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The study aimed to evaluate the formats and completeness of the current paper-based referral system and assess user needs for designing an electronic referral system. Conducted in eight public health facilities in Kigali city, the mixed methods approach identified seven different referral letter formats, with the external transfer form averaging 58.8% completeness. Of the 61 elements on this form, 38 were suggested as mandatory and 23 as optional. Focus group discussions confirmed some elements and disputed others. Healthcare providers shared their needs and expectations for the electronic system. The study's outcome provides a clear understanding of the existing referral system and healthcare provider requirements, leading to the design of an electronic referral form.

After the national introduction of the ePrescription in Belgium to the broader public in 2014, community pharmacists are still not satisfied completely. Reasons are (1) low acceptance of the implementation due to slow systems, (2) high reported downtimes, and (3) alert fatigue due to technical and incomprehensible error messages. Therefore, we investigated which technical errors occur in the flow of handling an ePrescription and how these errors can be avoided. A cross-sectional design was used to capture interactions of all national community pharmacists connected to the national eHealth platform on a randomly chosen working day. Per interaction, the number of errors made was observed. In total, 567,883 interactions were registered and analyzed, of which the getPrescription interaction, to download the ePrescription from the national server, was most prevalent (n = 196,433; 37.21%). A difference of 14,961 interaction calls was observed without reaching a final state (delivered or undelivered). Reasons for these differences are repetitive calls for obtaining the ePrescription or by trying to obtain the prescription again when this should no longer be possible (e.g., when an ePrescription is already delivered or archived). When looking at the markAsDelivered, markAsUndelivered or markAsArchived interactions, most of the technical handling errors are due to attempts that generate not allowed state transitions. Most of these incorrect state transitions could have been avoided by maintaining the state diagram in the pharmacist's system to enforce legal transitions and by training the community pharmacists to handle ePrescriptions appropriately.

Since the eighties, case mix evaluation methods based on diagnosis-related groups (DRG) were gradually introduced in developed countries. These methods of assessing the costs of diseases to measure the productivity of the hospital have been introduced in management softwares that are not accessible to low-income countries. In this study, the authors applied these methods to an open source hospital management information system (HMIS) implemented in three university hospitals in Great Lakes Africa. A comparative study of the financial burden of five major diseases, monitored as part of a universal health coverage (UHC) analysis, was carried out. The level of coverage of patients in the hospitals was evaluated and the impact of UHC policies demonstrated. Although the financial protection of patients treated in the three hospitals had improved, HIV and tuberculosis treatments that ought to be free, remained a considerable financial burden for the patient.

Clinical coding is a requirement to provide valuable data for billing, epidemiology and health care resource allocation. In sub-Saharan Africa, we observe a growing awareness of the need for coding of clinical data, not only in health insurances, but also in governments and the hospitals. Presently, coding systems in sub-Saharan Africa are often used for billing purposes. In this paper we consider the use of a nomenclature to also have a clinical impact. Often coding systems are assumed to be complex and too extensive to be used in daily practice. Here, we present a method for constructing a new nomenclature based on existing coding systems by considering a minimal subset in the sub-Saharan region. Evaluation of completeness will be done nationally using the requirements of national registries. The nomenclature requires an extension character for dealing with codes that have to be used for multiple registries. Hospitals will benefit most by using this extension character.

The Universal Health Coverage (UHC) is at the center of the 2030 Sustainable Development Goals agenda. In this study, the authors made an evaluation of the patient health coverage indicators in eight Burundian hospitals from 2011 to 2016. The relevant UHC indicators were calculated on the basis of patient administrative and health insurance data, collected via OpenClinic GA, an information and communication technology (ICT) supported health management information system (HMIS). The results show that the patient health services coverage rate was 70.8% for inpatients and 46.0% for outpatients. The patient health services payment rate as the proportion of total health service costs was above the 25% threshold recommended by WHO for inpatients (30.2%) and for outpatients (43.1%). The patient out-of-pocket payment was below the threshold of 180USD per patient per year for public hospitals. This study demonstrated the possibility to assess the degree of UHC in developing countries, by using routine data extracted automatically from the electronic HMIS.

In this retrospective study, the authors monitored the patient health coverage in 6 Rwandan hospitals in the period between 2011 and 2014. Among the 6 hospitals, 2 are third level hospitals, 2 district hospitals and 2 private hospitals. Patient insurance and financial data were extracted and analyzed from OpenClinic GA, an open source hospital information system (HIS) used in those 6 hospitals. The percentage of patients who had no health insurer globally decreased from 35% in 2011 to 15% in 2014. The rate of health insurance coverage in hospitals varied between 75% in private hospitals and 84% in public hospitals. The amounts paid by the patients for health services decreased in private hospitals to 25% of the total costs in 2014 (-7.4%) and vary between 14% and 19% in public hospitals. Although the number of insured patients has increased and the patient share decreased over the four years of study, the patients' out-of-pocket payments increased especially for in-patients. This study emphasizes the value of integrated hospital information systems for this kind of health economics research in developing countries.

Since 2011, the Regional e-Health Center of Excellence in Rwanda (REHCE) has run an MSc in Health Informatics programme (MSc HI). A programme review was commissioned in February 2014 after 2 cohorts of students completed the post-graduate certificate and diploma courses and most students had started preparatory activity for their master dissertation. The review developed a method for mapping course content on health informatics competences and knowledge units. Also the review identified and measured knowledge gaps and content redundancy. Using this method, we analyzed regulatory and programme documents combined with stakeholder interviews, and demonstrated that the existing MSc HI curriculum did not completely address the needs of the Rwandan health sector. Teaching strategies did not always match students' expectations. Based on a detailed Rwandan health informatics needs assessment, International Medical Informatics Association (IMIA)'s Recommendations on Education in Biomedical and Health Informatics and the IMIA Health Informatics Knowledge Base, a new curriculum was developed and provided a better competences match for the specifics of healthcare in the Central African region. The new approved curriculum will be implemented in the 2014/2015 academic year and options for regional extension of the programme to Eastern DRC (Bukavu) and Burundi (Bujumbura) are being investigated.

From 2007 through 2014, the authors participated in the implementation of open source hospital information systems (HIS) in 19 hospitals in Rwanda, Burundi, DR Congo, Congo-Brazzaville, Gabon, and Mali. Most of these implementations were successful, but some failed. At the end of a seven-year implementation effort, a number of risk factors, facilitators, and pragmatic approaches related to the deployment of HIS in Sub-Saharan health facilities have been identified. Many of the problems encountered during the HIS implementation process were not related to technical issues but human, cultural, and environmental factors. This study retrospectively evaluates the predictive value of 14 project failure factors and 15 success factors in HIS implementation in the Sub-Saharan region. Nine of the failure factors were strongly correlated with project failure, three were moderately correlated, and one weakly correlated. Regression analysis also confirms that eight factors were strongly correlated with project success, four moderately correlated, and two weakly correlated. The study results may help estimate the expedience of future HIS projects.

This research explores to what extent Information and Communication Technology (ICT)-based information management methods can help to improve efficiency and effectiveness of health services in sub-Saharan hospitals and how clinical information can be made available for secondary use enabling non-redundant reporting of health- and care performance indicators. In the course of a 6 years research effort between 2006 and 2012, it was demonstrated that patient identification, financial management and structured reporting improved dramatically after implementation of well adapted ICT-tools in a set of 19 African health facilities. Real-time financial management metrics helped hospitals to quickly identify fraudulent practices and defective invoicing procedures. Out-patient case load significantly increased compared to the national average, average length of stay has been shortened in 15 of 19 health facilities and global hospital mortality decreased. Hospital workforce-evaluated impact of hospital information system implementation on local working conditions and quality of care was very positive. It was demonstrated that local sub-Saharan health professionals strongly believe in the importance of health information systems.

This paper describes the results of the KINELECTRICS project. Since more and more clinical documents are stored and transmitted in an electronic way, the aim of this project was to design an electronic version of the registry that contains all acts of physiotherapists. The solution we present here, not only meets all legal constraints, but also enables to verify the traceability and inalterability of the generated documents, by means of SHA-256 codes. The proposed structure, using XML technology can also form a basis for the development of tools that can be used by the controlling authorities. By means of a certification procedure for software systems, we succeeded in developing a user friendly system that enables end-users that use a quality labeled software package, to automatically produce all the legally necessary documents concerning the registry. Moreover, we hope that this development will be an incentive for non-users to start working in an electronic way.

This study aims to describe primary care professionals' self-reported attitudes towards evidence-based practice (EBP), attention to information sources, perceptions of the barriers to EBP and strategies to improve insight in EBP and patient care. An e-mail invitation with link to an Internet-based survey was sent to Belgian medical doctors (MDs), nurses and paramedics. Under paramedics, we've included emergency medical technicians, firemen and medical volunteers (Red Cross). In general, respondents were supportive towards EBP and agreed that this concept improves patient care, but still, physicians claim that only 50% of their practice is evidence-based and nurses and paramedics spend respectively 59% and 54% of their time to EBP. Doctors depend mostly on clinical guidelines, the Internet and textbooks, while nurses prefer conferences and protocols and paramedics rely on courses and their own judgement. All respondents strongly rely on experimental knowledge gained through interaction with colleagues, although the majority reported that colleagues are often not supportive towards EBP. Lack of time, the overwhelming mass of literature, difficulties with implementation of evidence in to practice are the most common barriers. Nurses show lack of critical appraisal of research results and paramedics have difficulties understanding research and have limited access to computer facilities and their working environment. Communication in group and workshops are very highly valued. Nurses and paramedics are less reluctant towards the opinion of senior colleagues, audits on clinical practice and individual feedback than doctors. EBP generally enjoys a positive attitude at every level of the health care system, but still many obstacles have to be overcome to conquer 'experience-based practice'. The most appropriate method for actual implementation of evidence-based practice at all levels of health care is to provide summaries of evidence, easily understandable protocols and web-based databases accessible from the working environment. Students should not only learn the skills related to EBP, but should be able to integrate knowledge effectively in the clinical setting and routine care. Above all, their supervisors themselves need to evolve from 'experience-based' to evidence-based practice'.