiple barriers can hinder the process. These barriers include financial constraints, technical limitations, lack of standardization, attitudinal constraints related to user resistance to change, and organizational limitations.14
The most significant obstacle to EMR implementation at BTFCC was the attitudes and beliefs of the clinical staff. Many had no prior experience with a comprehensive EMR system and found the transition overwhelming. To address this, the team utilized real-time audit reports to provide staff feedback. We also provided support through on-site assistance and video conferences. Despite these efforts, some staff members struggled with the steep learning curve needed to implement changes. Several members of our medical staff found it difficult to adapt to the changes, which led to feelings of frustration and dissatisfaction with their roles in this process. The stress of mastering a new system, coupled with their usual clinical duties, eventually led two physicians and an administrative staff member to leave the organization.
Recognizing this challenge, BTFCC leadership decided to recruit new staff including a senior consultant, two house officers, and an administrative staff member, who were open to change and endorsed the importance of adequate EMR documentation to improve patient care. During the recruitment process, expectations, including the requirement for comprehensive EMR documentation, were clearly communicated to ensure the new hires were well-prepared for the demands of their roles. The shift was not just about the introduction of a new system or the recruitment of new staff members, but also about fostering a culture that is adaptable and open to change. Staff were encouraged to view the EMR system as a tool that enhances patient care rather than a burden, and regular meetings were held to address any concerns and challenges faced during the transition. This approach helped in creating a more supportive and collaborative environment.
The implementation of the EMR system at BTFCC has demonstrated several tangible benefits for both patients and healthcare personnel. It has improved the quality of patient care by providing clinicians with immediate access to comprehensive and up-to-date patient information. This accessibility supports clinicians in making informed decisions and helps reduce the likelihood of errors, contributing to enhanced patient safety. The integrated EMR system has also facilitated seamless transitions between departments, ensuring that all healthcare providers involved in a patient's care are informed of their medical history, treatment plans, and follow-up schedules. This improved continuity of care, particularly for patients requiring multidisciplinary management. In our ongoing efforts to maximize the impact of the EMR system, we are exploring options to extend its accessibility beyond the hospital setting. We plan to develop a patient portal and integrate telemedicine services to extend EMR accessibility beyond the hospital. These enhancements aim to improve care continuity and empower patients to engage in their healthcare actively.
We acknowledge the concern that EMR systems can sometimes prioritize administrative and billing functions over patient-centric outcomes. However, the implementation of the EMR system at BTFCC has been tailored with a clear focus on enhancing patient care. By incorporating features such as real-time access to patient information, decision support tools, and planned future integrations like patient portals and telemedicine, we aim to ensure that the primary benefits of the system are directed toward improving clinical outcomes and patient safety.
Conclusion
The implementation of a robust EMR system within a Nepali healthcare setting that was previously electronically naïve presented considerable challenges. However, through a systematic approach, careful planning, and the dedication of the implementation committee and our staff, we have made significant progress.
Despite initial resistance and a steep learning curve for the clinical staff, the audit system and regular feedback loops proved effective in improving documentation practices. The analysis of audit reports revealed substantial improvements in all documentation areas over time. The lessons learned during this first-year experience with an EMR system will allow us to continue this important work as we scale up to a new cancer site and a larger hospital with greater options for comprehensive cancer care.
Our experiences emphasize the necessity of a structured EMR implementation process. Key components of this process include continuous monitoring and feedback, thorough staff training, and a recruitment strategy that prioritizes patient care. This means selecting staff who understand and appreciate that the EMR system is not just a tool, but a crucial component in enhancing long-term patient care.
Future efforts will concentrate on areas needing improvement. For instance, the user-friendliness of the EMR system can be enhanced by simplifying the interface, minimizing the steps required for tasks, and ensuring the clarity of instructions within the system. We also plan to offer more extensive and ongoing training on all aspects of the EMR, ensuring staff are both comfortable and proficient in its use.
Conflict(s) of Interest
The authors declare no conflicts of interest.
Funding Information
N/A
Ethical Statements
N/A
Informed Consent
N/A
Data Availability Statement
N/A
Acknowledgements
We extend our gratitude to all the patients who entrusted their care to the Binaytara Foundation Cancer Center. We also thank Virginia M. Green, PhD, for her invaluable and expert editing and preparation of this manuscript.
Declaration of AI Use in Scientific Writing
N/A
Author Contributions
Concept and design: AKS, SH, SM, HAD, DMA
Data acquisition: AKS, SH, SM, HAD
Data analysis and interpretation: AKS, SH, SM, HAD, DMA
Drafting of the manuscript: AKS
Critical revision of the manuscript: AKS, SH, SM, HAD, DMA
All authors (AKS, SH, SM, HAD, DMA) approved the final version of the manuscript and agree to be accountable for all aspects of the work, in accordance with the International Committee of Medical Journal Editors criteria.
References
1. Honavar S. Electronic medical records—the good, the bad and the ugly. Indian J Ophthalmol. 2020;68(3):417-418. doi:10.4103/ijo.IJO_278_20
2. Dick RS, Steen EB, Detmer DE, eds. The Computer-Based Patient Record: Revised Edition: An Essential Technology for Health Care. National Academies Press; 1997. chap 3. Available from: https://www.ncbi.nlm.nih.gov/books/NBK233053/
3. DeSalvo KB, Dinkler AN, Stevens L. The US Office of the National Coordinator for Health Information Technology: progress and promise for the future at the 10-year mark. Ann Emerg Med. 2015;66(5):507-510. doi:10.1016/j.annemergmed.2015.03.032
4. Janett RS, Yeracaris PP. Electronic medical records in the American health system: challenges and lessons learned. Cien Saude Colet. 2020;25(4):1293-1304. doi:10.1590/1413-81232020254.28922019
5. Cowie MR, Blomster JI, Curtis LH, et al. Electronic health records to facilitate clinical research. Clin Res Cardiol. 2017;106(1):1-9. doi:10.1007/s00392-016-1025-6
6. Office of the National Coordinator for Health Information Technology. National trends in hospital and physician adoption of electronic health records. Accessed May 24, 2024. https://www.healthit.gov/data/quickstats/national-trends-hospital-and-physician-adoption-electronic-health-records
7. Fitzpatrick G, Ellingsen G. A review of 25 years of CSCW research in healthcare: contributions, challenges and future agendas. Comput Supported Coop Work. 2013;22(4-6):609-665. doi:10.1007/s10606-012-9168-0
8. Jamieson T, Ailon J, Chien V, Mourad O. An electronic documentation system improves the quality of admission notes: a randomized trial. J Am Med Inform Assoc. 2017;24(1):123-129. doi:10.1093/jamia/ocw064
9. Ohuabunwa EC, Sun J, Jean Jubanyik K, Wallis LA. Electronic medical records in low to middle income countries: the case of Khayelitsha Hospital, South Africa. Afr J Emerg Med. 2016;6(1):38-43. doi:10.1016/j.afjem.2015.06.003
10. Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55. doi:10.2147/RMHP.S12985
11. Raut A, Yarbrough C, Singh V, et al. Design and implementation of an affordable, public sector electronic medical record in rural Nepal. J Am Med Inform Assoc. 2018;25(8):1107-1112.
12. Acharya B, Maru D, Schwarz R, et al. Partnerships in mental healthcare service delivery in low-resource settings: developing an innovative network in rural Nepal. Global Health. 2017;13(1):2. doi:10.1186/s12992-016-0226-0
13. Parajuli R, Bohara D, KC M, Shanmuganathan S, Mistry SK, Yadav UN. Challenges and opportunities for implementing digital health interventions in Nepal: a rapid review. Front Digit Health. 2022;4:861019. doi:10.3389/fdgth.2022.861019
14. Cresswell KM, Bates DW, Sheikh A. Ten key considerations for the successful optimization of large-scale health information technology. J Am Med Inform Assoc. 2017;24(1):182-187. doi:10.1093/jamia/ocw037
15. Ajami S, Arab Chadegani R. Barriers to implement electronic health records (EHRs). Mater Sociomed. 2013;25(3):213-215. doi:10.5455/msm.2013.25.213-215
16. Kumar R. EHR/EMR software. KareXpert. Published April 18, 2024. Accessed May 24, 2024. https://www.karexpert.com/saas/ehr-emr-software/
17. Owens K. EMR implementation: big bang or a phased approach? J Med Pract Manage. 2008;23(5):279-281.
18. du Prel JB, Röhrig B, Hommel G, Blettner M. Choosing statistical tests: part 12 of a series on evaluation of scientific publications. Dtsch Arztebl Int. 2010;107(19):343-348. doi:10.3238/arztebl.2010.0343
19. Central Bureau of Statistics. National Population and Housing Census 2011 (National Report). Government of Nepal, National Planning Commission Secretariat; 2012. Available at: https://unstats.un.org/unsd/demographic/sources/census/wphc/Nepal/Nepal-Census-2011-Vol1.pdf
20. World Bank. World Bank Open Data. Accessed May 24, 2024. https://data.worldbank.org/country/nepal
21. Shrestha G, Thakur RK, Singh R, et al. Cancer burden in Nepal, 1990–2017: an analysis of the Global Burden of Disease study. PLoS One. 2021;16(8):e0255499.
22. World Health Organization. Tuberculosis Country Profiles: Nepal. World Health Organization; 2018. Available at: https://www.who.int/tb/country/data/profiles/en/
23. UNAIDS. Nepal 2019 Country Report. UNAIDS; 2019. Accessed May 24, 2024. https://www.unaids.org/sites/default/files/country/documents/NPL_2019_countryreport.pdf
24. Aryal KK, Mehata S, Neupane S, et al. The burden and determinants of non-communicable diseases risk factors in Nepal: findings from a nationwide STEPS survey. PLoS One. 2015;10(8):e0134834. doi:10.1371/journal.pone.0134834
Abbreviations Used
BTFCC: Binaytara Foundation Cancer Center
CMIO: Chief Medical Information Officer
EMR: Electronic medical record
HPI: History of presenting illness
IT: Information technology