Setting up a Customized Electronic Health Record System Fit for Internal Medicine in Dakar, Senegal

Objective: Describe the design and implementation of an electronic medical record—E-INTMED—customized for Internal Medicine in Dakar, Senegal. Methodology: This study was carried out in a public teaching hospital in Dakar Senegal. It entailed collaboration between physicians specialized in various fields in Internal Medicine and Computer Scientists to carry out the compilation of data and their electronic transcription to produce a prototype which met users’ needs. Results: E-INTMED software is structured around several hierarchical tables allowing users to register and store all relevant patients’ information. E-INTMED structures patient’s data to provide a clear overview of their medical history and users’ activity performance. E-INTMED makes medical users’ life so much easier. Users can generate and send letters and prescriptions quickly and efficiently using the customized templates which they can modify or create new ones. In addition to these capabilities, all of the features expected in an Internal Medicine EHR are handled by E-INTMED, such as lab orders and results, mechanisms for continuity of care, embedding and access to images and documents, and so much more. E-INTMED provides medical students with a number of educational, practical and administrative advantages. Conclusion: Computerization of medical records has become a necessity today. Crossing the line to Electronic medical records could help to improve medical practice and medical training.


Introduction
The first known record is Egyptian, but it is not a proper patient record, rather a written document on papyrus describing surgical treatment of war wounds [1].
The notion of "patient record" appeared during the 14 th century. It allowed the doctors to remember the story of their patients. Then followed the Greeks with Hippocrates, the father of medicine, who wrote careful notes of his patients about symptoms, appearance of the patient, social situation and other parameters to decide on the treatment [2]. The Arabs introduced the concept of hospital. They were the first to keep written records of patients and their medical treatment, which were later edited by doctors and referenced in future treatment [3]. Later on, the first formal medical record system was developed in Sweden in 1752 and continuously refined until 1980 [2]. From 1970, nursing records have been part of medical records. The whole has become a communication and data transmission tool between healthcare professionals.
To keep, analyze and share information collected on everyday activity, databases are required, which necessarily implies computerization of the patient's record [4]. The electronic medical record was created in the 1990s, with the aim of improving the quality of care. Computing is not only a valuable aid for health care providers, it is at the heart of modern medicine, a medicine that requires information sharing between health system stakeholders and the patient in order to coordinate and sustain continuity of care. Almost all hospitals in developed countries have electronic databases, including names, addresses, diagnoses and treatments for all inpatients and outpatients. Investigators can acquire access to these databases to identify subjects for a study after gaining approval from a hospital's ethics committee [5].
Just from a chronological perspective, several decades separate developed countries to Africa.
Internal Medicine department plays the role of coordinating medical care, managing difficult diagnoses, systemic diseases and chronic diseases such as diabetes. To address these issues, our department, in Aristide Le Dantec teaching hospital, has completely been renovated in order to provide users with an environment that guarantees their comfort, safety and quality of care. On this background and considering advantages of Electronic medical record systems in health, the Internal Medicine department has evolved and initiated a computerization of medical records. This paper describes the process and puts forward ways to maintain sustainability.

Methods
The study was carried out in a public teaching hospital in Dakar Senegal from January 2018 to December 2019. Aristide Le Dantec Hospital was created in 1912. This benchmark hospital gained acceptance since its set up in the management of complex medical and surgical health issues and also constitutes a at least fortnightly to review the content of each part of the database and agree on the relevant information to include in it. For each section, care was given to its electronic format for the sake of shareability and analysis.
As the process was going on, a prototype was generated and reviewed if required to meet users' needs until the final agreed database.

Tables and Layouts
E-INTMED structure is displayed in Figure 1.
 Core table, general information Regarding the structure, we designed the core of the database to be the E-Health Telecommunication Systems and Networks

 Appointments
Appointments are added into the database from any point and by any permitted user (secretaries, nurses, doctors). These can be modified or cancelled. Appointments are registered along with doctors' schedules and specialty.
Outputs sorted by doctors can be displayed, printed out or sent by mail in PDF format to doctors so they can be ready for their next day visits.

Discussion
Several medical data management systems have been developed and are commercially available [6]- [13]. E-INTMED is a client-server electronic medical record (EMR) system created using FileMaker. FileMaker was chosen because it was the only application with the necessary set of tools: a client/server application that works in a wireless LAN, on Windows or Mac OS laptops, on iOS mobile devices (iPad and iPhone) and a physician who had expertise in FileMaker. FileMaker is a great, cost-effective tool for making databases. The system itself provides quick access to all patients' data, plan screenshots and medical documentation. Compared with other systems, we have found Filemaker to be easy to get started, easy to deploy locally, running on both platforms (Mac OS X, Windows, iOS) with many plugins available to extend functionality. Mobility and scalability are well taken into account allowing changing field/database/script names. Finally, it allows for importing excel, csv, tab-formatted sheets. Additionally, the system allows a quick request on all the patient's medical information. Information is at hand during the follow-up examination and is accessible at any time.
Prospective data collection provides complete, accurate and valid data. The clearly organized and structured data entry and the continuous control scripts ensure the quality of data collection. Complex query scripts make it easy to retrieve large datasets. These datasets are processed for predefined statistical analyzes.
In addition to traditional learning resources such as lectures and textbooks, students are increasingly using e-learning tools like commercially available question banks to supplement their learning. E-INTEMED allows students to put into practice what they've learnt by using a tool that walk them through step by step patient's physical assessment. The EHR has changed how medicine is practiced and student experiences with the EHR early-on are likely to have a long-term impact. However, medical students along with other users need to be well trained They pointed out that, without guidance, the EHR can lead to unintended consequences and students would likely benefit from consistent observation and a structured curriculum for proper use [14]. Further research is required to evaluate the impact of student-centered EHR systems on learning outcomes.
Electronic medical record data represent a rich resource for clinical research.
Several Electronic medical records are, however, collected for the purposes of clinical documentation and billing rather than research. This fact creates obstacles to their use in scientific investigation. Particular issues include accuracy, completeness, comparability between settings, ease of extraction, and context of recording [15].
To avert this issue, clinicians and IT worked together during the whole process. To perform epidemiological studies, data can be imported into Excel or SPSS (Statistical Package for Social Science) for further statistical analysis.
Despite the growing literature on benefits of various EHR functionalities, some authors have identified potential disadvantages associated with this technology. These include financial issues, changes in workflow, temporary loss of productivity associated with EHR adoption, privacy and security concerns, and several unintended consequences [16].

Conclusions
This platform provides practitioners with a suitable tool with secure access which enables information to be entered; to ensure a "real time" control of the prescriptions and the management of the lab results.
It also makes available to medical students, during their internship, an interactive tool for learning practical semiology and drawing medical observation files.
Above all, it provides a secure computer archiving system for quality of care and clinical research. This project could be extended to other medical services.
We will continue to improve E-INTMED and work toward simplifying it with the goal of remaining paperless, streamlining visits, processes, and reducing operating costs for our clients.